Emerging perspectives from the hearing voices movement: implications for research and practice

Investigating AVHs narratives through text analysis: the proposal of Dialogic Science for tackling stigmatization

BACKGROUND

Auditory verbal hallucinations (AVHs) are a significant symptom of various psychological conditions, often stigmatized and misunderstood. Moving beyond traditional psychological, psychotherapeutic and psychiatric approaches, recent research shifts focus on understanding AVHs through community perspectives and the resulting stigmatization. This research approach is crucial for better support and understanding of AVHs, however it still suffers from the lack of a rigorous and shared methodology for studying and reducing stigma.

METHODS

Our study, part of the Italian "PsicoVoice" project, aims to investigate community discourses on AVHs, in order to observe whether and to what extent they are drivers of stigmatisation processes. Engaging 268 participants with direct (hearers) and indirect (such as relatives and professionals) experiences of AVHs, the research analyzes a corpus of 54,320 instances using MADIT: a text analysis methodology which is both qualitative and quantitative. MADIT allows for an innovative examination of the rhetorical-argumentative structures within narratives, producing an index for measuring the narratives' practical impact on people' interactions around AVHs.

RESULTS

The analysis revealed that the overall community discourses are predominantly shaped by absolute and personal belief-driven modalities. This way of conveying sense, even with non-necessarily-judgmental words, contributes to a stigmatizing environment for individuals with AVHs, cementing a static representation dominated by personal opinions and reducing the potential for more nuanced, diverse interactions about AVHs.

CONCLUSION

The study's findings underscore the importance of addressing the narrative structures within community discourses. By intervening in these narratives, there is potential to shift towards a less stigmatizing social construction of AVHs. Thus, the article concludes using the results to provide some insights on how to generate these interventions. This approach could significantly impact how communities understand and interact with individuals experiencing AVHs, promoting more inclusive and supportive environments and interventions.

'Sometimes You Have No Choice but to Give Them Medication': Experiences of Nurses Caring for People With Auditory Hallucinations in an Acute Unit

The aim of this study was to explore psychiatric nurse's experiences of caring for people with auditory hallucinations in an acute unit. A qualitative study was conducted using thematic analysis. The study involved semi-structured interviews with 18 acute unit nurses all of whom provided interventions to patients with auditory hallucinations. Overall, participants identified their role in the management of risk within an acute unit, the importance of their therapeutic role and a perceived over-reliance on medication administration as a primary nursing intervention. These findings thus demonstrate the personal and professional conflict that nurses face when working in an acute unit with patients who experience auditory hallucinations. Nurses are in a prime position to provide effective interventions and assistance for people with auditory hallucinations in an acute unit. The findings of this study indicate that mental health nurses may require additional support and education to provide care in a truly recovery-based manner, with training in specific interventions and engagement skills for people who hear voices. Due to an unpredictable environment and sometimes high-risk workplace, nurses may also benefit from organisational assistance in this area.

Neither saintly nor psychotic: a narrative systematic review of the evolving Western perception of voice hearing

We present a social-historical perspective on the evolution of the voice-hearing phenomenon in Western society. Based upon a systematic search from a selection of nine databases, we trace the way hearing voices has been understood throughout the ages. Originally, hearing voices was considered a gifted talent for accessing the divine, but the progressive influence of monotheistic religion gradually condemned the practice to social marginalization. Later, the medical and psychiatric professions of secular society were instrumental in attaching stigma to both voice hearers and the phenomenon itself, thereby reinforcing social exclusion. More recently, the re-integration of voice hearers into the community by health authorities in various countries appears to have provided a new, socially acceptable setting for the phenomenon.

Group Cohesion and Necessary Adaptations in Online Hearing Voices Peer Support Groups: Qualitative Study With Group Facilitators

BACKGROUND

Face-to-face hearing voices peer support groups (HVGs), a survivor-led initiative that enables individuals who hear voices to engage with the support of peers, have a long-standing history in community settings. HVGs are premised on the notion that forming authentic, mutual relationships enables the exploration of one's voice hearing experiences and, in turn, reduces subjective distress. As such, group cohesion is assumed to be a central mechanism of change in HVGs. The rise of digital mental health support, coupled with the COVID-19 pandemic, has resulted in many HVGs adapting to online delivery. However, to date no studies have examined the implementation of these online groups and the adaptations necessary to foster cohesion.

OBJECTIVE

This study aims to understand the experience of group cohesion among HVG facilitators in online groups compared with face-to-face groups. Specifically, we examined the ways in which the medium through which groups run (online or face-to-face) impacts group cohesion and how facilitators adapted HVGs to foster group cohesion online.

METHODS

Semistructured qualitative interviews were conducted with 11 facilitators with varied experience of facilitating online and face-to-face HVGs. Data were analyzed using reflexive thematic analysis.

RESULTS

The findings are organized into 3 themes and associated subthemes: nonverbal challenges to cohesion (lack of differentiation, transitional space, inability to see the whole picture, and expressions of empathy); discursive challenges to cohesion (topic-based conversation and depth of disclosure); and necessary adaptations for online groups (fostering shared experience and using the unique context to demonstrate investment in others). Despite challenges in both the setting and content of online groups, facilitators felt that group cohesion was still possible to achieve online but that it had to be facilitated intentionally.

CONCLUSIONS

This study is the first to specifically investigate group cohesion in online HVGs. Participants noted numerous challenges to group cohesion when adapting groups to run online, including the unnaturally linear narrative flow of dialogue in online settings; lack of transitional spaces, and associated small talk before and after the session; ease of disengagement online; inhibited sharing; and absence of shared physical presence online. Although these challenges were significant, facilitators nevertheless emphasized that the benefits provided by the accessibility of online groups outweighed these challenges. Necessary adaptations for cultivating group cohesion online are outlined and include capitalizing on moments of humor and spontaneity, using group activities, encouraging information sharing between participants using the chat and screen-sharing features, and using objects from participants' environments to gain deeper insight into their subjective worlds.

Assessment of Voice Content for Voice Hearers: Psychometric Evaluation of the Perth Voice Content Questionnaire

The experience of hearing voices is common to an estimated 7% of the general population, with the presence of negative content being the best predictor of whether individuals will require clinical support. Whilst largely neglected in the literature to date, there are calls to consider the significance of voice content for reducing voice-related distress. However, no quantitative and comprehensive measure of voice content with suitability for research and clinical use exists. This pilot study aimed to demonstrate preliminary psychometric properties of a newly developed measure, the Perth Voice Content Questionnaire (PVCQ), designed to measure the intensity and themes of positively and negatively valenced voice content, primarily of the dominant voice. The PVCQ and measures of voice severity and related beliefs were completed by 47 voice-hearing participants. The measure was found to be internally consistent, loaded onto two distinct factors of positive and negative content, and these factors were associated with voice-related distress and negative beliefs about voices and positive beliefs about voices, respectively, indicating good validity. The PVCQ offers the first self-report measure of voice content, with preliminary psychometric properties indicating its suitability for clinical and research use.

Representation of Voice Hearing Groups by French Mental Health Professionals

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

Can computational models help elucidate the link between complex trauma and hallucinations?

Recently, a number of predictive coding models have been proposed to account for post-traumatic stress disorder (PTSD)'s symptomatology, including intrusions, flashbacks and hallucinations. These models were usually developed to account for traditional/type-1 PTSD. We here discuss whether these models also apply or can be translated to the case of complex/type-2 PTSD and childhood trauma (cPTSD). The distinction between PTSD and cPTSD is important because the disorders differ in terms of symptomatology and potential mechanisms, how they relate to developmental stages, but also in terms of illness trajectory and treatment. Models of complex trauma could give us insights on hallucinations in physiological/pathological conditions or more generally on the development of intrusive experiences across diagnostic classes.

Trauma therapies for psychosis: A state-of-the-art review

BACKGROUND

Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis.

METHOD

This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis.

RESULTS

We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies.

CONCLUSION

We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.

A pilot trial examining the effects of veteran voices and visions, an adaptation of hearing voices groups for a large public health system in the United States

BACKGROUND

The Hearing Voices Approach, a community-based peer-led support group model, is generating interest as a novel way to engage with psychosis. Hearing Voices (HV) groups are run by peers, 'experts-by-experience', and emphasize group ownership and community-building rather than adherence to a therapist-led, predetermined structure. Diverse beliefs about experiences are respected and viewed as potentially meaningful. Groups work within each individual's explanatory framework to reframe understandings.

AIMS

This paper describes the effects of participation in Veteran Voices and Visions (VVV) groups, an adaptation of the HV approach, co-led by clinicians and Veteran peer support specialists, adapted for Veterans who have experienced psychosis and receive care at the VA, a large public health system in the United States.

METHOD

This mixed methods pilot study has a convergent parallel design, integrating quantitative and qualitative data from participants in pre-intervention and post-intervention assessments.

RESULTS

Over 16 weeks, quantitative analysis showed a statistically significant reduction in distress, due to auditory hallucinations, as measured by the Psychotic Symptom Rating Scales (PSYRATS). The Beliefs about Voices Questionnaire- Revised (BAVQ-R) results showed a reduction in malevolence and omnipotence and an increase in benevolence related to auditory hallucinations, but no change in resistance. Engagement showed a trend-level reduction. Qualitative data from midpoint (Week 8) and endpoint (Week 16) interviews revealed several perceived benefits from groups: 1) normalization and camaraderie, 2) increased hope and confidence, 3) self-understanding and reframing of experiences, and 4) building relationships outside of groups. Overall, VVV groups reduced distress due to voices, negative beliefs about voices, and perceived power of voices.

CONCLUSIONS

Study findings contribute to a growing body of literature indicating HV groups support those who have experienced psychosis by reducing social isolation and fostering community, which may facilitate social integration. Overall, our findings highlight the potential benefits of adapting HV groups to health systems.

Intersections of phenomenology, voice beliefs and distress in bipolar disorder: a comparison with schizophrenia

BACKGROUND

Auditory verbal hallucinations (AVH), or voice-hearing, can be a prominent symptom during fluctuating mood states in bipolar disorder (BD).

AIMS

The current study aimed to: (i) compare AVH-related distress in BD relative to schizophrenia (SCZ), (ii) examine correlations between phenomenology and voice beliefs across each group, and (iii) explore how voice beliefs may uniquely contribute to distress in BD and SCZ.

METHOD

Participants were recruited from two international sites in Australia (BD=31; SCZ=50) and the UK (BD=17). Basic demographic-clinical information was collected, and mood symptoms were assessed. To document AVH characteristics, a 4-factor model of the Psychotic Symptoms Rating Scale and the Beliefs about Voices Questionnaire-Revised were used. Statistical analyses consisted of group-wise comparisons, Pearson's correlations and multiple hierarchical regressions.

RESULTS

It was found that AVH-related distress was not significantly higher in BD than SCZ, but those with BD made significantly more internal attributions for their voices. In the BD group, AVH-related distress was significantly positively correlated with malevolence, omnipotence and resistance, However, only resistance, alongside mania and depressive symptoms, significantly contributed to AVH-related distress in BD.

DISCUSSION

Our findings have several clinical implications, including identification of voice resistance as a potential therapeutic target to prioritise in BD. Factoring in the influence of mood symptoms on AVH-related distress as well as adopting more acceptance-oriented therapies may also be of benefit.

Voice hearers' explanations of trauma-related voices and processes of change throughout imagery rescripting: A qualitative exploration

OBJECTIVES

Post-traumatic stress is common among people who hear voices (auditory verbal hallucinations), many of whom hear trauma-related voices, whereby voice content is related to past trauma. Preliminary evidence suggests that imagery rescripting (ImRs) may more effectively reduce post-traumatic stress and voices compared to treatments that are based on existing models of PTSD or positive symptoms. No known studies have explored the potential maintaining factors of trauma-related voices in relation to ImRs. We aimed to uncover insights into the factors that maintain trauma-related voices and how ImRs may influence such factors by exploring voice hearers' explanations of voices and experiences of change throughout ImRs.

DESIGN

Thematic analytical methodology was used due to the study's critical epistemological framework.

METHODS

Semi-structured interviews explored relationships between trauma and voices, and experiences of change and stability throughout ImRs in a transdiagnostic sample (N = 10) who underwent 10-18 weekly ImRs sessions. Thematic analysis was used to develop themes.

RESULTS

Two themes captured explanations of voices, which suggested voices may have counterproductive protective functions. Three themes captured psychological experiences during ImRs, which reflected concepts such as freedom to experience emotions, and experiences of justice, closure and grieving. Three themes described the outcomes of ImRs, reflecting concepts such as increased confidence, coping, perceived safety and voices becoming less powerful.

CONCLUSIONS

Trauma-related voices may have underlying protective functions and ImRs may support emotional expression, adaptive trauma re-appraisals and improve self-worth and coping self-efficacy. These change processes may have clinical implications in ImRs and other treatments for trauma-affected voice hearers.

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.

When therapists talk to voices: Perspectives from service-users who experience auditory hallucinations

PURPOSE

The purpose of the study was to investigate service-users' experiences of a therapist engaging with their voices (auditory hallucinations) using psychological formulation and direct dialogue.

METHOD

A nested qualitative study was conducted within a randomised controlled trial of a novel intervention for supporting voice hearers with a diagnosis of psychosis (Talking With Voices: TwV). Of 24 participants allocated to therapy, 13 (54%) consented to a semi-structured, in-depth interview which was audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

Participants described their experiences of using the intervention to improve the relationship between themselves and their voice(s). The findings are organised within three themes and associated subthemes: (1) A desire for suitable help (Motivation to reduce voice-related distress, Limitation of other treatment options); (2) Engaging with voices (Challenges, Support and safety, Exploration and revelation); and (3) Contemplating the future (The aftermath of adversity, Living well with voices, Resources for moving forward).

CONCLUSION

Despite the emotional challenges of the work, many participants experienced tangible gains in the ways they related to their voices post-intervention. For those who responded well, the development of safety strategies, including a strong therapeutic alliance, could facilitate a basis for developing new insights about the origin/nature of the voices which could then be applied in constructive ways. Further research is needed to understand which client characteristics indicate suitability for TwV as opposed to relational therapies that require less direct engagement with voices and/or the psychosocial conflicts with which they may be associated.

Strategies for the Management of Voices Shared in a Brazilian Hearing Voices Group

Hearing Voices peer support groups allow people to construct understandings of their voices. The groups focus on supporting voice hearers in reducing distress associated with voices through an array of strategies. This study sought to describe the voice management strategies shared in a hearing voices peer support group within a Brazilian public mental health service. In this qualitative study we recorded 10 group meetings. Transcripts were coded and analyzed using thematic analysis. The findings indicated five themes, described as: (1) strategies used to avoid distressing experiences; (2) strategies for managing the voices; (3) strategies for seeking social support; (4) strategies for creating a sense of belonging in the community; and (5) strategies related to spirituality and religiosity. These strategies appear to be essential in helping voice hearers feel less alone, reducing the amount of distress associated with hearing voices, and developing coping strategies. These groups provide people who hear voices with the opportunity to share their stories with peers in a group setting, construct new understandings about the experience, and learn strategies for managing their voices. Accordingly, there are great possibilities for the use of these groups within mental health services throughout Latin America.

"Goals in Focus"-a targeted CBT approach for motivational negative symptoms of psychosis: study protocol for a randomized-controlled feasibility trial

BACKGROUND

The reduction of goal-directed behavior is the main characteristic in motivational negative symptoms of psychosis as it accounts for the long-term decline in psychological well-being and psychosocial functioning. However, the available treatment options are largely unspecific and show only small effects on motivational negative symptoms. Interventions that directly target the relevant psychological mechanisms are likely to be more effective. For "Goals in Focus", we translated findings from basic clinical research on mechanisms underlying motivational negative symptoms into a tailored and comprehensive novel psychological outpatient treatment program. With this study, we will test the feasibility of the therapy manual and the trial procedures. We also aim to examine first estimates of the effect size that can be expected from "Goals in Focus" to inform the sample size calculation of a subsequent fully powered trial.

METHODS

Thirty participants diagnosed with a schizophrenia spectrum disorder and at least moderate motivational negative symptoms will be randomly assigned to either 24 sessions of "Goals in Focus" over the course of 6 months (n = 15) or to a 6-month wait-list control group (n = 15). Single-blind assessments will be conducted at baseline (t₀) and 6 months after baseline completion (t₁). Feasibility outcomes include patient recruitment, retention, and attendance rates. Acceptability will be rated by trial therapists and by participants at end of treatment. Primary outcome for effect size estimation is the motivational negative symptom subscale sum score of the Brief Negative Symptom Scale at t₁ corrected for baseline values. Secondary outcomes include psychosocial functioning, psychological well-being, depressive symptoms, expressive negative symptoms, negative symptom factor scores, and goal pursuit in everyday life.

DISCUSSION

The feasibility and acceptability data will be used to improve trial procedures and the "Goals in Focus" intervention where necessary. The treatment effect on the primary outcome will provide the basis for the sample size calculation for a fully powered RCT.

TRIAL REGISTRATION

1) ClinicalTrials.gov, NCT05252039 . Registered on 23 February 2022. 2) Deutsches Register Klinischer Studien, DRKS00018083 . Registered on 28 August 2019.

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.

Mediators of negative content and voice-related distress in a diverse sample of clinical and non-clinical voice-hearers

OBJECTIVES

Negative content in hearing voices (i.e., auditory verbal hallucinations) has been associated with adverse clinical outcomes including voice-related distress. Voice appraisals and responding mindfully to voices are theorized to reduce voice-related distress. This study aimed in examine mediators of the negative content voice-related distress relationship in clinical (those who recently received input from mental health services) and non-clinical voice-hearers.

METHODS

One hundred and twenty-one adults (71.9% female; 35.5% mixed or non-white ethnic background) who hear voices were recruited online and completed self-report measures of negative content of voices, voice-related distress, mindfulness of voices, interpretation of loss of control, thought suppression and intrusion.

RESULTS

Clinical voice-hearers had significantly higher levels of negative content, voice-related distress and interpretation of loss of control than non-clinical voice-hearers. A mindful approach to voices and interpretation of loss of control mediated the relationship between negative content and voice-related distress across the whole sample. Thought suppression and intrusion did not mediate the relationship.

CONCLUSIONS

The results support the use of mindfulness-based psychological intervention to reduce voice-related distress. Further development of valid and reliable measures specifically relating to constructs of voice content, voice-related distress and voice suppression will support further research in this area.

A systematic review and thematic synthesis of qualitative literature on personal recovery and voice hearing

BACKGROUND

Personal recovery literature has been influential in the conceptualization of emotional distress and service provision. While personal recovery in psychosis has been well-studied, voice hearing literature has not been reviewed to elucidate recovery processes.

METHOD

Five databases were systematically searched to identify relevant qualitative recovery literature. Twelve eligible studies were included in this review, and an appraisal tool was applied to assess quality. Thematic synthesis was used to examine the results.

RESULTS

Three superordinate themes were found relating to 'Recovery Phases', 'Recovery Facilitators' and 'Barriers to Recovery'. Papers included descriptions of finding voices distressing initially yet moving towards integrating and accepting voices. Searching for meaning versus seeking distance from voices were pivotal processes to recovery pathways. Enabling and disrupting recovery experiences are discussed within a proposed model.

CONCLUSIONS

Recovery in voice hearing is an individual and potentially ongoing process. Future research should seek to examine recovery factors in voice hearing longitudinally and add further evidence to the supportive role services can play in recovery and voice hearing.

A psychological intervention for engaging dialogically with auditory hallucinations (Talking With Voices): A single-site, randomised controlled feasibility trial

There is growing clinical interest in addressing relationship dynamics between service-users and their voices. The Talking With Voices (TwV) trial aimed to establish feasibility and acceptability of a novel dialogical intervention to reduce distress associated with voices amongst adults diagnosed with schizophrenia spectrum disorders. The single-site, single-blind (rater) randomised controlled trial recruited 50 participants who were allocated 1:1 to treatment as usual (TAU), or TAU plus up to 26 sessions of TwV therapy. Participants were assessed at baseline and again at end of treatment (six-months). The primary outcomes were quantitative and qualitative assessments of feasibility and acceptability. Secondary outcomes involved clinical measures, including targeted instruments for voice-hearing, dissociation, and emotional distress. The trial achieved 100 % of the target sample, 24 of whom were allocated to therapy and 26 to TAU. The trial had high retention (40/50 [80 %] participants at six-months) and high intervention adherence (21/24 [87.5 %] receiving ≥8 sessions). Signals of efficacy were shown in targeted measures of voice-hearing, dissociation, and perceptions of recovery. Analysis on the Positive and Negative Syndrome Scale indicated that there were no differences in means of general psychosis symptom scores in TwV compared to the control group. There were four serious adverse events in the therapy group and eight in TAU, none of which were related to study proceedings. The trial demonstrates the acceptability of the intervention and the feasibility of delivering it under controlled, randomised conditions. An adequately powered definitive trial is necessary to provide robust evidence regarding efficacy evaluation and cost-effectiveness. Trial registration: ISRCTN 45308981.

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.

Adaptation of a Hearing Voices Group Facilitation Training for VA Stakeholders

The Hearing Voices (HV) Movement promotes diverse understandings of voice-hearing and seeing visions, which mental health professionals commonly refer to as 'auditory hallucinations,' 'schizophrenia,' or 'psychosis.' Central to this movement are peer support groups through which attendees connect with others who have similar experiences. This paper describes an adaptation of a Hearing Voices group facilitation training at VA Greater Los Angeles (VAGLA) and discusses training modifications, along with trainee perceptions and implementation and intervention outcomes. This is a first step towards adapting HV-inspired groups to VA systems of care. Data collection involved surveys of trainees (n = 18) and field notes throughout the 24 h online training. Findings indicate high acceptability and appropriateness of the training and high feasibility in implementation, suggesting the training was well-adapted to VAGLA. This research contributes to global efforts to integrate the Hearing Voices approach in diverse settings and increase awareness about its benefits among providers.

"Figuring out how to be normal": Exploring how young people and parents make sense of voice-hearing in the family context

OBJECTIVES

Making sense of voice-hearing-exploring the purpose, cause, and relationship with voices-is seen as therapeutically valuable for adults, but there is a paucity of research with adolescents. Family intervention is recommended for young people, yet little is known about families' perspectives on, or role in, a child's voice-hearing. This study therefore aimed to explore how both young people and parents had made sense of voice-hearing in the family context.

METHOD

Semi-structured interviews were conducted with seven young people who hear voices (six females, one male, age M = 17 years) and six parents of young people who hear voices (five females, one male). Data were analysed using interpretative phenomenological analysis.

RESULTS

The young people struggled to reconcile their voice-hearing experiences within themselves, wanted control, 'normality', and not to let their mental health hold them back. Parents saw the voices as separate to their child, who they were protective of, and came to an acceptance and hope for the future amidst continued uncertainty. Pragmatism, and shame, ran through parents' and young people's accounts. Tensions between them, such as autonomy versus involvement, were also apparent.

CONCLUSIONS

Few participants had made sense of their experiences in any concrete form, yet hope, control, and getting on with their lives were not conditional on having done so. Young people valued the family as a safe, non-enquiring space to be 'normal' and not to talk about their experiences. While all had been challenged by their experiences, an energy and strength ran through their accounts.

Measuring Voluntary Control Over Hallucinations: The Yale Control Over Perceptual Experiences (COPE) Scales

Auditory verbal hallucinations (AVH) frequently cause significant distress and dysfunction, and may be unresponsive to conventional treatments. Some voice-hearers report an ability to fully control the onset and offset of their AVH, making them significantly less disruptive. Measuring and understanding these abilities may lead to novel interventions to enhance control over AVH. Fifty-two voice-hearers participated in the pilot study. 318 participants with frequent AVH participated in the validation study. A pool of 59 items was developed by a diverse team including voice-hearers and clinicians. After the pilot study, 35 items were retained. Factorial structure was assessed with exploratory (EFA, n = 148) and confirmatory (CFA, n = 170) factor analyses. Reliability and convergent validity were assessed using a comprehensive battery of validated phenomenological and clinical scales. CFA on the final 18 items supported two factors for a Methods of Control Scale (5 items each, average ω = .87), and one factor for a Degree of Control Scale (8 items, average ω = .95). Correlation with clinical measures supported convergent validity. Degree of control was associated with positive clinical outcomes in voice-hearers both with and without a psychosis-spectrum diagnosis. Degree of control also varied with quality of life independently of symptom severity and AVH content. The Yale control over perceptual experiences (COPE) Scales robustly measure voice-hearers' control over AVH and exhibit sound psychometric properties. Results demonstrate that the capacity to voluntarily control AVH is independently associated with positive clinical outcomes. Reliable measurement of control over AVH will enable future development of interventions meant to bolster that control.

'Like jumping off a ledge into the water': A qualitative study of trauma-focussed imaginal exposure for hearing voices

OBJECTIVE

There is growing evidence of a link between the experience of hearing voices and past traumatic events, and trauma-focussed psychological interventions are being applied to hearing voices as an emerging treatment direction. To inform the ongoing development and implementation of this application, there is a need to understand clients' therapy experiences.

DESIGN

Qualitative study exploring the experience of people who received an intervention for voices linked to a previous traumatic event.

METHOD

Ten participants experiencing voices with some connection to a previous traumatic event participated in individual semi-structured interviews following six sessions of imaginal exposure, an exposure-based trauma-focussed intervention. Participant responses were analysed using thematic analysis.

RESULTS

Participants reported a range of benefits from the intervention, including improved mental health, reduction of distressing voice-hearing experiences, and increased clarity of the traumatic event. The therapy was perceived as distinctly different to previous therapy experiences, and participants noted that therapy could be intense and challenging, yet helpful later. Participants also reported that outside circumstances impacted on their progress in therapy and their voice-hearing experience.

CONCLUSIONS

The findings suggest that exposure-based trauma-focussed therapies may be beneficial for people who hear trauma-related voices. However, this intervention can be intense and clinicians and consumers need to consider the timing of delivery, and pay attention to internal and external resources that can increase participants' sense of safety.

PRACTITIONER POINTS

Imaginal exposure may be an effective intervention for people who hear voices that they perceive to be associated with a past traumatic event. Positive changes associated with the intervention may be highly variable between individuals, and encompass changes in sense of self, changes to internal states, and changes to voice-hearing experience. Imaginal exposure interventions may involve some temporary discomfort and symptom exacerbation, which may affect the acceptability of the intervention. This needs to be considered in both future research and clinical delivery.

'It's like having a core belief that's able to speak back to you': Therapist accounts of dialoguing with auditory hallucinations

PURPOSE

To investigate the clinical perspectives and experiences of therapists when engaging in direct dialogue with auditory hallucinations.

METHOD

Therapist accounts were explored via a qualitative study nested within a pilot randomized controlled trial of a novel intervention for supporting distressed voice-hearers (Talking with Voices). Five therapists were involved, none of whom had substantive previous experience of the technique. All agreed to take part in two semi-structured, in-depth interviews which were arranged prior to delivering therapy and again after therapists had experience of conducting dialogues. Data were analysed using inductive thematic analysis.

RESULTS

Participants described their impressions of seeking to improve the relationship between voice(s) and voice-hearer using dialogue. The findings are organized within three main themes and associated subthemes: (1) Commitment to delivery (professional values, mentorship, professional growth); (2) Communication and collaboration (therapeutic alliance, relationships with voices, managing clinical perceptions); and (3) Challenges of delivery (client/voice engagement, impact of trauma, systemic issues). A series of recommendations are derived from the findings to support implementation and guide the practice of therapists undertaking dialogue work with clients who hear voices.

CONCLUSION

Despite clinical challenges, therapists also identified professional gains from conducting their work. Their accounts demonstrate that it is possible for practitioners with no previous formal experience to engage in direct communication with voices within a context of appropriate training and supervision.

PRACTITIONER POINTS

Therapists with no previous experience of dialogue work can be trained and supported to verbally engage with the voices heard by people experiencing psychosis. Therapeutic alliance and therapist values are important components of successful therapy. Confidence for dialoguing with voices can be increased through drawing on therapist's existing transferable clinical skills. The emotional and practical needs of therapists undertaking such work should be addressed through training and regular group supervision.

Talk-based approaches to support people who are distressed by their experience of hearing voices: A scoping review

BACKGROUND

The positive effects of both antipsychotic medication and cognitive behavioral therapy in psychosis (CBTp) for people who are distressed by their experience of hearing voices remain limited. As a result, there has been a recent surge in talk-based individual approaches. Many of these continue not to be very well known nor implemented in practice. Some of the approaches may focus more on understanding and dealing constructively with voices, an element that has been identified as potentially helpful by voice hearers. Existing barriers to a wider implementation include both the widespread pathologization of hearing voices and a lack of mental health professionals who have been trained and trusted to carry out these new interventions.

METHODS

This scoping review aimed to identify and describe a current synthesis of talk-based individual approaches for people who hear voices, including studies independently of method of study or approach, diagnosis of voice hearers nor of the professional background of interventionists.

RESULTS

Nine different talk-based approaches were identified. These included: (1) Cognitive Behavioral Therapy for Psychosis (CBTp); (2) AVATAR therapy; (3) Making Sense of Voices (MsV) aka Experience Focused Counselling (EFC); (4) Relating Therapy; (5) Acceptance and Commitment Therapy; (6) Smartphone-based Coping-focused Intervention; (7) Prolonged and Virtual Reality Exposure Therapy; (8) Eye Movement Desensitization and Reprocessing, and (9) Individual Mindfulness-based Program for Voice Hearing. The different approaches differed greatly in relation to the number of sessions, length of time offered and the scientific evidence on efficacy. Psychologists represented the main professional group of interventionists. CBTp and the MsV/EFC approach also included health professionals, like nurses, as implementers. Most of the approaches showed positive outcomes in relation to voice related distress levels. None identified overall or voice specific deteriorations.

CONCLUSION

There appears to be a strong case for the implementation of a broader heterogeneity of approaches in practice. This would also be in line with recommendations for recovery focused services and requirements of voice hearers. A greater emphasis on whole systems implementation and thus the involvement of frontline staff, like nurses, in the delivery of these approaches would likely reduce the research-practice implementation gap.

As vozes dos usuários participantes de grupos de ouvidores de vozes

O objetivo deste artigo é investigar as vivências e possíveis efeitos da participação em grupos de Ouvidores de Vozes. Trata-se de um estudo qualitativo com participantes acima de 18 anos, que concordaram em fazer parte do estudo e frequentaram os grupos por um período mínimo de três meses. Foram realizadas 14 entrevistas até obtenção de saturação em grupos de Centros de Atenção Psicossocial, em seguida transcritas e analisadas usando a hermenêutica Gadameriana. A análise evidenciou cinco núcleos argumentais: a chegada no grupo; modo de funcionamento; uso de medicamentos; sentidos e efeitos. Demonstrou-se que os grupos podem ser uma das estratégias de cuidado e recuperação dos indivíduos, permitindo com que as suas experiências sejam reconhecidas e ressignificadas, promovendo, além da melhora clínica, acolhimento, compartilhamento entre pares e socialização.

Epistemic injustice, children and mental illness

The concept of epistemic (specifically testimonial) injustice is the latest philosophical tool with which to try to theorise what goes wrong when mental health service users are not listened to by clinicians, and what goes right when they are. Is the tool adequate to the task? It is argued that, to be applicable at all, the concept needs some adjustment so that being disbelieved as a result of prejudice is one of a family of alternative necessary conditions for its application, rather than a necessary condition all on its own. It is then argued that even once adjusted in this way, the concept does not fit well in the area where the biggest efforts have been made to apply it so far, namely the highly sensitive case of adult patients suffering from delusions. Indeed it does not serve the interests of service users struggling for recognition to try to apply it in this context, because there is so much more to being listened to than simply being believed. However, the concept is found to apply smoothly in many cases where the service users are children, for example, in relation to children's testimony on the efficacy of treatment. It is suggested that further research would demonstrate the usefulness of the concept in adult cases of a similar kind.

Your diagnosis will not protect you (and neither will academia): Reckoning with education and Dis-Ease

This article is an autoethnographic exploration of institutionalized responses to uncontrolled substance use informed by medical paradigms. Theoretically, it is situated within a lineage of work in critical drug and Mad studies that challenge assumptions about choice, including - and especially - by interrogating the extent to which choice is an apt conceptual tool for making sense of "addiction." Throughout, I focus on two discrete but analogous events, both of which entailed binging on substances, entering altered states, and being rejected from academic spaces through a lens of biomedicine. My objective in doing so is two-fold: First, I hope to incite what I feel is a long overdue conversation between Mad and critical drug studies in service of theoretical cross-pollination. Second, I wish to outline how codifying people as Mad and addicted can amount to a "cutting out" (Smith, 1978) of relevant extraneous factors that motivate one's deviant actions, including within education institutions whose members research these same identities. I conclude by discussing the implications of this "cutting out" for my and possibly others' academic trajectories.

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.

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.

Grupo de Ouvidores de Vozes: experiência inovadora realizada por suporte de pares

El objetivo de este artículo es describir el proceso de implementación y el funcionamiento de un grupo de oyentes de voz, pacientes diagnosticados de esquizofrenia, en un servicio de salud mental en Brasil. Es un relato de experiencia. Este grupo fue creado en 2015 y tiene lugar en un Centro de Atención Psicosocial (CAPS) en la ciudad de Ribeirão Preto - São Paulo, Brasil. Es un grupo abierto, con periodicidad semanal, de una hora de duración, siendo un espacio donde las personas pueden hablar libremente de sus vivencias con las voces. Participan en los encuentros personas que escuchan voces, sus familiares, profesionales y estudiantes del área de salud. En los encuentros grupales se comparten los significados atribuidos a la experiencia, se utilizan estrategias para afrontar situaciones más desafiantes, experiencias de sufrimiento y superación. El grupo también se constituye como una herramienta para construir vínculos y redes de apoyo, además de ser un espacio de encuentro de historias de vida. Así, el grupo ha ofrecido la posibilidad de nuevos diálogos, nuevos significados y posiciones respecto a la audición de voces, siendo considerado como un espacio de respeto y reciprocidad para los oyentes de voces. Siguiendo los supuestos del Movimiento de Oyentes de Voz, se presenta como una innovación para la atención en los servicios de salud mental.

Critical qualitative research on 'madness': knowledge making and activism among those designated 'mad'

This paper charts the background to a project which aimed to map the knowledge being generated across the world by people silenced for centuries - the 'mad': a term with derogatory historical resonances but which is now being reclaimed. The idea that those designated 'mad' can produce knowledge is novel: 'mad' people are imagined as lacking rationality, and incapable of producing knowledge; they are subject to epistemic injustice. Patient engagement in research has grown in the last 20 years but we lack methodological frameworks through which such knowledge can be surfaced. One goal of the project is to let the mad speak their knowledge, often practical knowledge. To do this we had to innovate methodology. Centrally, we refuse the distinction between theory and method for these are constantly intertwined in all research. Thus, what typically comes under 'Method' in background papers is infused with implicit conceptualisation. We carried out 48 interviews in North America, England, Australia, New Zealand, and Eastern and Western Europe. We argue all aspects of these interviews are radically different than is usual for exploratory research in this area. Psychiatry is not central here - it is present only when present in the words of our participants; situated in material and symbolic spaces. We also seek to move away from the individualising therapies of medicines and psychological treatment because they strip participants from their situated realities. Psychiatry enters also because of what it does not do - engage with the life world of its patients. We call then for 'recontextualisation' of madness at all levels. The project was user-led and all researchers had experienced distress and responses to it. Future papers will develop and demonstrate this approach.

Emerging Processes Within Peer-Support Hearing Voices Groups: A Qualitative Study in the Dutch Context

Purpose/Aims: This study aimed to gain insight into the value of Hearing Voices Groups (HVGs) in the Dutch context. Specifically, we aimed to learn more about the meaning of HVG participation, as well as the aspects that contribute to that meaning, from the perspective of participants' experiences. Method: The study used a qualitative design with in-depth interviews to explore the experiences of 30 members within seven HVGs in the Netherlands. Interviews were recorded, transcribed, and analyzed using interpretative analysis inspired by the Grounded Theory method. Findings: The individual-level analysis revealed four different group processes that appear to determine the value that HVGs have for their participants: (i) peer-to-peer validation, (ii) exchanging information and sharing self-accumulated knowledge, (iii) connection and social support, and (iv) engaging in mutual self-reflection. We found that specific characteristics of HVGs facilitate these group processes and lead to specific personal outcomes. Combining the interview data from people who joined the same HVG reveals that, although all four described group processes occur in all groups, each group's emphasis differs. Three related factors are described: (i) the composition of the group, (ii) the style of the facilitators, and (iii) the interaction between group processes and individual processes. Implications: Unique processes, for which there is little to no place within regular mental health care (MHC), occur within HVGs. MHC professionals should be more aware of the opportunities HVG can offer voice-hearers. Essential matters regarding the implementation of HVGs are discussed.

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.

Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review

Antipsychotics are the first-line treatment for people with schizophrenia or psychosis. There is evidence that they can reduce the symptoms of psychosis and risk of relapse. However many people do not respond to these drugs, or experience adverse effects and stop taking them. In the UK, clinical guidelines have stressed the need for research into psychosocial interventions without antipsychotics. This systematic review examines the effects of psychosocial interventions for people with schizophrenia or psychosis who are on no/minimal antipsychotics. Databases were searched for empirical studies investigating a psychosocial intervention in people with a schizophrenia spectrum disorder who were not taking antipsychotics or had received an antipsychotic minimisation strategy. We identified nine interventions tested in 17 studies (N = 2250), including eight randomised controlled trials. Outcomes were generally equal to or in a small number of cases better than the control group (antipsychotics/treatment as usual) for Cognitive Behavioural Therapy (CBT), Need Adapted Treatment and Soteria. The remaining interventions provided some encouraging, but overall inconsistent findings and were Psychosocial Outpatient Treatment, Open Dialogue, Psychosocial Inpatient Treatment, Psychoanalysis/Psychodynamic Psychotherapy, Major Role Therapy, and Milieu Treatment. Study quality was generally low with little recent research. In conclusion, nine psychosocial interventions have been studied for patients on no/minimal antipsychotics. The majority of studies reported outcomes for the intervention which were the same as the control group, however, study quality was problematic. Given the adverse effects of antipsychotics and that many people do not want to take them, high quality trials of psychosocial treatments for people on minimal/no antipsychotics are needed.

Nonmedical Interventions for Schizophrenia: A Review of Diet, Exercise, and Social Roles

Schizophrenia is a major mental illness with a disease course that is influenced by lifestyle. The risk-benefit ratio for alternative interventions is more favorable than for antipsychotics in long-term treatment. Dietary interventions may target autoimmune features, vitamin or mineral deficiencies, abnormal lipid metabolism, gluten sensitivity, or others. Examples of interventions involving diet, physical activity, or physical processes or social interventions including talk therapy exist in the literature. Notwithstanding, the general utility of these types of interventions remains inconclusive, awaiting long-term randomized trials. A perspective that separates the cause of the disease from its symptoms may be helpful in treatment planning and is warranted to distinguish between short-term and long-term recovery goals.

A “trigger”, a cause or obscured? How trauma and adversity are constructed in psychiatric stress-vulnerability accounts of “psychosis”

How do mental health professionals link adverse life experiences with the kinds of beliefs and experiences which attract a diagnosis of psychosis and what implications does this have for women with these diagnoses? Drawing on a broadly critical realist framework, we present data from two studies relevant to these questions. First, we analyse the discursive practices engaged in during a staff-only discussion of a female in-patient with a psychosis diagnosis who had been raped some years previously. Staff oriented to the irrationality and factuality of her ostensibly delusional statements about rape and pregnancy in the present and formulated adverse experience as a “stress factor” triggering a manic episode, thereby precluding alternative contextualising interpretations. In a second, interview-based, study, psychiatrists drew on a range of discursive resources which differentiated “psychosis” from other forms of distress, constructed trauma as a stressor which could trigger psychosis because of a genetic predisposition, and constructed medication as the primary intervention whilst trauma was de-emphasised. We discuss the implications of these findings for the kinds of explanations and forms of help offered and suggest ways in which distress might be contextualised as well as possible future directions for feminist research and practice.

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

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

Destabilising social inclusion and recovery, and pursuing 'lines of flight' in the mental health sector

People who have been diagnosed with serious mental illness have a long history of confinement, social stigma and marginalisation that has constrained their participation in society. Drawing upon the work of Gilles Deleuze and Felix Guattari, we have used the concepts of: assemblages, major and minor and deterritorialisation to critically analyse two pervasive and 'taken-for-granted' assemblages in mental health: recovery (including clinical recovery, social recovery and recovery-oriented practice) and social inclusion. Our analysis explores how dominant and oppressive forces have been entangled with liberating and transformative forces throughout both of these assemblages - with dominant forces engaging in ongoing processes of capture and control, and transformative forces resisting and avoiding capture. In pursuit of social transformation for people categorised with serious mental illness, deterritorialisation is posited as a potential way forward. To have transformation in the lives of mental health service users, we present the possibility that ongoing, disruptive movements of deterritorialisation can unsettle majoritarian practices of capture and control - producing liberating lines of flight.

Shame, social deprivation, and the quality of the voice-hearing relationship

OBJECTIVES

Many individuals hold different beliefs about the voices that they hear and have distinct relationships with them, the nature of which may determine the distress experienced. Understanding what factors contribute to these beliefs and relationships and consequently the resulting distress is important. The current research examined whether shame and social deprivation, in a sample of adult voice-hearers, were related to the relationships that individuals had with their voices or the beliefs that they held about them.

DESIGN

The study utilized a cross-sectional, Internet-based design.

METHODS

Eighty-seven adult voice-hearers from England were recruited to the online survey. Participants completed measures regarding shame, beliefs about voices, and relationships with voices and provided demographic information and postcodes that were used to refer to Index of Multiple Deprivation data.

RESULTS

Social deprivation and shame were not associated. Shame was positively associated with variables describing negative voice-hearing beliefs/relationships but not positive voice-hearing beliefs/relationships. Principal component analysis on the eight voice-hearing variables yielded two components related to positive and negative voice-hearing qualities. A multiple regression conducted on the two components identified that shame was only associated with negative voice-hearing qualities.

CONCLUSIONS

The results suggest that therapies that target shame may be helpful when working with negative voice-hearing beliefs and relationships. Future research should utilize experimental or longitudinal designs to examine the direction of the relationship.

PRACTITIONER POINTS

The results contribute to the limited research evidence available regarding the relationship between shame and voice-hearing. The results suggest the utility of psychological therapies that focus on shame such as compassion-focused therapy and that conceptualize voices interpersonally such as cognitive analytic therapy. No conclusions can be made regarding causation. The sample size was relatively small, and results cannot be generalized to other areas of the United Kingdom. Future research should utilize experimental and longitudinal designs to examine the impact of shame on voice-hearing experiences and to examine other factors that may predict shame.