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A treatment protocol to guide the delivery of dialogical engagement with auditory hallucinations: Experience from the Talking With Voices pilot trial
Abstract
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.
... There is growing interest in developing treatments, which are tailored to diverse phenomenological features of voice-hearing (13). This includes a new wave of psychological interventions which target the relationship between the person and their voice, specifically Relating Therapy (14), Talking with Voices (15), and AVATAR therapy (16). In AVATAR therapy, a novel therapeutic context allows 'face-toface' dialogue between the person and a computerised representation of their persecutory voice. ...
... This inclusion decision is based on a discussion with participants to establish whether the approach is a 'good fit' for the person. Pilot work in the Talking with Voices approach suggests that instances in which people were unable or unwilling to engage in voice dialogue were relatively uncommon (15). Nonetheless, if characterisation as assessed by VoCC is shown to moderate treatment outcome to AVATAR therapy, it would be of interest to explore whether this is also observed in other dialogical approaches. ...
... A richer understanding of voice characterisation, including attribution of thought and intention, can facilitate the process of building understanding and meaning making. It also acts as an invitation to consider possible mirroring of current voice experiences with other relationships, autobiographical context, and the role of trauma (See also (15)). Future work using the VoCC could also ...
Aim
There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses degree of voice characterisation, identified as relevant to a new wave of relational approaches.
Methods
The sample comprised participants experiencing distressing voices, recruited at baseline on the AVATAR2 trial between January 2021 and July 2022 ( n = 170). Inter-rater reliability (IRR) and internal consistency analyses (Cronbach’s alpha) were conducted.
Results
The majority of participants reported some degree of voice personification (94%) with high endorsement of voices as distinct auditory experiences (87%) with basic attributes of gender and age (82%). While most identified a voice intention (75%) and personality (76%), attribution of mental states (35%) to the voice (‘What are they thinking?’) and a known historical relationship (36%) were less common. The internal consistency of the VoCC was acceptable (10 items, α = 0.71). IRR analysis indicated acceptable to excellent reliability at the item-level for 9/10 items and moderate agreement between raters’ global (binary) classification of more vs. less highly characterised voices, κ = 0.549 (95% CI, 0.240–0.859), p < 0.05.
Conclusion
The VoCC is a reliable and internally consistent tool for assessing voice characterisation and will be used to test whether voice characterisation moderates treatment outcome to AVATAR therapy. There is potential wider utility within clinical trials of other relational therapies as well as routine clinical practise.
... In conceptualising voice-hearing, TwV draws from a specific theoretical position that locates the experience (at least for some individuals) as dissociative; specifically, as a subjectively real state of consciousness which may serve a 'protective' function by drawing attention to unresolved emotional conflicts (Moskowitz et al., 2017). Coping enhancement and psychological formulation are incorporated within the protocol, although a central feature is direct verbal engagement wherein a therapist speaks to the voice by asking it questions while the client repeats the voice's responses aloud (Longden et al., 2021). In doing so, TwV aims to facilitate a process of reconciliation and integration between hearer and voice, thereby improving aspects of emotional awareness, self-concept and interpersonal relating. ...
... In Phase 2, while empowerment remains crucial, dialogues focus on developmental context and personal meaning. The AVATAR therapy approach to trauma work has been informed by important insights from the TwV approach (Longden et al., 2021;Longden, Corstens, et al., 2022;Middleton et al., 2022). Commonalities include the use of facilitated dialogue to understand: (1) possible function(s) or meaning(s) of voices, (2) links with early (and in many instances ongoing) disempowering experiences and (3) the relationship between voices and what is experienced as 'the self'. ...
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.
... With these concepts as the underlying philosophy, the Hearing Voices approach has developed various tools and techniques for dealing with voices. These include the 'Making sense of voices' approach, which facilitates a thorough exploration of voices and changing the person's relationship with the voices (Steel et al., 2020); and 'Talking With Voices' , which is a novel intervention for individuals with psychosis which involves dialogical engagement with the voices (Longden et al., 2021). ...
Auditory hallucinations or hearing voices are often associated with schizophrenia and other psychotic disorders. However, several voice-hearers do not have any mental health issues or diagnoses. The study presented in this paper aimed to explore how voice-hearers understand and react to their concerns by reflecting on and exploring their experiences and interpretations of these experiences. The participants were nine individuals - three females, four males and two others, all experiencing auditory hallucinations for at least five years, residing either at their home or at one of the Hostels run by Richmond Foundation (Malta). A qualitative approach following the principles of Interpretative Phenomenological Analysis was used. In-depth interviews were conducted to explore how the participants perceive their voices, what coping strategies are used, and how their experiences affect their lives. Four super-ordinate themes related to the participants' perceptions and their interpretation of the experience of hearing voices were identified: 'A tough experience', 'Methods used to cope with voices', 'Factors linked to recovery' and 'Relationships'. Furthermore, the study elicited the voice-hearers' recommendations (both for other voice-hearers and mental health professionals).
... Future research examining the differential effects of therapy modalities on participants' descriptions of their voices, PTSD symptoms, and dissociative experiences may be of interest. For instance, in the current study, one participant referred to engaging in voice "dialoguing" as part of her therapy, consistent with | 1025 VOICES, DISSOCIATION, AND PTSD SYMPTOMS new treatments which emphasise relational aspects of voice hearing and promote engagement with voices to reduce conflict (Longden et al., 2021). However, another participant described an experience of a therapist talking "directly" to their voices as unhelpful. ...
Objectives
Extensive research has shown voice hearing to be associated with symptoms of Post‐Traumatic Stress Disorder (PTSD) and dissociation. However, most studies have adopted a quantitative design, using cross‐sectional data sampling methods, precluding temporal relationships between variables from being defined.
Design
Using a qualitative design, this study sought to identify potential symptom relationships by addressing the research question: what is the nature of the temporal relationship between voices, dissociation and PTSD symptoms?
Methods
Seven voice hearers (aged 27 to 68 years) participated in a semi‐structured interview exploring voice hearing, PTSD symptoms, and dissociation. The interviews were analysed using Interpretative Phenomenological Analysis.
Results
One superordinate theme was identified in the data. Voices were observed to occur in dynamic interrelationship with PTSD symptoms and dissociation, and were frequently experienced before and after PTSD symptoms and dissociative episodes.
Conclusions
Implications for theoretical understandings of voice hearing and future research are discussed.
... Dissoziative Persönlichkeitszustände können als Ausdruck traumatischer Erinnerungen oder als Bewältigungsversuche verstanden werden [15,16]. Da Hinweise vorliegen, dass die Phänomenologie auditivverbaler Halluzinationen einem Spiegel der traumatischen Vergangenheit der Betroffenen entspricht [17], erscheint eine respektvolle Eröffnung eines Dialogs mit "Stimmen" angezeigt, ohne diese zu "Anteilen" zu verdinglichen [18]. Angesichts der Suggestibilität, den intermittierenden Einschränkungen in der Realitätstestung sowie eines oft kindlich anmutenden magischen Denkens Betroffener [2,19] erscheint darüber hinaus wie auch im Umgang mit Erinnerungen eine Haltung des skeptischen Glaubens und empathi-schen Zweifelns hilfreich. ...
Dissociative identity disorder is the most severe of the dissociative disorders and neither the trauma model nor the sociocognitive model provide a satisfactory account of its complexity. Transtheoretical models propose an interaction of traumatic experiences as well as cultural, cognitive, and social factors in the development of the disorder. This perspective has important implications for the treatment which should encompass a reprocessing of traumatic memories, emotional regulation skills, and a modification of dysfunctional beliefs about memory. An elaboration of dissociative identities should be prevented. A corresponding inpatient treatment approach is described.
Die dissoziative Identitätsstörung ist die schwerste dissoziative Störung und kann in ihrer Komplexität weder durch das Trauma-Modell noch durch das soziokognitive Modell hinreichend erklärt werden. Transtheoretische Modelle legen eine Interaktion von traumatischen Erfahrungen mit kulturellen, kognitiven und sozialen Einflüssen für die Ätiopathogenese des Störungsbildes nahe. Daraus ergeben sich bedeutende Impulse für die Behandlung, in der neben einer Verarbeitung traumatischer Erinnerungen auch eine Verbesserung der Emotionsregulation sowie eine Modifikation dysfunktionaler Annahmen über das Gedächtnis erfolgen sollte. Einer Ausgestaltung von Teilidentitäten sollte kein Vorschub geleistet werden. Ein derartiges therapeutisches Vorgehen im Rahmen stationärer Psychotherapie wird beschrieben.
... Therapy for individuals diagnosed with psychosis who experience auditory hallucinations can similarly use dialogical methods that attempt to correct fear or passivity when hearing voices and create a more constructive relationship with them. The aim is to understand the role of the voices and relate to them as useful rather than problematic parts of the self that are the products of the individual's life history (Longden et al., 2021). The creation of a comprehensive mental model of the self is part of mentalization treatment for BPD, which recognizes that an inability to mentalize leads to major problems in affect regulation (Bateman & Fonagy, 2010). ...
The 11th version of the International Classification of Diseases (ICD-11) includes complex posttraumatic stress disorder (CPTSD) as a separate diagnostic entity alongside posttraumatic stress disorder (PTSD). ICD-11 CPTSD is defined by six sets of symptoms, three that are shared with PTSD (reexperiencing in the here and now, avoidance, and sense of current threat) and three (affective dysregulation, negative self-concept, and disturbances in relationships) representing pervasive "disturbances in self-organization" (DSO). There is considerable evidence supporting the construct validity of ICD-11 CPTSD, but no theoretical account of its development has thus far been presented. A theory is needed to explain several phenomena that are especially relevant to ICD-11 CPTSD such as the role played by prolonged and repeated trauma exposure, the functional independence between PTSD and DSO symptoms, and diagnostic heterogeneity following trauma exposure. The memory and identity theory of ICD-11 CPTSD states that single and multiple trauma exposure occur in a context of individual vulnerability which interact to give rise to intrusive, sensation-based traumatic memories and negative identities which, together, produce the PTSD and DSO symptoms that define ICD-11 CPTSD. The model emphasizes that the two major and related causal processes of intrusive memories and negative identities exist on a continuum from prereflective experience to full self-awareness. Theoretically derived implications for the assessment and treatment of ICD-11 CPTSD are discussed, as well as areas for future research and model testing. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
... One notable trend has been a group of therapies that work with the experience that people have of the voices as agents or entities with whom they relate interpersonally (e.g. Craig et al., 2018;Hayward et al., 2014Hayward et al., , 2017Leff et al., 2013;Longden et al., 2021). A further major trend has been the third wave, or "acceptance and mindfulness-based," approaches, which we consider in more detail. ...
... Moreover, because of the afore-mentioned heterogeneity of madness, clinicians ought to have a large toolbox of treatments and approaches at their disposal. There is some research on alternative approaches such as engaging in dialogue with the voices one hears (Longden et al., 2021), but we should continue to expand the toolbox and study the tools. This is an area where one size is unlikely to fit all. ...
Wouter Kusters argues that madness has much to offer philosophy, as does philosophy to madness. In this paper, I support both claims by drawing on a mad phenomenon which I label Radical Psychotic Doubt, or RPD. First, although skepticism is a minority position in epistemology, it has been claimed that anti-skeptical arguments remain unsatisfying. I argue that this complaint can be clarified and strengthened by showing that anti-skeptical arguments are irrelevant to RPD sufferers. Second, there’s a debate about whether so-called hinge commitments are beliefs or not. I argue that RPD can be used to strengthen the case that they are. Moreover, if hinges are beliefs, some madpeople are more epistemically rational than some sane philosophers. Third, drawing on my own mad experiences, I challenge evidentialism by presenting a better candidate for a truly forced choice about what to believe than William James’ traditional religious example. I further show that in certain psychiatric contexts, evidentialism has more radical implications than Jamesian pragmatism, which comes out as more conservative. Finally, I discuss how philosophical theories like pragmatism and Pyrrhonism can provide inspiration for new and much – needed coping strategies for RPD sufferers.
... Provision of a broader range of trauma therapies is also likely to improve therapy uptake, engagement, and outcomes, and it would be preferable for people to be offered a choice of therapeutic interventions. For example, dialogical approaches, such as Talking with Voices and AVATAR therapy, show promise in supporting people with trauma-related voice hearing, and warrant further investigation (63)(64)(65). ...
Background
Emerging evidence supports the safety, acceptability, and efficacy of trauma therapies for people experiencing post-traumatic stress and psychosis, despite common concerns about iatrogenic harm when processing trauma memories for this population. However, to date there have been no mixed-method studies examining whether trauma-focused therapy can be implemented in routine care. This study reports an audit of a post-traumatic stress in psychosis clinic based in an inner-city trust in the U.K. National Health Service.
Materials and methods
People under the care of psychosis community mental health teams with a significant history of past trauma were referred to the clinic by their multidisciplinary clinicians. Referral outcomes were recorded, including the proportion of people for whom trauma-focused cognitive-behavior therapy for psychosis was indicated. Post-traumatic stress symptoms were assessed pre- and post-therapy for clinically significant change on the Post-traumatic Stress Checklist (version 4) and Post-traumatic Stress Checklist (version 5). A subgroup of service users was also interviewed about their experience of therapy, with transcripts analyzed using inductive thematic analysis.
Results
Seventy one service-users were referred to the clinic between 2014 and 2018, of which 51 (71.8%) attended an assessment. Of these, 20 (39.2%) were identified as having clinically significant PTSD symptoms with re-experiencing and were offered trauma-focused cognitive-behavior therapy for psychosis. Sixteen (80%) accepted and completed therapy, with no dropouts, and received a mean of 17.54 sessions (SD = 17.60, range = 12–91). There were no serious adverse events related to therapy. Clinically significant change was observed in 68.8% ( n = 11) of the therapy group and post-therapy six people (37.5%) no longer met the threshold for clinically significant PTSD. Six service users completed an interview about their therapy experiences with findings organized within four main themes and associated subthemes: (1) Perseverance, (2) Establishing safety, (3) The challenges of therapy, and (4) Rebuilding one’s life after trauma.
Conclusion
Trauma-focused cognitive-behavior therapy for psychosis can be safe, acceptable, and effective when implemented in routine care. Lived experience perspectives highlight the emotional demands of therapy and long-term impact of trauma, thus underscoring the necessity of sufficient support and continuity of care both during and after therapy.
... Similarly, relationally based therapies, such as relating therapy (Hayward et al., 2017;Paulik et al., 2013), the Talking With Voices approach (e.g. Longden et al., 2021), or AVATAR therapy (Craig et al., 2018;Ward et al., 2020) may be indicated where relationships with voices mirror past experiences of discrimination, victimization, or marginalization and this appears to fuel negative content. Large trials that assess negative voice content as an outcome and which use mediation analysis to assess mechanisms of change in therapy would provide increased knowledge in this area. ...
Objective:
People who experience distressing voices frequently report negative (e.g. abusive or threatening) voice content and this is a key driver of distress. There has also been recognition that positive (e.g. reassuring, or guiding) voice content contributes to better outcomes. Despite this, voice content has been neglected as a standalone outcome in evaluations of psychological therapies for distressing voices. We aimed to examine whether a modular cognitive-behavioural therapy (CBT) intervention for voices led to changes in negative and positive voice content.
Design/methods:
In a naturalistic, uncontrolled pre- and post- service evaluation study, 32 clients at an outpatient psychology service for distressing voices received eight sessions of CBT for distressing voices and completed self-report measures of negative and positive voice content at pre-, mid- and post- therapy.
Results:
There was no significant change in positive voice content. There was no significant change in negative voice content from pre- to post-therapy; however, there was a significant change in negative voice content between mid and post-treatment in which the cognitive therapy component was delivered. The CBT treatment was also associated with significant changes in routinely reported outcomes of voice-related distress and voice severity.
Conclusions:
The cognitive component of CBT for distressing voices may be associated with changes in negative, but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content.
... These findings bring additional support to the Making Sense of Voices-approach to therapy (Steel et al., 2020), which advocates engagement and understanding of the voices rather than dampening them with medication. Psychological interventions such as Talking with Voices therapy (Longden et al., 2021) could be useful for increasing resilience, and in helping people to navigate through the new, complex circumstances related to the global pandemic. ...
The COVID-19 pandemic is likely to affect people who have had previous experiences of psychosis – either positively or negatively. A research gap exists in looking at qualitative experiences of the pandemic. In the present study, we address the research gap in those who self-identified as having psychosis via Reddit discussion forum posts, collecting data from a popular online community. Sixty-five posts were analysed using inductive thematic analysis. Five overarching themes were identifie; declining mental health, changed psychosis experiences, personal coping experiences, social connectedness and disconnectedness, and COVID-19 as a metaphor. The data show that there are varied experiences associated with the pandemic. People who have experiences of psychosis do not only have vulnerabilities but may also perceive themselves as having strengths that allow them to cope better.
... Accordingly, the aim of talking with voices is to comprehend the biography, meaning, and intentions of voices and resolve voice-hearer conflicts (Corstens, Longden, & May, 2012). Studies suggest that, for people experiencing psychosis, Voice Dialogue provides understanding and increased control over voices and reduces voice-related distress (Longden et al., 2021a;Longden et al., 2021b;Schnackenberg, Fleming, Walker, & Martin, 2018;Steel et al., 2020). However, research is yet to explore the applications of Voice Dialogue to voices experienced in other groups. ...
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 semi‐structured interview following a single Voice Dialogue session. Interview transcripts were analysed using interpretative phenomenological analysis (IPA). Three overarching themes were identified: (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.
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.
Persisting distressing experiences of hearing voices (auditory hallucinations) are a common target for psychological therapies in psychosis. Whilst cognitive behavioural therapy for psychosis has emerged as the standard treatment approach in practice guidelines, a range of further therapeutic approaches have been applied to people with this experience. To meet the challenge of combining best-evidenced therapy with innovations that may meet individualised needs, our specialist Voices Clinic in Melbourne uses a framework we call Functional Analysis Informed Therapy for Hallucinations (FAITH) to tailor therapeutic methods to the individual. This involves using a collaborative formulation of antecedents and maintaining factors for voices and voice-related distress to guide alternate responses and targeted therapeutic strategies. We present a case study of the incorporation of acceptance and commitment therapy (ACT) methods within this approach, describing a client for whom initial work focused on enhancing coping strategies elicited increasingly critical voice content and attempts to suppress the experience. The case illustrates how an overall behavioural formulation can provide a coherent framework for incorporating third-wave therapeutic methods into therapy.KeywordsHallucinationsPsychosisFunctional analysisAcceptance and commitment therapyCognitive behavioural therapy
Learning to relate differently to hearing voices is a challenge for all of us not just people who hear voices. In this chapter, we will look at approaches that have come out of the hearing voices movement and share stories of how people have made use of these developments.KeywordsHearing voicesVoice dialogueTalking with voices
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.
Background
The “Talking with Voices” (TwV) approach is a novel, formulation-driven approach to helping people who hear distressing voices. It is based on an understanding of voice-hearing as a relational phenomenon, often linked to trauma. Therapy involves facilitation of dialogical engagement between hearers and their voices. There are as yet few empirical studies of the approach.
Method
The current study explored experiences of the TwV approach from the perspectives of voice-hearers and also of their voices. Ten qualitative interviews were subjected to Interpretative Phenomenological Analysis.
Results
Both hearers and their voices felt that the TwV approach can be a powerful enabler of positive change, and that it provides a valuable means of working through past trauma. Establishing a safe base – with time to build trust in the process – was considered key, as were the personal qualities of the facilitator, including openness, courage and a non-judgemental approach. Participants also saw flexibility as important, including the ability to try things out within the work. It was also important that the ideas behind the approach made sense to the participant. Perceived barriers included the medicalised nature of current services and the lack of availability of the TwV approach.
Conclusion
The findings provide support for the acceptability and value of dialogical approaches to helping people who hear voices. In particular, they suggest that participating in TwV can help people develop an understanding of, and a more peaceful relationship with, their voices. The study is novel in eliciting perspectives from the voices themselves, and this yielded valuable insights.
In Western culture, “hearing voices” is often considered a symptom of mental illness. After reinterpreting this phenomenon from perspectives that emphasise the socio-cultural aspects of the construction of these voices, this paper describes a case report involving a psychological intervention divided into six phases. The aim is to challenge the dominant narratives that stigmatise the experience of hearing voices, and propose alternative meanings that can improve the hearer’s ability to manage the voices by converting them from a disease into a personal and relational resource. Using the metaphor of an “inner dialogue”, we show how changes in the client’s interpretation of the voices, and way of relating to them, can be co-constructed by the client and the therapist. The paper concludes with some critical reflections on the medicalisation of mental distress, highlighting the importance of expanding our understanding of the experience of hearing voices, not only in clinical terms, but also on a social and cultural level.
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.
The ‘Making Sense of Voices’ (MsV), or ‘Maastricht’ approach has become established within large sections of the voice hearing community, as well as being adopted by some professional mental health workers. However, there has been limited research to assess this intervention. A recent case series using the MsV approach reported promising results across a number of standardised outcome measures. The current study reports on the voice hearers’ experience of having received the MsV intervention, through the use of “exit interviews” conducted as part of the case series. Individual participants’ experiences indicated a range of reactions to the intervention. Positive outcomes appeared to relate to a better understanding of voice hearing experiences and a greater sense of control over voices. Not all participants reported a positive experience of communicating with their voices. Outcomes are discussed within the context of potential common and distinct “ingredients” of the MsV approach, compared to other approaches to working with distressing voices. https://www.tandfonline.com/eprint/V4VVUQQGDMSCZYDKZXF6/full?target=10.1080/17522439.2019.1707859
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.
The current evidence-base for the psychological treatment of distressing voices indicates the need for further clinical development. The Maastricht approach (also known as Making Sense of Voices) is popular within sections of the Hearing Voices Movement, but its clinical effectiveness has not been systematically evaluated. The aim of the approach is to develop a better understanding of the role of the voice, in part through opening a dialogue between the voice hearer and the voice. The current study was a (N = 15) case series adopting a concurrent multiple baseline design. The Maastricht approach was offered for up to 9-months. The main outcome, weekly voice-related distress ratings, was not statistically significant during intervention or follow-up, although the effect size was in the moderate range. The PSYRATS Hallucination scale was associated with a large effect size both at the end of treatment, and after a 3-month follow-up period, although again the effect did not reach statistical significance. The results suggest further evaluation of the approach is warranted. However, given the large variance in individual participant outcome, it may be that a better understanding of response profiles is required before conducting a definitive randomised controlled trial.
Hostile voices are a common problem in both dissociative identity disorder and psychosis. They may take the form of command hallucinations for suicide, or express negative thoughts and feelings about the self. The authors describe a psychotherapeutic treatment approach for hostile voices that converse with each other, keep up a running commentary on the person’s behavior, or otherwise speak in intelligible sentences and paragraphs. This approach can be useful, in the authors’ opinion, whether the diagnosis is a psychotic or a dissociative disorder. The authors provide clinical detail, with a case example, on the psychotherapy of hostile voices.
The purpose of this study is to offer a model in which auditory verbal hallucinations (AVHs) can be conceptualized as dialogical experiences. This model is of interest in that it integrates several different perspectives (phenomenological, cognitive, social, and evolutionary) and the findings of empirical research on the subject. Hallucinations are understood as the product of a state of consciousness in which the self is dissociated into different positions or perspectives. After reviewing the most relevant results of psychological research, dialogical self theory is proposed as the theoretical framework for understanding hallucinatory experiences. It is argued that the voices possess a series of characteristics, pragmatic properties, relationships with the voices similar to their social surroundings, and more
dissociative experiences in people who experience voices than in those who do not, with which they may be considered a dialogical experience. Finally, a model attempting to integrate psychological research on AVHs within the framework of dialogical self theory is presented.
We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient's control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design. One group went straight into the therapy arm: "immediate therapy". The other continued with standard clinical care for 7 weeks then crossed over into Avatar therapy: "delayed therapy". There was a significant reduction in the frequency and intensity of the voices and in their omnipotence and malevolence. Several individuals had a dramatic response, their voices ceasing completely after a few sessions of the therapy. The average effect size of the therapy was 0.8. We discuss the possible psychological mechanisms for the success of Avatar therapy and the implications for the origins of persecutory voices.
The phenomenological diversity of auditory verbal hallucinations (AVH) is not currently accounted for by any model based around a single mechanism. This has led to the proposal that there may be distinct AVH subtypes, which each possess unique (as well as shared) underpinning mechanisms. This could have important implications both for research design and clinical interventions because different subtypes may be responsive to different types of treatment. This article explores how AVH subtypes may be identified at the levels of phenomenology, cognition, neurology, etiology, treatment response, diagnosis, and voice hearer's own interpretations. Five subtypes are proposed; hypervigilance, autobiographical memory (subdivided into dissociative and nondissociative), inner speech (subdivided into obsessional, own thought, and novel), epileptic and deafferentation. We suggest other facets of AVH, including negative content and form (eg, commands), may be best treated as dimensional constructs that vary across subtypes. After considering the limitations and challenges of AVH subtyping, we highlight future research directions, including the need for a subtype assessment tool.
The international Hearing Voices Movement (HVM) is a prominent mental health service-user/survivor movement that promotes the needs and perspectives of experts by experience in the phenomenon of hearing voices (auditory verbal hallucinations). The main tenet of the HVM is the notion that hearing voices is a meaningful human experience, and in this article, we discuss the historical growth and influence of the HVM before considering the implications of its values for research and practice in relation to voice hearing.
Among other recommendations, we suggest that the involvement of voice-hearers in research and a greater
use of narrative and qualitative approaches are essential. Challenges for implementing user-led research are identified, and avenues for future developments are discussed
Little is known about the possible predictors of treatment outcome in early chronically sexually abused adults. The current study aimed to investigate what impact initial levels of dissociation and pre-treatment negative change in interpersonal functioning have on treatment response after 3 months of first-phase trauma inpatient treatment as well as after a period of 1 year the patients returned to their usual lives.
The sample comprised 48 inpatients with childhood sexual abuse histories and mixed trauma-related disorders who were examined at discharge and prospectively followed up for a period of 1 year under naturalistic conditions. Outcome variables were general psychiatric symptoms and interpersonal problems as measured with the Symptom Check List-Revised (SCL-R) and the Inventory of Interpersonal Problems (IIP) Circumplex.
The central findings were that pathological dissociation and deterioration in interpersonal functioning prior to admittance predicted general psychiatric symptom levels and interpersonal problems at the end of treatment and at 1-year follow-up. Pathological dissociation, involving memory and identity problems, alone predicted negative outcome at the end of treatment. The findings at 1-year follow-up indicate that it is not pathological dissociation in isolation that affects outcomes, but rather the interaction between dissociation and change in interpersonal functioning prior to treatment.
These findings indicate the need of addressing dissociation and interpersonal problems in treatment planning and favor an integrated treatment approach for complex trauma patients. Future research should investigate whether and how this leads to better outcome, including long-term maintenance of gains after the end of treatment.
A data synthesis is presented from 100 clinical cases, 80% with a diagnosis of schizophrenia or other psychotic disorder, in which Romme and Escher’s “con- struct” method was used to formulate voice-hearing content and characteristics in relation to life events. Across the sample, most participants heard between two and five voices and the average duration of voice hearing was 18 years. At least one adverse childhood experience was reported by 89% of the sample, including family conflict, neglect, physical/sexual/emotional maltreatment, and bullying. In addition, a broad range of acute, precipitating stressors were associ- ated with the onset of voice hearing itself in both childhood and adulthood. In 94% of cases, it was possible to clearly formulate the underlying emotional con- flicts embodied by the voices (e.g., low self-worth, anger, shame and guilt). Representations for voice identity (e.g., disowned aspects of self, a family mem- ber, a past abuser) were formulated in 78% of cases. It is proposed that many individuals hear voices that make psychological sense in the context of life events, and that this information can be clinically applied in ways that serve personal recovery.
Although people who hear voices may dialogue with them, they are regularly caught in destructive communication patterns that disturb social functioning. This article presents an approach called Talking With Voices, derived from the theory and practice of Voice Dialogue (Stone & Stone, 198930.
Stone , H. and Stone , S. 1989 . Embracing our selves: The voice dialogue training manual , New York , NY : Nataraj Publishing . View all references: Embracing our selves: The voice dialogue training manual, New York: Nataraj Publishing), whereby a facilitator directly engages with the voice(s) in order to heighten awareness and understanding of voice characteristics. The method provides insight into the underlying reasons for voice emergence and origins, and can ultimately inspire a more productive relationship between hearer and voice(s). We discuss the rationale for the approach and provide guidance in applying it. Case examples are also presented.
While auditory hallucinations are considered a core psychotic symptom, central to the diagnosis of schizophrenia, it has long been recognized that persons who are not psychotic may also hear voices. There is an entrenched clinical belief that distinctions can be made between these groups, typically on the basis of the perceived location or the ‘third-person’ perspective of the voices. While it is generally believed that such characteristics of voices have significant clinical implications, and are important in the differential diagnosis between dissociative and psychotic disorders, there is no research evidence in support of this. Voices heard by persons diagnosed schizophrenic appear to be indistinguishable, on the basis of their experienced characteristics, from voices heard by persons with dissociative disorders or with no mental disorder at all. On this and other bases outlined below, we argue that hearing voices should be considered a dissociative experience, which under some conditions may have pathological consequences. In other words, we believe that, while voices may occur in the context of a psychotic disorder, they should not be considered a psychotic symptom.
Growing evidence suggests a meaningful association between life experience, particularly trauma and loss, and subsequent psychotic symptomatology. This paper describes a method of psychological formulation to analyse the relation- ship between the content and characteristics of voices (“auditory hallucinations”) and experienced adversity in the life of the voice-hearer. This systematic process of enquiry, termed a construct, is designed to explore two questions: (1) who or what might the voices represent; and (2) what social and/or emotional problems may be represented by the voices? The resulting information provides the basis for an individualized psychotherapeutic treatment plan that examines the influ- ence of interpersonal stress in creating vulnerability for emotional crises (i.e. psychological predisposition) and the personally significant events that cluster before onset or relapse (i.e. the actual stressors which provoke voice onset or continuance). A case example using this method is presented.
This secondary analysis of data from a randomized controlled trial of cognitive processing therapy (CPT) and its constituent components investigated whether dissociation decreased over the course of treatment primarily targeting symptoms of posttraumatic stress disorder (PTSD) and explored whether levels of dissociation predicted treatment outcome differentially by treatment condition.
An intention to treat sample of 150 women were randomized to CPT, cognitive therapy only (CPT-C) or written trauma accounts only (WA). Dissociation was measured by the dissociation subscale of the Traumatic Stress Inventory and the Multiscale Dissociation Inventory.
Multilevel regression analyses revealed significant decreases in dissociation that did not vary as a function of treatment condition. Growth curve modeling revealed significant treatment condition by dissociation interactions such that the impact of pretreatment levels of dissociation impacted the treatment conditions differently.
Women who endorsed low pretreatment levels of dissociation responded most efficiently to CPT-C, whereas women with the highest levels of dissociation, in particular high levels of depersonalization, responded better to CPT.
Cognitive behavior therapy (CBT) evolved from behavioral theory and developed to focus more on cognitive models that incorporated
reappraisal of thinking errors and schema change strategies. This article will describe the key elements of CBT for schizophrenia
and the current evidence of its efficacy and effectiveness. We conclude with a description of recent concepts that extend
the theoretical basis of practice and expand the range of CBT strategies for use in schizophrenia. Mindfulness, meta-cognitive
approaches, compassionate mind training, and method of levels are postulated as useful adjuncts for CBT with psychotic patients.
Auditory hallucinations in psychosis often contain critical evaluations of the voice-hearer (for example, attacks on self-worth). A voice-hearer's experience with their dominant voice is a mirror of their social relationships in general, with experiences of feeling low in rank to both voices and others being associated with depression. However, the direction of the relationship between psychosis, depression and feeling subordinate is unclear.
Covariance structural equation modelling was used with data from 125 participants diagnosed with schizophrenia to compare three 'causal' models: (1) that depression leads to the appraisal of low social rank, voice power and distress; (2) that psychotic illness leads to voice activity (frequency, audibility), which in turn leads to depression and the appraisal of voices' power; (3) our hypothesized model, that perceptions of social rank and social power lead to the appraisal of voice power, distress and depression.
Findings supported model 3, suggesting that the appraisal of social power and rank are primary organizing schema underlying the appraisal of voice power, and the distress of voices.
Voices can be seen to operate like external social relationships. Voice content and experience can mirror a person's social sense of being powerless and controlled by others. These findings suggest important new targets for intervention with cognitive and social therapy.
Evidence suggests that dissociation is associated with psychotic experiences, particularly hallucinations, but also other symptoms. However, until now, symptom-specific relationships with dissociation have not been comprehensively synthesized. This is the first prospectively registered (CRD42017058214) meta-analysis to quantify the magnitude of association between dissociative experiences and all symptoms of psychosis. MEDLINE, PsycINFO, PubMed, and Scopus databases were searched using exhaustive terms denoting dissociation and psychotic symptoms. We included both nonclinical (58 studies; 16 557 participants) and clinical (46 studies; 3879 patient participants) samples and evaluated study quality. Ninety-three eligible articles considering 20 436 participants were retained for analysis. There was a robust association between dissociation and clinical and nonclinical positive psychotic symptoms (r = .437; 95%CI: .386 -.486), with the observed effect larger in nonclinical studies. Symptom-specific associations were also evident across clinical and nonclinical studies, and included significant summary effects for hallucinations (r = .461; 95%CI: .386 -.531), delusions (r = .418; 95%CI: .370 -.464), paranoia (r = .447; 95%CI: .393 -.499), and disorganization (r = .346; 95%CI: .249 -.436). Associations with negative symptoms were small and, in some cases, not significant. Overall, these findings confirm that dissociative phenomena are not only robustly related to hallucinations but also to multiple positive symptoms, and less robustly related to negative symptoms. Our findings are consistent with proposals that suggest certain psychotic symptoms might be better conceptualized as dissociative in nature and support the development of interventions targeting dissociation in formulating and treating psychotic experiences.
Objective:
Increasing evidence suggests experiences of childhood trauma may be causally related to the development of hallucinations. Cognitive theories of psychosis suggest post-traumatic intrusions to be a primary mechanism in this relationship. These theories predict that the content of hallucinations will be related to traumatic experiences; however, few studies have investigated this. This study examined the relationship between childhood trauma, the content of hallucinations, and the content of post-traumatic intrusions in a sample with first-episode psychosis.
Methods:
Sixty-six young people aged 15-25 experiencing a first episode of psychosis were recruited from an early intervention service. Participants completed assessments of traumatic experiences, hallucination content, and post-traumatic intrusion content using a systematic coding frame. The coding frame assessed for three types of relationships between traumatic experiences, the content of hallucinations, and the content of post-traumatic intrusions: direct relationships (hallucination content exactly matching the trauma/intrusion), thematic relationships (hallucinations with the same themes as the trauma/intrusion), and no relationship (hallucination and trauma/intrusion content unrelated).
Results:
Of those people who reported trauma and hallucinations (n = 36), 22 of these (61%) experienced post-traumatic intrusions, and of these, 16 (73%) experienced hallucinations that were directly or thematically related to their post-traumatic intrusions. Twelve people experienced hallucination content directly related to their trauma, six of whom (50%) also had intrusions relating to the same traumatic event as their hallucinations.
Conclusions:
The finding that some people experience hallucinations and post-traumatic intrusions relating to the same traumatic event supports theories proposing a continuum of memory intrusion fragmentation. These results indicate that early intervention services for young people with psychosis should provide assessment and intervention for trauma and PTSD and should consider the impact of past traumatic events on the content of current hallucinatory experience.
Practitioner points:
Trauma and post-traumatic stress disorder should be assessed in those experiencing a first episode of psychosis. Interventions for trauma should be offered in early intervention for psychosis services. In a notable proportion of people, hallucination content is related to traumatic experiences. Clinical assessment and formulation of hallucinations requires consideration of how past traumatic events may be contributing to hallucinatory experience. It is important for clinicians to have an understanding of the phenomenological differences between hallucinations and post-traumatic intrusions when conducting clinical assessments with people with comorbid psychosis and PTSD.
Over the past three decades in Maastricht, the Netherlands, psychiatrist Marius Romme and researcher Sandra Escher have developed a new approach to hearing voices which emphasizes accepting and making sense of the experience. Since Romme and Escher's initial work, substantial empirical support has been provided for the Maastricht approach's key propositions. The alternative approach of the Maastricht model is based on helping people make sense of their voices and learning to cope and relate with them. A clinical strategy particularly associated with this endeavour is the Maastricht Hearing Voices Interview (MHVI). In the Voice Dialogue method, every person is viewed as consisting of many individual selves or sub‐personalities, each with its own personal history, physical characteristics, emotional and physical reactions, and ways of perceiving the world. The Maastricht approach rejects the conception of voice hearing as a meaningless pathological symptom and, instead, emphasizes the need to place the experience within an interpersonal context.
NICE guidelines recommend use of treatment protocols that have trial-based evidence of efficacy to guide the delivery of CBT for psychosis. The rationale for using such an approach, and a manual that has been used to ensure fidelity and adherence within six clinical trials, is described. The protocol emphasises principles and values, such as collaborative teamwork, active participation involving between session tasks for service users and therapists and a normalising philosophy, as well as specific milestones such as early agreement of a shared goal, maintenance formulations and use of defined change strategies. Challenges to implementation and methods for promoting good practice are considered and implications for future research and practice are discussed.
Despite the long association between auditory verbal hallucinations (AVH) or voice hearing and schizophrenia, recent research has demonstrated AVH's presence in other disorders and in persons without a diagnosis, particularly amongst those with a history of traumatization. But are there differences in the type of voices between these populations?
Cognitive behavioural therapy for psychosis (CBTp) is, at times, perceived as a technical therapy that undervalues the importance of human relationships and the fundamental principles on which CBTp itself is based (such as collaboration, validation, optimism and recovery-orientated practice). As such, it can be dismissed by service users or practitioners as undesirable. It is also possible that delivering CBTp that does not adhere to these values can be unhelpful or harmful. We review the evidence regarding what service users want from mental health services and the ability of CBTp to meet these standards. Evidence from qualitative studies and randomised controlled trials suggests that CBTp should be delivered in a manner that is both acceptable to, and empowering of, service users. We suggest strategies that are likely to maximise the likelihood of successful implementation that is consistent with both values base and evidence base.
Auditory hallucinations (AH) are a common and distressing experience and patients report distress reduction to be a priority. Relating Therapy adopts a symptom-specific and mechanism focused approach to the reduction of AH distress. We conducted this single-blind, pragmatic, parallel groups, superiority pilot RCT within a single mental health centre in the UK. Patients (18+years) with persistent and distressing AH, irrespective of diagnosis were randomly allocated to receive either Relating Therapy and Treatment-as-usual (RT) or Treatment as-usual alone (TAU). Assessment of outcome was completed pre-randomisation (T0), 16weeks post-randomisation (T1) and 36weeks post-randomisation (T2). The primary outcome was the 5-item Distress scale of the Psychotic Symptoms Rating Scale - Auditory Hallucinations (PSYRATS-AHRS) at T1. We randomly assigned 29 patients to receive RT (n=14) or TAU (n=15). Twenty-five patients (86%) provided complete datasets. Compared with TAU, RT led to reductions in AH distress in the large effect size range across T1 and T2. Our findings suggest that Relating Therapy might be effective for reducing AH distress. A larger, suitably powered phase 3 study is needed to provide a precise estimate of the effects of Relating Therapy for AH distress.
Background: There is a need for improved psychosocial interventions for distressed voice hearers.
Aims: To evaluate a novel approach to hearing voices: Experience Focused Counselling (EFC) aka Making Sense of Voices.
Study design and methods: Twelve voice hearers were randomly assigned to a 44-week EFC or Treatment As Usual intervention as part of a pilot study design.
Results: At the end of intervention, EFC showed clinically large treatment effect improvements on the Brief Psychiatric Rating Scale – Expanded Version psychotic symptoms (Cohen’s d=1.6) and overall psychopathology domains (d=1.3), and the Psychotic Symptom Rating Scales voices (d=1) and delusions (aka non-shared reality) (d=1) scales. EFC voice hearers also felt more able to do first trauma disclosures (n=4) than TAU group voice hearer (n=1).
Discussion: EFC improvements may have been related to the focus on reducing voices-related distress. EFC holds some promise as a safe and effective intervention for voice hearers, with possible improvements in general psychopathology, psychosis, voices and non-shared reality (aka delusions)-related distress. This will need replicating in more powerful studies.
Auditory hallucinations are relatively common in those with chronic trauma disorders (12–98 %). They typically begin after a traumatic event and following the development of trauma-related disorders. They often contain themes related to trauma. Auditory hallucinations in chronic trauma disorders are commonly negative in content, heard inside the head or both inside and outside the head, occur relatively frequently, and cause distress. Those with PTSD who experience auditory hallucinations often have experienced more severe trauma and have a more severe symptom presentation than those who do not experience them. Dissociation, especially depersonalization, has been routinely linked to post-traumatic auditory hallucinations. As a phenomenon, depersonalization may transform mental activity into strange and foreign experiences that manifest as auditory hallucinations. Yet, depersonalization seems unable to account for many of the key features of auditory hallucinations. Structural dissociation at the level of personality, either in isolation or in combination with depersonalization, seems to offer a more complete account of auditory hallucinations in chronic trauma disorders.
There are an increasing number of studies exploring the association between voice-hearing (auditory verbal hallucinations) and dissociative experiences. The current study provides a systematic literature review and meta-analytic synthesis of quantitative studies investigating the relationship between voice-hearing and dissociation. A systematic search identified and included 19 clinical studies, comprising 1620 participants, and 12 non-clinical studies, comprising 2137 participants, published between 1986 and 2014. Nineteen of these studies provided sufficient data to be included within the meta-analysis. The narrative review findings suggested that dissociative experiences may be implicated in voice-hearing, and may potentially be a mediating factor within the well-established trauma and voice-hearing relationship. Similarly, the meta-analytic findings suggested that the majority of the identified studies showed a significant positive relationship between dissociative experiences and voice-hearing. The magnitude of the summary effect was large and significant (r=.52), indicating a robust relationship between these two phenomena. However, considerable heterogeneity within the meta-analytic results and methodological limitations of the identified studies were evident, highlighting areas for future investigation. As the majority of the studies were cross-sectional by design, we recommended future research to include longitudinal designs with a view to exploring directional effects. Additionally, future studies should control for potential confounding factors. Clinical implications of the findings were also considered.
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A cognitive approach to the understanding of psychotic symptoms that focuses on the interpretation of intrusions into awareness is outlined. It is argued that many positive psychotic symptoms (such as hallucinations and delusions) can be conceptualized as intru-sions into awareness or culturally unacceptable interpretations of such intrusions, and that it is the interpretation of these intrusions that causes the associated distress and disability. It is also argued that the nature of these interpretations is affected by faulty self and social knowledge and that both the intrusions and their interpretations are maintained by mood, physiology, and cognitive and behavioural responses (including selective attention, safety behaviours and counterproductive control strategies). The literature is reviewed and found to be compatible with such a model and the clinical implications are discussed.
A substantial proportion of Borderline Personality Disorder (BPD) patients respond by a marked decrease of psychopathology when treated with Dialectical Behavioral Therapy (DBT). To further enhance the rate of DBT-response, it is useful to identify characteristics related to unsatisfactory response. As DBT relies on emotional learning, we explored whether dissociation-which is known to interfere with learning- predicts poor response to DBT. Fifty-seven Borderline Personality Disorder (BPD) patients (DSM-IV) were prospectively observed during a three-month inpatient DBT program. Pre-post improvements in general psychopathology (SCL-90-R) were predicted from baseline scores of the Dissociative Experiences Scale (DES) by regression models accounting for baseline psychopathology. High DES-scores were related to poor pre-post improvement (β = -0.017 ± 0.006, p = 0.008). The data yielded no evidence that some facets of dissociation are more important in predicting DBT-response than others. The results suggest that dissociation in borderline-patients should be closely monitored and targeted during DBT. At this stage, research on treatment of dissociation (e.g., specific skills training) is warranted.
Although an association between hallucinations and sexual abuse has been documented, the relation between specifically auditory verbal hallucinations (AVHs) and childhood sexual abuse (CSA) is less clear. This study reviewed quantitative studies of AVHs and CSA. 36% of psychiatric patients with AVHs, and 22% of non-psychiatric patients with AVHs, reported CSA. At least 16% of the general population with auditory hallucinations also reported CSA. The majority of studies reviewed found that those with AVHs were more likely to be survivors of CSA than individuals without AVHs. 56% of psychiatric patients with CSA reported AVHs, and at least 21% of the general population with CSA reported auditory hallucinations. A majority of studies found survivors of CSA were more likely to report AVHs than individuals without CSA. Ability to impute a causal role for CSA was impaired by such studies' failures to control for potentially confounding variables. Yet, studies of AVH content showed links between the content of voices and the content of CSA in some voice-hearers. It is concluded that although a clear association between CSA and AVHs exists, there is not yet reliable quantitative evidence of a causal relation. Implications for mental health professionals and for future research, are discussed.
We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations.
Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology
- D. Corstens
- S. Escher
- M. Romme
- E. Longden
EMDR and dissociation. The progressive approach
- A. Gonzalez
- D. Mosquera
Psychosis as a personal crisis: An experience based approach
- D. Corstens
- R. May
- E. Longden
Coping with trauma‐related dissociation: Skills training for patients and therapists
- S. Boon
- K. Steele
- O. Hart
Attachment theory and psychosis: Current perspectives and future directions
- E. Longden
- D. Corstens
Embracing our selves: The Voice Dialogue training manual
- H. Stone
- S. Stone
Embracing your inner critic: Turning self‐criticism into a creative asset
- H. Stone
- S. Stone
Making sense of voices: A guide for mental health professionals working with voice‐hearers
- M. Romme
- S. Escher
Trauma model therapy: A treatment approach to trauma, dissociation, and complex comorbidity
- C. A. Ross
- N. Halpern