Applying interpersonal theories to the understanding of and therapy for auditory hallucinations: a review of the literature and directions for further research

Echoes of shame: a comparison of the characteristics and psychological sequelae of recalled shame experiences across the voice hearing continuum

BACKGROUND

Voice hearing occurs across a number of psychiatric diagnoses and appears to be present on a continuum within the general population. Previous research has highlighted the potential role of past experiences of shame in proneness to voice hearing in the general population.

AIMS

This study aimed to extend this past research and compare people with distressing voices, people with voices but no distress, and a non-voice hearing control group, on various dimensions of shame and shame memory characteristics.

METHOD

In a cross-sectional, online study 39 distressed voice hearers, 31 non-distressed voice hearers and 50 non-voice hearers undertook a shame memory priming task in which they were prompted to recall a memory of a shaming experience from their past. They then completed questionnaires assessing the characteristics of the recalled shame event and the psychological sequalae of this event (i.e. intrusions, hyperarousal, avoidance, the centrality of shame memories, external shame, and self-criticism).

RESULTS

The majority of recalled shame memories involved experiences such as interpersonal criticism or experiences of being devalued. Univariate analyses found no significant differences between the three groups with regard to the shame events that were recalled, but the distressed voice hearer group reported significantly more hyperarousal, intrusions, self-criticism, and external shame in relation to their experience.

CONCLUSIONS

The findings suggest that voice hearers recall similar types of shame experiences to non-voice hearers, but that problematic psychological sequelae of these shame experiences (in the form of intrusive memories, hyperarousal, external shame, and self-criticism) may specifically contribute to distressing voice hearing.

Corpus linguistics and clinical psychology: Investigating personification in first-person accounts of voice-hearing

Triangulating corpus linguistic approaches with other (linguistic and non-linguistic) approaches enhances "both the rigour of corpus linguistics and its incorporation into all kinds of research" (McEnery & Hardie, 2012:227). Our study investigates an important area of mental health research: the experiences of those who hear voices that others cannot hear, and particularly the ways in which those voices are described as person-like. We apply corpus methods to augment the findings of a qualitative approach to 40 interviews with voice-hearers, whereby each interview was coded as involving 'minimal' or 'complex' personification of voices. Our analysis provides linguistic evidence in support of the qualitative coding of the interviews, but also goes beyond a binary approach by revealing different types and degrees of personification of voices, based on how they are referred to and described by voice-hearers. We relate these findings to concepts that inform therapeutic interventions in clinical psychology.

A proof-of-concept study for the use of a computerised avatar to embody the eating disorder voice in anorexia nervosa

PURPOSE

This study assessed (1) the experience of the eating disorder voice in people with anorexia nervosa or in remission, and (2) the feasibility of creating and interacting with a computerised representation (i.e., avatar) of this voice.

METHODS

Twenty-one individuals with anorexia nervosa and 18 individuals who were in remission participated in the study. They reported on the characteristics of their eating disorder voice and created a personalised avatar (a visual and auditory representation of the eating disorder voice), using a computerised software. Participants assessed closeness of match between the voice and the avatar, perceived distress and acceptability of re-exposure to the avatar.

RESULTS

Patients felt less powerful than their eating disorder voice and unable to disregard the voice's commands. The experience of the voice was associated with negative, as well as some positive emotions, reflecting the prototypical ambivalence towards the illness. Individuals in remission had an opposite pattern of responses. They attributed only negative emotions to the voice, felt more powerful than the voice, and able to disregard its commands. Overall participants reported that there was a good match between the voice and the sound of the avatar. Patients expressed willingness to repeat exposure to the avatar.

CONCLUSION

Individuals with anorexia can create personalised digital avatars representing the eating disorder voice and are willing to engage therapeutically with the avatar. The next step is to test the feasibility of repeated exposure to the avatar to address the power and distress associated with the eating disorder voice.

LEVEL OF EVIDENCE

Level III.

Distress factors of voice-hearing in young people and social relating: Exploring a cognitive-interpersonal voice-hearing model

OBJECTIVES

Little is known about the factors that can maintain the distress related to voice-hearing experiences in youth. Building upon understandings developed with adults, this study aimed to explore the associations between negative relating between hearer and voices, persecutory beliefs about voices and voice-related distress in a clinical sample of adolescents. The study also aimed to investigate associations between relating to voices and wider patterns of social relating.

DESIGN

This was an observational, cross-sectional, survey study.

METHODS

Thirty-four young people (age 14-18 years) who were hearing voices completed measures about voices (characteristics, relating and beliefs) and relating to social others (negative relating styles, social connectedness and belongingness). Participants were patients of NHS mental health services. Bivariate correlations explored associations between relating to voices and distress, beliefs about voices and distress, and between relating to voices and social relating variables.

RESULTS

Perceiving the voices as dominant, intrusive, and persecutory and resisting them was significantly associated with distress. Adjusting for loudness and negative content rendered the association between persecutory beliefs and distress non-significant. Fear of separation and of being alone in relation to social others was associated with distancing from voices. Being suspicious, uncommunicative and self-reliant and/or being sadistic and intimidating towards social others was significantly associated with dependence towards the voices. Greater hearer-to-voice dependence was associated with lower perceived social belongingness and connectedness.

CONCLUSIONS

Beliefs about voices being persecutory, dominant, intrusive and resisting voices seem to be significant contributors of distress in young people. In terms of proximity and power, relating to voices and social others appears to be contrasting.

Smartphone-assisted guided self-help cognitive behavioral therapy for young people with distressing voices (SmartVoices): study protocol for a randomized controlled trial

Background

The long-standing view that auditory verbal hallucinations (AVH) or hearing voices is a sign of schizophrenia has been challenged by research demonstrating that they lie on a continuum ranging from normal to pathological experience related to distress and need for care. Hearing voices is more prevalent in adolescence than in later life, and hearing voices during adolescence indicates a risk for severe psychopathology, functional impairments, and suicide later in life. While there is increasing evidence for the efficacy of cognitive behavioral therapy for voices (CBTv) in adults with schizophrenia, research on psychological treatments for youth with distressing voices has been scarce. The aim of the current study is to examine the efficacy of CBTv, delivered using smartphone-based Ecological Momentary Assessment Intervention (EMI) in a transdiagnostic sample of youth.

Methods

This is a superiority randomized controlled trial comparing 8 weeks of CBTv-based EMI in addition to treatment as usual (TAU) versus TAU only. TAU covers both no treatment and any form of psychiatric/psychological treatment. In the EMI condition, participants will be prompted twice a day to complete an EMA survey, and receive one intervention proposal per assessment. One-hundred fifty-four youth aged 14–25 years with distressing voices will be recruited from psychiatric clinics, local private practices, internet forums, and advertisements in print and social media. Before and after the intervention phase, participants will undergo a 9-day EMA. Single-blinded assessments will be conducted at baseline (T0) and at 3-month (T1) and 6-month (T2) follow-up. The primary outcome is the distress dimension of the Auditory Hallucinations subscale of the Psychotic Symptom Rating Scales at T1. Secondary outcomes include perceived hostile intention, power, and dominance of voices, passive, aggressive, and assertive relating to voices, and negative core beliefs about the self.

Discussion

Adolescence provides a crucial window of opportunity for early intervention for hearing voices. However, youth are notoriously reluctant help-seekers. This study offers a low-intensity psychological intervention for youth with distressing voices beyond diagnostic boundaries that, using a mobile technology approach, may match the treatment preferences of the generation of “digital natives.”

Trial registration

German Clinical Trials Register DRKS00026243. Registered on 2 September 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06846-0.

A systematic review of relational-based therapies for the treatment of auditory hallucinations in patients with psychotic disorders

BACKGROUND

Auditory hallucinations in patients with psychotic disorders may be very distressing. Unfortunately, a large proportion of individuals are resistant to pharmacological interventions and the gold-standard cognitive-behavioral therapy for psychosis offers at best modest effects. To improve therapeutic outcomes, several therapies have been created to establish a relationship between voice-hearers and their voices. With increasing literature, we conducted a systematic review of dialogical therapies and examined the evidence behind their efficacy.

METHODS

A systematic search was performed in PubMed, PsycINFO, Web of Science, and Google Scholar. Articles were included if they discussed the effects of dialogical interventions for patients with psychotic disorders.

RESULTS

A total of 17 studies were included within this systematic review. Cumulative evidence from various therapies has shown that entering in a dialog with voices is beneficial to patients, even those who are resistant to current pharmacological treatments. Heightened benefits have been mainly observed with Relating Therapy and Avatar Therapy/Virtual Reality assisted Therapy, with evidence generally of moderate quality. Both these interventions have shown large to very large effects on voices and voice-related distress as well as moderate to large magnitude improvements on affective symptoms. Though, cognitive-behavioral therapy for command hallucinations and making sense of voices noted no improvements on voices.

CONCLUSIONS

Literature on relational-based interventions with a strong emphasis on the relational aspects of voice hearing has shown positive effects. Results suggest that these dialogical therapies might surpass the efficacy of current gold-standard approaches.

Visual P300 as a neurophysiological correlate of symptomatic improvement by a virtual reality-based computer AT system in patients with auditory verbal hallucinations: A Pilot study

Previous comparative trials showed that virtual reality (VR) therapies achieved larger effects than gold-standard cognitive-behavioral therapy (CBT) on overall auditory verbal hallucinations (AVHs). However, no trial has examined the corresponding underlying electrophysiological mechanisms. We performed a pilot randomized comparative trial evaluating the efficacy of a virtual reality-based computer AT system (CATS) over CBT for schizophrenia (SCZ) patients with treatment-resistant AVHs and explored these potential electrophysiological changes via the visual P300 component. Patients (CATS, n = 32; CBT, n = 33) completed the clinical assessments pre- and post-interventions and at 12-week follow-up. The visual P300 were measured before and after both therapies. The analysis of changes in psychiatric symptoms used linear mixed-effects models, and the P300 response in temporal and time-frequency domains was analyzed with repeated-measures analysis of variance. There was no interaction effect between change in clinical symptoms and treatment group. However, several statistically significant within-group improvements were found for CATS and CBT over time. AVH improved significantly after both treatments, as measured with the Psychotic Symptom Rating Scales-Auditory Hallucinations (PSYRATS-AH) sub-scores. Especially for the CATS group, omnipotence beliefs, anxiety symptoms, self-esteem, and quality of life also remained improved at the 12-week follow-up. Moreover, P300 amplitude had a significant interaction effect and correlation with AVH response. Overall, our analysis did not demonstrate general clinical superiority of CATS over CBT, but CATS improved refractory AVH in SCZ patients, likely by increasing P300 amplitude. These findings support the continued development of CATS for persistent AVH and suggest further trials to clarify the neurological effects of CATS.

Associations between responses to voices, distress and appraisals during daily life: an ecological validation of the cognitive behavioural model

BACKGROUND

Cognitive models propose that behavioural responses to voices maintain distress by preventing disconfirmation of negative beliefs about voices. We used Experience Sampling Methodology (ESM) to examine the hypothesized maintenance role of behavioural responses during daily life.

METHOD

Thirty-one outpatients with frequent voices completed a smartphone-based ESM questionnaire 10 times a day over 9 days, assessing voice-related distress; resistance and compliance responses to voices; voice characteristics (intensity and negative content); appraisals of voice dominance, uncontrollability and intrusiveness.

RESULTS

In line with predictions, behavioural responses were associated with voice appraisals (dominance and uncontrollability), but not voice characteristics. Greater resistance and compliance were reported in moments of increased voice distress, but these associations did not persist after controlling for concurrent voice appraisals and characteristics. Voice distress was predicted by appraisals, and, unexpectedly, also by voice characteristics. As predicted, compliance and resistance were related to increases in distress at subsequent timepoints, whilst antecedent voice appraisals and characteristics had no such effect. Compliance, but not resistance, additionally predicted subsequent increases in voice uncontrollability. In both cases, the reverse models showed no association, indicating directional effects of responses on subsequent distress, and of compliance on uncontrollability appraisals.

CONCLUSIONS

These results provide support for the cognitive model by suggesting that momentary behavioural and emotional responses to voices are associated with concurrent negative voice appraisals. Findings suggest that behavioural responses may be driven by voice appraisals, rather than directly by distress, and may in turn maintain voice appraisals and associated distress during the course of daily life.

L’amélioration de la qualité de vie chez les patients atteints d’une schizophrénie réfractaire ayant suivi la Thérapie assistée par la Réalité Virtuelle : une analyse de contenu

Objectifs La schizophrénie, en particulier la schizophrénie résistante aux traitements (SRT), est considérée comme l’un des troubles psychiatriques les plus invalidants en termes d’effets indésirables sur la qualité de vie (QV) des patients. La QV subjective est devenue une cible particulièrement cruciale qui devrait être améliorée avec le traitement, car une QV améliorée peut entraîner le rétablissement chez les patients atteints de schizophrénie. Il existe cependant peu de preuves des effets des interventions psychosociales recommandées sur les mesures non symptomatiques comme la QV. À cet égard, le traitement de la schizophrénie peut être renforcé si, en plus du traitement des symptômes, l’accent thérapeutique est mis sur d’autres sphères importantes pour les patients. Avec les progrès technologiques, la Thérapie assistée par la Réalité Virtuelle (TRV) permet aux entendeurs de voix d’entrer en dialogue direct avec un avatar, animé entièrement par le thérapeute, qui représente leur voix la plus persécutrice. Ceci dans le but de leur permettre d’acquérir un meilleur contrôle sur leurs voix et de travailler sur leur estime de soi. Au-delà de la symptomatologie, les résultats des projets pilotes sur cette thérapie innovante ont montré des résultats significatifs sur la QV.

Méthode Afin de peaufiner les résultats quantitatifs trouvés, cet article a exploré les thèmes émergents d’une analyse de contenu découlant du discours spontané de 10 patients ayant bien répondu à la TRV.

Résultats Quatre thèmes généraux ont émergé : 1) impact de la thérapie sur les voix ; 2) relations interpersonnelles ; 3) bien-être psychologique ; et 4) mode de vie. Cette analyse de contenu a permis d’identifier plusieurs sphères de vie qui sont davantage améliorées chez les patients ayant une SRT à l’aide de la TRV.

Conclusion : La TRV met en évidence l’avenir des approches adaptées aux objectifs des patients qui intègrent plusieurs processus pertinents pour potentiellement améliorer leur QV. La TRV peut avoir des implications potentiellement immenses sur la santé et la qualité de vie des patients. Cette étude fut une première étape vers l’exploration des effets subjectifs de la TRV sur la vie des patients au-delà des symptômes.

Whispers, echoes, friends and fears: forms and functions of voice-hearing in adolescence

BACKGROUND

Despite the high prevalence of voice-hearing in childhood, research with adolescents aged under 16 years is scarce. Theoretical connections between clinical and developmental conceptualizations of voice-hearing are limited, resulting in missed opportunities to explore unusual sensory experiences with young people.

METHODS

Demographic, contextual and qualitative data were collected through a web-based survey with 68 adolescents (M = 14.91; SD = 2.77) from Australia, Canada, Ireland, New Zealand, Spain, the United Kingdom and United States of America. A Foucauldian-informed narrative analysis captured phenomenologically meaningful individual accounts and systemically informed narratives. Analytic layers attended specifically to the form and function of voices, including relational, protective, distressing and nuanced experiences, offering new insights into individual, systemic and cultural interpretative narratives surrounding voice-hearing to inform research, policy and tailored support.

RESULTS

The average self-reported age of onset of voices was 9 years, 5 months. Reciprocal relationships with pleasant voices were evidenced through the narratives and characterization of voices, while distressing voices were described without reciprocity and the voices held greater power over the young person. Positive aspects of negative voices were discussed and are illustrated with a continuum matrix reflecting interpretation and related affect.

CONCLUSIONS

Voice-hearing is a heterogeneous and often complex relational experience for young people, with structural inequalities, relational traumas and social isolation attributed causes of voice-hearing. Developing personal meaning-making mitigated voice-related distress through contextualizing the origin of the voices in past experiences, without attribution to mental illness. Recommendations are proposed for assessment, formulation and relational interventions that recognize the potential impact of the voice-child-other relationship upon psychosocial functioning and wellbeing.

Is there an association between caregiver antipathy and psychosis? A systematic review

PURPOSE

Existing reviews of trauma and psychosis have identified associations between childhood emotional abuse (CEA) and psychosis. However, conceptual issues relating to assessment of CEA limit the conclusions that can be drawn from the literature. The aim of this review was to identify and evaluate studies reporting an association between childhood experiences of caregiver antipathy (i.e. criticism, hostility, coldness, or rejection from a parental figure experienced prior to age 17 years) and psychosis symptoms/diagnosis.

METHODS

Five databases were systematically searched for articles published until May 2020. Studies were evaluated against inclusion/exclusion criteria, and a narrative synthesis of findings was completed. Study quality was assessed by two independent raters.

RESULTS

Fourteen studies comprised of 1,848 participants met inclusion criteria. Twelve of these studies found significant associations between caregiver antipathy and psychosis, and two did not. There was evidence that adults with schizophrenia-spectrum diagnoses report more severe caregiver antipathy in childhood than non-clinical controls and that caregiver antipathy severity is positively correlated with psychosis symptom severity. Most studies received weak or moderate quality ratings and all used cross-sectional or case-control designs which showed associations, rather than causal relationships, between childhood caregiver antipathy and later psychosis.

CONCLUSIONS

Future research would benefit from more rigorous and valid assessment of CEA, use of multivariate methods to account for possible patterns of co-occurrence, and longitudinal study designs to make more robust causal claims. The findings may have important implications for the delivery of psychological care for people with psychosis who report adverse caregiving experiences.

PRACTITIONER POINTS

People with schizophrenia-spectrum diagnoses may report more severe caregiver antipathy in childhood than non-clinical controls. Caregiver antipathy severity appears to be positively correlated with psychosis symptom severity in clinical and non-clinical populations. Clinicians should consider the possible impact of caregiver antipathy on psychosis symptoms, their content and distress maintenance. Clinicians should also recognise the potential impact of adverse caregiving experiences on therapeutic relationships, patterns of help-seeking and service engagement. Best practice in clinical services would be to adopt individual, formulation-based approaches within trauma-informed models of care.

Person-ness of voices in lived experience accounts of psychosis: combining literary linguistics and clinical psychology

In this paper, we use concepts and insights from the literary linguistic study of story-world characters to shed new light on the nature of voices as social agents in the context of lived experience accounts of voice-hearing. We demonstrate a considerable overlap between approaches to voices as social agents in clinical psychology and the perception of characters in the linguistic study of fiction, but argue that the literary linguistic approach facilitates a much more nuanced account of the different degrees of person-ness voices might be perceived to possess. We propose a scalar Characterisation Model of Voices and demonstrate its explanatory potential by comparing two lived experience descriptions of voices in interviews with voice-hearers in a psychosis intervention. The new insights into the phenomenology of voice-hearing achieved by applying the model are relevant to the understanding of voice-hearing as well as to therapeutic interventions.

Changing Attitudes Towards Voice Hearers: A Literature Review

Auditory verbal hallucinations, or voice hearing, is increasingly understood as a common experience. Despite this, voice hearers still experience a great deal of stigma, which can have serious negative impacts on the person's experience of their voices, and their recovery. Research has demonstrated that healthcare professionals may be a major source of the stigma surrounding voice hearing, with service-level implications for the development and delivery of evidence-based interventions. Therefore, reducing this stigma is a critical intervention target. The purpose of this narrative review is to examine evidence for interventions aimed at reducing stigma towards people who hear voices, in populations of healthcare professionals, students, and the general public. The available evidence supports the use of anti-stigma interventions based around direct contact with voice hearers and education about voice hearing. However, further research is necessary in this area to confirm these findings.

The role of characterisation in everyday voice engagement and AVATAR therapy dialogue

BACKGROUND

Voices are commonly experienced as communication with a personified 'other' with ascribed attitudes, intentionality and personality (their own 'character'). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural engagement with voices or within psychological therapy for distressing voices.

METHODS

Baseline characterisation (the degree to which the voice is an identifiable and characterful entity) of the dominant voice was rated (high, medium or low) using a newly developed coding framework, for n = 60 people prior to starting AVATAR therapy. Associations between degree of characterisation and (i) everyday behavioural engagement with voices (The Beliefs about Voices Questionnaire-Revised; n = 60); and (ii) interaction within avatar dialogue [Session 4 Time in Conversation (participant-avatar); n = 45 therapy completers] were explored.

RESULTS

Thirty-three per cent reported high voice characterisation, 42% medium and 25% low. There was a significant association between characterisation and behavioural engagement [H(2) = 7.65, p = 0.022, ɛ2 = 0.130] and duration of participant-avatar conversation [F(2,42) = 6.483, p = 0.004, η2 = 0.236]. High characterisation was associated with increased behavioural engagement compared with medium (p = 0.004, r = 0.34; moderate effect) and low (p = 0.027, r = 0.25; small-moderate effect) with a similar pattern observed for the avatar dialogue [high v. medium: p = 0.008, Hedges' g = 1.02 (large effect); high v. low: p = 0.023, Hedges' g = 1.03 (large effect)]. No differences were observed between medium and low characterisation.

DISCUSSION

Complex voice characterisation is associated with how individuals interact with their voice(s) in and out of therapy. Clinical implications and future directions for AVATAR therapy and other relational therapies are discussed.

Help, I can't help: A qualitative study of psychiatric nurse's perspectives on their care for people who hear voices

WHAT IS KNOWN ABOUT THE SUBJECT?: There are no studies on the perceptions of psychiatric nurses on interventions they provided to people hearing voices while in an acute psychiatric unit in Ireland. There are three studies focussed on psychiatric nurses' experiences of caring for people that hear voices, two based in England and one based in Australia. Only two of these studies is focussed on nurses working in an acute psychiatric unit. WHAT IS THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study used semi-structured interviews to explore perceptions of psychiatric nurses in the Republic of Ireland on interventions they provided people hearing voices while in an acute psychiatric unit. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further quantitative and qualitative research into the nursing practice for people experiencing auditory hallucinations, in both in-patient and community settings. Follow up supports and supervision after the completion training programmes should be implemented, to ensure the transition of skills and knowledge to the clinical environment. Further investigation into whether or not psychiatric nurses are well prepared for the developments outlined in national polices. ABSTRACT: Aims and Objectives To explore the perspectives and experiences of Irish psychiatric nurses working in acute care in regard to their role in addressing hearing voices in the people in their care, with a view to gain insight in the nurses' personal experiences, interventions they provide, attitudes, knowledge, facilitating factors and challenges. Background Treatment of auditory hallucinations often takes place in acute psychiatric care. Traditionally treatment was focused on medication, but this is no longer the sole approach, with psychosocial interventions gaining ground. Psychiatric nurses have the potential to provide these interventions. As part of the changing emphasis of mental health care in Ireland towards more responsibilities for psychiatric nurses, there is a need to establish whether psychiatric nurses are prepared to take up these added responsibilities. Design A qualitative study, comprising of semi-structured interviews (n = 16). Results Four themes emerged through thematic analysis. These included (a) the importance of therapeutic relationships; (b) reservations about the emphasis on medication; (c) limitations to interventions; and (d) the lack of focus/structure of interventions. Conclusions The use of systematic psychosocial interventions for people who hear voices is not well supported in the acute psychiatric settings the psychiatric nurses in the study worked in.

One-year randomized trial comparing virtual reality-assisted therapy to cognitive-behavioral therapy for patients with treatment-resistant schizophrenia

The gold-standard cognitive-behavioral therapy (CBT) for psychosis offers at best modest effects. With advances in technology, virtual reality (VR) therapies for auditory verbal hallucinations (AVH), such as AVATAR therapy (AT) and VR-assisted therapy (VRT), are amid a new wave of relational approaches that may heighten effects. Prior trials have shown greater effects of these therapies on AVH up to a 24-week follow-up. However, no trial has compared them to a recommended active treatment with a 1-year follow-up. We performed a pilot randomized comparative trial evaluating the short- and long-term efficacy of VRT over CBT for patients with treatment-resistant schizophrenia. Patients were randomized to VRT (n = 37) or CBT (n = 37). Clinical assessments were administered before and after each intervention and at follow-up periods up to 12 months. Between and within-group changes in psychiatric symptoms were assessed using linear mixed-effects models. Short-term findings showed that both interventions produced significant improvements in AVH severity and depressive symptoms. Although results did not show a statistically significant superiority of VRT over CBT for AVH, VRT did achieve larger effects particularly on overall AVH (d = 1.080 for VRT and d = 0.555 for CBT). Furthermore, results suggested a superiority of VRT over CBT on affective symptoms. VRT also showed significant results on persecutory beliefs and quality of life. Effects were maintained up to the 1-year follow-up. VRT highlights the future of patient-tailored approaches that may show benefits over generic CBT for voices. A fully powered single-blind randomized controlled trial comparing VRT to CBT is underway.

The therapeutic processes of avatar therapy: A content analysis of the dialogue between treatment-resistant patients with schizophrenia and their avatar

OBJECTIVE

Because the therapeutic processes of Avatar Therapy remain equivocal, the current study aims to further extend our previous findings by analysing the evolution of the avatars' and patients' speech and changes in patient responses as sessions progressed.

DESIGN

Eighteen patients with treatment-resistant schizophrenia were selected from two clinical trials on Avatar Therapy. Three coders analysed both the avatars' and patients' discourse during immersive therapy sessions using content analysis methods.

RESULTS

Our analyses enabled the categorization of the avatar discourse into confrontational techniques (e.g., provocation) and positive techniques (e.g., reinforcement). Patients responded to these utterances using coping mechanism or by expressing emotions, beliefs, self-perceptions or aspirations. Through identification of mutual changes in the interaction between the patient and their avatar, a shift was observed over the sessions from confrontation to a constructive dialogue. Assertiveness, emotional responses and prevention strategies seemed to be central to the therapeutic process, and these usually occur in response to positive techniques.

CONCLUSION

Investigating AT's therapeutic process may help to identify components to achieve positive outcomes and can enable the development of more effective treatments. Further studies should explore the association between these themes and therapeutic response to help predict which patients will better respond to Avatar Therapy.

A relationship of sorts: gender and auditory hallucinations in schizophrenia spectrum disorders

Voice hearing has been conceptualized as an interrelational framework, where the interaction between voice and voice hearer is reciprocal and resembles "real-life interpersonal interactions." Although gender influences social functioning in "real-life situations," little is known about respective effects of gender in the voice hearing experience. One hundred seventeen participants with a schizophrenia spectrum disorder took part in a semi-structured interview about the phenomenology of their voices and completed standardized self-rating questionnaires on their beliefs about their most dominant male and female voices and the power differentials in their respective voice-voice hearer interactions. Additionally, the voice hearers' individual masculine/feminine traits were recorded. Men heard significantly more male than female dominant voices, while the gender ratio of dominant voices was balanced in women. Although basic phenomenological characteristics of voices were similar in both genders, women showed greater amounts of distress caused by the voices and reported a persistence of voices for longer time periods. Command hallucinations that encouraged participants to harm others were predominantly male. Regarding voice appraisals, high levels of traits associated with masculinity (=instrumentality/agency) correlated with favorable voice appraisals and balanced power perceptions between voice and voice hearer. These positive effects seem to be more pronounced in women. The gender of both voice and voice hearer shapes the voice hearing experience in manifold ways. Due to possible favorable effects on clinical outcomes, therapeutic concepts that strengthen instrumental/agentic traits could be a feasible target for psychotherapeutic interventions in voice hearing, especially in women.

Relating between the voice and voice-hearer: Validation of a revised version of the Voice And You

Advancements in CBT for distressing voices have led to the development of understandings and the treatment of voice hearing within relational frameworks. In this study, we aim to validate and revise the Voice And You (VAY), one of the first measures that was developed to assess distressing relationships with voices. Data was pooled from 5 sources (n = 192) including the VAY and an interview-based assessment of voice-hearing. The VAY was subjected to confirmatory factor analysis and revised based on item loadings. Criterion validity was assessed by correlating the VAY with measures of voice-related distress and other voice characteristics from the Psychotic Symptom Rating Scales (PSYRATS) interview. For the original VAY, we found sufficient model fit for the voice-to-hearer relating factors (voice dominance and intrusiveness), but not for the hearer-to-voice relating factors (hearer dependence and distance). A revised version showed sufficient overall model-fit while retaining the level of criterion validity of the original scale. Thus, we derived a revised, valid, and parsimonious 14 item VAY (VAY-R) that provides a feasible tool to assess the interrelating between hearer and voice. Nevertheless, hearer-to-voice relating needs a more differentiated assessment of hearer relating styles that includes the possibility of actively engaging with the voice.

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.

Beliefs about voices in voice-hearers: the role of schema functioning

BACKGROUND

Evidence is emerging that beliefs about voices are influenced by broader schematic beliefs about the self and others. Similarly, studies indicate that the relationship an individual has with their voice may mirror wider patterns of relating observed in social relationships, which may be influenced by schematic beliefs.

AIMS

This study examined associations between beliefs about voices and self and other schemas. Furthermore, associations between schemas and the perceived relationship between the hearer and their predominant voice were explored.

METHOD

Forty-four voice-hearing participants were recruited across mental health services. Participants completed self-report measures of beliefs about voices, schema functioning, and relating between the hearer and their voice. Dimensions of voice experience, such as frequency and content, were assessed using a clinician-rated scale.

RESULTS

Beliefs about voices correlated with negative voice content and schemas. After controlling for negative voice content, schemas were estimated to predict between 1 and 17% of the variance in the six measured beliefs about voices; three of the associations reached statistical significance. Negative-self schema were the strongest predictors of beliefs about voices, whilst positive-self also showed potential relationships. Schemas also correlated with dimensions of relating between the hearer and their voice.

CONCLUSIONS

In line with previous research, this study provides evidence that schemas, particularly self-schema, may be important in the development of beliefs about voices. This study offers preliminary findings to suggest that schemas are also associated with the perceived relationship between the hearer and their voice.

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.

The auditory-verbal hallucinations of Welsh-English bilingual people

OBJECTIVES

Psychological models of voice-hearing propose that auditory-verbal hallucinations occur when inner speech is attributed to a source external to the self. Approximately half of the world's population is multilingual, and the extent to which they use a second language for inner speech depends on their experience and competency in it. Bilingualism therefore provides a natural window into the processes operating in auditory-verbal hallucinations, but no systematic study of voice-hearing in bilinguals has hitherto been conducted.

DESIGN

A mixed-methods observational study of psychiatric service users who hear voices and who are Welsh-English bilingual.

METHODS

Thirty-seven participants were interviewed about their history and use of Welsh and English and divided into three groups: those who learnt Welsh first (L1 Welsh), those who learnt English first (L1 English), and those who learnt the two languages simultaneously. Detailed phenomenological data were collected using The Mental Health Research Institute Unusual Perceptions Schedule.

RESULTS

Both qualitative and quantitative data indicated very considerable variation in the extent to which voices were in Welsh, English, or both, with some voice-hearers reporting that the predominant language of their voices had changed with time. There were modest but statistically significant associations between the predominant language of voices and age of language acquisition (late Welsh learners did not hear voices in Welsh), frequency of language use (more frequent use of Welsh was associated with more Welsh voices), and subjective language proficiency (proficiency in English was associated with a tendency to hear English voices).

CONCLUSIONS

Although this was a small study, it was the first of its kind. There is a need for more research on the implications of bilingualism for psychosis in particular and mental illness more generally. The results are broadly consistent with the hypothesis that hallucinated voices are misattributed inner speech.

PRACTITIONER POINTS

Assessments of people with mental health difficulties should routinely inquire whether they are multilingual and, if so, which language they prefer to use. People with mental health difficulties may have difficulty expressing complex issues and emotions in a second language, despite apparent fluency. When working with bilingual people who hear voices, mental health professionals should consider the language used by the voices when conducting assessments and proposing formulations.

Characterizing core beliefs in psychosis: a qualitative study

BACKGROUND

Cognitive behavioural treatments are recommended for people with psychosis. Core beliefs regarding the self and others are a key part of the models underpinning cognitive behavioural therapy but detailed understanding of these putative beliefs in people with psychosis are limited. A greater understanding of these mechanisms is necessary to improve and refine treatments.

AIMS

This study utilized a qualitative approach to explore core schematic beliefs in psychosis (strongly held positive and negative beliefs about the self and others) and their relation to hallucinations and delusions.

METHOD

Twenty individuals with psychosis participated in individual semi-structured interviews. Inductive thematic analysis was used to analyse the interviews.

RESULTS

Four emergent themes were identified: (i) the solidity and permanency of core beliefs, (ii) the causes and development of core beliefs, (iii) a synergistic relationship between core beliefs and symptoms, and (iv) core beliefs associated with images and their influence on psychotic symptoms.

CONCLUSIONS

This study provides new insights into the range and character of core beliefs in psychosis and provides important data to guide ongoing and future development of treatment approaches for psychosis.

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.

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.

Does mindfulness help people adapt to the experience of hearing voices?

Mindfulness-based interventions show promise in the treatment of psychotic symptoms. From a theoretical perspective, there may be several benefits of mindfulness for individuals who experience hearing voices. Related cross-sectional findings suggest mindfulness may protect against distress, disruption, negative beliefs, dysfunctional relational style and responding, and mood symptoms for individuals who hear voices. To extend on previous findings, this study aimed to identify whether mindful relating to voices predicted voice-related negative impacts (distress, disruption and resistance), when the influence of voice-topography and mood symptoms were controlled for. Overall, 62 participants with a psychotic disorder who had experienced hearing voices in the previous week were given the Southampton Mindfulness of Voices Questionnaire, Psychotic Symptom Rating Scales, Beliefs About Voices Questionnaire, Beck Depression Inventory-II, and Beck Anxiety Inventory. As predicted, greater mindfulness of voices predicted less voice-related distress and lower resistance to voices. Regression analyses revealed that when associated voice topography and mood symptoms were controlled for, mindful relating to voices explained a significant proportion of variance in voice-related distress and resistance. Conversely, mindfulness of voices did not significantly predict voice-related disruption. In the context of existing literature, these findings suggest further mindfulness-based protocols for persistent voices should be developed and trialled.

Exploration of the dialogue components in Avatar Therapy for schizophrenia patients with refractory auditory hallucinations: A content analysis

Auditory verbal hallucinations are hallmark symptoms of schizophrenia and are amongst the most disturbing symptoms of the disorder. Although not entirely understood, the relationship between the voice hearer and their voices has been shown to be an important treatment target. Understanding voice hearers' standpoints through qualitative analysis is central to apprehend a deeper comprehension of their experience and further explore the relevance of interpersonal interventions. Compared with other dialogical intervention, virtual reality-assisted therapy (Avatar Therapy) enables patients to be in a tangible relation with a representation of their persecutory voice. This novel therapy has shown favourable results, though the therapeutic processes remain equivocal. We consequently sought to begin by characterizing the main themes emerging during the therapy by exploring the hearer's discussion with their avatar. The therapy sessions of 12 of our referrals were transcribed, and the patients' responses were analysed using content analysis methods. Five themes emerged from data saturation: emotional responses to the voices, beliefs about voices and schizophrenia, self-perceptions, coping mechanisms, and aspirations. All patients had at least one element within each of these themes. Our analyses also enabled us to identify changes that were either verbalized by the patients or noted by the raters throughout therapy sessions. These findings are relevant as they allowed to identify key themes that are hypothesized to be related to therapeutic targets in a novel relational therapy using virtual reality. Future studies to further explore the processes implicated within Avatar Therapy are necessary.

Virtual reality therapy for refractory auditory verbal hallucinations in schizophrenia: A pilot clinical trial

Schizophrenia is a chronic and severe mental illness that poses significant challenges. While many pharmacological and psychosocial interventions are available, many treatment-resistant schizophrenia patients continue to suffer from persistent psychotic symptoms, notably auditory verbal hallucinations (AVH), which are highly disabling. This unmet clinical need requires new innovative treatment options. Recently, a psychological therapy using computerized technology has shown large therapeutic effects on AVH severity by enabling patients to engage in a dialogue with a computerized representation of their voices. These very promising results have been extended by our team using immersive virtual reality (VR). Our study was a 7-week phase-II, randomized, partial cross-over trial. Nineteen schizophrenia patients with refractory AVH were recruited and randomly allocated to either VR-assisted therapy (VRT) or treatment-as-usual (TAU). The group allocated to TAU consisted of antipsychotic treatment and usual meetings with clinicians. The TAU group then received a delayed 7weeks of VRT. A follow-up was ensured 3months after the last VRT therapy session. Changes in psychiatric symptoms, before and after TAU or VRT, were assessed using a linear mixed-effects model. Our findings showed that VRT produced significant improvements in AVH severity, depressive symptoms and quality of life that lasted at the 3-month follow-up period. Consistent with previous research, our results suggest that VRT might be efficacious in reducing AVH related distress. The therapeutic effects of VRT on the distress associated with the voices were particularly prominent (d=1.2). VRT is a highly novel and promising intervention for refractory AVH in schizophrenia.

Relating to the Speaker behind the Voice: What Is Changing?

We introduce therapeutic techniques that encourage voice hearers to view their voices as coming from intentional agents whose behavior may be dependent on how the voice hearer relates to and interacts with them. We suggest that this approach is effective because the communicative aspect of voice hearing might fruitfully be seen as explanatorily primitive, meaning that the agentive aspect, the auditory properties, and the intended meaning (interpretation) are all necessary parts of the experience, which contribute to the impact the experience has on the voice hearer. We examine the experiences of a patient who received Relating Therapy, and explore the kinds of changes that can result from this therapeutic approach.

Avatar Therapy for Persistent Auditory Verbal Hallucinations in an Ultra-Resistant Schizophrenia Patient: A Case Report

Effective treatment strategies for schizophrenia remain very challenging and many treatment-resistant patients will suffer from persistent auditory verbal hallucinations (AVH). While clozapine is the gold-standard medication for this complex population, many will not respond to this molecule. For these ultra-resistant patients, limited options are available. Cognitive-behavioral therapy (CBT) is the most widely used psychological intervention, though it offers modest effects. With the interpersonal dimension of AVH being recognized, Avatar Therapy (AT), a novel experiential treatment enabling patients to create an avatar of their persecutor and allowing them to gain control over their symptoms, was developed and tested. Results have shown significant improvements in AVH symptomatology. This paper details a case report showcasing the beneficial results of AT for even the most severe and symptomatic cases of schizophrenia. Mr. Smith has been afflicted with the persistency of all his voices for almost 20 years. To our knowledge, this patient tried almost all possible treatments with little efficacy. This case highlights the difficulty of finding an adequate treatment for ultra-resistant patients. Mr. Smith first followed CBT before initiating AT. With AT, he significantly improved in a way that was not observed with any other intervention and these improvements remained afterward. The severity of his positive symptoms as well as his depressive symptoms diminished, and his most distressing persecutory voice disappeared. He was able to regain a life. The effects of AT went well beyond the patient, the morale of the entire family improved. This ultra-resistant case suggests that AT may be a promising intervention for refractory AVH in schizophrenia.

The Meaning of Voices in Understanding and Treating Psychosis: Moving Towards Intervention Informed by Collaborative Formulation

From a medical perspective, hearing voices is perceived as a symptom of mental illness and their content as largely irrelevant. The effectiveness of antipsychotic medication has made it central to the treatment of psychosis. However pharmacological treatment alone is rarely sufficient for this disabling condition. This review examined the feasibility of formulating an understanding of the meaning of voices in psychosis to inform intervention. Examination of the literature demonstrated the need for a paradigm shift to a recovery model, drawing on biopsychosocial factors in formulating an understanding of the meaning of voices in the context of a person's life. Providing the opportunity to talk about their experiences may aid the development of an interpersonally coherent narrative representing opportunities for psychological growth. Findings have implications for treatment planning and assessment of outcome. Collaborative formulation regarding the subjective meaning of voices may aid in understanding their development and maintenance and guide intervention. Hearing voices with reduced negative effects on wellbeing and functioning may reduce distress and improve quality of life even in the presence of voices. CFT, CBT, Relating Therapy and Open Dialogue may be effective in applying these principles. Findings are limited by the lack of controlled studies. Further controlled studies and qualitative explorations of individual experiences are recommended.

Rethinking Social Cognition in Light of Psychosis: Reciprocal Implications for Cognition and Psychopathology

The positive symptoms of psychosis largely involve the experience of illusory social actors and yet our current measures of social cognition, at best, only weakly predict their presence. We review evidence to suggest that the range of current approaches in social cognition is not sufficient to explain the fundamentally social nature of these experiences. We argue that social agent representation is an important organising principle for understanding social cognition and that alterations in social agent representation may be a factor in the formation of delusions and hallucination in psychosis. We evaluate the feasibility of this approach in light of clinical and non-clinical studies, developmental research, cognitive anthropology and comparative psychology. We conclude with recommendations for empirical testing of specific hypotheses and how studies of social cognition could more fully capture the extent of social reasoning and experience in both psychosis and more prosaic mental states.

Relating Therapy for distressing auditory hallucinations: A pilot randomized controlled trial

Auditory hallucinations (AH) are a common and distressing experience and patients report distress reduction to be a priority. Relating Therapy adopts a symptom-specific and mechanism focused approach to the reduction of AH distress. We conducted this single-blind, pragmatic, parallel groups, superiority pilot RCT within a single mental health centre in the UK. Patients (18+years) with persistent and distressing AH, irrespective of diagnosis were randomly allocated to receive either Relating Therapy and Treatment-as-usual (RT) or Treatment as-usual alone (TAU). Assessment of outcome was completed pre-randomisation (T0), 16weeks post-randomisation (T1) and 36weeks post-randomisation (T2). The primary outcome was the 5-item Distress scale of the Psychotic Symptoms Rating Scale - Auditory Hallucinations (PSYRATS-AHRS) at T1. We randomly assigned 29 patients to receive RT (n=14) or TAU (n=15). Twenty-five patients (86%) provided complete datasets. Compared with TAU, RT led to reductions in AH distress in the large effect size range across T1 and T2. Our findings suggest that Relating Therapy might be effective for reducing AH distress. A larger, suitably powered phase 3 study is needed to provide a precise estimate of the effects of Relating Therapy for AH distress.

Stigma and need for care in individuals who hear voices

BACKGROUND

Voice hearing experiences, or auditory verbal hallucinations, occur in healthy individuals as well as in individuals who need clinical care, but news media depict voice hearing primarily as a symptom of mental illness, particularly schizophrenia.

AIMS

This article explores whether, and how, public perception of an exaggerated association between voice hearing and mental illness might influence individuals' need for clinical care.

METHOD

A narrative literature review was conducted, using relevant peer-reviewed research published in the English language.

RESULTS

Stigma may prevent disclosure of voice hearing experiences. Non-disclosure can prevent access to sources of normalizing information and lead to isolation, loss of social support and distress. Internalization of stigma and concomitantly decreased self-esteem could potentially affect features of voices such as perceived voice power, controllability, negativity and frequency, as well as distress. Increased distress may result in a decrease in functioning and increased need for clinical care.

CONCLUSION

The literature reviewed suggests that stigma has the potential to increase need for care through many interrelated pathways. However, the ability to draw definitive conclusions was constrained by the designs of the studies reviewed. Further research is needed to confirm the findings of this review.

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.

Establishing the "Fit" between the Patient and the Therapy: The Role of Patient Gender in Selecting Psychological Therapy for Distressing Voices

The experience of hearing distressing voices has recently attracted much attention in the literature on psychological therapies. A new “wave” of therapies is considering voice hearing experiences within a relational framework. However, such therapies may have limited impact if they do not precisely target key psychological variables within the voice hearing experience and/or ensure there is a “fit” between the profile of the hearer and the therapy (the so-called “What works for whom” debate). Gender is one aspect of both the voice and the hearer (and the interaction between the two) that may be influential when selecting an appropriate therapy, and is an issue that has thus far received little attention within the literature. The existing literature suggests that some differences in voice hearing experience are evident between the genders. Furthermore, studies exploring interpersonal relating in men and women more generally suggest differences within intimate relationships in terms of distancing and emotionality. The current study utilized data from four published studies to explore the extent to which these gender differences in social relating may extend to relating within the voice hearing experience. The findings suggest a role for gender as a variable that can be considered when identifying an appropriate psychological therapy for a given hearer.

The Representation of Agents in Auditory Verbal Hallucinations

Current models of auditory verbal hallucinations (AVHs) tend to focus on the mechanisms underlying their occurrence, but often fail to address the content of the auditory experience. In other words, they tend to ask why there are AVHs at all, instead of asking why, given that there are AVHs, they have the properties that they have. One such property, which has been largely overlooked and which we will focus on here, is why the voices are often experienced as coming from (or being the voices of) agents, and often specific, individualised agents. In this article, we argue not only that the representation of agents is important in accurately describing many cases of AVH, but also that deeper reflection on what is involved in the representation of agents has potentially vital consequences for our aetiological understanding of AVH, namely, for understanding how and why AVHs come about.

Auditory verbal hallucinations: Social, but how?

Auditory verbal hallucinations (AVH) are experiences of hearing voices in the absence of an external speaker. Standard explanatory models propose that AVH arise from misattributed verbal cognitions (i.e. inner speech), but provide little account of how heard voices often have a distinct persona and agency. Here we review the argument that AVH have important social and agent-like properties and consider how different neurocognitive approaches to AVH can account for these elements, focusing on inner speech, memory, and predictive processing. We then evaluate the possible role of separate social-cognitive processes in the development of AVH, before outlining three ways in which speech and language processes already involve socially important information, such as cues to interact with others. We propose that when these are taken into account, the social characteristics of AVH can be explained without an appeal to separate social-cognitive systems.

Auditory Verbal Hallucinations: can Beliefs about Voices Mediate the Relationship Patients establish with them and Negative Affect?

This study was designed to find out whether a person's relationship with his voices and the negative affect he suffers from are mediated by beliefs about the voices. Research done to date shows contradictory results (Sorrell, Hayward, & Meddings, 2010, Vaughan & Fowler, 2004). A cross-sectional study was done to study the associations among variables, and a multiple mediation model (Preacher & Hayes, 2008) in which the beliefs about voices were the mediating variables was tested. Sixty subjects who heard voices participated. The VAY (Hayward, Denney, Vaughan, & Fowler, 2008), BAVQ (Chadwick & Birchwood, 1995), BAI (Beck & Steer, 1993) and BDI-II (Beck, Steer & Brown, 1996) were given. We found a significant positive correlation between perception of voices as dominant and intrusive and maintaining a position of distance from them on one hand, and negative affect [anxiety (r = .57, p < .001; r = .40, p < .001; r = .34, p < .01 respectively) and depression (r = .58, p < .001; r = .37, p < .01; r = .38, p < .001 respectively)] on the other. We also found that beliefs of malevolence and omnipotence mediated between relating style and negative affect (anxiety and depression). The theoretical implications of the results and clinical implications of the mediating relationships found are discussed.

Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services.

Experiences of hearing voices: analysis of a novel phenomenological survey

BACKGROUND

Auditory hallucinations--or voices--are a common feature of many psychiatric disorders and are also experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the people who hear voices themselves.

METHODS

We made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged 16-84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks, hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used inductive thematic analysis to code the data and χ(2) tests to test additional associations of selected codes.

FINDINGS

Between Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the participants reported hearing literally auditory voices--70 (46%) individuals reported either thought-like or mixed experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were significantly associated with experiences of abusive or violent voices (p=0·024). Although fear, anxiety, depression, and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time (p=0·030), be internally located (p=0·010), and be conversational in nature (p=0·010).

INTERPRETATION

This study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities.

FUNDING

Wellcome Trust.

Relating therapy for voices (the R2V study): study protocol for a pilot randomized controlled trial

Background

Evidence exists for the effectiveness of cognitive behaviour therapy for psychosis with moderate effect sizes, but the evidence for cognitive behaviour therapy specifically for distressing voices is less convincing. An alternative symptom-based approach may be warranted and a body of literature has explored distressing voices from an interpersonal perspective. This literature has informed the development of relating therapy and findings from a case series suggested that this intervention was acceptable to hearers and therapists.

Methods/Design

An external pilot randomized controlled trial (RCT) comparing outcomes for 15 patients receiving 16 hours (weekly sessions of one hour) of relating therapy and their usual treatment with 15 patients receiving only their usual treatment. Participants will be assessed using questionnaires at baseline, 16 weeks (post-intervention), and 36 weeks (follow-up).

Discussion

Expected outcomes will include a refined study protocol and an estimate of the effect size to inform the sample size of a definitive RCT. If evidence from a fully powered RCT suggests that relating therapy is effective, the therapy will extend the range of evidence-based psychological therapies available to people who hear distressing voices.

Trial registration

Current Controlled Trials ISRCTN registration number 44114663. Registered on 13 June 2013.

Studying hallucinations within the NIMH RDoC framework

We explore how hallucinations might be studied within the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) framework, which asks investigators to step back from diagnoses based on symptoms and focus on basic dimensions of functioning. We start with a description of the objectives of the RDoC project and its domains and constructs. Because the RDoC initiative asks investigators to study phenomena across the wellness spectrum and different diagnoses, we address whether hallucinations experienced in nonclinical populations are the same as those experienced by people with psychotic diagnoses, and whether hallucinations studied in one clinical group can inform our understanding of the same phenomenon in another. We then discuss the phenomenology of hallucinations and how different RDoC domains might be relevant to their study. We end with a discussion of various challenges and potential next steps to advance the application of the RDoC approach to this area of research.

Psychological therapies for auditory hallucinations (voices): current status and key directions for future research

This report from the International Consortium on Hallucinations Research considers the current status and future directions in research on psychological therapies targeting auditory hallucinations (hearing voices). Therapy approaches have evolved from behavioral and coping-focused interventions, through formulation-driven interventions using methods from cognitive therapy, to a number of contemporary developments. Recent developments include the application of acceptance- and mindfulness-based approaches, and consolidation of methods for working with connections between voices and views of self, others, relationships and personal history. In this article, we discuss the development of therapies for voices and review the empirical findings. This review shows that psychological therapies are broadly effective for people with positive symptoms, but that more research is required to understand the specific application of therapies to voices. Six key research directions are identified: (1) moving beyond the focus on overall efficacy to understand specific therapeutic processes targeting voices, (2) better targeting psychological processes associated with voices such as trauma, cognitive mechanisms, and personal recovery, (3) more focused measurement of the intended outcomes of therapy, (4) understanding individual differences among voice hearers, (5) extending beyond a focus on voices and schizophrenia into other populations and sensory modalities, and (6) shaping interventions for service implementation.

Auditory verbal hallucinations in persons with and without a need for care

Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research.