As CBTp for voices (CBTv) has evolved, a generation of new therapeutic approaches, referred to as “third wave” (Hayes, 2004) have been developed. While still within a broad CBT framework, most of the approaches centre upon how people respond and relate to voices, rather than changing them (Dannahy et al., 2011). Control is considered to play a key role within mental health issues. Development in thinking and practice have explored different forms of control such as reduced interpersonal control and control of one’s life (Tai & Turkington, 2009; Wilson, 1999).
Consideration will now be given to some of these variables – decentred awareness; social schema; beliefs about the self.
1.6.1.1 Decentred Awareness
An area of development within therapy has been psychological interventions that are informed by acceptance and mindfulness-based approaches (Thomas et al., 2014). These therapeutic philosophies espouse non-judgemental acceptance of experiences whilst, at the same time, believe in living one’s life in accordance with one’s values (Hayes, 2004; Veiga-Martinez, 2008). In the case of hearing voices, Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) proposes that, rather than attempting to eradicate voices, the individual accepts them without judgement (Veiga-Martinez, 2008). Instead of focusing on beliefs, ACT draws attention to the relationship with voices. These interventions propose a decentred relationship with internal events (Thomas et al., 2014). The individual is encouraged to re-direct attention away from the verbal content and invasiveness of voices, while attempting to reduce unhelpful behavioural responses (Tonarelli, Pasillas, Alvarado, Dwivedi & Cancellare, 2016). Noticing voices, thoughts and feelings and accepting them as transient events is central to mindfulness and ACT therapy for voice-related distress (Thomas et al, 2014).
A recent meta-analysis (Louise, Fitzpatrick, Strauss, Rossell and Thomas, 2018) evaluated ten RCTs of third-wave CBT interventions for psychosis. Compared with control groups, third-wave approaches demonstrated a small-to-medium post- intervention (between-group) effect. These findings indicated that third-wave
approaches were comparable to CBTp (Wykes et al., 2008) in the reduction of overall symptoms and depression in psychosis. Group mindfulness-based trials displayed larger treatment effects than individual ACT trials, which were found to be non-significant. However, the meta-analysis failed to find a significant between-group post-intervention effect for positive (hallucinated-distress) and negative (functioning and disability) symptoms. The authors note that third-wave approaches may be effective for general symptoms of psychosis (e.g. depression) rather than specific symptoms (e.g. voice- related distress). Findings suggest that acceptance-based therapies may not be targeting underlying mechanisms (e.g. trauma, beliefs about self, beliefs about voices, voice content) thought to be involved in the maintenance of voice-related distress.
1.6.1.2 Social Schema
In seeking to identify variables which mediate voice-related distress, attention has been drawn to the role of social schema in the interpretation of social information and subsequent responses (Paulik, 2012). Research has explored the relationship
between social rank (comparison of one’s social statues or power to others) and beliefs about voices, associated distress and behavioural responses (Birchwood et al., 2000). Studies have drawn on social rank theory to investigate how voices mirror these relationships.
Social rank (Gilbert & Allan, 1994; Gilbert et al., 2001) has influenced both current models and therapies of voice hearing. Social rank theory posits that
understanding of our core self develops from the social comparisons that we make. Humans have evolved mental mechanisms for identifying dominant-submissive interactions. Individuals within groups are classified (by themselves and others) as either ‘high rank’ or ‘low rank’. These ranks regulate social behaviour and how the individual acts to others (assertively or submissively) as well as how others act accordingly. Through threat, dominant members of a group may assert power and control over subordinate members of a group. The theory proposes that, in order to survive such threats, subordinates have evolved ways of coping, typically termed as appeasement and submission (Byrne, Birchwood, Trower, & Meaden., 2007). These ranks may be viewed as dominant-subordinate cognitive schemas and contribute to the core image of our self. Consequently, perception of one’s social status/rank influences one’s mood and emotions (Trower & Gilbert, 1989).
The ABC model of voice-related distress (Chadwick & Birchwood, 1994) was further developed to integrate a “social mentalities” approach (see Figure 7).
A
(Activating event)
Voice activity
B
(Beliefs about voices)
Power Identity Intention C (Consequences) Emotional consequences Behavioural responses Early experiences Interpersonal experiences Power-subordination
Figure 7 Cognitive model of distressing voices extended to include interpersonal schema (Birchwood et al., 2004)
Drawing on social rank theory (Gilbert & Allan, 1994; Gilbert et al., 2001) Birchwood and colleagues (Birchwood et al., 2004) propose that hearers make
assessments between their own power and their voices power i.e. a relational judgement (Craig, Ward, & Rus-Calafell, 2016). Hearers who report feelings of powerlessness and inferiority with voices are more likely to have had similar experiences within previous social relationships (Birchwood et al., 2000). Negative social relationships create negative social schemata. These influence negative appraisals of voices and result in associated voice-related distress (Birchwood, 2004).
For example, a person who has been maltreated by an abusive dominant in early development will continue the dominant-subordinate social rank into adulthood,
manifesting as a dysfunctional schema (Byrne et al., 2007). Consequently, the dysfunctional schema becomes a processing system that draws attention to, and
interprets, social information. This information takes the form of both the social domain and the perceived voice. Beliefs regarding one’s social rank (e.g. ‘I am powerless’– ‘other people are powerful’) are mirrored in the beliefs about voices (e.g. ‘I am
powerless’–‘voices are powerful’) (Birchwood et al., 2004). Although the dysfunctional schema does not explain cause of voices, it does account for the dominant-subordinate- relating style to voices (Birchwood et al., 2004; Byrne et al., 2007).
The theory that social processes (social schemas) act as a mediator between voice appraisal and distress has been supported by recent reviews (Mawson et al., 2010; Paulik, 2012). Changes in interpersonal schemas may have positive outcomes (Mawson et al., 2010). It has been suggested that therapies should aim to target social and
interpersonal variables (Mawson et al., 2010; Paulik, 2012). Consequently, a group of therapies have developed out of the recognised importance of relational dynamics.
Relational Therapies and Hearing Voices
Recent research which has examined interpersonal relating and voices appears promising. As well as social-rank theory, relational therapies have also drawn on two other social theories applied to voices: Benjamin’s (Benjamin, 1974, 1989) Structural Analysis of Social Behaviour (SASB) and Birtchnell’s (1994) relating theory. Benjamin employed the SASB model, a method of studying different types of interpersonal behaviours, to a study with voice hearers (1989). Findings reported that voice hearers related to voices within an interpersonal framework. Benjamin suggests that hearers
form integrated relationships with voices which reflect ways of relating to others (i.e. family). Given that hearers often recognise voices as someone they know (Nayani & David,1996), plus the high prevalence of previous trauma found amongst this
population (Read, van Os, Morrison & Ross, 2005), hierarchical relationships in real life are often found to be replicated between the hearer and their voice (Paulik, 2012)
Birtchnell’s (1994, 1996) relating theory hypothesises that relating is comprised of two elements occurring across two intersecting axes – power (upper-lower) and proximity (close-distant). Power represents the degree of control or influence between two people and proximity represents the level of closeness between two people. The ‘interpersonal octagon’, theoretical structure, is formed from the transitional positions of upper/lower close and upper/lower distant. Each place is viewed as a ‘state of
relatedness’. No position is better than the other, but each one supports the individual in relation to others to meet specific needs (Birtchnell, 1994; Hayward, 2003).
Trials of Relating Therapy (RT) (e.g. Hayward, Jones, Bogen-Johnston, Thomas & Stauss, 2017) have examined the usefulness of Birtchnell’s (1994) model with respect to the variables of power and distress in voice hearing (Hayward et al., 2017; Paulik, 2012). Evidence suggests that the manner of relating between hearer and voice is linked to different affective responses to voices. Hearer-voice relationships, whereby the voice relates in a dominant, critical manner and the hearer responds with suspicion and non- communication, have been shown to be associated with distress (Vaughan & Fowler, 2004). Therapy (RT), a symptom-specific approach, focuses on interpersonal (negative) relating as a mechanism linked to distressing voices (Hayward et al., 2017). The aim of RT is to change ‘negative relating’ through helping patients to develop assertiveness skills (ibid).
Avatar Therapy (Leff et al., 2013) a digitally enhanced form of relating, employs a computer-generated audio-visual Avatar of a person’s voice to encourage a dialogue. Therapy centres upon targeting feelings of helplessness (reported by hearers as one of the worst aspects of voice hearing) and control (Leff et al., 2014). Leff et al. (2013). It draws upon the phenomenological findings of Nayani and David (1996) whereby engagement with voices was associated with less distress and more control. To enable hearers to engage in a dialogue with voices, individuals are assisted in creating a computer-generated audio-visual Avatar of their voice. The Avatar, which is controlled by the therapist, interacts with the patient. This allows safe ‘exposure’ to the
Avatar changes from abusive to supportive, enabling the individual to gain control over the voice. In addition, therapy draws upon associations of low self-esteem and negative voice content (Leff et al., 2013).
Empirical findings from RCTs for RT (Hayward et al., 2017) and Avatar Therapy (Leff et al., 2014) are tentatively encouraging. At post therapy, both RT and Avatar Therapy found a significant effect of therapy on the reduction of distress. This effect was maintained at follow-up for RT. However, it is worth noting that the study was a pilot RCT of 29 patients. Alternatively, while Avatar Therapy also demonstrated a large significant effect on total score of PSYRATS-AH (Haddock et al., 1999) (compared to supportive counselling), as well as a reduction regarding voice omnipotence, these comparisons (with supportive counselling) were no longer significant at 24-week follow-up.
Other approaches have focused therapy upon the perceived power differential between voice and voice hearer, and the compliance with harmful command
hallucinations. Cognitive Behaviour Therapy for Command Hallucinations, (CTCH; Birchwood et al., 2004; Birchwood et al., 2018) targets beliefs about voices’ power, a single mechanism associated with compliance to voice-related commands (Birchwood et al., 2004; Birchwood et al., 2018). Theoretically, CTCH draws on social rank theory (Gilbert & Allan, 1994; Gilbert et al., 200) and is by Birchwood et al.’s (2004) work regarding the compliance and appeasement of voices appraised as malevolent and powerful. Consequently, voice content plus the nature of the relationship between hearer and voice have been found to be predictive of behavioural (compliance) and affective (distress and depression) response to voices (Birchwood et al., 2011; Trower, Birchwood, & Meaden, 2004). Birchwood et al. (2011) argue that the subordinate- dominate positions between hearer and voice, whereby the hearer believes that non- compliance to voice commands risks retribution from the voice, reflects social rank theory.
CTCH focuses on weakening beliefs about voice power mechanism, enabling the hearer to resist harmful commands and reduce associated distress (Birchwood, 2014). The COMMAND (Birchwood et al., 2018) RCT, investigated CTCH with 197 participants assigned to either therapy or usual treatment. At post-therapy, findings demonstrated a between-group medium effect favouring therapy suggesting that voice power acted as a mediator of change. However, the trial was insufficiently powered to confidently rule out influences from any other non-therapy mediating variable. In
addition, the trial did not demonstrate a significant between-group effect upon voice- related distress (both groups demonstrated a reduction in distress) (ibid).
Taken together, findings suggest that relationally based therapies demonstrate significant effects during therapy. However, findings are mixed as to whether these gains are maintained once therapy has stopped.
1.6.1.3 Beliefs about the Self
One area which has been foregrounded as a potential mediator of voice-related distress, and a key therapeutic target, is self-esteem (Thomas et al., 2014; van der Gaag, van Oosterhout, Daalman, Sommer, & Korrelboom, 2012). Low self-esteem has been associated with positive symptoms of psychosis in both clinical and non-clinical
populations (Barrowclough et al., 2003; Krabbendam et al., 2002). Self-esteem develops early in life, and although flexible to new experiences, can still be reactivated during negative events i.e. feelings of powerlessness (Gilbert, 1992).
Smith et al. (2006) found in a study of 100 participants with psychosis, that people with lower self-esteem and increased depression experienced greater severity of voices, as well as more voices with intensely negative content. Those with lower self- esteem were also found to be more distressed by their voice hearing experiences. Fannon et al. (2009) contend that low self-esteem plays an important role in the affective response of voice hearers. In a study (Fannon et al., 2009) of 82 participants who heard voices, both beliefs about voices and low self-esteem were found to contribute to voice persistence and depression. The authors conclude that, in patients diagnosed with schizophrenia, therapeutic interventions should target both appraisals of self and voices.
Two approaches which focus on negative beliefs about the self, compassionate mind training (CMT) and competitive memory training (COMET; van der Gaag et al., 2012), shall be considered.
Compassionate Mind Training (CMT)
CMT encourages awareness to negative self-relating and was developed to target heightened levels of shame and self-criticism (Mayhew & Gilbert, 2008; Tai &
Turkington, 2009). It is informed by Compassion-Focused Therapy (CFT; Gilbert, 2009) which uses compassion to care for oneself and others. CMT advocates that people from traumatic, critical and shaming backgrounds, have difficulty with self-supporting and self-reassurance (Mayhew & Gilbert, 2008). It argues that shame and self-criticism act as negative internal signals, promoting submissive and negative affective responses
which, in turn, sustain chronic mental health issues (Gumley, Braehler, Laithwaite, MacBeth & Gilbert, 2010). CMT ideology centres on supporting people to identify and accept their own needs; to act with compassion and empathy towards themselves; and to develop self-supportive thoughts (Mayhew & Gilbert, 2008). Such practices are
believed to promote the regulation of neural systems involved with self-soothing and contentment. These systems are involved in the modulation of threat systems which are activated during negative events such as hostile voices (Mayhew & Gilbert, 2008; Thomas et al., 2014). CMT seeks to shift people from a threat-based motivational system to a care-based motivational system (Heriot-Maitland, McCarthy-Jones,
Longden, & Gilbert, 2019). In respect to voices, it encourages the individual to engage with voices from a position of the compassionate self (ibid).
Evidence suggests that compassion focused therapies are therapeutically beneficial (Braehler et al., 2013). A feasibility RCT study of 40 patients with a
diagnosis of schizophrenia-spectrum disorder found that, compared to usual treatment, compassion focused therapy demonstrated a significant increase in compassion, reduction in depression and perceived social marginalisation (ibid).
Competitive Memory Training (COMET)
An RCT investigated the effect of competitive memory training (COMET; van der Gaag et al., 2012) on depression, low self-esteem and voice content in patients experiencing voice hearing. COMET was developed from theories relating to competing memory networks (Brewin, 2006). It was developed as a training protocol to increase positive self-esteem through the use of positive imagery (van der Gaag et al., 2012). The RCT aimed to decrease depression and change submissive hearer-voice relationships. Described as a technique, it sought to increase self-esteem by supporting people to retrieve positive long-term memories. The retrievability of positive memories was considered to help people experience what is already known about themselves, which could be used to change and weaken negative voice content. Changes in submissive behaviour would occur through the reappraisal of the meaning of voices and reducing emotional affect (ibid).
Findings were encouraging with respect to the primary outcome of depressive symptoms, exhibiting a medium-to-large effect which was mediated by self-esteem and the acceptance of voices, with partial mediation attributed to power and social-rank. COMET failed to achieve a significant effect on the reduction of voices or their negative content on PSYRATS-AHRS. However, this was not a primary aim of the
trial. A significant medium effect was found on PSYATS -AHRS for cognitive
interpretation of voices compared to usual treatment. It is worth noting that, although a symptom specific approach, COMET did not focus on voice-related distress.