Voice mapping: a guide to support voice hearing

Understanding AVATAR therapy: who, or what, is changing?

Many people hear voices but do not access psychiatric services and their experiences are largely unknown, not least because of the difficulty in contacting such people. This study investigates the beliefs held about voices, distress experienced, and provides a topographical account of the experience of hearing voices in a sample of individuals who hear voices in a non-psychiatric population. A quantitative questionnaire internet-based study with a within-subjects and between-subjects design was used. The internet was used to make contact with people who hear voices. One hundred and eighty-four participants in the general population who heard voices completed measures online assessing anxiety, depression, and beliefs about their dominant voice. Participants reported a broad range of experiences associated with hearing voices, some in keeping with the previous research on clinical populations. The use of the internet to recruit and research non-clinical samples of people who hear voices is supported. This study provides details regarding demographic information and the experience of voice hearing from a fairly large sample of people who hear voices in a non-psychiatric population. It lends support to the idea that voice hearing occurs on a continuum, with evidence that many people hear voices in the general population and are not distressed by the experience.

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

BackgroundResearch shows us that auditory hallucinations or ‘hearing voices’ may be more common than previously thought, particularly in childhood and adolescents. Importantly, not all individuals are affected negatively by their voice hearing experiences, yet child and adolescent mental health services (CAMHS) have traditionally understood voice hearing as a symptom of psychosis and severe mental illness, with implications for the way interventions are offered. The purpose of the present study was to gain an understanding of how young people who hear voices and their families find engaging with mental health service, and to better understand their experience of mental health professionals.MethodsA two-stage, mixed methods study was used. In the first stage, semi-structured interviews were carried out with two young people and their parents who had engaged with mental health services, and the collected data were analysed using Interpretative Phenomenological Analysis (IPA). In the second stage, a questionnaire was designed to test the generalizability of the themes arising from the first stage, and was completed online by 32 young voice hearers and 27 parents.ResultsIPA analysis produced 4 themes: (1) The struggle to understand the hearing voices phenomenon; (2) Battle with the Mental Health Services; (3) ‘Stuck in a limbo’; and (4) The wish for a more holistic approach from mental health services and professionals. The survey partially confirmed the findings of study one, with young people and parents finding useful information difficult to come by, and many reported feeling lost in CAMHS. Additionally, young voice hearers and parents often felt not listened to, and many parents expressed the need for a holistic care, whilst young people wanted a more normalizing and less stigmatizing experience.ConclusionsYoung people and their families had varying experiences of mental health services. Whilst the survey showed that some young people and their families had more positive experiences, many expressed dissatisfaction. To fulfil the needs of young people and their families, mental health services would benefit from developing alternative approaches to voice hearing and running support groups that could form part of a ‘normalising’ and ‘holistic care’ package.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0527-z) contains supplementary material, which is available to authorized users.

Background: Auditory hallucinations (voices) in people with a diagnosis of borderline personality disorder (BPD) have traditionally been regarded as ‘pseudohallucinations’. However, recent research suggests that these voice hearing experiences can be highly distressing and share many of the same qualities as those found in diagnoses such as schizophrenia. Given these similarities, can any psychological therapies effectively treat distressing voices in the context of a BPD diagnosis? Aim: To add to the growing literature exploring voice-related distress in people with a diagnosis of BPD and to answer the unique question of whether brief psychological therapy is effective at reducing voice-related distress for people with a diagnosis of BPD. Methods: 37 people with a diagnosis of BPD and 49 with a diagnosis of schizophrenia received up to four sessions of Coping Strategy Enhancement therapy. The primary outcome measure at baseline and post intervention was the distress subscale of the Psychotic Symptoms Rating Scales (PSYRATS). The frequency, attribution and loudness subscales of the PSYRATS, the Depression Anxiety and Stress Scales (DASS21), the CHoice of Outcome in Cbt for PsychosEs (CHOICE), the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) and drop-out rates were secondary measures. Results: The BPD group reported significantly greater voice-related distress at baseline. The BPD group, but not the schizophrenia group, reported statistically significant improvements on voice-related distress at post-therapy. Only a small minority of participants (BPD = 15% and schizophrenia = 16.7%) showed reliable improvements in voice-related distress, with this not differing significantly between the groups. When controlling for baseline distress and other covariates, the BPD group reported statistically greater improvement in voice-related distress than the schizophrenia group. Withdrawal rates were low for both groups. When controlling for covariates, the attribution dimension of the PSYRATS, the stress subscale of the DASS21, and well-being were the only secondary measures that was predicted by diagnosis. Conclusion: Voices can be experienced as highly distressing for people with a diagnosis of BPD. Brief psychological therapy appears to be appropriate for helping people who experience distressing voices to engage with therapy as part of a stepped-care process, but it is unlikely to produce reliable and clinically meaningful improvements as a standalone treatment.

This article reports a study of nurses' assessments of a voice hearer's voices and psychiatric symptoms, and associations of these perceptions with nurses' education, career experience and primary care role. Traditional views in nursing suggest that to engage voice hearers in a discussion of their voices is to support the psychopathology of the voice hearers. Research into how voice hearers conceptualize voice hearing has generated a range of perspectives, raising concerns about whether nurses capture sufficient, accurate and specific assessment data about the experiences of voice hearers. One hundred and fifteen psychiatric nurses rated items on an Inventory of Voice Experiences and the Brief Psychiatric Rating Scale while viewing a videotaped assessment of a voice hearer with serious and persistent mental illness. The voice hearer in the videotape used the same instruments to rate his own voices and symptoms. This self-assessment was undertaken 30 days before and immediately before production of the video-recorded assessment. The data were collected between 2000 and 2002. The voice hearer's ratings of his voice hearing experiences and psychiatric symptoms were consistent over a 30-day period. Most nurse ratings of the voice hearer's voices and psychiatric symptoms did not match those of the voice hearer. However, the voice hearer and nurses demonstrated a moderately positive association between the voice hearer's voices and symptoms. Ratings of graduate-educated case managers and clinical nurse specialists (n=30) in clinical practice settings were more consistent with one another and corresponded more closely with the ratings of the voice hearer, particularly for the association between the voice hearer's voices and symptoms. Accurate and specific assessment of voice hearing may facilitate engagement with voice hearers and improve the selection of strategies to help them manage the voices that upset them.

Accessible Summary We ran a group for people with learning disabilities who hear voices that nobody else can hear. During the group, people talked about what it is like to hear voices nobody else can hear and how they cope. We interviewed people before and after the group. We asked them about what their voices say, how they felt about their voices and why they thought they heard voices. We also asked them about their quality of life and if they liked the group. People told us that they liked the group and found it helpful to talk to other people who hear voices. Some people said they felt better after the group. We want to run another group in the future and make it run for longer. We might run a group for family members, friends and carers. AbstractBackgroundHearing voices groups (HVGs) are effective avenues of support for people who hear voices in the general population yet their application and adaptation for people with learning disabilities who hear voices are scarce.MethodsThis paper is an evaluation of a pilot HVG for people with learning disabilities. Five people attended the group which ran once weekly for 6 weeks. Measures of psychological functioning and quality of life were collected before and after the group. Participants' understanding of their voice hearing experiences and the stigma associated with voice hearing were explored at the pre‐ and post‐group stage.ResultsHigh attendance rates and positive satisfaction ratings suggested the group was acceptable to clients. Participants said they had increased understanding of voice hearing and endorsed the positive value of social support.ConclusionsThe use of quantitative outcome measures should be reviewed when conducting HVGs. Although the 6‐week group was associated with positive feedback, there might be benefit in extending the number of sessions offered as well as involving carers. Bridging the gap between services available for those who hear voices in the general population compared to people with a learning disability is essential.

Hearing voices is generally linked to biological factors, but its psychosocial aspects should not be overlooked. The empirical literature indicates the need for acknowledging the psychosocial aspects of voice-hearing experiences. We conducted a review of online health information about voice-hearing experiences and examined if the most widely accessible websites equally covered the biological and psychosocial aspects of voice-hearing. Forty-seven websites (including 23 English websites and 24 Chinese websites) were reviewed and rated. The English websites did not adequately mention trauma-related disorders as potential diagnoses for hearing voices, but there was a balanced discussion regarding the causes and treatment options for hearing voices. In contrast, most Chinese websites failed to acknowledge any psychosocial aspects of hearing voices. A comprehensive approach that recognizes both the biological and the psychosocial aspects of voice-hearing experiences is required to reduce stigma and ethically inform potential service users and the public about the possible causes, diagnoses and treatment options for voice-hearing experiences. Implications are discussed. Online information concerning voice-hearing experiences in the Chinese context should be updated. Mental health information providers in both language contexts should be familiar with the relationship between hearing voices and trauma-related disorders too.

Despite the prevalence of voice hearing in childhood and adolescence, little qualitative research has been undertaken with young people directly to advance phenomenological and aetiological insights into their experiences and interpretations. Consequently, the researchers sought demographic, contextual, and qualitative data from 74 young people from eleven countries, aged 13-18years (28%=male; 61%=female; 21%=Transgender and Gender Non-Binary [TGNB]), who self-identified as hearing voices. A Foucauldian-informed narrative analysis yielded four analytic chapters, offering novel perspectives into individual, relational, systemic, and cultural interpretative narratives surrounding multisensory and multi-self voice hearing. Overall, young people reported heterogenous experiences of voice hearing and associated sensory experiences, and most participants reported voice hearing beginning between ages 8 and 11. Further, the emotions felt by the child, as well as reactions displayed by people around the child in relation to the voices, influenced voice-related distress and the nature of the voices in a triadic relationship. A continuum of multisensory features of voice content, nature, and relational significance is tentatively proposed to capture the breadth and depth of voice hearing for adolescents to offer a possible framework for future study and intervention design. Specifically, participants described that voice-related distress could be exacerbated by observed anxiety or internalized stigma about voice hearing, social isolation, and attribution to illness. These findings suggest that we may need to reconsider how the experience of hearing voices in childhood influences their relationships and how relationships influence the voice hearing experience. Further, young people seem to have a broad understanding of what the term "hearing voices" means, which could inform how researchers and practitioners work with this group of young people. Finally, participants described benefitting from multisensory coping strategies, such as imagery and meditation, which could offer important considerations for tailoring therapeutic interventions for adolescent voice hearers.

The purpose of this review was to identify, appraise, and synthesize the current peer-reviewed qualitative literature which explores the phenomenon of hearing voices from a first person perspective. A comprehensive systematic search of the literature was conducted. Seven studies utilizing various qualitative methodologies met the criteria to be included in the synthesis. An appraisal tool (Walsh & Downe, 2005, J. Adv. Nurs., 50, 204-211) was used to assess their quality. A meta-ethnographic approach was used to synthesize the data extracted from them. The interpretation of the findings suggested five key themes: identity of the voice(s), power of the voice(s), impact of hearing voices on relationships, relationship with the voice(s), and the distinction between thoughts and voices. The identity of the voices seemed inextricably linked to the perceived power the voice(s) wielded over the voice hearer. The quality of the studies included in the synthesis varied greatly. The findings of this synthesis highlight the importance of the voice hearer's individual frame of reference for understanding their experience. Clinical implications include the need for mental health professionals to explore an individual's understanding of their experience of hearing voices and address the perceived power of the voice(s). Further research is indicated in this area with a focus of improving the quality of qualitative research studying this phenomenon. There are multiple frames of reference in which to understand an individual's experience of hearing voices. Mental health professionals should attend to the meaning and understanding voice hearers give to the experience.

Using Q-methodology and structured interviews, this preliminary study set out to explore how a diverse range of voice hearers construed their experience of hearing voices. Following factor analysis of 20 completed Q-sorts, six factors emerged. Pejorative media stereotypes about voice hearers were rejected, and despite the dominance of the biomedical model in our culture, on no factor did participants adhere to all of the biomedical concepts. All six factors endorsed some elements of psychological discourse on voice-hearing experiences. It is argued that attempting to understand voice hearers within a single theoretical framework may limit or adversely affect engagement and understanding of an individual. Consistent with previous research, users of mental-health services were more likely to find voices frightening and perceive them as negative experiences than non-users. However, some non-users found managing some of their voices difficult despite having seemingly positive beliefs about the experience of hearing voices. Comment is made on the potential therapeutic implications of this study along with some acknowledgement of its limitations.

Understandings of auditory verbal hallucinations (also referred to as “hearing voices”), and help for people distressed by them, are dominated by a biomedical framework. Yet, many people who have sought help for the distress and/or impairment caused by hearing voices express dissatisfaction with treatment solely within this framework, highlighting the need for a more rounded, biopsychosocial-spiritual approach. This paper examines the neglected role of a fundamental part of human experience, love, in the experience of hearing voices. First, we argue a lack of love is likely to play a causal role in voice-hearing experiences. Second, we demonstrate that a lack of love is central to the distress and dysfunction often caused by hearing voices. Finally, we show that love plays a core role in recovery. Given this centrality of love, we argue that an interdisciplinary approach to hearing voices involving the mind sciences and theology/religion may be fruitful. The relevance of this for psychotherapeutic interventions for people who hear voices is discussed.

The experience of hearing voices (‘auditory hallucinations’) can cause significant distress and disruption to quality of life for people with a psychosis diagnosis. Psychological therapy in the form of cognitive behavior therapy (CBT) for psychosis is recommended for the treatment of positive symptoms, including distressing voices, but is rarely available to patients in the United Kingdom. CBT for psychosis has recently evolved with the development of symptom-specific therapies that focus upon only one symptom of psychosis at a time. Preliminary findings from randomized controlled trials suggest that these symptom-specific therapies can be more effective for distressing voices than the use of broad CBT protocols, and have the potential to target voices trans-diagnostically. Whilst this literature is evolving, consideration must be given to the potential for a symptom-specific approach to overcome some of the barriers to delivery of evidence-based psychological therapies within clinical services. These barriers are discussed in relation to the United Kingdom mental health services, and we offer suggestions for future research to enhance our understanding of these barriers.

This study aimed to explore how adults with lived experiences of voice hearing, who have participated in hearing voices groups based on approaches of the Hearing Voices Movement, understand their voice hearing experiences (VHE). A phenomenological approach guided the study design. In-depth semi-structured interviews were conducted with five participants who attended a hearing voices group. Participants experienced a journey of understanding VHE. The overarching theme 'tension and recalibration' permeated five themes: beliefs about voices; navigating the relationship with my voices; learning to live with my voices; rediscovering myself with my voices; and, influences to understanding my voices. This study highlights how voice hearers' understanding can evolve over time and throughout phases of recovery. Implications regarding intervention to support individuals to explore VHE are discussed.

SummaryBackgroundAuditory hallucinations—or voices—are a common feature of many psychiatric disorders and are also experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the people who hear voices themselves.MethodsWe made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged 16–84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks, hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used inductive thematic analysis to code the data and χ2 tests to test additional associations of selected codes.FindingsBetween Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the participants reported hearing literally auditory voices—70 (46%) individuals reported either thought-like or mixed experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were significantly associated with experiences of abusive or violent voices (p=0·024). Although fear, anxiety, depression, and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time (p=0·030), be internally located (p=0·010), and be conversational in nature (p=0·010).InterpretationThis study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities.FundingWellcome Trust.