Voice hearing in a biographical context: A model for formulating the relationship between voices and life history

The effect of trauma-focused therapy on voice-hearing: An experience sampling study

Trauma and post-traumatic stress are involved in the aetiology and maintenance of voice-hearing. It has been proposed that trauma-focused therapy (TFT) might affect voice-hearing, but previous studies are limited and remain undecided.

OBJECTIVES

We aimed to investigate the effect of TFT on voice-hearing in people with PTSD and psychosis using experience sampling method (ESM). A secondary aim was to explore how changes in voice-hearing are related to changes in PTSD.

DESIGN

This is an adjunct longitudinal ESM study of a sub-group of participants (N = 39) from a randomised controlled trial that compared TFT to a waiting-list control group.

METHODS

Voice-hearing participants filled in 10 daily voice-hearing-related questionnaires for six consecutive days at baseline and post-treatment at pseudo-random times during the day. PTSD symptom severity was assessed at baseline and post-treatment. Multilevel linear regression was used to test the effect of TFT on voice-hearing and to analyse the relationship between changes in voice-hearing and changes in PTSD.

RESULTS

The intention-to-treat analysis showed a significant interaction effect between time and treatment condition (p < .00001) with a small effect size (dppc2 = -0.27), indicating a larger decrease in voice-hearing in the TFT group than in the waiting-list control group. Also, a significant association was observed between changes in PTSD symptoms and changes in voice-hearing (p < .00001).

CONCLUSIONS

Our findings tentatively suggest that, even when voices are not targeted directly, TFT for PTSD can alleviate distressing voices.

Meaning in Psychosis: A Veteran's Critique of the Traumas of Racism, Sexual Violence, and Intersectional Oppression

This clinical case study presents the case of a Latina Veteran experiencing psychosis and draws on eclectic theoretical sources, including user/survivor scholarship, phenomenology, meaning-oriented cultural psychiatry & critical medical anthropology, and Frantz Fanon's insight on 'sociogeny,' to emphasize the importance of attending to the meaning within psychosis and to ground that meaning in a person's subjective-lived experience and social world. The process of exploring the meaning and critical significance of the narratives of people experiencing psychosis is important for developing empathy and connection, the fundamental prerequisite for developing trust and therapeutic rapport. It also helps us to recognize some of the relevant aspects of a person's lived experiences. To be understood, this Veteran's narratives must be contextualized in her past and ongoing life experience of racism, social hierarchy, and violence. Engaging in this way with her narratives pushes us towards a social etiology that conceptualizes psychosis as a complex response to life experience, and in her case, a critical embodiment of intersectional oppression.

How first-episode psychosis patients' subjective beliefs about their childhood trauma's causal effect provide support for potential schizophrenia subtypes

BACKGROUND

Childhood and adolescent trauma is a risk factor for developing psychosis-spectrum disorders. The current study aimed to assess how childhood trauma might predict psychosis symptomatology, and how patients' beliefs of whether trauma is the cause of psychosis might affect this association.

METHODS

Ninety-six first-episode psychosis patients were assessed for childhood traumatic experiences with the Brief Betrayal Trauma Survey, and for psychosis symptoms with the Positive and Negative Syndrome Scale.

RESULTS

Non-interpersonal trauma predicted higher positive symptoms, whereas more trauma domains experienced predicted lower negative symptoms. Almost half of the participants believed trauma to be related to psychosis, were 12 times more likely to reexperience trauma through psychosis, and had higher excitative and emotional symptoms. Non-interpersonal trauma also predicted higher positive symptoms in this group. Those who did not believe trauma to be the cause of psychosis had higher negative symptoms, and a negative dose-response was found for negative and disorganised symptoms, in which more trauma domains experienced predicted lower scores.

CONCLUSIONS

Results imply two traumagenic pathways to psychosis, one characterised by positive, excitative, and emotional symptoms, and one negative subtype, characterised by negative and disorganised symptoms. Clinical implications for how findings might contribute to better treatments are discussed.

Benefits of Hearing Voices Groups & Other Self-Help Groups for Voice Hearers: A Systematic Review

People who hear voices that others do not often rely on mainstream mental health services. Several alternatives to treatment have grown in popularity including "Hearing Voices Groups" and other self-help groups for voice hearers. The aim of this systematic review is to evaluate the current evidence relating to the use of Hearing Voices Groups (HVGs) and other self-help groups for voice hearers, and identify the benefits felt by those attending such groups. The following databases were searched for relevant academic articles: CINAHL; APA PsycArticles; APA PsycInfo; Social Sciences; SocINDEX; UK & Ireland Reference Centre and Medline, with 13 papers identified for inclusion. Participants reported several benefits of attending a HVG/self-help group, which reduced isolation, improved social and coping skills, and gave them a better understanding of the meaning and context of their voices. The groups also provide hope for the future and act as a catalyst for recovery. These study findings suggest that voice hearers find some benefits from attending HVGs/self-help groups. Evidence indicates that voice hearers can live meaningful lives and continue to hear voices once context and meaning to their voices become clear. HVGs/self-help groups provide a vital service to voice hearers, which they felt was not available within mainstream mental health services. If mental health providers gained a better understanding of the HVN, they may be able to integrate the values and ethos of the HVN into groups for voice hearers within mainstream mental health services or signpost voice hearers to these groups.

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.

A treatment protocol to guide the delivery of dialogical engagement with auditory hallucinations: Experience from the Talking With Voices pilot trial

PURPOSE

To present a treatment protocol for delivering Talking With Voices, a novel intervention for people with psychosis that involves dialogical engagement with auditory hallucinations.

METHOD

This paper presents a manualized approach to therapy employed in the Talking With Voices trial, a feasibility and acceptability randomized control trial of 50 adult participants. A rationale for following a treatment manual is provided, followed by the theoretical underpinnings of the intervention and its principles and values, including the main tenet that voices can often be understood as dissociated parts of the self which serve a protective function by indicating social-emotional vulnerabilities. The four therapy phases for improving the relationship between the voice-hearer and their voices are outlined: (1) engagement and psychoeducation, (2) creating a formulation, (3) dialoguing with voices, and (4) consolidating outcomes, including key milestones at each phase. Implementation issues are discussed, as well as recommendations for best practice and future research.

RESULTS

The Talking With Voices treatment protocol indicates that it is feasible to manualize a dissociation-based approach to support service users who are distressed by hearing voices.

CONCLUSION

For some individuals, it is possible to engage in productive dialogue with even extremely hostile or distressing voices. Developing coping strategies, creating a formulation, and ultimately establishing a dialogue with voices has the potential to improve the relationship between voice(s) and voice-hearer. Further research is now required to evaluate feasibility, acceptability, and efficacy.

PRACTITIONER POINTS

It is feasible to integrate a dissociation model of voice-hearing within a psychological intervention for people with psychosis. Combining psychosocial education, formulation and direct dialogue can be used to facilitate a more peaceful relationship between clients and their voices. Practitioners trained in other therapeutic modalities can draw on existing transferrable skills to dialogue with their clients' voices. The input of those with lived experience of mental health difficulties has an important role in guiding treatment design and delivery.

Interviewing anorexia: How do individuals given a diagnosis of anorexia nervosa experience Voice Dialogue with their eating disorder voice? A qualitative analysis

A proportion of individuals given an eating disorder diagnosis describe the experience of an eating disorder 'voice' (EDV). However, methods for working with this experience are currently lacking. Voice Dialogue (Stone & Stone, 1989) involves direct communication between a facilitator and parts of the self to increase awareness, understanding, and separation from inner voices. Adapted forms of this method have shown promise in working with voices in psychosis. This study aimed to explore the experience and acceptability of Voice Dialogue amongst individuals with anorexia nervosa who experience an EDV. Nine women participated in a semistructured interview following a single Voice Dialogue session. Interview transcripts were analysed using interpretative phenomenological analysis (IPA). Three overarching themes were identified as follows: (i) "separating from the EDV"; (ii) "better understanding of the EDV"; and (iii) "hopeful, motivated, and afraid of recovery". The majority of participants found Voice Dialogue acceptable and helpful for exploring their EDV. Whilst preliminary, the results suggest that Voice Dialogue has potential in terms of helping individuals establish a more constructive relationship with their EDV and motivating change. Further research is needed to build upon these findings. Implications for addressing the EDV using voice-focused interventions are explored.

Optimising AVATAR therapy for people who hear distressing voices: study protocol for the AVATAR2 multi-centre randomised controlled trial

BACKGROUND

AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucinations (henceforth 'voices'). A digital simulation (avatar) of the voice is created and used in a three-way dialogue between participant, avatar and therapist. To date, therapy has been delivered over 6 sessions, comprising an initial phase, focusing on standing up to a hostile avatar, and a second phase in which the avatar concedes and focus shifts to individualised treatment targets, including beliefs about voices. The first fully powered randomised trial found AVATAR therapy resulted in a rapid and substantial fall in voice frequency and associated distress that was superior to supportive counselling at 12 weeks. The main objective of this AVATAR2 trial is to test the efficacy of two forms of AVATAR therapy in reducing voice-related distress: AVATAR-brief (standardised focus on exposure, assertiveness and self-esteem) and AVATAR-extended (phase 1 mirroring AVATAR-brief augmented by a formulation-driven phase 2). Secondary objectives include the examination of additional voice, wellbeing and mood outcomes, the exploration of mediators and moderators of therapy response, and examining cost-effectiveness of both forms of therapy compared with usual treatment (TAU).

METHODS

This multi-site parallel group randomised controlled trial will independently randomise 345 individuals to receive AVATAR-brief (6 sessions) plus TAU or AVATAR-extended (12 sessions) plus TAU or TAU alone (1:1:1 allocation). Participants will be people with a diagnosis of schizophrenia spectrum and other psychotic disorders who have heard distressing voices for more than 6 months. The primary outcome is the PSYRATS Auditory Hallucinations Distress dimension score at 16 and 28 weeks, conducted by blinded assessors. Statistical analysis will follow the intention-to-treat principle and data will be analysed using linear mixed models. Mediation and moderation analyses using contemporary causal inference methods will be conducted as secondary analyses. Service costs will be calculated, and cost-effectiveness assessed in terms of quality-adjusted life years accrued.

DISCUSSION

This study will clarify optimal therapy delivery, test efficacy in a multi-site study and enable the testing of the AVATAR software platform, therapy training and provision in NHS settings.

TRIAL REGISTRATION

ISRCTN registry ISRCTN55682735 . Registered on 22 January 2020. The trial is funded by the Wellcome Trust (WT).

The Application of Maultsby’s Rational Behavior Therapy in Psychosis – A Case Report

The purpose of this paper is to present the applicability of Rational Behavior Therapy (RBT) for a patient with psychosis. RBT is a form of cognitive-behavioral therapy developed by an American psychiatrist, Maxie C. Maultsby, Jr. RBT teaches rational self-counseling to achieve emotive and behavioral goals, reduce distress and the symptoms of the disease, improve functioning, improve treatment adherence, and prevent relapse. The challenges in applying cognitive behavior therapy in psychosis are described. We report the case of a 17-year-old patient who had been recently diagnosed with schizophrenia according to ICD-10 criteria, presenting with recurrent psychotic symptoms and suicidal ideation. Over 1.5 years, the patient was treated in an outpatient setting with antipsychotic medications and, intermittently, with RBT-based psychotherapy (by the first author). The therapy process was interrupted periodically due to temporary improvements in the patient’s status, non-adherence, or relapses, including one episode requiring hospitalization. Nevertheless, the treatment eventually resulted in a long-lasting remission. We present examples of the RBT techniques used in this therapeutic process and highlight this treatment modality’s unique features which support patients utilizing rational self-counseling skills to become more independent in coping with their problems. We emphasize that patients with a mental illness like schizophrenia or bipolar disorder also suffer from learned emotional disturbances that are amenable to treatment with cognitive-behavior therapies like RBT. In conclusion, we submit that with its self-counseling properties, RBT offers non-intrusive ways of helping people experiencing psychotic symptoms as part of their diagnosis and in prodromal or non-diagnostic states.

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.

A qualitative study exploring how Practitioners within Early Intervention in Psychosis Services engage with Service Users' experiences of voice hearing?

WHAT IS KNOWN ON THE SUBJECT?: The experience of hearing distressing voices is commonly reported by service users with a diagnosis of first-episode psychosis, but their access to formal conversations about voices in the form of psychological therapies can be limited. Service users within Early Intervention in Psychosis (EIP) services can benefit from informal opportunities to talk about their voice hearing experiences. However, they can be reluctant to engage with these conversations. Little is known about the experiences of EIP practitioners as they try to engage service users in conversations about their voices. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Despite EIP Services specializing in the treatment of the symptoms of psychosis such as voice hearing, practitioners can still be reluctant to initiate and continue informal conversations about voices. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: EIP practitioners may benefit from the introduction of interview guides and brief interventions to assist them with the initiation and continuation of conversations about voices. ABSTRACT: Introduction Hearing voices is a common and distressing symptom of first-episode psychosis. Formal and informal conversations about voices are helpful, but service users within Early Intervention in Psychosis (EIP) Services can be reluctant to discuss their voice hearing experiences. There is currently no literature that explores the experiences of EIP practitioners as they try to facilitate conversations about distressing voices. Aim/Question A qualitative methodology was used to investigate how EIP practitioners work with service users who hear voices. Ten practitioners were interviewed, and interviews were analysed using template analysis. Results Two themes that offer novel insights are presented: "starting a conversation about voices" and "continuing the conversation about voices." Discussion Starting and continuing a conversation about voices was considered important but not all practitioners were confident in this respect. The initiation and continuation of these conversations may need to be systematically supported. Implications for practice To support the initiation of informal conversations, a standardized interview guide for voice hearing could be introduced and systematically utilized. The continuation of these conversations could be supported by practitioners being given the opportunity to receive training in and the opportunity to deliver brief symptom-specific therapies for distressing voices.

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.

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

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

Hearing voices: From the Experience Qualification to the Possibility of Care

Abstract This article aimed to analyze hearing voices experiences in patients of a Psychosocial Care Center. In this regard, ten people were interviewed. The qualitative method was used, with content analysis. Four categories were chosen: “origin” of voices, phenomenology of voices, coping strategies, and family support. Hallucinatory experiences have emerged in contexts of violence and isolation. Topographic variables of the voices indicate possibilities of understanding the phenomenon. The movement is a basic condition to deal with the experiences. Family support is key to cope with difficulties. It is necessary to qualify the auditory hallucination as a meaningful experience, which must be respected in any intervention that intends care.

Childhood maltreatment and treatment outcome in psychotic disorders: a systematic review and meta-analysis

OBJECTIVE

Childhood maltreatment (CM) plays an important role in the aetiology and course of psychotic disorders and is associated with characteristics that could be relevant for treatment. We aimed to conduct a systematic review and meta-analysis on the association between CM and treatment outcome in psychotic disorders.

METHODS

Treatment outcome was defined as change in psychotic symptoms or in social or occupational functioning between first and last reported measurement in the course of a pharmacological and/or psychological treatment.

RESULTS

Twelve treatment results from seven studies (636 patients, average treatment duration: 59.2 weeks) were included. CM was related to poorer treatment outcomes in psychotic disorders (OR = 1.51, 95% CI = [1.08, 2.10]). There is evidence that this association might increase with illness duration and increasing age and might be stronger in schizophrenia samples.

CONCLUSIONS

Childhood maltreatment is highly understudied with regard to treatment outcome in psychotic disorders. The need for more studies is emphasized by the fact that this meta-analysis reveals evidence for a poorer treatment response in patients with CM. If this association is confirmed, the identification of patients with CM and the consideration of associated clinical and biological conditions could contribute to improve treatment outcome in psychotic disorders.

Compassion Focused Approaches to Working With Distressing Voices

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

Engines of alternative objectivity: Re-articulating the nature and value of participatory mental health organisations with the Hearing Voices Movement and Stepping Out Theatre Company

Through two case studies, the Hearing Voices Movement and Stepping Out Theatre Company, we demonstrate how successful participatory organisations can be seen as 'engines of alternative objectivity' rather than as the subjective other to objective, biomedical science. With the term 'alternative objectivity', we point to collectivisations of experience that are different to biomedical science but are nonetheless forms of objectivity. Taking inspiration from feminist theory, science studies and sociology of culture, we argue that participatory mental health organisations generate their own forms of objectivity through novel modes of collectivising experience. The Hearing Voices Movement cultivates an 'activist science' that generates an alternative objective knowledge through a commitment to experimentation, controlling, testing, recording and sharing experience. Stepping Out distinguishes itself from drama therapy by cultivating an alternative objective culture through its embrace of high production values, material culture, aesthetic standards. A crucial aspect of participatory practice is overcoming alienation, enabling people to get outside of themselves, encounter material worlds and join forces with others.

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.

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

BACKGROUND

A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.

METHODS

We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790.

FINDINGS

Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy.

INTERPRETATION

To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.

FUNDING

Wellcome Trust.

The hearing voices network: initial lessons and future directions for mental health professionals and Systems of Care

For more than two decades, the Hearing Voices Network (HVN) has provided alternative approaches to supporting voice hearers, and an emerging body of research is now confirming their value. HVN approaches present unique opportunities and challenges for mental health professionals and systems of care that work with individuals who hear voices. An overview of the HVN is presented, including its history, principles and approaches. HVN approaches are compared and contrasted with traditional mental health treatments. HVN's potential contribution to the transformation of mental health care is discussed. Directions for future research are presented.

The PCL as a brief screen for posttraumatic stress disorder within schizophrenia

OBJECTIVES

To assess the utility of using the posttraumatic checklist (PCL) as a screening measure for identifying posttraumatic stress disorder (PTSD) in individuals diagnosed with a psychotic disorder.

METHODS

The PCL was administered to 165 participants as part of a clinical trial. Those scoring 44 or above on the PCL underwent further assessment using the clinician administered PTSD scale (CAPS).

RESULTS

Overall 18.2% of the sample exhibited a diagnostic level of PTSD symptoms, as indicated by the CAPS assessment. Only 29.7% of those who scored above the PCL threshold were diagnostic of PTSD.

CONCLUSIONS

The use of PCL for identifying PTSD within this population is not recommended.

Listening and Hearing: A Voice Hearer's Invitation into Relationship

Although historically overlooked, empirical links between trauma and psychosis have received growing attention over the past decade. Increasingly, clinical researchers have also zeroed in on the role that distressing or traumatic life events play in the psychosocial formation and maintenance of psychosis. This paper re-locates anomalous experiences in their human contexts, and asks that clinicians and researchers engage with these contexts. The author shares a first person account of her experience changing her relationships with dominance in order to reclaim and accept her human being-ness, a reorientation supported by her involvement in the world hearing voices network movement and community. She calls for mental health systems, providers, and researchers to collaborate with the persons at the center of their work—to dare to listen, hear, and connect for mutual learning, healing, and wholeness. The article concludes with recommendations and a rallying call for services to be made more inclusive and to re-center in meaningful collaboration with people with lived experience. More comprehensive, meaningful, and accountable practices can be co-created when people are met equally as human subjects, both responsible and accountable for change.

Listening to the Voices People Hear: Auditory Hallucinations Beyond a Diagnostic Framework

While voice hearing (auditory verbal hallucinations) is closely allied with psychosis/schizophrenia, it is well-established that the experience is reported by individuals with nonpsychotic diagnoses, as well as those with no history of psychiatric contact. The phenomenological similarities in voice hearing within these different populations, as well as increased recognition of associations between adversity exposure and voice presence/content, have helped strengthened the contention that voice hearing may be more reliably associated with psychosocial variables per se rather than specific clinical diagnoses. Evidence is examined for understanding voice hearing as a psychological response to environmental stressors, and the implications of this for clinical practice. Consideration is also given to the impact of the International Hearing Voices Movement, an influential survivor-led initiative that promotes person-centered, nondiagnostic approaches to the voice-hearing experience.

Childhood adversity and psychosis: generalised or specific effects?

BACKGROUND

This study examines relationships between childhood adversity and the presence of characteristic symptoms of schizophrenia. It was hypothesised that total adversity exposures would be significantly higher in individuals exhibiting these symptoms relative to patients without. Recent proposals that differential associations exist between specific psychotic symptoms and specific adversities was also tested, namely: sexual abuse and hallucinations, physical abuse and delusions, and fostering/adoption and delusions.

METHOD

Data were collected through auditing 251 randomly selected medical records, drawn from adult patients in New Zealand community mental health centres. Information was extracted on presence and subtype of psychotic symptoms and exposure to ten types of childhood adversity, including five types of abuse and neglect.

RESULTS

Adversity exposure was significantly higher in patients experiencing hallucinations in general, voice hearing, command hallucinations, visions, delusions in general, paranoid delusions and negative symptoms than in patients without these symptoms. There was no difference in adversity exposure in patients with and without tactile/olfactory hallucinations, grandiose delusions or thought disorder. Indication of a dose-response relationship was detected, in that total number of adversities significantly predicted total number of psychotic symptoms. Although fostering/adoption was associated with paranoid delusions, the hypothesised specificity between sexual abuse and hallucinations, and physical abuse and delusions, was not found. The two adversities showing the largest number of associations with psychotic symptoms were poverty and being fostered/adopted.

CONCLUSIONS

The current data are consistent with a model of global and cumulative adversity, in which multiple exposures may intensify psychosis risk beyond the impact of single events. Implications for clinical intervention are discussed.

Experiences of continued presence: On the practical consequences of 'hallucinations' in bereavement

OBJECTIVES

We document the properties of experiences of continued presence (ECPs) helping to resolve controversies about their significance.

METHOD

We used qualitative methods in data collection and analysis. This enabled us to document the properties of ECPs. Narrative biographic interviews were carried out with 17 bereaved informants, and conversation analysis was used to identify the sources of meaning and functions of these experiences.

RESULTS

Our informants heard voices of the deceased, saw their images, felt their touch, and sometimes felt their presence unspecified in any of the senses. Analysis revealed that ECPs were meaningfully connected to the immediate environments in which they happened but also to the personal histories of the bereaved. The narratives reveal helpful and destructive potentials of these experiences. In all cases, the functions relied on the relationship with the deceased.

CONCLUSIONS

The authors warn against oversimplification of ECPs, as significantly contrasting practical consequences commonly occurred within as well as between cases. The findings support the use of talking therapies based on personal meanings to help those disturbed by their experiences of presence.

PRACTITIONER POINTS

Practitioners should not assume that ECPs are signs of pathology - often they have healing consequences. Where ECPs cause distress, the problem is likely to concern relationship difficulties with the deceased. Therapists can help clients with distressing ECPs by working on the relationship with the deceased.

Bringing the "self" into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of "self" (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

The typology and function of private speech in a young man with intellectual disabilities: An empirical case study

A naturalistic observational single case study was carried out to investigate the form and function of private speech (PS) in a young man with Dandy-Walker variant syndrome and trisomy 22. Video recordings were observed, transcribed and coded to identify all combinations of type and form of PS. Through comparison between theories of PS and the results, five putative functions were identified in this case. In contrast to the predominant theoretical models of inner and PS, it is proposed that PS cannot necessarily be reduced to a single functional definition.

The effect of lifetime adversities on resistance to antipsychotic treatment in schizophrenia patients

AIM

The aim of this study is to examine whether there is an association between cumulative life adversities and treatment-resistant schizophrenia.

METHODS

We recruited 186 participants diagnosed with schizophrenia spectrum disorders. Adverse life-events were assessed using the Stressful Life Events Screening Questionnaire (SLESQ) and the Childhood Trauma Questionnaire (CTQ). Treatment resistant status was identified using the criteria of the American Psychiatric Association for refractory schizophrenia. We performed a multiple logistic regression model, including life adversities, to predict the treatment resistant status controlling for confounding variables.

RESULTS

Forty two percent of the patients were found to be treatment resistant (n=78) and 58% were non-treatment resistant (n=108). The treatment resistant group had higher score on both SLESQ and CTQ (4.5±3.3 and 54.7±19.7) than the non-treatment resistant group (2.5±2.3 and 47.7±17.5) and the difference between the two groups was significant for both SLESQ (p<0.001) and CTQ (p=0.011). After adjustment for demographic variables and previously reported risk factors of treatment resistance, the association remained significant for SLESQ (OR=1.20, 95% CI 1.05-1.38; p=0.009) but not for CTQ (p=0.13).

DISCUSSION

The results suggest that cumulative lifetime adversities could have an independent effect on the resistance to treatment in schizophrenia spectrum disorders. Routine assessment of trauma exposures and an individualized bio-psycho-social formulation is necessary for a personalized treatment.

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.

The voice-hearer

BACKGROUND

For 25 years, the international Hearing Voices Movement and the U.K. Hearing Voices Network have campaigned to improve the lives of people who hear voices. In doing so, they have introduced a new term into the mental health lexicon: "the voice-hearer."

AIMS

This article offers a "thick description" of the figure of "the voice-hearer."

METHOD

A selection of prominent texts (life narratives, research papers, videos and blogs), the majority produced by people active in the Hearing Voices or consumer/survivor/ex-patient movements, were analysed from an interdisciplinary medical humanities perspective.

RESULTS

"The voice-hearer" (i) asserts voice-hearing as a meaningful experience, (ii) challenges psychiatric authority and (iii) builds identity through sharing life narrative. While technically accurate, the definition of "the voice-hearer" as simply "a person who has experienced voice-hearing or auditory verbal hallucinations" fails to acknowledge that this is a complex, politically resonant and value-laden identity.

CONCLUSIONS

The figure of "the voice-hearer" comes into being through a specific set of narrative practices as an "expert by experience" who challenges the authority and diagnostic categories of mainstream psychiatry, especially the category of "schizophrenia."

A new phenomenological survey of auditory hallucinations: evidence for subtypes and implications for theory and practice

A comprehensive understanding of the phenomenology of auditory hallucinations (AHs) is essential for developing accurate models of their causes. Yet, only 1 detailed study of the phenomenology of AHs with a sample size of N ≥ 100 has been published. The potential for overreliance on these findings, coupled with a lack of phenomenological research into many aspects of AHs relevant to contemporary neurocognitive models and the proposed (but largely untested) existence of AH subtypes, necessitates further research in this area. We undertook the most comprehensive phenomenological study of AHs to date in a psychiatric population (N = 199; 81% people diagnosed with schizophrenia), using a structured interview schedule. Previous phenomenological findings were only partially replicated. New findings included that 39% of participants reported that their voices seemed in some way to be replays of memories of previous conversations they had experienced; 45% reported that the general theme or content of what the voices said was always the same; and 55% said new voices had the same content/theme as previous voices. Cluster analysis, by variable, suggested the existence of 4 AH subtypes. We propose that there are likely to be different neurocognitive processes underpinning these experiences, necessitating revised AH models.

Spirituality and hearing voices: considering the relation

For millennia, some people have heard voices that others cannot hear. These have been variously understood as medical, psychological and spiritual phenomena. In this article we consider the specific role of spirituality in voice-hearing in two ways. First, we examine how spirituality may help or hinder people who hear voices. Benefits are suggested to include offering an alternative meaning to the experience which can give more control and comfort, enabling the development of specific coping strategies, increasing social support, and encouraging forgiveness. Potential drawbacks are noted to include increased distress and reduced control resulting from placing frightening or coercive constructions on voices, social isolation, the development of dysfunctional beliefs, and missed/delayed opportunities for successful mental health interventions. After examining problems surrounding classifying voices as either spiritual or psychotic, we move beyond an essentialist position to examine how such a classification is likely to be fluid, and how a given voice may move between these designations. We also highlight tensions between modernist and postmodernist approaches to voice-hearing.

Hear today, not gone tomorrow? An exploratory longitudinal study of auditory verbal hallucinations (hearing voices)

BACKGROUND

Despite an increasing volume of cross-sectional work on auditory verbal hallucinations (hearing voices), there remains a paucity of work on how the experience may change over time.

AIMS

The first aim of this study was to attempt replication of a previous finding that beliefs about voices are enduring and stable, irrespective of changes in the severity of voices, and do not change without a specific intervention. The second aim was to examine whether voice-hearers' interrelations with their voices change over time, without a specific intervention.

METHOD

A 12-month longitudinal examination of these aspects of voices was undertaken with hearers in routine clinical treatment (N = 18).

RESULTS

We found beliefs about voices' omnipotence and malevolence were stable over a 12-month period, as were styles of interrelating between voice and hearer, despite trends towards reductions in voice-related distress and disruption. However, there was a trend for beliefs about the benevolence of voices to decrease over time.

CONCLUSIONS

Styles of interrelating between voice and hearer appear relatively stable and enduring, as are beliefs about the voices' malevolent intent and power. Although there was some evidence that beliefs about benevolence may reduce over time, the reasons for this were not clear. Our exploratory study was limited by only being powered to detect large effect sizes. Implications for clinical practice and future research are discussed.

Engaging with voices: rethinking the clinical treatment of psychosis

Although the hearing voices movement (HVM) has yet to take root in the US to the extent it has in the UK (and parts of Australia and Europe), recent publications and events, including a keynote presentation by UK hearing voices trainer Ron Coleman at the 2012 Annual NAMI convention and a TED 2013 talk in Los Angeles by British voice hearer and psychologist Eleanor Longden, suggest that the tide is starting to turn (Arenella, 2012; Grantham, 2012; Thomas, 2012). At its core, the HVM emphasizes a few basic, but important, points: that antipsychotic pharmacotherapy and various forms of psychotherapy that aim to suppress psychotic experiences are often--for too many people--ineffective or insufficient; that voices and other extreme experiences and beliefs carry important messages that need to be explored rather than silenced, and that voices themselves are often less of the problem than the difficulties individuals have in coping and negotiating with them (Corstens, Escher, & Romme, 2008; Longden, Corstens, Escher, & Romme, 2012; Place, Foxcroft, & Shaw, 2011).