AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

BACKGROUND

Combining cognitive behavioral therapy (CBT) for psychosis with another psychosocial intervention comprising virtual reality (VR)-assisted therapy (VRT) may improve targeted outcomes in treatment-resistant schizophrenia patients.

METHODS

Ten participants having followed CBT were part of our comparative clinical trial comparing VRT to CBT and were selected at the end of the study as they desired to continue to achieve improvements with VRT (CBT + VRT). Clinical assessments were administered before/after treatments and at follow-ups. Changes in outcomes were examined using linear mixed-effects models. To gain a more in depth understanding on CBT + VRT, therapists' notes, and open interviews on a sub-group of patients were qualitatively analyzed.

RESULTS

Findings showed that the sequence of both interventions was appreciated by all patients. Several significant improvements were found throughout time points on auditory verbal hallucinations, beliefs about voices, depressive symptoms, symptoms of schizophrenia and quality of life. Although most of these improvements were in similar range to those observed in our comparative trial, effects of CBT + VRT on depressive symptoms and symptoms of schizophrenia were larger than those found for either intervention alone.

CONCLUSION

This proof of concept is the first to merge gold-standard CBT with VRT for treatment refractory voices and to suggest a certain synergistic effect.

Tailoring cognitive behavioural therapy to subtypes of voice-hearing using a novel tabletised manual: a feasibility study

BACKGROUND

Cognitive behavioural therapy for psychosis (CBTp) is a recommended treatment for psychotic experiences, but its effectiveness has been questioned. One way of addressing this may be to tailor therapy materials to the phenomenology of specific psychotic experiences.

AIM

In this study, we investigated the acceptability of a novel treatment manual for subtypes of 'voice-hearing' experiences (i.e. auditory verbal hallucinations). An uncontrolled, single-arm design was used to assess feasibility and acceptability of using the manual in routine care for people with frequent voice-hearing experiences.

METHOD

The manual was delivered on a smart tablet and incorporated recent research evidence and theory into its psychoeducation materials. In total, 24 participants completed a baseline assessment; 19 started treatment, 15 completed treatment and 12 participants completed a follow-up assessment (after 10 sessions of using the manual).

RESULTS

Satisfaction with therapy scores and acceptability ratings were high, while completion rates suggested that the manual may be more appropriate for help with participants from Early Intervention in Psychosis services rather than Community Mental Health Teams.

CONCLUSION

Within-group changes in symptom scores suggested that overall symptom severity of hallucinations - but not other psychosis features, or beliefs about voices - are likely to be the most appropriate primary outcome for further evaluation in a full randomised controlled trial.

AVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets along with information on acceptability and potential side effects. Interest in the approach is growing rapidly and this report acts as a necessary touchstone for future development.

What Constitutes Sufficient Evidence for Case Formulation-Driven CBT for Psychosis? Cumulative Meta-analysis of the Effect on Hallucinations and Delusions

OBJECTIVE

Following 2 decades of research on cognitive behavioral therapy for psychosis (CBTp), it is relevant to consider at which point the evidence base is considered sufficient. We completed a cumulative meta-analysis to assess the sufficiency and stability of the evidence base for hallucinations and delusions.

METHOD

We updated the systematic search from our previous meta-analytic review from August 2013 until December 2019. We identified 20 new randomized controlled trials (RCTs) resulting in inclusion of 35 RCTs comparing CBTp with treatment-as-usual (TAU) or active controls (AC). We analyzed data from participants with psychosis (N = 2407) over 75 conventional meta-analytic comparisons. We completed cumulative meta-analyses (including fail-safe ratios) for key comparisons. Publication bias, heterogeneity, and risk of bias were examined.

RESULTS

Cumulative meta-analyses demonstrated sufficiency and stability of evidence for hallucinations and delusions. The fail-safe ratio demonstrated that the evidence base was sufficient in 2016 for hallucinations and 2015 for delusions. In conventional meta-analyses, CBTp was superior for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01) when compared with any control. Compared with TAU, CBTp demonstrated superiority for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01). Compared with AC, CBT was superior for hallucinations (g = 0.34, P < .01), but not for delusions although this comparison was underpowered. Sensitivity analyses for case formulation, primary outcome focus, and risk of bias demonstrated increases in effect magnitude for hallucinations.

CONCLUSIONS

The evidence base for the effect of CBTp on hallucinations and delusions demonstrates sufficiency and stability across comparisons, suggesting limited value of new trials evaluating generic CBTp.

The Role of Sense of Voice Presence and Anxiety Reduction in AVATAR Therapy

AVATAR therapy offers a unique therapeutic context that uses virtual reality technology to create a virtual embodiment of the voice-hearing experience, enabling the person to visualize their persecutory voice and engage in real-time "face-to-face" dialogue. The present study explores, for the first time, the contribution of sense of voice presence, together with session-by-session reduction of anxiety and paranoid attributions about the avatar, to changes in primary outcomes following AVATAR therapy. Data from 39 participants, who completed AVATAR therapy and attended a 12-week follow-up assessment, were analysed. Mid- to high-levels of sense of voice presence were reported across the therapy sessions, along with significant reductions of anxiety levels and paranoid attributions about the avatar. The interaction of sense of voice presence and reduction of anxiety was associated with two of the significant therapy outcomes: PSYRATS total and frequency of voices. The findings suggest that improvements in voice severity and frequency at post AVATAR therapy may be influenced by the combination of feeling less anxious in the context of a realistic simulation of the voice, while voice-related distress may involve additional cognitive and relational processes.

Immersive Virtual Reality Applications in Schizophrenia Spectrum Therapy: A Systematic Review

(1) Background: Virtual Reality (VR) is a fully immersive computer simulated experience consisting of a three-dimensional interactive virtual environment, through a head-mounted display (HMD) and controller. The use of virtual reality has recently been proposed for the treatment of various psychiatric conditions, including the spectrum of schizophrenia. Our review aims to investigate the current available evidence regarding the use of immersive virtual reality in the treatment of psychotic symptoms. (2) Methods: From April 2019 to June 2020, we conducted a systematic review aimed at identifying therapeutic applications in immersive virtual reality for the spectrum of schizophrenia, searching for relevant studies on Web of Science, EMBASE, PsycINFO and CINHAL. (3) Results: We identified a total of 2601 unique records. Of these, 64 full-text articles were assessed for eligibility, and six out of these met the inclusion criteria and were included in the final systematic review. (4) Conclusions: The available data on immersive virtual reality are currently limited due to the few studies carried out on the topic; however, it has demonstrated its effectiveness and versatility in successfully treating various psychotic symptoms including delusions, hallucinations, or cognitive and social skills. Existing literature agrees on safe, tolerable, and long-term persistence of the therapeutic effects obtained by immersive VR. No serious side effects have been reported. In some specific cases, VR therapy was found to be very effective compared to usual treatment, allowing effective drug free interventions, and therefore without side effects for patients, even in those resistant to normal drug therapies.

Evidence on Virtual Reality-Based Therapies for Psychiatric Disorders: Meta-Review of Meta-Analyses

Background

Among all diseases globally, mental illnesses are one of the major causes of burden. As many people are resistant to conventional evidence-based treatments, there is an unmet need for the implementation of novel mental health treatments. Efforts to increase the effectiveness and benefits of evidence-based psychotherapy in psychiatry have led to the emergence of virtual reality (VR)–based interventions. These interventions have shown a wide range of advantages over conventional psychotherapies. Currently, VR-based interventions have been developed mainly for anxiety-related disorders; however, they are also used for developmental disorders, severe mental disorders, and neurocognitive disorders.

Objective

This meta-review aims to summarize the current state of evidence on the efficacy of VR-based interventions for various psychiatric disorders by evaluating the quality of evidence provided by meta-analytical studies.

Methods

A systematic search was performed using the following electronic databases: PubMed, PsycINFO, Web of Science, and Google Scholar (any time until February 2020). Meta-analyses were included as long as they quantitatively examined the efficacy of VR-based interventions for symptoms of a psychiatric disorder. To avoid overlap among meta-analyses, for each subanalysis included within this meta-review, only one analysis provided from one meta-analysis was selected based on the best quality of evidence.

Results

The search retrieved 11 eligible meta-analyses. The quality of evidence varied from very low to moderate quality. Several reasons account for the lower quality evidence, such as a limited number of randomized controlled trials, lack of follow-up analysis or control group, and the presence of heterogeneity and publication bias. Nonetheless, evidence has shown that VR-based interventions for anxiety-related disorders display overall medium-to-large effects when compared with inactive controls but no significant difference when compared with standard evidence-based approaches. Preliminary data have highlighted that such effects appear to be sustained in time, and subjects may fare better than active controls. Neurocognitive disorders also appear to improve with VR-based approaches, with small effects being found for various clinical outcomes (eg, cognition, emotion). Finally, there are insufficient data to classify VR-based interventions as an evidence-based practice for social skills training in neurodevelopmental disorders and compliance among patients with schizophrenia.

Conclusions

VR provides unlimited opportunities by tailoring approaches to specific complex problems and individualizing the intervention. However, VR-based interventions have not shown superiority compared with usual evidence-based treatments. Future VR-based interventions should focus on developing innovative approaches for complex and treatment-resistant symptoms that are difficult to address with traditional treatments. Future research should also aim to gain a better understanding of the potential factors that may mediate VR outcomes to improve treatment.

A Review of Multimodal Hallucinations: Categorization, Assessment, Theoretical Perspectives, and Clinical Recommendations

Hallucinations can occur in different sensory modalities, both simultaneously and serially in time. They have typically been studied in clinical populations as phenomena occurring in a single sensory modality. Hallucinatory experiences occurring in multiple sensory systems-multimodal hallucinations (MMHs)-are more prevalent than previously thought and may have greater adverse impact than unimodal ones, but they remain relatively underresearched. Here, we review and discuss: (1) the definition and categorization of both serial and simultaneous MMHs, (2) available assessment tools and how they can be improved, and (3) the explanatory power that current hallucination theories have for MMHs. Overall, we suggest that current models need to be updated or developed to account for MMHs and to inform research into the underlying processes of such hallucinatory phenomena. We make recommendations for future research and for clinical practice, including the need for service user involvement and for better assessment tools that can reliably measure MMHs and distinguish them from other related phenomena.

Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) for People With a Psychotic Disorder: Single-Group Feasibility and Acceptability Study

BACKGROUND

People with a psychotic disorder commonly experience problems in social cognition and functioning. Social cognition training (SCT) improves social cognition, but may inadequately simulate real-life social interactions. Virtual reality (VR) provides a realistic, interactive, customizable, and controllable training environment, which could facilitate the application of skills in daily life.

OBJECTIVE

We developed a 16-session immersive VR SCT (Dynamic Interactive Social Cognition Training in Virtual Reality [DiSCoVR]) and conducted a single-group feasibility pilot study.

METHODS

A total of 22 people with a psychotic disorder and reported problems in social cognition participated. Feasibility and acceptability were assessed using a survey for participants and therapists, and by examining relevant parameters (eg, dropouts). We analyzed preliminary treatment effects on social cognition, neurocognition, and psychiatric symptoms.

RESULTS

A total of 17 participants completed the study. Participants enjoyed DiSCoVR (mean 7.25, SD 2.05; range 3-10), thought it was useful for daily social activities (mean 7.00, SD 2.05; range 3-10), and enjoyed the combination of VR and a therapist (mean 7.85, SD 2.11; range 3-10). The most frequently mentioned strength of DiSCoVR was the opportunity to practice with personalized social situations (14/20, 70%). A significant improvement of emotion perception was observed (Ekman 60 Faces; t₁₆=-4.79, P<.001, d=-0.67), but no significant change was found in other measures of social cognition, neurocognition, psychiatric symptoms, or self-esteem.

CONCLUSIONS

DiSCoVR was feasible and acceptable to participants and therapists, and may improve emotion perception.

Computer-Controlled Virtual Humans in Patient-Facing Systems: Systematic Review and Meta-Analysis

BACKGROUND

Virtual humans (VH) are computer-generated characters that appear humanlike and simulate face-to-face conversations using verbal and nonverbal cues. Unlike formless conversational agents, like smart speakers or chatbots, VH bring together the capabilities of both a conversational agent and an interactive avatar (computer-represented digital characters). Although their use in patient-facing systems has garnered substantial interest, it is unknown to what extent VH are effective in health applications.

OBJECTIVE

The purpose of this review was to examine the effectiveness of VH in patient-facing systems. The design and implementation characteristics of these systems were also examined.

METHODS

Electronic bibliographic databases were searched for peer-reviewed articles with relevant key terms. Studies were included in the systematic review if they designed or evaluated VH in patient-facing systems. Of the included studies, studies that used a randomized controlled trial to evaluate VH were included in the meta-analysis; they were then summarized using the PICOTS framework (population, intervention, comparison group, outcomes, time frame, setting). Summary effect sizes, using random-effects models, were calculated, and the risk of bias was assessed.

RESULTS

Among the 8,125 unique records identified, 53 articles describing 33 unique systems, were qualitatively, systematically reviewed. Two distinct design categories emerged - simple VH and VH augmented with health sensors and trackers. Of the 53 articles, 16 (26 studies) with 44 primary and 22 secondary outcomes were included in the meta-analysis. Meta-analysis of the 44 primary outcome measures revealed a significant difference between intervention and control conditions, favoring the VH intervention (SMD = .166, 95% CI .039-.292, P=.012), but with evidence of some heterogeneity, I2=49.3%. There were more cross-sectional (k=15) than longitudinal studies (k=11). The intervention was delivered using a personal computer in most studies (k=18), followed by a tablet (k=4), mobile kiosk (k=2), head-mounted display (k=1), and a desktop computer in a community center (k=1).

CONCLUSIONS

We offer evidence for the efficacy of VH in patient-facing systems. Considering that studies included different population and outcome types, more focused analysis is needed in the future. Future studies also need to identify what features of virtual human interventions contribute toward their effectiveness.

Voice-Hearing and Personification: Characterizing Social Qualities of Auditory Verbal Hallucinations in Early Psychosis

Recent therapeutic approaches to auditory verbal hallucinations (AVH) exploit the person-like qualities of voices. Little is known, however, about how, why, and when AVH become personified. We aimed to investigate personification in individuals' early voice-hearing experiences. We invited Early Intervention in Psychosis (EIP) service users aged 16-65 to participate in a semistructured interview on AVH phenomenology. Forty voice-hearers (M = 114.13 days in EIP) were recruited through 2 National Health Service trusts in northern England. We used content and thematic analysis to code the interviews and then statistically examined key associations with personification. Some participants had heard voices intermittently for multiple years prior to clinical involvement (M = 74.38 months), although distressing voice onset was typically more recent (median = 12 months). Participants reported a range of negative emotions (predominantly fear, 60%, 24/40, and anxiety, 62.5%, 26/40), visual hallucinations (75%, 30/40), bodily states (65%, 25/40), and "felt presences" (52.5%, 21/40) in relation to voices. Complex personification, reported by a sizeable minority (16/40, 40%), was associated with experiencing voices as conversational (odds ratio [OR] = 2.56) and companionable (OR = 3.19) but not as commanding or trauma-related. Neither age of AVH onset nor time since onset related to personification. Our findings highlight significant personification of AVH even at first clinical presentation. Personified voices appear to be distinguished less by their intrinsic properties, commanding qualities, or connection with trauma than by their affordances for conversation and companionship.

Hallucinations in Older Adults: A Practical Review

Older adults experience hallucinations in a variety of social, physical, and mental health contexts. Not everyone is open about these experiences, as hallucinations are surrounded with stigma. Hence, hallucinatory experiences in older individuals are often under-recognized. They are also commonly misunderstood by service providers, suggesting that there is significant scope for improvement in the training and practice of professionals working with this age group. The aim of the present article is to increase knowledge about hallucinations in older adults and provide a practical resource for the health and aged-care workforce. Specifically, we provide a concise narrative review and critique of (1) workforce competency and training issues, (2) assessment tools, and (3) current treatments and management guidelines. We conclude with a brief summary including suggestions for service and training providers and future research.

A pilot digital intervention targeting loneliness in young people with psychosis

PURPOSE

Loneliness has been identified as a significant challenge for people with psychosis. Interventions targeting loneliness are lacking but adopting a positive psychology approach may reduce loneliness, promote well-being, and support meaningful social interactions. Together with youth mental health consumers, we developed a digital smartphone application (app) called +Connect, which delivers positive psychology content daily for 6 weeks.

MATERIALS AND METHODS

Twelve participants diagnosed with a psychotic disorder were recruited from early psychosis services. Loneliness was assessed pre-intervention, post-intervention, and 3-month post-intervention. Acceptability, feasibility, and usability were measured post-intervention, including a semi-structured interview on the user's experience of +Connect.

RESULTS

We found evidence for the feasibility of +Connect. All but two participants completed the +Connect program, completing 95% (40.10 out of 42 days) of the program. Furthermore, 66.67% (8 out of the 12 participants) remained engaged with the program 3-months post-intervention. Our data indicates preliminary evidence that +Connect may reduce loneliness, with scores from pre-intervention (M = 50.00, SD = 8.47) to post-intervention (M = 48.10, SD = 10.38) and 3-months post-intervention (M = 42.89, SD = 7.04). We found that positive reinforcement of in-game rewards and evidence of positive mood changes added to the feasibility of the app. Regarding acceptability, while 10% (1/10 participants) reported not finding +Connect useful or enjoyable, 90% of participants agreed that +Connect helped them to increase their social confidence, enjoy life, look forward to being with other people, and feel more connected with others. Participant interviews supported these results, with participants highlighting the app's strengths in providing useful information, stimulating self-reflection, fostering positive affect, and encouraging transfer of skills into their social interactions.

DISCUSSION

While preliminary findings indicated that +Connect yielded high levels of acceptability and feasibility, it is important to consider that we recruited a small and selected sample of lonely young people. Further iterations of this proof of concept app, which can incorporate participant feedback such preferences for increased personalisation, in-app feedback, and gamification, may allow an opportunity to test an improved version in the future.

Global functional connectivity density alterations in patients with bipolar disorder with auditory verbal hallucinations and modest short-term effects of transcranial direct current stimulation augmentation treatment-Baseline and follow-up study

OBJECTIVES

To investigate the neuroimaging characteristics of auditory verbal hallucinations (AVHs) in patients with bipolar disorder (BP) experiencing depressive episodes with and without AVHs, and alterations in those characteristics after transcranial direct current stimulation (tDCS).

METHODS

For a baseline pilot study, we recruited 80 patients with BP and depressive status (40 with and 40 without AVHs), and 40 healthy controls (HCs). Their global functional connectivity density (gFCD) was screened by functional magnetic resonance imaging (fMRI). Voxel-wise one-way analysis of covariance (ANCOVA) was conducted to detect intergroup differences in gFCD. In a follow-up study, the effects of 5 weeks of tDCS augmentation treatment on clinical symptoms and gFCD were assessed in the 40 BP patients with AVHs.

RESULTS

Compared to HCs, BP patients with and without AVHs exhibited increased gFCD in the central parietal lobe, insular lobe, and middle cingulate cortex, with decreased gFCD in the posterior parietal cortex, lateral prefrontal cortex, and occipital lobe (all bilateral). Only patients with AVHs showed increased gFCD in the Broca and Wernicke regions, and decreased gFCD in the hippocampus (all bilateral). After 5 weeks of tDCS, AVHs were slightly alleviated and gFCD abnormalities in the hippocampus were mildly attenuated.

CONCLUSIONS

Patients with BP and AVHs showed disturbances in the brain's communication capacity mainly in the left frontoparietal network, control network, and memory circuitry. Five weeks of tDCS alleviated AVHs slightly, without improving depressive symptoms, and attenuated hippocampal gFCD alterations in these patients.

Construction and validation of the Approve questionnaires - Measures of relating to voices and other people

BACKGROUND

The effectiveness of psychological treatments for auditory hallucinations ('voices') needs to be enhanced. Some forms of novel treatment are working within relational frameworks to support patients to relate assertively to distressing voices. Yet, no measure of assertive relating to voices is available to assess the extent to which this skill is developed during therapy. This study aimed to assess the factor structure and validity of two new questionnaires: a measure of relating to voices and a measure of social relating.

METHODS

The relating measures were developed in consultation with members of the international research community and validated in a large sample (N = 402) of voice hearing patients within the UK. The measures were subjected to factor analysis and compared to measures of voice hearing, mental health and well-being to evaluate construct, convergent, discriminant, and criterion validity.

RESULTS

Factor analysis confirmed a three-dimensional set of items that measure assertive and non-assertive (passive and aggressive) relating. This resulted in the validation of the 'Approve' questionnaires - two 15-item measures of relating to voices and other people.

CONCLUSION

The Approve questionnaires can be used to assess a patient's suitability for relationally-based psychological therapies for distressing voices and the extent to which assertive relating skills are developed during the therapy.

Avatar Therapy for people with schizophrenia or related disorders

BACKGROUND

Many people with schizophrenia do not achieve satisfactory improvements in their mental state, particularly the symptom of hearing voices (hallucinations), with medical treatment.

OBJECTIVES

To examine the effects of Avatar Therapy for people with schizophrenia or related disorders.

SEARCH METHODS

In December 2016, November 2018 and April 2019, the Cochrane Schizophrenia Group's Study-Based Register of Trials (including registries of clinical trials) was searched, review authors checked references of all identified relevant reports to identify more studies and contacted authors of trials for additional information.

SELECTION CRITERIA

All randomised clinical trials focusing on Avatar Therapy for people with schizophrenia or related disorders.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and 95% confidence intervals (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and 95% CIs. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. Our main outcomes of interest were clinically important change in; mental state, insight, global state, quality of life and functioning as well as adverse effects and leaving the study early.

MAIN RESULTS

We found 14 potentially relevant references for three studies (participants = 195) comparing Avatar Therapy with two other interventions; treatment as usual or supportive counselling. Both Avatar Therapy and supportive counselling were given in addition (add-on) to the participants' normal care. All of the studies had high risk of bias across one or more domains for methodology and, for other risks of bias, authors from one of the studies were involved in the development of the avatar systems on trial and in another trial, authors had patents on the avatar system pending. 1. Avatar Therapy compared with treatment as usual When Avatar Therapy was compared with treatment as usual average endpoint Positive and Negative Syndrome Scale - Positive (PANSS-P) scores were not different between treatment groups (MD -1.93, 95% CI -5.10 to 1.24; studies = 1, participants = 19; very low-certainty evidence). A measure of insight (Revised Beliefs about Voices Questionnaire; BAVQ-R) showed an effect in favour of Avatar Therapy (MD -5.97, 95% CI -10.98 to -0.96; studies = 1, participants = 19; very low-certainty evidence). No one was rehospitalised in either group in the short term (risk difference (RD) 0.00, 95% CI -0.20 to 0.20; studies = 1, participants = 19; low-certainty evidence). Numbers leaving the study early from each group were not clearly different - although more did leave from the Avatar Therapy group (6/14 versus 0/12; RR 11.27, 95% CI 0.70 to 181.41; studies = 1, participants = 26; low-certainty evidence). There was no clear difference in anxiety between treatment groups (RR 5.54, 95% CI 0.34 to 89.80; studies = 1, participants = 19; low-certainty evidence). For quality of life, average Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (QLESQ-SF) scores favoured Avatar Therapy (MD 9.99, 95% CI 3.89 to 16.09; studies = 1, participants = 19; very low-certainty evidence). No study reported data for functioning. 2. Avatar Therapy compared with supportive counselling When Avatar Therapy was compared with supportive counselling (all short-term), general mental state (Psychotic Symptom Rating Scale (PSYRATS)) scores favoured the Avatar Therapy group (MD -4.74, 95% CI -8.01 to -1.47; studies = 1, participants = 124; low-certainty evidence). For insight (BAVQ-R), there was a small effect in favour of Avatar Therapy (MD -8.39, 95% CI -14.31 to -2.47; studies = 1, participants = 124; low-certainty evidence). Around 20% of each group left the study early (risk ratio (RR) 1.06, 95% CI 0.59 to 1.89; studies = 1, participants = 150; moderate-certainty evidence). Analysis of quality of life scores (Manchester Short Assessment of Quality of Life (MANSA)) showed no clear difference between groups (MD 2.69, 95% CI -1.48 to 6.86; studies = 1, participants = 120; low-certainty evidence). No data were available for rehospitalisation rates, adverse events or functioning.

AUTHORS' CONCLUSIONS

Our analyses of available data shows few, if any, consistent effects of Avatar Therapy for people living with schizophrenia who experience auditory hallucinations. Where there are effects, or suggestions of effects, we are uncertain because of their risk of bias and their unclear clinical meaning. The theory behind Avatar Therapy is compelling but the practice needs testing in large, long, well-designed, well-reported randomised trials undertaken with help from - but not under the direction of - Avatar Therapy pioneers.

A typical antipsychotic treatment induced gradually expanding white matter alterations in healthy individuals with persistent auditory verbal hallucinations-an artificially controlled pilot study

OBJECTIVE

The aim of this study was to explore the effects of atypical antipsychotics (AaPs) on brain white matter (WM) tracts in healthy individuals with auditory verbal hallucinations (Hi-AVHs).

METHODS

We analyzed neuroimaging, AVH symptoms, and cognitive assessment data obtained from 39 Hi-AVHs who reported being distressed by persistent AVHs and volunteered to receive AaP treatment. We used tract-based spatial statistics (TBSS) and t tests to explore AaP pharmacotherapy effects on AVH symptoms and brain WM alterations in Hi-AVH subjects.

RESULTS

TBSS and t tests revealed WM alterations after AaP treatment, relative to pretreatment observations. Although AaPs alleviated AVH symptoms, WM alterations in these subjects expanded over 8 months of AaP treatment, encompassing most major WM tracts by the end of the observation period, including the corpus callosum, arcuate fasciculus, cortico-spinal tracts, anterior commissure, and posterior commissure.

CONCLUSIONS

The worsening of AaP-associated WM alterations observed in this study suggest that AaPs may not be a good choice for the treatment of Hi-AVHs despite their ability to alleviate AVHs.

A palliative care approach in psychiatry: clinical implications

Background

Traditionally, palliative care has focused on patients suffering from life-threatening somatic diseases such as cancer or progressive neurological disorders. In contrast, despite the often chronic, severely disabling, and potentially life-threatening nature of psychiatric disorders, there are neither palliative care units nor clinical guidelines on palliative measures for patients in psychiatry.

Main text

This paper contributes to the growing literature on a palliative approach in psychiatry and is based on the assumption that a change of perspective from a curative to a palliative approach could help promote patient-centeredness and increase quality of life for severely ill patients in psychiatry as well as in somatic medicine. To exemplify this, we offer three different clinical scenarios: severe and enduring anorexia nervosa, treatment-refractory schizophrenia, and chronic suicidality and persistent self-injury in borderline personality disorder.

Conclusion

We emphasize that many typical interventions for treatment-refractory psychiatric disorders may indeed be of a palliative nature. Furthermore, introducing traditional features of palliative care, e.g. so-called goals of care conversations, could aid even further in ensuring that caregivers, patients, and families agree on which treatment goals are to be prioritized in order to optimize quality of life in spite of severe, persistent mental disorder.

Increasing access to CBT for psychosis patients: a feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2)

Background

The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behaviour Therapy for psychosis (CBTp) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBTp. This is attributable, in part, to the resource-intensive nature of CBTp. One response to this problem has been the development of CBTp in brief formats that are targeted at a single symptom and the mechanisms that maintain distress. We have developed a brief form of CBTp for distressing voices and reported preliminary evidence for its effectiveness when delivered by highly trained therapists (clinical psychologists). This study will investigate the delivery of this intervention by a cost-effective workforce of assistant psychologists following a brief training and evaluate the acceptability and feasibility of conducting a future, definitive, randomised controlled trial (RCT).

Methods

This is a feasibility study for a pragmatic, three-arm, parallel-group, superiority 1:1:1 RCT comparing a Guided self-help CBT intervention for voices and treatment as usual (GiVE) to Supportive Counselling and treatment as usual (SC) to treatment as usual alone (TAU), recruiting across two sites, with blinded post-treatment and follow-up assessments. A process evaluation will quantitatively and qualitatively explore stakeholder experience.

Discussion

Expected outcomes will include an assessment of the feasibility of conducting a definitive RCT, and data to inform the calculation of its sample size. If evidence from a subsequent, fully powered RCT suggests that GiVE is clinically and cost-effective when delivered by briefly trained assistant psychologists, CBTp offered in these less resource-intensive forms has the potential to generate benefits for individual patients (reduced distress, enhanced recovery and enhanced quality of life), service-level patient benefit (increased access to evidence-based psychological therapies) and economic benefits to the NHS (in terms of the reduced use of mental health inpatient services).

Trial registration

Current Controlled Trials, ISRCTN registration number: 16166070. Registered on 5 February 2019.

Clinical and theoretical relevance of responses to analogues of psychotic experiences in people with psychotic experiences with and without a need-for-care: an experimental study

BACKGROUND

Certain ways of responding to psychotic experiences (PEs) appear more commonly associated with clinical distress (e.g. avoidance) and other ways with benign or positive outcomes (e.g. reappraisal and acceptance). Past research has largely been limited to retrospective self-report. We aimed to compare clinical and non-clinical individuals on experimental analogues of anomalous experiences.

METHOD

Response styles of two groups with persistent PEs (clinical n = 84; non-clinical n = 92) and a control group without PEs (n = 83) were compared following experimental analogues of thought interference (Cards Task, Telepath) and hearing voices (Virtual Acoustic Space Paradigm).

RESULTS

The non-clinical group with PEs were less likely to endorse unhelpful response styles, such as passive responding or attempts to avoid, suppress, worry about or control mental experiences, compared with the clinical group on all three tasks. The clinical group were more likely to endorse unhelpful response styles compared with controls on two out of three tasks (Cards Task and Telepath). The non-clinical group performed similarly to controls on unhelpful responding across all tasks. There were no group differences for helpful response styles, such as cognitive reappraisal or mindful acceptance of experiences.

CONCLUSIONS

In line with cognitive models of psychosis, the findings suggest that the way in which individuals respond to unusual experiences may be an important factor in understanding clinical distress, supporting the therapeutic rationale of targeting potentially unhelpful patterns of response.

Power to the voice hearer - The German version of the voice power differential scale

Voice power is an important concept in daily life of voice hearers and in the support and therapy for voice hearers who seek help. Therefore, the ability to examine voice power differentials between a voice and a voice hearer is essential. The present study aimed to collect data on voice power differentials and to further validate the Voice Power Differential Scale (VPD). 105 participants aged ≥ 18 with an ICD10 F2-diagnosis that included hearing voices were included in this study. Internal consistency was good (alpha = 0.792), as well as test-retest-reliability (r = 0.855) and correlations with other constructs were generally as expected. The VPD questionnaire results correlated negatively with the Beliefs About Voices Questionnaire-Revised’s (BAVQ-R) items of Benevolence and Engagement-emotion. It correlated positively with Omnipotence and Resistance-emotion, as well as with Negative Content on the Psychotic Symptoms Rating-Scale (PSYRATS). Unexpectedly, no correlations were found with overall severity and command hallucinations. The Voice Power Differential Scale is an important tool for assessing and formulating a voice hearer’s experience when they seek treatment or support for their verbal auditory hallucinations. The results of this study enrich the on-going discussion about the importance of voice power for voice hearers.

Linguistic dual tasking reduces emotionality, vividness and credibility of voice memories in voice-hearing individuals: Results from a controlled trial

Dual taxation of the working memory during recall is an effective strategy to reduce the emotionality and vividness of visual intrusive memories and potentially changes dysfunctional beliefs associated with the memories. This study tested the hypothesis that dual tasking decreases emotionality, vividness and credibility of auditory intrusive images (i.e., memories of auditory hallucinations) with a two-level (time: pre and post; condition: dual tasking and recall only) within-subjects design. Thirty-seven voice-hearing participants selected two negative voice-hearing experiences. They recalled one of these experiences while performing a lingual dual task (i.e., language game on smartphone app) and recalled one memory without a dual task (in counterbalanced order). During the pre-test and post-test, emotionality and vividness of the voice-hearing memories were rated, as well as the credibility of the voice statements. There was a significantly greater decrease in emotionality, vividness and credibility during dual tasking than during recall only. This study provides proof of principle that the salience and credibility of the content of auditory hallucinations can be reduced by dual tasking; the clinical implications are also discussed.

Functional brain alterations in auditory hallucination subtypes in individuals with auditory hallucinations without the diagnosis of specific neurological diseases and mental disorders at the current stage

BACKGROUND

We explored common and distinct pathological features of different subtypes of auditory hallucinations (AHs) to elucidate the underlying pathological mechanisms.

METHODS

We recruited 39 individuals with constant commanding and commenting auditory verbal hallucinations (CCCAVHs), 49 with own thought auditory verbal hallucinations (OTAVHs), 46 with nonverbal AHs (NVAHs), 32 with replay AVHs (RAVHs), and 50 healthy controls. Functional connectivity density mapping was used to investigate global functional connectivity density (gFCD) alterations in these AH groups relative to the control group.

RESULTS

We observed common brain functional alterations among four subtypes of AHs, such as increased gFCD in the bilateral superior temporal gyrus and mesial frontal lobe, and decreased gFCD in the bilateral medial prefrontal cortex. Increased gFCD was detected in the bilateral insula in CCCAVH individuals, bilateral thalamus in OTAVH individuals, bilateral precuneus in NVAH individuals, and bilateral hippocampus in RAVH individuals. The common and distinct gFCD alterations among four AH subtypes were located in main components of the frontoparietal, default mode, salience, central executive, and memory networks. Different AH subtypes exhibited specific aberrant patterns.

CONCLUSIONS

Our findings suggest that aberrant functional activity and metabolism in the abovementioned networks play key roles in the occurrence of AHs. Our findings provide evidence for distinct gFCD alterations in specific AH subtypes.

Are we there yet?!-a literature review of recent digital technology advances for the treatment of early psychosis

Access to psychological interventions during early stages of psychosis is essential for ameliorating outcomes and improving prognosis. However, reaching and engaging individuals at these stages of the illness can be very challenging for early intervention teams. Recent digital technological advances have emerged to overcome some of these challenges and to improve access to psychological interventions. The aim of the present literature review is to summarise main findings of relevant studies published during the last 10 years on the utilization of digital technologies (i.e., virtual reality, smartphone technology and web-based interventions) to enhance psychological treatment outcomes in early psychosis. A literature search from January 2009 to June 2019 was performed to identify relevant papers. Of 1,502 studies identified, nine met inclusion criteria for the review and only five presented results from finalised trials. Overall, these studies showed positive feasibility and acceptability results, along with preliminary evidence of improved therapy outcomes. The present review offers a state-of-the-art summary of the main features of these user-centered digital interventions for early stages of psychosis and a critical discussion about their future implementation in mental health services.

Don’t abandon RCTs in IVF. We don’t even understand them

The conclusion of the Human Fertilisation and Embryology Authority that ‘add-on’ therapies in IVF are not supported by high-quality evidence has prompted new questions regarding the role of the randomized controlled trial (RCT) in evaluating infertility treatments. Critics argue that trials are cumbersome tools that provide irrelevant answers. Instead, they argue that greater emphasis should be placed on large observational databases, which can be analysed using powerful algorithms to determine which treatments work and for whom. Although the validity of these arguments rests upon the sciences of statistics and epidemiology, the discussion to date has largely been conducted without reference to these fields. We aim to remedy this omission, by evaluating the arguments against RCTs in IVF from a primarily methodological perspective. We suggest that, while criticism of the status quo is warranted, a retreat from RCTs is more likely to make things worse for patients and clinicians.

The relationship with the voices as a dialogical experience: The role of self-focused attention and dissociation

OBJECTIVE

The purpose of this article was to study the relationship of self-focused attention and dissociation with the dialogical relationship persons diagnosed with psychosis have with their voices.

METHOD

The DAIMON Scale was applied to 62 persons diagnosed with psychosis to measure the dialogical relationship with their voices, and the Cambridge depersonalization scale, the Tellegen absorption scale, and the self-focused attention scale.

RESULTS

The results showed that the dialogical relationship with the voices was associated with high levels of self-focused attention (private and public), depersonalization, and absorption. It was also found that absorption mediated significantly between public self-focused attention and the dialogical relationship with the voices.

CONCLUSIONS

The role of dissociation and self-focused attention in forming the dialogical relationship a person with psychosis has with the voices is discussed and approaches to treatment are suggested.

How to Treat Depression With Low-Intensity Virtual Reality Interventions: Perspectives on Translating Cognitive Behavioral Techniques Into the Virtual Reality Modality and How to Make Anti-Depressive Use of Virtual Reality-Unique Experiences

Depression is a common mental disorder with a large treatment gap. Low-intensity, automated virtual reality (VR) interventions (not requiring a therapist) is a scalable and promising solution now that VR is an accessible and mature, consumer technology. Yet unlike with phobias, there have been few attempts at translating evidence-based cognitive behavioral therapeutic (CBT) techniques for depression into the VR modality. In this paper, we discuss how specific CBT techniques can be made into VR experiences, including psychoeducation, behavioral activation, cognitive restructuring, and social skills training. We also discuss how VR-unique experiences, such as alternative embodiment and virtual pet interactions, can be made therapeutic. Creating a pre-clinical and clinical evidence base for these types of novel interventions should be considered a research priority, and high-quality development on par with other consumer VR applications will be essential to the success of any consumer-targeted intervention. If this is achieved, low-intensity VR interventions for depression have great potential to make an impact on public mental health.

Key Considerations for Incorporating Conversational AI in Psychotherapy

Conversational artificial intelligence (AI) is changing the way mental health care is delivered. By gathering diagnostic information, facilitating treatment, and reviewing clinician behavior, conversational AI is poised to impact traditional approaches to delivering psychotherapy. While this transition is not disconnected from existing professional services, specific formulations of clinician-AI collaboration and migration paths between forms remain vague. In this viewpoint, we introduce four approaches to AI-human integration in mental health service delivery. To inform future research and policy, these four approaches are addressed through four dimensions of impact: access to care, quality, clinician-patient relationship, and patient self-disclosure and sharing. Although many research questions are yet to be investigated, we view safety, trust, and oversight as crucial first steps. If conversational AI isn't safe it should not be used, and if it isn't trusted, it won't be. In order to assess safety, trust, interfaces, procedures, and system level workflows, oversight and collaboration is needed between AI systems, patients, clinicians, and administrators.

Nursing Process Addressing the Nursing Focus "Hallucination": A Scoping Review

Although hallucinations are prevalent in psychiatric disorders, such as psychosis or dementia, no studies were to be found in literature about the nursing process addressing the focus "Hallucination". This literature review, which is integrated with a scoping study framework, was performed to determine a clinical data model addressing the focus "Hallucination". PRISMA checklist for scoping reviews was followed. From the total of 328 papers found, 32 were selected. The findings of this review were summarized according to the nursing process addressing the focus "Hallucination". These findings led to determine a clinical data model addressing the focus "Hallucination", comprising the elements of the nursing process. This clinical data model may contribute toward improving nursing decision-making and nursing care quality in relation to a client suffering from hallucination, as well as contribute toward producing more reliable nursing-sensitive indicators.

E-Clinical High Risk for Psychosis: Viewpoint on Potential of Digital Innovations for Preventive Psychiatry

E-mental health is an emerging area of research that has the potential to overcome some of the current barriers to progress in working with people at clinical high risk for psychosis (CHR-P). This article provides an overview of how e-mental health could be used in the detection, prediction, and treatment in the CHR-P population. Specifically, we evaluate e-detection, e-prediction, and e-therapeutics for this clinical population. E-mental health holds great promise to improve current management of CHR-P individuals.

A technology-assisted life of recovery from psychosis

Developments in digital health technologies have the potential to expedite and strengthen the path towards recovery for people with psychosis. This perspective piece provides a snapshot of how a range of digital technologies can be deployed to support a young adult’s efforts to cope with schizophrenia-spectrum illness. In conjunction with a day in the life of this individual, we provide examples of innovations in digital health research designed for this clinical population, as well as brief summaries of the evidence supporting the usability, feasibility, or effectiveness of each approach. From early detection to ongoing symptom management and vocational rehabilitation, this day-in-the-life vignette provides an overview of the ways in which digital health innovations could be used in concert to augment, scaffold, and enhance schizophrenia-spectrum illness management and recovery.

Comprehensive review on virtual reality for the treatment of violence: implications for youth with schizophrenia

Youth violence is a complex and multifactorial issue that has severe health and social consequences. While treatment options exist to treat/reduce violence in at-risk populations such as schizophrenia, there remains limitations in the efficacy of current interventions. Virtual reality (VR) appears to be a unique possibility to expose offenders and to train coping skills in virtual situations that are capable of eliciting aggression-relevant behavior without threatening others. The focus of this paper is to provide a comprehensive review of studies using VR to manage violence across several at-risk populations, with a particular emphasis on youth with schizophrenia. Despite the encouraging success of VR applications for the treatment of different mental health problems, no studies have explored the usability of VR to specifically treat violence in patients with schizophrenia. A limited number of studies have focused on violence risk factors in other mental health problems (i.e., emotion regulation in individual suffering from post-traumatic disorders) that may be targeted in treatments to reduce the risk of violence. The preliminary studies using VR as a therapeutic element have shown reductions in anger, improvements in conflict-resolution skills as well as in empathy levels, and decreases in aggression. Possible applications of these interventions in youth with schizophrenia will be discussed.

Structure/function interrelationships in patients with schizophrenia who have persistent auditory verbal hallucinations: A multimodal MRI study using parallel ICA

There is accumulating neuroimaging evidence for both structural and functional abnormalities in schizophrenia patients with persistent auditory verbal hallucinations (AVH). So far, the direct interrelationships between altered structural and functional changes underlying AVH are unknown. Recently, it has become possible to reveal hidden patterns of neural dysfunction not sufficiently captured by separate analysis of these two modalities. A data-driven fusion method called parallel independent component analysis (p-ICA) is able to identify maximally independent components of each imaging modality as well as the link between them. In the present study, we utilized p-ICA to study covarying components among gray matter volume maps computed from structural MRI (sMRI) and fractional amplitude of low-frequency fluctuations (fALFF) maps computed from resting-state functional MRI (rs-fMRI) data of 15 schizophrenia patients with AVH, 16 non-hallucinating schizophrenia patients (nAVH), and 19 healthy controls (HC). We found a significant correlation (r = 0.548, n = 50, p < .001) between a sMRI component and a rs-fMRI component, which was significantly different between the AVH and non AVH group (nAVH). The rs-fMRI component comprised temporal cortex and cortical midline regions, the sMRI component included predominantly fronto-temporo-parietal regions. Distinct clinical features, as measured by the Psychotic Symptoms Rating Scale (PSYRATS), were associated with two different modality specific rs-fMRI components. There was a significant correlation between a predominantly parietal resting-state network and the physical dimension of PSYRATS and the posterior cingulate/temporal cortex network and the emotional dimension of PSYRATS. These data suggest AVH-specific interrelationships between intrinsic network activity and GMV, together with modality-specific associations with distinct symptom dimensions of AVH.

A systematic review of the 'eating disorder voice' experience

The 'eating disorder voice' experience has been reported by both clinicians and by patients with eating disorders (ED) as an important feature of eating psychopathology, however this has only become an area of research in the last decade. The main aim of this paper was to systematically review and synthesize the available literature on this topic. Systematic searches of seven electronic databases were performed up to June 2018. Thirteen peer-reviewed articles were identified. Findings suggested that the existence of an 'ED voice' is often recognized by patients with eating disorders and that this voice has a powerful, negative and omnipotent nature. Feelings of entrapment and defeat are commonly experienced in response to it and patients appear ambivalent towards it. The negative characteristics and responses to the voice are associated with eating disorder symptoms. Addressing the eating disorder voice using relational and interpersonal approaches has the potential to improve clinical and treatment outcomes for patients with eating disorders.

Your Robot Therapist Will See You Now: Ethical Implications of Embodied Artificial Intelligence in Psychiatry, Psychology, and Psychotherapy

Background

Research in embodied artificial intelligence (AI) has increasing clinical relevance for therapeutic applications in mental health services. With innovations ranging from ‘virtual psychotherapists’ to social robots in dementia care and autism disorder, to robots for sexual disorders, artificially intelligent virtual and robotic agents are increasingly taking on high-level therapeutic interventions that used to be offered exclusively by highly trained, skilled health professionals. In order to enable responsible clinical implementation, ethical and social implications of the increasing use of embodied AI in mental health need to be identified and addressed.

Objective

This paper assesses the ethical and social implications of translating embodied AI applications into mental health care across the fields of Psychiatry, Psychology and Psychotherapy. Building on this analysis, it develops a set of preliminary recommendations on how to address ethical and social challenges in current and future applications of embodied AI.

Methods

Based on a thematic literature search and established principles of medical ethics, an analysis of the ethical and social aspects of currently embodied AI applications was conducted across the fields of Psychiatry, Psychology, and Psychotherapy. To enable a comprehensive evaluation, the analysis was structured around the following three steps: assessment of potential benefits; analysis of overarching ethical issues and concerns; discussion of specific ethical and social issues of the interventions.

Results

From an ethical perspective, important benefits of embodied AI applications in mental health include new modes of treatment, opportunities to engage hard-to-reach populations, better patient response, and freeing up time for physicians. Overarching ethical issues and concerns include: harm prevention and various questions of data ethics; a lack of guidance on development of AI applications, their clinical integration and training of health professionals; ‘gaps’ in ethical and regulatory frameworks; the potential for misuse including using the technologies to replace established services, thereby potentially exacerbating existing health inequalities. Specific challenges identified and discussed in the application of embodied AI include: matters of risk-assessment, referrals, and supervision; the need to respect and protect patient autonomy; the role of non-human therapy; transparency in the use of algorithms; and specific concerns regarding long-term effects of these applications on understandings of illness and the human condition.

Conclusions

We argue that embodied AI is a promising approach across the field of mental health; however, further research is needed to address the broader ethical and societal concerns of these technologies to negotiate best research and medical practices in innovative mental health care. We conclude by indicating areas of future research and developing recommendations for high-priority areas in need of concrete ethical guidance.

Digital Technology for Internet Access by Patients With Early-Stage Schizophrenia in Spain: Multicenter Research Study

Background

Digital technology and social networks are part of everyday life in the current internet age, especially among young people. To date, few studies have been published worldwide on the pattern of use of digital technology devices and applications in patients with early-stage schizophrenia and even fewer comparing them with healthy participants (not using data from general population surveys) from the same demographic areas. In Spain, no such study has been carried out.

Objective

The aim of this study was to analyze how patients with early-stage schizophrenia use internet and social networks compared with healthy participants matched by age and gender and also to examine which devices are utilized to access internet resources.

Methods

A cross-sectional, multicentric study was carried out through a semistructured interview asking about the use of digital technology devices and internet. The sample comprised 90 patients and 90 healthy participants. The semistructured interview was conducted on 30 outpatients and 30 healthy subjects in each of the 3 different cities (Madrid, Alicante, and Cuenca). Student t test was used for continuous variables and chi-square test for categorical variables. In the case of ordinal variables, nonparametric Mann-Whitney U and Kruskal-Wallis H tests for independent samples were performed to compare groups.

Results

The results indicated that a large proportion of patients with early-stage schizophrenia have access to different digital devices and use them frequently. In addition, both groups coincide in the order of preference and the purpose for which they use the devices. However, a lower frequency of use of most digital technology devices was detected in patients compared with healthy participants. In the case of some devices, this was due to the impossibility of access and not a lack of interest.

Conclusions

To our knowledge, this is the first study to analyze patterns of internet access and use of digital technology devices and applications in Spanish patients with early-stage schizophrenia compared with healthy participants from the same demographic areas. The results on significant access and use of digital technology and internet shown in this cross-sectional study will allow enhanced and more efficient treatment strategies to be planned, utilizing digital technology devices, for patients with early-stage schizophrenia.

Compassion Focused Approaches to Working With Distressing Voices

This paper presents an outline of voice-hearing phenomenology in the context of evolutionary mechanisms for self- and social- monitoring. Special attention is given to evolved systems for monitoring dominant-subordinate social roles and relationships. These provide information relating to the interpersonal motivation of others, such as neutral, friendly or hostile, and thus the interpersonal threat, versus safe, social location. Individuals who perceive themselves as subordinate and dominants as hostile are highly vigilant to down-rank threat and use submissive displays and social spacing as basic defenses. We suggest these defense mechanisms are especially attuned in some individuals with voices, in which this fearful-subordinate – hostile-dominant relationship is played out. Given the evolved motivational system in which voice-hearers can be trapped, one therapeutic solution is to help them switch into different motivational systems, particularly those linked to social caring and support, rather than hostile competition. Compassion focused therapy (CFT) seeks to produce such motivational shifts. Compassion focused therapy aims to help voice-hearers, (i) notice their threat-based (dominant-subordinate) motivational systems when they arise, (ii) understand their function in the context of their lives, and (iii) shift into different motivational patterns that are orientated around safeness and compassion. Voice-hearers are supported to engage with biopsychosocial components of compassionate mind training, which are briefly summarized, and to cultivate an embodied sense of a compassionate self-identity. They are invited to consider, and practice, how they might wish to relate to themselves, their voices, and other people, from the position of their compassionate self. This paper proposes, in line with the broader science of compassion and CFT, that repeated practice of creating internal patterns of safeness and compassion can provide an optimum biopsychosocial environment for affect-regulation, emotional conflict-resolution, and therapeutic change. Examples of specific therapeutic techniques, such as chair-work and talking with voices, are described to illustrate how these might be incorporated in one-to-one sessions of CFT.

Beyond Trauma: A Multiple Pathways Approach to Auditory Hallucinations in Clinical and Nonclinical Populations

That trauma can play a significant role in the onset and maintenance of voice-hearing is one of the most striking and important developments in the recent study of psychosis. Yet the finding that trauma increases the risk for hallucination and for psychosis is quite different from the claim that trauma is necessary for either to occur. Trauma is often but not always associated with voice-hearing in populations with psychosis; voice-hearing is sometimes associated with willful training and cultivation in nonclinical populations. This article uses ethnographic data among other data to explore the possibility of multiple pathways to voice-hearing for clinical and nonclinical individuals whose voices are not due to known etiological factors such as drugs, sensory deprivation, epilepsy, and so forth. We suggest that trauma sometimes plays a major role in hallucinations, sometimes a minor role, and sometimes no role at all. Our work also finds seemingly distinct phenomenological patterns for voice-hearing, which may reflect the different salience of trauma for those who hear voices.

Potential Applications of Digital Technology in Assessment, Treatment, and Self-help for Hallucinations

The field of digital mental health is rapidly expanding with digital tools being used in assessment, intervention, and supporting self-help. The application of digital mental health to hallucinations is, however, at a very early stage. This report from a working group of the International Consortium on Hallucinations Research considers particular synergies between the phenomenon of hallucinations and digital tools that are being developed. Highlighted uses include monitoring and managing intermittently occurring hallucinations in daily life; therapeutic applications of audio and video media including virtual and augmented reality; targeting verbal aspects of hallucinations; and using avatars to represent hallucinatory voices. Although there is a well-established Internet-based peer support network, digital resources for hallucinations have yet to be implemented in routine practice. Implementation may benefit from identifying how to market resources to the broad range of populations who experience hallucinations and identifying sustainable funding models. It is envisaged that digital tools will contribute to improved self-management and service provision for people experiencing hallucinations.

A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations

Studies on cognitive behavioural therapy for psychosis (CBTp) have developed from evaluating generic approaches to focusing on specific symptoms. The evidence for targeted studies on delusions and hallucinations was reviewed. We included randomized controlled trials (RCTs) examining the effect of individualized CBT-based interventions focusing either on delusions or on hallucinations. Twelve suitable RCTs were identified. Four RCTs focused on delusions, of which three took a focused approach targeting mechanisms assumed causal to persecutory delusions. Eight RCTs focused on hallucinations, a common component of these studies being a focus on the perceived power imbalance between the voice(s) and the voice-hearer, to reduce distress and dysfunction. Only three RCTS were powered adequately; the remainder were pilot trials. All trials reported effect sizes against treatment-as-usual above d=0.4 on at least one primary outcome at post-therapy, with several effects in the large range. Effects on the primary outcome were maintained for five of the seven studies that had significant outcomes and reported a follow-up comparison, but most of the follow-up periods were brief. Although targeted studies are still in their infancy, the results are promising with a tendency towards higher effects compared to the small-to-moderate range found for generic CBTp. In clinical practice, CBTp will need to continue including a range of approaches that can be adapted to patients in a flexible manner according to the primary goals and prevalent combination of symptoms. However, symptom-focused and causal-interventionist approaches are informative research strategies to evaluate the efficacy of separate components or mechanisms of generic CBTp.