A review of hearing voices groups: evidence and mechanisms of change

The Shaman and Schizophrenia, Revisited

This paper presents evidence that some-but not all-religious experts in a particular faith may have a schizophrenia-like psychotic process which is managed or mitigated by their religious practice, in that they are able to function effectively and are not identified by their community as ill. We conducted careful phenomenological interviews, in conjunction with a novel probe, with okomfo, priests of the traditional religion in Ghana who speak with their gods. They shared common understandings of how priests hear gods speak. Despite this, participants described quite varied personal experiences of the god's voice. Some reported voices which were auditory and more negative; some seemed to describe trance-like states, sometimes associated with trauma and violence; some seemed to be described sleep-related events; and some seemed to be interpreting ordinary inner speech. These differences in description were supported by the way participants responded to an auditory clip made to simulate the voice-hearing experiences of psychosis and which had been translated into the local language. We suggest that for some individuals, the apprenticeship trained practice of talking with the gods, in conjunction with a non-stigmatizing identity, may shape the content and emotional tone of voices associated with a psychotic process.

Representation of Voice Hearing Groups by French Mental Health Professionals

Hearing voices groups (HVGs) are an alternative way of treating acoustic-verbal hallucinations. Although they have been developing in France for the last decade, they have lagged behind their international expansion. The representations that circulate about their functioning and their effects are likely to influence the referral to these groups by mental health professionals. We created and used a questionnaire to survey mental health professionals' representations of voice hearing groups. We surveyed 79 French health professionals using a questionnaire with 19 closed items. 7 additional items allowed us to specify the professional status and familiarity of the participants with the HVGs. Professionals generally shared positive representations of HVGs but had very approximate knowledge of them. The subgroup of the most familiar professionals (N = 45) differed significantly on 7 items from the subgroup of non-familiars (N = 35). HVGs are represented as one medical offer among others, of little clinical use and indicated only for psychotic voice-hearing patients, which seems to be a misunderstanding in every case. However, our study also shows that these opinions evolve with the degree of familiarity with HVGs. Certain representations need to be corrected so that quality information can be circulated about HVGs and improve their integration into their ecosystem.

The Experience of Hearing Voices: Challenges and Coping Mechanisms

Auditory hallucinations or hearing voices are often associated with schizophrenia and other psychotic disorders. However, several voice-hearers do not have any mental health issues or diagnoses. The study presented in this paper aimed to explore how voice-hearers understand and react to their concerns by reflecting on and exploring their experiences and interpretations of these experiences. The participants were nine individuals - three females, four males and two others, all experiencing auditory hallucinations for at least five years, residing either at their home or at one of the Hostels run by Richmond Foundation (Malta). A qualitative approach following the principles of Interpretative Phenomenological Analysis was used. In-depth interviews were conducted to explore how the participants perceive their voices, what coping strategies are used, and how their experiences affect their lives. Four super-ordinate themes related to the participants' perceptions and their interpretation of the experience of hearing voices were identified: 'A tough experience', 'Methods used to cope with voices', 'Factors linked to recovery' and 'Relationships'. Furthermore, the study elicited the voice-hearers' recommendations (both for other voice-hearers and mental health professionals).

When Spirit Calls: A Phenomenological Approach to Healthy Voice-Hearers

We present a mixed-methods study, from an anthropological perspective, of 22 healthy voice-hearers ie, people who report hearing voices but have no need for clinical care. They were interviewed using the Varieties Of Individual Voice-Experiences Scale (VOICES), a new scale assessing phenomenology, beliefs and relationships with voices, and their emotional and behavioral impact. Despite in many cases hearing voices daily, they report remarkably little distress, with almost all mentioning a positive impact on their life. Most interpreted their voices as spirits, and spoke of learning to understand, to manage, and even to train their experience of communicating with spirits productively. There was, however, considerable diversity in their voice experiences. Some described experiences they seemed to have discovered after starting a practice. Others described reaching for a practice to make sense of unusual experiences. This raises the possibility that cultural ideas about spirit communication may have two effects. On the one hand, they may help those who begin to hear voices involuntarily to interpret and manage their experience in a non-threatening way, through a meaning framework imposed on experiences. On the other hand, it also suggests that cultural ideas about spirit communication may lead some people to identify some thoughts as voices, and to come to feel that those thoughts are generated outside of themselves, through a meaning-framework shaping experiences. This should remind us that the culture-mind relationship is complex. There may be different kinds of phenomena described by individuals as "voices," with practice and interpretation changing how these phenomena are experienced.

Experience of Inpatient Mental Health Care Assessed With Service User-Developed and Conventional Patient-Reported Outcome Measures

OBJECTIVE

The goal of this study was to examine and compare the psychometric properties of a patient-reported outcome measure (PROM) generated with patients’ input (Views on Inpatient Care [VOICE]) and a PROM conventionally generated without patients’ input (Service Satisfaction Scale: Residential Services Evaluation [SSS-Res]) for assessing a patient’s perception of psychiatric ward care.

METHODS

In a stepped-wedge cluster-randomized trial conducted in the United Kingdom, 1,058 participants admitted to 16 wards reported on their perceptions of care via VOICE and SSS-Res before or up to 2 years after the staff training. Exploratory and confirmatory factor analyses were used to investigate the structure of the PROMs and to assess reliability and convergent validity as well as sensitivity to change; the analyses also considered whether study participants had been admitted voluntarily to the ward.

RESULTS

Two factors emerged from VOICE, labeled “trust” and “involvement,” and from SSS-Res, labeled “environment” and “care,” at baseline. All subscales had high internal consistency and good convergent validity. An ability to detect change in care due to the staff training was observed on the trust subscale of VOICE (N=1,058, mean difference=−0.25, 95% CI=−0.48 to −0.02), but no change was detected on any of the SSS-Res subscales. Patients admitted involuntarily benefited the most from the staff training.

CONCLUSIONS

VOICE captured patients’ perceptions of ward care better than SSS-Res and was sensitive to changes in aspects of trust, suggesting that participatory approaches for developing PROMs improve patients’ self-reports on the care they received.

Psychosis and psychedelics: Historical entanglements and contemporary contrasts

Experiences of psychedelics and psychosis were deeply entangled in scientific practices in the mid-20th century, from uses of psychedelic drugs that could model psychosis, to detailed phenomenological comparisons of endogenous and drug-induced madness. After the moral panic of the 1960s shut down psychedelic research, however, these two phenomena became disentangled. In the decades following, the science of psychosis transformed, shedding the language of psychoanalysis, and adopting the new scientific veneer of psychiatry. Today, as psychedelic science re-emerges, the research programs surrounding psychosis and psychedelics now stand in stark contrast. Here, I look closely at how these research programs respond to questions related to what is worth measuring, what is worth investigating, and how we ought to respond to these experiences. This comparison reveals radically different assumptions and values that guide each research paradigm and shape clinical practice. While psychedelic research often includes scales that seek to capture experiences of mysticism, meaningfulness, and ego dissolution, research related to psychosis focuses on the measurement of pathological symptoms and functioning. Research into psychosis primarily seeks universal and reductionist causal explanations and interventions, while psychedelic research embraces the importance of set and setting in shaping unique experiences. Responses to psychedelic crisis involve warmth, compassion, and support, while responses to psychotic experiences often involve restraint, seclusion, and weapons. I argue that these differences contain important lessons for psychiatry. However, as psychedelic research struggles to meet regulatory requirements and fit within the paradigm of evidence-based medicine, these differences may quickly dissolve.

Measuring the longitudinal course of voice hearing under psychological interventions: A systematic review

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course and impact of voice hearing under these interventions and to evaluate how these variables change over time. Inclusion and exclusion criteria were applied, resulting in a total of 66 articles. Of these, 60 studies (28 RCTs, 23 uncontrolled, 9 non-randomised) were published in peer-reviewed journals, whilst 6 were recently completed or currently ongoing. The findings of this review suggest that a range of variables that are not directly relevant to psychological interventions have been used (e.g., depression, characteristics of voice hearing experience), whilst those directly impacted by psychological interventions (e.g., voice-related distress), broader concepts of outcome (e.g., functioning) and specific associated processes (e.g., self-schema) have received less attention. Findings also showed that the majority of variables demonstrated improvements, but effect sizes varied considerably across trials. This may be attributed to methodological differences such as statistical power, blinding, control groups and different methods of measurement. Our review highlights the importance of determining a set of outcomes that are directly targeted and should change under psychological interventions. Recommendations include the use of voice-related distress as a primary outcome. This can ultimately facilitate comparisons across studies and inform the development of psychological interventions.

The challenges and opportunities of social connection when hearing derogatory and threatening voices: A thematic analysis with patients experiencing psychosis

OBJECTIVES

Relationships with other people are important determinants of the course of psychosis, yet social isolation is common. This study sought to learn about the patient experience of being around other people when hearing derogatory and threatening voices (DTVs).

DESIGN

A qualitative interview study.

METHODS

Fifteen participants with experience of hearing DTVs in the context of non-affective psychosis were recruited from NHS services. Data were obtained by semi-structured interviews and analysed using thematic analysis.

RESULTS

Three themes were identified: (1) reasons why interacting with people is difficult when hearing DTVs; (2) the relationship between social connection and DTVs; and (3) factors which enable voice hearers to connect with others. A further ten sub-themes are outlined as reasons why hearing DTVs led to lower social connection, including difficulties during conversations (e.g., the concentration required is hard), negative expectations of interactions (e.g., fearing negative judgement from others), and difficulties sharing experiences of voices (e.g., people will be hurt or upset if I tell them about the voices). Isolation was a common response to hearing DTVs but also a time of vulnerability for hearing voices. Managing the challenges of interacting with people led to some improvements in DTVs.

CONCLUSIONS

There are understandable reasons why hearing DTVs leads to lower social connection. Yet isolating oneself can also be a time of vulnerability for DTVs. Social connection might be one vehicle for disengaging from and disputing derogatory and threatening voice content. The effect on voice hearing of social recovery interventions warrants further investigation.

PRACTITIONER POINTS

Participants shared 10 reasons why being around people is challenging when hearing derogatory and threatening voices. These typically affected both daily social experiences and contact with clinicians. Common initial responses to hearing DTVs were to reduce contact with people, experience difficulties connecting during conversations and to avoid sharing the experience of voice hearing. However, social isolation was a time of vulnerability to DTVs, and hence, increasing social connection might be a target for interventions. A range of factors enabled voice hearers to manage social situations, for example: the fostering of trust, self-acceptance, learning when it is better to stay at home, and developing a narrative to explain voice hearing to others. Addressing the barriers to connecting with others might have an important role in personal recovery from voice hearing.

The recovery model in chronic mental health: A community-based investigation of social identity processes

The recovery model has been enormously influential in shaping mental health services globally over the last two decades. However, empirical research on its outcomes and psychological mechanisms is sparse. This community-based case study utilised both semi-structured qualitative interviews and quantitative survey methods to investigate perceptions of recovery, identity, and wellbeing among people with chronic and severe mental illness attending recovery-oriented support groups. Consistent with a social identity approach and the recovery model, to the extent that people identified as "in recovery", they reported better recovery outcomes (e.g., sense of purpose) and reduced psychological distress. Furthermore, recovery identity more strongly predicted recovery outcomes than it did psychological distress. Both the quantitative and qualitative data pointed to collective efficacy (i.e., group-based empowerment) as a key mediator of these outcomes. These findings are consistent with the recovery model and speak to the utility of a social identity approach for conceptualizing its efficacy. However, these findings also speak to the need for further evaluation of how and when recovery-oriented mental health services achieve their intended goal of improving quality of life for people with chronic and severe mental illness.

Change in the Neural Response to Auditory Deviance Following Cognitive Therapy for Hallucinations in Patients With Schizophrenia

Adjunctive psychotherapeutic approaches recommended for patients with schizophrenia (SZ) who are fully or partially resistant to pharmacotherapy have rarely utilized biomarkers to enhance the understanding of treatment-effective mechanisms. As SZ patients with persistent auditory verbal hallucinations (AVH) frequently evidence reduced neural responsiveness to external auditory stimulation, which may impact cognitive and functional outcomes, this study examined the effects of cognitive behavioral therapy for voices (CBTv) on clinical and AVH symptoms and the sensory processing of auditory deviants as measured with the electroencephalographically derived mismatch negativity (MMN) response. Twenty-four patients with SZ and AVH were randomly assigned to group CBTv treatment or a treatment as usual (TAU) condition. Patients in the group CBTv condition received treatment for 5 months while the matched control patients received TAU for the same period, followed by 5 months of group CBTv. Assessments were conducted at baseline and at the end of treatment. Although not showing consistent changes in the frequency of AVHs, CBTv (vs. TAU) improved patients' appraisal (p = 0.001) of and behavioral/emotional responses to AVHs, and increased both MMN generation (p = 0.001) and auditory cortex current density (p = 0.002) in response to tone pitch deviants. Improvements in AVH symptoms were correlated with change in pitch deviant MMN and current density in left primary auditory cortex. These findings of improved auditory information processing and symptom-response attributable to CBTv suggest potential clinical and functional benefits of psychotherapeutical approaches for patients with persistent AVHs.

The side effects of service changes: exploring the longitudinal impact of participation in a randomised controlled trial (DOORWAYS) on staff perceptions of barriers to change

BACKGROUND

Staff and service users have expressed concerns that service improvements in British mental health wards have been slow or transient. It is possible that certain changes are positive for some (e.g. service users), but negative for others (e.g. staff), which may affect implementation success. In this study, we explore whether a programme of change to improve the therapeutic milieu on mental health wards influenced staff perceptions of barriers to change, 12 months after implementation.

METHOD

A cluster randomised controlled trial called DOORWAYS was conducted on eight British, inner-city acute mental health wards. Randomisation was achieved using a list randomly generated by a computer. A psychologist trained ward staff (mainly nurses) to deliver evidence-based groups and supported their initial implementation. The impact of these changes was measured over 12 months (when 4 wards were randomised), according to nurses' perceptions of barriers to change (VOCALISE), using unstructured multivariate linear regression models. This innovative analysis method allows maximum use of data in randomised controlled trials with reduced sample sizes due to substantial drop out rates. The contextual influences of occupational status (staff) and of workplace setting (ward) were also considered.

RESULTS

Staff who participated in the intervention had significantly worse perceptions of barriers to change at follow up. The perceptions of staff in the control group did not change over time. In both groups (N = 120), direct care staff had more negative perceptions of barriers to change, and perceptions varied according to ward. Across time, direct care staff in the intervention group became more negative than those in the control group.

CONCLUSION

Participation in this program of change, worsened staff perceptions of barriers to change. In addition, occupational status (being from the direct care group) had a negative effect on perceptions of barriers to change, an effect that continued across time and was worse in the intervention group. Those providing direct care should be offered extra support when changes are introduced and through the implementation process. More effort should be placed around reducing the perceived burden of innovation for staff in mental health wards.

TRIAL REGISTRATION

ISRCTN, ISRCTN 06545047. Registered 29/04/2010, https://www.isrctn.com/search?q=06545047.

The Phenomenon of "Hearing Voices": Not Just Psychotic Hallucinations-A Psychological Literature Review and a Reflection on Clinical and Social Health

The phenomenon of hearing voices is currently a much-discussed topic, both in the field of research and in the field of care services. The majority of people who report "hearing voices" do not subsequently receive services or receive a diagnosis of psychopathology. This topic raises questions for professionals in the health field about the lack of tools that can help illuminate the phenomenon. The purposes of this work are (a) to highlight the psychological studies that approach the phenomenon in a non-psychopathological way and (b) to determine which concepts could aid the comprehension of the phenomenon. The method consists of a systematic review of the literature that characterizes the phenomenon of hearing voices from a non-pathological perspective. The literature offers different theoretical approaches to interpret the phenomenon in a way that is not necessarily pathological and presents new tools for examining the phenomenon. For example, a few studies state that it is possible to coexist with voices, while others indicate that it is necessary to know how to manage voices. We highlighted and discussed several concepts that can support doctors, psychiatrists and practitioners in understanding "hearer" patients, particularly attention to the context of belonging, attention to language, and the role of the sense-making process.

Impact of a brief worry-based cognitive therapy group in psychosis: a study of feasibility and acceptability

Previous research suggests that CBT focusing on worry in those with persecutory delusions reduces paranoia, severity of delusions and associated distress. This preliminary case series aimed to see whether it is feasible and acceptable to deliver worry-focused CBT in a group setting to those with psychosis. A secondary aim was to examine possible clinical changes. Two groups totalling 11 participants were run for seven sessions using the Worry Intervention Trial manual. Qualitative and quantitative data about the experience of being in the group was also collected via questionnaires, as was data on number of sessions attended. Measures were delivered pre- and post-group and at 3-month follow-up. These included a worry scale, a measure of delusional belief and associated distress and quality of life measures. Of the 11 participants who started the group, nine completed the group. Qualitative and quantitative feedback indicated that most of the participants found it acceptable and helpful, and that discussing these issues in a group setting was not only tolerable but often beneficial. Reliable Change Index indicated that 6/7 of the group members showed reliable reductions in their levels of worry post-group and 5/7 at follow-up. There were positive changes on other measures, which appeared to be more pronounced at follow-up. Delivering a worry intervention in a group format appears to be acceptable and feasible. Further research with a larger sample and control group is indicated to test the clinical effectiveness of this intervention.

Key learning aims

(1)

Acceptance and Commitment Therapy for Parental Management of Childhood Asthma: An RCT

BACKGROUND

Few trials have been conducted to address the psychological difficulties of parents in managing their child's asthma. Fostering parental psychological flexibility through Acceptance and Commitment Therapy (ACT) may help parents to accept these psychological difficulties and improve their management of childhood asthma.

METHODS

In this randomized controlled trial, a 4-session, group-based ACT plus asthma education (ACT group) was compared with an asthma education talk plus 3 telephone follow-ups (control group) to train parents of children diagnosed with asthma. The use of health care services due to asthma exacerbations in children and the psychological well-being of their parents were assessed before, immediately after, and at 6 months after the intervention.

RESULTS

A total of 168 parents and their children aged 3 to 12 years with asthma were consecutively recruited in a public hospital in Hong Kong. When compared with the control group, children whose parents were in the ACT group made significantly fewer emergency department visits (adjusted 6-month incidence rate ratio = 0.20; confidence interval [CI] 0.08 to 0.53; P = .001) due to asthma exacerbations at 6 months postintervention. These parents also reported a decrease in psychological inflexibility (mean difference = -5.45; CI -7.71 to -3.30; P = .014), less anxiety (mean difference = -2.20; CI -3.66 to -0.73; P = .003), and stress (mean difference = -2.50; CI -4.54 to -0.47; P = .016).

CONCLUSIONS

Integrating ACT into parental asthma education was effective at decreasing parental anxiety and stress and reducing the asthma-related emergency department visits of children at 6 months postintervention.

O GRUPO DE OUVIDORES DE VOZES: DISPOSITIVO DE CUIDADO EM SAÚDE MENTAL

A alucinação auditiva é um fenômeno que participa da vida de muitas pessoas que fazem tratamento no sistema público de saúde mental de nosso país. No cotidiano de um Centro de Atenção Psicossocial de uma capital brasileira, ouvidores de vozes relatavam com frequência que continuavam sofrendo em função de experiências alucinatórias, mesmo seguindo o tratamento prescrito pela equipe de saúde. Considerando esse problema, foi criado no local um grupo voltado para a lida com o fenômeno. Este artigo teve como objetivo analisar experiências desse grupo. Para isso, utilizou-se o método qualitativo, o qual envolveu o registro de 62 sessões sob a forma de diário de campo, e a análise do corpus. A organização dos dados se deu em três espectros temporais estruturantes de (psico)terapias de grupo em geral: “apresentação”, “trocas de experiências”, e “fechamento”; além de um aspecto dinâmico, denominado de “manejo terapêutico”. A apresentação promoveu a ambientação dos participantes e possibilitou o surgimento de temas importantes, os quais foram trabalhados no decorrer da sessão. Ao trocarem experiências, os integrantes conseguiram compreender algumas dinâmicas relativas às vozes, e houve a promoção de determinados fatores terapêuticos. O manejo serviu para alinhavar os espectros temporais e garantir a fluidez da atividade. Recomenda-se a adoção de grupos com esse foco e formato nos serviços de saúde mental, considerando que eles ampliam a capacidade de cuidado.

Improving patient experiences of mental health inpatient care: a randomised controlled trial

BACKGROUND

Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients' views of ward care.

METHOD

Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.

RESULTS

In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect -0·35, 95% CI -0·57 to -0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, -0.01, 95% CI -0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect -0.18 s.d., 95% CI -0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI -£76 to £98, p = 0.774).

CONCLUSION

Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.

"That little doorway where I could suddenly start shouting out": Barriers and enablers to the disclosure of distressing voices

Hearing distressing voices is a key feature of psychosis. The time between voice onset and disclosure may be crucial as voices can grow in complexity. This study aimed to investigate barriers and enablers to early voice disclosure. In total, 20 voice hearers were interviewed, and Thematic Analysis was used to identify themes. Beliefs about the effect of disclosure on self and others acted as a barrier and enabler to voices being discussed. Voice hearing awareness should be increased among young people, the public, and care services. To support earlier disclosure, measures should be taken to increase skill among those likely to be the recipients of disclosure.

Grupos de ouvidores de vozes: estratégias e enfrentamentos

RESUMO O objetivo deste artigo é discutir as estratégias utilizadas por diferentes grupos de pessoas que ouvem vozes, para o enfrentamento de tal experiência. Trata-se de um estudo etnográfico realizado junto a grupos italianos de ouvidores de vozes. Os dados, que foram obtidos no período entre outubro de 2014 e janeiro de 2016, através da observação participante, com registros em diários de campo, demonstram que estratégias de enfrentamento em espaço grupal, tais como o diálogo com as vozes, a busca de informação e a escrita sobre as mesmas são importantes para a superação das dificuldades decorrentes dessa vivência e estimulam o protagonismo daqueles que as ouvem.

The experience of voice hearing and the role of self-help group: An interpretative phenomenological analysis

BACKGROUND

Auditory verbal hallucinations (AVHs) played an important role in the psychiatric diagnostics, but in the last few decades the diagnostic-free complex phenomenological understanding of the phenomena of voice hearing became the focus of studies.

MATERIALS

Six semi-structured interviews with recovering voice hearers were conducted and analysed using interpretative phenomenological analysis (IPA).

DISCUSSION

The self-help group gives significant help in identification and dealing with the voices; therefore, it serves as turning point in the life story of voice hearers.

CONCLUSION

Applying self-help group in clinical context contributes to better outcomes in treatment of voice hearers.

Investigating the Lived Experience of Recovery in People Who Hear Voices

Although there is evidence of both clinical and personal recovery from distressing voices, the process of recovery over time is unclear. Narrative inquiry was used to investigate 11 voice-hearers' lived experience of recovery. After a period of despair/exhaustion, two recovery typologies emerged: (a) turning toward/empowerment, which involved developing a normalized account of voices, building voice-specific skills, integration of voices into daily life, and a transformation of identity, and (b) turning away/protective hibernation, which involved harnessing all available resources to survive the experience, with the importance of medication in recovery being emphasized. Results indicated the importance of services being sensitive and responsive to a person's recovery style at any given time and their readiness for change. Coming to hold a normalized account of voice-hearing and the self and witnessing of preferred narratives by others were essential in the more robust turning toward recovery typology.

The feasibility and acceptability of a brief Acceptance and Commitment Therapy (ACT) group intervention for people with psychosis: The 'ACT for life' study

BACKGROUND AND OBJECTIVES

Acceptance and Commitment Therapy (ACT) is a contextual cognitive-behavioural approach with a developing evidence base for clinical and cost-effectiveness as an individually-delivered intervention to promote recovery from psychosis. ACT also lends itself to brief group delivery, potentially increasing access to therapy without inflating costs. This study examined, for the first time, the feasibility and acceptability of ACT groups for people with psychosis (G-ACTp).

METHODS

Participants were recruited from community psychosis teams. Ratings of user satisfaction, and pre-post change in self-rated functioning (primary outcome), mood (secondary outcome) and ACT processes were all completed with an independent assessor. Of 89 people recruited, 83 completed pre measures, 69 started the four-week G-ACTp intervention, and 65 completed post measures.

RESULTS

Independently assessed acceptability and satisfaction were high. Functioning (Coeff. = -2.4, z = -2.9, p = 0.004; 95% CI: -4.0 to -0.8; within subject effect size (ES) d = 0.4) and mood (Coeff. = -2.3, z = -3.5, p = 0.001; 95% CI: -3.5 to -1.0; d = 0.4) improved from baseline to follow-up. Commensurate changes in targeted ACT processes were consistent with the underlying model.

LIMITATIONS

The uncontrolled, pre-post design precluded blinded assessments, and may have inflated effect sizes. Participants may have improved as a result of other factors, and findings require replication in a randomized controlled trial (RCT).

CONCLUSIONS

This preliminary study showed that brief group ACT interventions for people with psychosis are feasible and acceptable. Uncontrolled, pre-post assessments suggest small clinical improvements, and changes in psychological processes consistent with an ACT model. Replication in an RCT is required, before implementation can be recommended.

Exploring views about mindfulness groups for voice-hearing from the perspective of service users and staff: A Q-methodology study

OBJECTIVES

Despite prevailing beliefs about the potential benefits and harmfulness of mindfulness for people who hear voices, there is a paucity of research into staff and service user views. Q-methodology was used to explore views about mindfulness groups for voice-hearers.

METHOD

Opportunistic sampling of mental healthcare staff (N = 14) and service users with psychosis (N = 17). Both samples were analysed using principle components factor analysis to identify the range of attitudes held by staff and service users.

RESULTS

Staff participants were particularly knowledgeable and interested in mindfulness. A single staff consensus factor was found suggesting mindfulness is helpful, and not harmful for mental health, but uncertainty surrounded its usefulness for voice-hearers. Service users held four distinct attitudes: (i) mindfulness helps to calm a racing mind; (ii) mindfulness helps to manage stress; (iii) mindfulness improves well-being, and does not alter the brain, reality beliefs, or cause madness; and (iv) mindfulness helps with managing thoughts, fostering acceptance, and is acceptable when delivered in a group format.

CONCLUSIONS

Staff viewed mindfulness groups for psychosis as helpful, not harmful, but were uncertain about their utility. Consistent with previous research, service users viewed mindfulness groups as useful to promote well-being and reduce distress for individuals experiencing psychosis.

Culture and hallucinations: overview and future directions

A number of studies have explored hallucinations as complex experiences involving interactions between psychological, biological, and environmental factors and mechanisms. Nevertheless, relatively little attention has focused on the role of culture in shaping hallucinations. This article reviews the published research, drawing on the expertise of both anthropologists and psychologists. We argue that the extant body of work suggests that culture does indeed have a significant impact on the experience, understanding, and labeling of hallucinations and that there may be important theoretical and clinical consequences of that observation. We find that culture can affect what is identified as a hallucination, that there are different patterns of hallucination among the clinical and nonclinical populations, that hallucinations are often culturally meaningful, that hallucinations occur at different rates in different settings; that culture affects the meaning and characteristics of hallucinations associated with psychosis, and that the cultural variations of psychotic hallucinations may have implications for the clinical outcome of those who struggle with psychosis. We conclude that a clinician should never assume that the mere report of what seems to be a hallucination is necessarily a symptom of pathology and that the patient's cultural background needs to be taken into account when assessing and treating hallucinations.

A case series exploring possible predictors and mechanisms of change in hearing voices groups

OBJECTIVES

Hearing voices groups (HVGs) are increasingly common in National Health Services and are often preferred to individual therapy by both service users and providers. Whilst a range of approaches exist, mixed results have been found and only cognitive behaviour therapy (CBT) was supported by well-controlled trials. This study aimed to explore possible predictors and mechanisms of change in a seven-session CBT group for voice hearers.

DESIGN

An exploratory case series design was used. Method. Fifteen outpatients with a diagnosis of schizophrenia or schizoaffective disorder completed a HVG and carried out weekly measures of distress, negative beliefs about voices, self-esteem, effective coping strategies, and activity levels. Visual inspection and quantitative rules were used to group participants with similar results and cross-correlations and t tests were used to verify key findings.

RESULTS

Several pathways emerged across therapy. Despite measurement frequency, changes on different outcomes tended to occur simultaneously, making conclusions about mechanisms difficult. However, changes in beliefs about voice malevolence and omnipotence correlated most frequently with changes in distress. Visual analysis indicated 53% of participants improved on a measured outcome but satisfaction scores were higher, with 93% feeling the group helped them deal with their problems more effectively. Clients especially valued the chance to meet similar others.

CONCLUSIONS

The results suggest HVGs are valued by clients, regardless of their background or symptoms. HVGs should emphasize testing negative beliefs about voices and allow space for supportive discussions between clients. Recommendations for future research are discussed, including consideration of benefits not detected by outcome measures.