Abstract
Trauma, voice hearing, and dissociation tend to be closely linked. Cognitive models of voice hearing largely agree that traumatic events may predispose people to voice hearing via dissociative processes. While treating trauma in voice hearers may help to reduce voice distress and frequency, dissociation may be a barrier to this therapeutic work. This case series reports on the dissociative experiences of a subsample of voice hearing clients who reported dissociation during Imagery Rescripting (ImRs) for trauma (N = 6, 50% of original sample) in the case series study reported on previously (Paulik et al., 2019). The aims in the current paper were to explore the impact of dissociation on outcomes, the type of dissociative experiences encountered, where in the ImRs protocol they occurred, and the use of therapeutic techniques to address them. We found that clients who dissociated during therapy showed reductions in their trauma intrusions and voice-related distress and frequency. However, when compared to nondissociators, these benefits took more sessions to achieve. The most common types of dissociation were flashbacks, losing control over the image, emotional detachment, and trance/absorbed state. These were most likely to occur at points during the therapy where negative affect was heightened. Grounding and soothing techniques, as well as strategies to reduce the level of negative affect, were reported effective by participants in preventing or interrupting dissociation. We recommend that dissociation should not be a barrier to implementing imagery rescripting with this group.
Highlights
A LTHOUGH hearing voices is commonly associated with psychosis, the experience can appear in people with other mental health disorders, including posttraumatic stress disorder (PTSD), dissociative identity disorder, mood disorders, personality disorders, or in people with no disorder at all (Aleman & Laroi, 2008)
Despite experiencing episodes of dissociation during the rescripting procedure, most clients who dissociated made improvements in PTSD-related intrusions, voice frequency and voice distress on completion of therapy, as seen from the data reported in Tables 2 and 3 and Figure 1
On the basis of our examination of the types and patterns of dissociation during Imagery rescripting (ImRs), we make recommendations regarding adaptations to the treatment protocol and assessment, as well as means of preventing, managing, and monitoring dissociation when this occurs. This case series was comprised of a subsample of voice hearing clients who reported dissociation during Imagery Rescripting for trauma (N = 6, 50% of original sample) in the case series reported on previously (Paulik et al, 2019)
Summary
A LTHOUGH hearing voices (auditory verbal hallucinations) is commonly associated with psychosis, the experience can appear in people with other mental health disorders, including posttraumatic stress disorder (PTSD), dissociative identity disorder, mood disorders, personality disorders, or in people with no disorder at all (Aleman & Laroi, 2008). One of the strongest risk factors for hearing voices is a history of trauma, and childhood sexual abuse in particular (McCarthy-Jones & Longden, 2015) In line with this association, high levels of dissociation are reported by people who hear voices (see Pilton et al, 2015, for a review). No randomized controlled trials (RCT) of trauma-focused therapy for voice hearers have been conducted, RCTs of trauma-focused therapies in clients with psychosis have not shown a reduction in voice activity (see Brand et al, 2018) This may be because the interventions used in these studies have not directly targeted traumatic events thematically linked to the voices, and/or that the key underlying psychological processes were not targeted. Exposure-based interventions typically do not generalize well from one memory to another, which is needed for people with multiple or repeat traumas, which is typically the case with voice hearers (Whitfield et al, 2005)
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