Imagery-Focused Therapy for Visual Hallucinations: A Case Series.

INTRODUCTION: Visual hallucinations (VH) are more common than previously thought and are linked to higher levels of distress and disability in people with a psychotic illness. Despite this, scant attention has been given to VHs in the clinical literature, and the few therapy case series of cognitive behavioural therapy (CBT) published to date have not demonstrated reliable change. In other areas of clinical research, problematic mental imagery has been found to be more strongly related to negative affect in psychological disorders than negative linguistic thinking, and imagery focused techniques have commonly been found to improve the outcomes in CBT trials. Given VHs have many similarities with visual mental imagery and many of the distressing beliefs associated with VHs targeted in CBT are maintained by accompanying mental imagery (i.e., imaging a hallucinated figure attacking them), it seems plausible that an imagery-focused approach to treating VHs may be most effective. METHODS: The current study is a multiple baseline case series (N = 11) of a 10-session imagery-focused therapy for VH in a transdiagnostic sample. RESULTS: The study had good attendance and feedback, no adverse events and only one [seemly unrelated] drop-out, suggesting good feasibility, safety and acceptability. The majority of clients reported reduction on both full-scale measures (administered at 3 baselines, midtherapy, posttherapy and 3-month follow-up) and weekly measures of VH severity and distress, ranging from medium to large effect sizes. CONCLUSIONS: The case series suggests that an imagery-focused approach to treating VHs may be beneficial, with a recommendation for more rigorous clinical trials to follow.

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.

Emotional and non-emotional mental imagery and auditory verbal hallucinations (hearing voices): A systematic review of imagery assessment tools.

It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non-emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non-emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full-text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non-emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non-emotional mental imagery.

A narrative review of psychological theories of post-traumatic stress disorder, voice hearing, and other psychotic symptoms.

BACKGROUND: Most voice hearers report childhood trauma. Many voice hearers report comorbid post-traumatic stress symptoms and that the content of their voices (auditory verbal hallucinations) is directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma is thematically similar) related to their trauma. The factors that maintain trauma-related voices are unknown, and there is limited research in this area. This study aimed to identify potential maintaining factors of trauma-related voices by reviewing models of post-traumatic stress disorder (PTSD) and positive symptoms of psychosis. METHOD: Models of PTSD and positive symptoms were reviewed to identify potential factors that are unique and common to both sets of symptoms. RESULTS: We reviewed 10 models of PTSD, 4 models of positive symptoms, and 2 trauma-informed models of voice hearing. One model provided a theoretical explanation of different types of trauma-related voices. Twenty-one factors were extracted from 16 theoretical models. No existing model incorporated all these factors. DISCUSSION: Existing PTSD and positive symptom models present a range of common and unique factors. There may be value in extending existing integrative models to include a broader range of potential factors that could explain different pathways to, and expressions of, trauma-related voices. A future research agenda is presented to investigate how such an extension could lead to more complete individualized case formulations and targeted treatments.

The role of self-compassion on the relationship between trauma and hearing voices.

Traumatic life events are associated with increased risk of hearing voices and posttraumatic stress (PTS) symptoms have been implicated in this relationship. Studies indicate that increased self-compassion is associated with reduced PTS symptoms and voice-distress. The present study sought to examine whether self-compassion moderated the relationship between PTS symptoms and voice-distress. Self-report and clinician-administered questionnaires were used to measure self-compassion, PTS symptom severity, voice-frequency, and voice-distress in 62 trauma-affected voice-hearers who presented to a community voice-hearing clinic. Correlation analyses revealed that PTS symptom severity was positively correlated with voice-distress, but not voice-frequency, and that self-compassion was negatively correlated with voice-distress and PTS symptom severity. While self-compassion did not moderate the relationship between PTS symptom severity and voice-distress, it was associated with a significant reduction in voice-distress, at all levels of PTS symptom severity. Preliminary findings suggest self-compassion may play an important role in reducing voice-distress and thus warrant further consideration of self-compassion as a target in treatment for help-seeking voice-hearers.

Delivering Imagery Rescripting via Telehealth: Clinical Concerns, Benefits, and Recommendations.

PURPOSE OF THE REVIEW: Delivery of psychological therapies via telehealth has increased with the emergence of the COVID-19 pandemic. Therapists may be hesitant in moving to telehealth when delivering therapies targeting memories of traumatic experiences. This paper collates the clinical experiences of clinicians and clients who have delivered or received imagery rescripting, respectively, via telehealth across a range of clinical presentations, and describes key clinical considerations and recommendations. RECENT FINDINGS: It is important to consider perceived and real safety; practical and technological issues; therapeutic alliance; depth of emotional processing; and dissociation. There was support for the delivery of imagery rescripting via telehealth being no less effective than face-to-face delivery; however, telehealth delivery was not a viable option for many clients during COVID-19 lockdowns who were living in high density housing, old houses with thin walls, or with some complex disorders.

Changing Healthcare Professionals' Attitudes Towards Voice Hearers: An Education Intervention.

Despite being a relative common experience, hearing voices remains highly stigmatised, with serious consequences. Numerous interventions have been developed to reduce stigma towards mental illness in general, however most have failed to include implicit measures of stigma, and these have yet to be applied to hearing voices. The current study examined the efficacy of an education intervention in changing the explicit and implicit stigma held by healthcare professionals (N = 59) towards voice hearers. Results indicated that the education intervention led to significant decreases in explicit but not implicit measures of stigma, though participants demonstrated relatively positive baseline implicit attitudes towards voice hearers. These findings suggest that education interventions could be one way of reducing stigma towards voice hearers. Further research is necessary to explore the impact of education interventions in samples with more negative baseline attitudes, such as early career professionals, students, and the general population.

Changing Attitudes Towards Voice Hearers: A Literature Review.

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

An exploration of relationship between self-compassion and voice-related distress in people who hear voices.

OBJECTIVE: The cognitive behavior model of voice hearing suggests individuals who have lower self-esteem, perceive themselves to be of low social rank, and hold negative beliefs about their voices, are more distressed by their voices. Self-compassion may help reduce voice-related distress through the activation of positive self and social mentalities. The aim of the present study was to examine the role of self-compassion in variables within the cognitive behavior model. METHOD: Measures assessing self-compassion, negative affect, self-esteem, voice malevolence, omnipotence, and distress were administered to a sample of clinical voice hearers (N = 53). RESULTS: Correlation and mediation analyses were conducted. Higher self-compassion was associated with lower negative affect, voice malevolence, omnipotence, and distress. Voice malevolence was found to mediate the relationship between self-compassion and voice distress. Self-compassion was a stronger predictor of these constructs than self-esteem. CONCLUSION: Improving self-compassion may have significant clinical benefits in reducing voice-related distress.

Assessing the clinical significance of treatment outcomes for distressing voices in routine clinical practice.

Determining reliable and clinically significant change is central to evidence-based practice yet rarely used in routine clinical settings. This paper illustrates these methods in the context of an evaluation of cognitive behaviour therapy for distressing auditory hallucinations ("voices"). We used data from a clinical sample attending Perth Voices Clinic, a transdiagnostic outpatient service for distressing voices, and a previously published reference sample of healthy voice hearers. Our outcomes on the primary measure of voice distress, derived from a previous factor analysis of the Psychotic Symptom Rating Scale-Auditory Hallucinations subscale, showed that 62.9% of clients were classified as Recovered/Improved, 35.5% were classified as Unchanged, and 0.02% were classified as Deteriorated. Partial support for the validity of these classifications was obtained from the scores on the Depression, Anxiety, Stress Scales (Lovibond & Lovibond, 1995) but not on the Social and Occupational Functional Assessment Scale (Goldman et al., 1992). Clients classified as Recovered showed better emotional functioning on the Depression, Anxiety, Stress Scales compared with those who did not make a clinically significant change in voice distress. A tool is provided to assist practitioners to evaluate whether individual clients have benefited from therapy for distressing voices or not, which can be used to guide future treatment decisions (https://osf.io/gd9e5/).

Study protocol: a randomised controlled trial of a telephone delivered social wellbeing and engaged living (SWEL) psychological intervention for disengaged youth.

BACKGROUND: Internationally, from 12.2-23.4% of youth (aged 16-24 years) are not in employment, education or training (NEET). These disengaged youth are more likely to experience social exclusion, increased psychological distress and poor quality of life. Youth at risk of disengagement are less likely to access traditional support services, requiring development of innovative interventions. METHODS: The trial is a single blind, three arm, randomised controlled trial evaluating the effectiveness of a telephone delivered psychological intervention for disengaged youth (12-25 years). Participants will be randomised to receive either (i) SWEL, (ii) Befriending, or (iii) Single Session Psycho-Education. Therapy will be over an 8 week period with a minimum of four and maximum of eight sessions for the SWEL or Befriending conditions, or a single session for the Psycho-Education condition. Outcomes will be assessed at baseline and at 2, 8 and 14-month follow-up with the primary outcome being re-engagement in education, training or employment. DISCUSSION: This large, multi-site, randomised controlled trial will inform the delivery of services for young people at risk of disengaging from education or training. The provision of psychological therapy by telephone increases access by youth - especially those in rural and remote areas - both to the trial and the treatment, if adopted by services. The outcomes of this trial could have meaningful societal impact for a vulnerable population. It is expected that recruitment, intervention and retention will present challenges for the trial given the focus on disengaged youth. TRIAL REGISTRATION: ANZCTR, ACTRN12614001212640 , Registered 18 Nov 2014. Retrospectively registered. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the participating institutions. Results of the trial will be submitted for publication in peer reviewed journals and findings presented at scientific conferences and to key service providers and policy makers.

Imagery rescripting for the treatment of trauma in voice hearers: a case series.

BACKGROUND: High rates of trauma and post-traumatic stress disorder (PTSD) are reported in people who hear voices (auditory hallucinations). A recent meta-analysis of trauma interventions in psychosis showed only small improvements in PSTD symptoms and voices. Imagery Rescripting (ImRs) may be a therapy that is more effective in this population because it generalizes over memories, which is ideal in this population with typically repeated traumas. AIMS: The primary aims of this study were to investigate whether ImR reduces (1) PTSD symptoms, and (2) voice frequency and distress in voice hearers. METHOD: We used a single arm open trial study, case-series design. Twelve voice hearers with previous traumas that were thematically related to their voices participated. Brief weekly assessments (administered in sessions 1-8, post-intervention, and at 3-month follow-up) and longer measures (administered pre-, mid- and post-intervention) were administered. Mixed regression analysis was used to analyse the results. RESULTS: There was one treatment drop-out. Results of the weekly measure showed significant linear reductions over time in all three primary variables - voice distress, voice frequency, and trauma intrusions - all with large effect sizes. These effects were maintained (and continued to improve for trauma intrusions) at 3-month follow-up. On the full assessment tools, all measures showed improvement over time, with five outcomes showing significant time effects: trauma, voice frequency, voice distress, voice malevolence and stress. CONCLUSIONS: The findings of the current study suggest that ImRs for PTSD symptoms is generally well tolerated and can be therapeutically beneficial among individuals who hear voices.

Evaluating the "C" and "B" in brief cognitive behaviour therapy for distressing voices in routine clinical practice in an uncontrolled study.

Brief and single-symptom forms of cognitive behaviour therapy (CBT) for distressing voices may increase access to evidence-based psychological therapy and transcend diagnostic barriers. The current study evaluated the "C" and "B" in CBT for distressing voices in a transdiagnostic voices clinic. The B module (component of therapy) sought to enhance coping with voices, and the C module evaluated the accuracy of negative beliefs about the self and voices. The aims of the study were to investigate (a) whether modules B and/or C led to significant and clinically meaningful improvements on the primary outcome of voice-related distress, and (b) if changes in beliefs about self and voices (proposed change mechanisms) underpinned changes in voice distress across module C. Each module consisted of four sessions, individually tailored yet manualized, and designed with ease of staff training and delivery in mind. Assessment measures were administered at baseline (T1), post-module B (T2), and post-module C (T3). The results (N = 62) showed statistically significant medium-sized pre- and post-effects for voice-related distress from T1 to T2 and from T2 to T3, with large effects from T1 to T3. Just over half of the clients reported clinically meaningful improvements from T1 to T3. Neither beliefs about self nor voices were found to mediate improvements in voice distress during module C. The findings from this study suggest that both the B and C in CBT for voices can contribute to positive outcomes within routine clinical practice.

Brief coping strategy enhancement for distressing voices: Predictors of engagement and outcome in routine clinical practice.

Cognitive behaviour therapy is recommended internationally as a treatment for psychosis (targeting symptoms such as auditory hallucinations, or "voices"). Yet mental health services are commonly unable to offer such resource-intensive psychological interventions. Brief, symptom-specific and less resource-intensive therapies are being developed as one initiative to increase access. However, as access increases, so might the risk of offering therapy to clients who are not optimally disposed to engage with and benefit from therapy. Thus, it is important to identify who is most/least likely to engage with and benefit from therapy, and when. In the current study, 225 clients were assessed for suitability for a brief, 4-session, manualized, cognitive behaviour therapy-based intervention for voices (named coping strategy enhancement therapy) and 144 commenced therapy, at a transdiagnostic voices clinic based in Sussex, UK. This article reports on the value of depression, anxiety, stress, insight into the origin of voices, length of voice hearing, and demographics in the prediction of engagement and outcomes. The study found that higher levels of baseline depression, anxiety, and stress were significantly associated with poorer outcomes, especially if clients also had high levels of voice-related distress. The engagement analyses showed that levels of voice-related distress at baseline predicted dropout. These findings highlight the importance of assessing negative affect and voice-related distress prior to commencing therapy for distressing voices, to help determine if the client is suitable or ready for brief-coping strategy enhancement.

Multi-modal hallucinations across diagnoses: What relationships do they have with voice-related distress?

BACKGROUND: Research into hallucinatory experiences has focused primarily upon hallucinations within the auditory modality, to the relative neglect of other modalities. Furthermore, the exploration of auditory hallucinations (or 'voices') has focused primarily upon the experiences of people with a diagnosis of psychosis. The presence of multi-modal hallucinations may have implications across diagnoses for levels of distress, formulation and the targeting of psychological interventions. METHODS: This study presents a cross-sectional analysis of observational data from the PREFER survey (N = 335). Linear regression was used to explore the relationships between voice-related distress and the presence, number, type and timing of multi-modal hallucinations. RESULTS: Simple relationships were not found between distress and the presence of hallucinations in visual, tactile, olfactory or gustatory modalities, or in the number of modalities experienced. When considering the degree to which another modality hallucination was experienced simultaneously with voices, there was some evidence that the degree of co-occurrence with visual hallucinations was predictive of distress. CONCLUSIONS: The co-occurrence of voices with visual hallucinations may be associated with relatively greater distress, but not consistently, and the association between multimodal hallucinations and clinical impact appear complex and potentially variable from individual to individual. Further study of associated variables such as perceived voice power may further illuminate these relationships.

Cognitive Behavioural Relating Therapy (CBRT) for voice hearers: a case study.

BACKGROUND: There has been a recent focus on the interpersonal nature of the voice hearing experience, with studies showing that similar patterns of relating exist between voice hearer and voice as between voice hearer and social others. Two recent therapeutic approaches to voices, Cognitive Therapy for Command Hallucinations and Relating Therapy, have been developed to address patterns of relating and power imbalances between voice hearer and voice. AIMS: This paper presents a novel intervention that combines elements of these two therapies, named Cognitive Behavioural Relating Therapy (CBRT). METHOD: The application of CBRT is illustrated through a clinical case study. RESULTS: The clinical case study showed changes in patterns of relating, improved self-esteem and reductions in voice-related distress. CONCLUSIONS: The outcomes provide preliminary support for the utility of CBRT when working with voice hearers.

An exploration of the relationship between voices, dissociation, and post-traumatic stress disorder symptoms.

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.

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.

Pathways from trauma to unusual perceptual experiences: Modelling the roles of insecure attachment, negative affect, emotion regulation and dissociation.

BACKGROUND: A range of traumas have been linked to voices (auditory verbal hallucinations) and unusual perceptual experiences (UPEs) in other perceptual-sensory domains. Models of PTSD and positive symptoms of psychosis are insufficient in explaining the relationship between trauma and voices. The trauma-related voices (TRV) model was developed to generate novel research in this area. AIMS: This study aimed to investigate pathways from trauma to the frequency of UPEs based on a subset of hypothesised relationships in the TRV model. MATERIALS: The PTSD Diagnostic Scale for DSM-5, State Adult Attachment Measure, Depression Anxiety and Stress Scales-21, Perth Emotion and Regulation Competency Inventory, Dissociative Experiences Measure Oxford, and Multi-modality Unusual Perceptual Experiences Questionnaire. METHODS: We used path analysis in a non-clinical sample (N = 528) to model indirect effects from diverse trauma experiences to the frequency of multi-sensory UPEs via a subset of mediators within the TRV model: insecure attachment, emotion regulation deficits, negative affect and dissociation. RESULTS: Our model was an excellent fit to the data and accounted for 37.1% of variance in UPE frequency, and all direct (ßs = .14-.61) and indirect pathways (ßs = .01-.08) were significant (ps < .001). DISCUSSION: Our findings suggest that insecure attachment may link diverse trauma experiences to emotion regulation deficits and negative affect, which are linked to UPE frequency via dissociation. CONCLUSION: Our findings provide preliminary evidence for a subset of relationships within the TRV model. Future studies are needed to gather stronger evidence of temporality and causation between these factors, and to test broader pathways within the TRV model.

The role of social schema in the experience of auditory hallucinations: a systematic review and a proposal for the inclusion of social schema in a cognitive behavioural model of voice hearing.

UNLABELLED: The interpersonal nature of the voice-hearing experience has been highlighted in recent studies investigating whether social processes (or 'schemas') that guide interpersonal interactions also govern the relationship between voice hearer and voice. A systematic literature review of relevant studies was undertaken, including those that investigated how social processes interact with appraisals of voices, as well as affective and behavioural responding to voices. The review included 13 studies published between 2000 and 2010. Two well-replicated findings emerged from the review. First, voice hearers who perceive themselves to be of low social rank (inferior) relative to others also feel inferior in relation to their voice and behave accordingly. Second, responding to voices from a position of closeness/dependency is associated with least distress. The review advocates for an extension of the Chadwick and Birchwood cognitive behavioural model of voices to include the mediating role of social schemata in explaining the affective and behavioural responses to voices. Only two interventions have yet targeted social schema variables utilizing different therapeutic approaches, both with some success. These clinical studies, as well as clinical implications drawn from the reviewed literature, will be discussed. KEY PRACTITIONER MESSAGE: Social processes governing relationships in the real world are also at play in the relationship between voice hearer and voice. Social schemas also shape beliefs about-and responses to-voices and thus are important to target in therapy. Voice hearers may be able to develop a more equal, and thus less distressing, relationship with their voice by improving their perceived social rank relative to others. This may be achieved through assertiveness training, social skills training and/or self-esteem work. Cognitive behavioural therapy techniques can be instrumental in helping an individual to consider the beliefs they hold about their voices and the way in which they respond and relate to them. Addressing how past traumatic experiences have influenced the voice hearer's relationships with others and their voices in therapy is recommended.