People with psychosis do not have routine access to trauma-focused cognitive behavioural therapy (CBT) interventions such as imagery rescripting (IR), partly due to clinical caution. This case study describes the use of a simple imagery task designed to engender ‘felt security’, as a means of facilitating IR with a woman struggling with distressing memory intrusions, linked to her voices and paranoia. We assessed the impact of the felt security task, which was used before IR to enable Kip to engage in reprocessing of her trauma memories, and again after IR so that she would leave sessions feeling safe. The brief imagery task was effective in improving felt security before IR sessions. Felt security then reduced during IR, when distressing material was recalled and reprocessed, and increased again when the task was repeated. It is not yet clear whether trauma-focused interventions such as IR need to be routinely adapted for people with psychosis. In the event that individuals express concerns about IR, if the person’s formulation indicates that high levels of arousal may trigger an exacerbation of voices, paranoia or risk, or where clinicians are otherwise concerned about interventions likely to increase emotional arousal in the short term, the felt security task may facilitate safe and effective reprocessing of trauma memories. This in turn may increase access to trauma-focused CBT for people with psychosis.

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.

Background: A prominent area of advancement in the psychological treatment for people with persisting psychosis has been the application of mindfulness-based therapies. Recent literature has recommended the investigation of focused mindfulness interventions for voices (auditory hallucinations) as a specific experience. To date, only mindfulness programs in group format have been examined. Aims: This non-randomized pilot study aimed to assess the acceptability, feasibility and potential outcomes of an individual mindfulness program for persistent voices on the negative impact of voices on the subjective experience of mental health and wellbeing, depression and voice-related distress and disruption. Also, it aimed to identify potential psychological and neurocognitive mechanisms of change. Method: A new 4-week individual Mindfulness Program for Voices (iMPV) was developed, and piloted with a group of 14 participants with a schizophrenia-spectrum disorder and persisting voices. Participants completed clinical and neurocognitive measures pre- and post-intervention and at 2-month follow-up. Results: Results revealed low attrition rates, high formal practice engagement levels and positive participant feedback. Pre–post outcomes suggested small to moderate effects for a reduction in the negative impact of voices on experience, depression and disruption. Large effects for changes in mindful responding and attentional switching were also identified. Conclusions: Our findings suggest that this novel treatment protocol is appropriate, engaging and safe for persistent voice hearers. Findings for mindful responding and attentional switching suggest these to be potential mechanisms of change for further investigation. Further RCTs are warranted to ascertain the feasibility and efficacy for focused mindfulness interventions for voices of individual format.

Auditory hallucinations (AH) are often considered a sign of a psychotic disorder. This is promoted by the DSM-5 category of Other Specified Schizophrenia Spectrum And Other Psychotic Disorder (OSSSOPD), the diagnostic criteria for which are fulfilled with the sole presence of persistent AH, in the absence of any other psychotic symptoms. And yet, persistent AH are not synonymous with having a psychotic disorder, and should therefore not be uncritically treated as such. Many people who seek treatment for persistent AH have no other psychotic symptoms, have preserved reality-testing capacities, and will never develop a schizophrenia spectrum disorder. Instead, hallucinations may be the result of many different causes, including borderline personality disorder, post-traumatic stress disorder (PTSD), hearing loss, sleep disorders or brain lesions, and they may even occur outside the context of any demonstrable pathology. In such cases, the usage of the DSM-5 diagnosis of OSSSOPD would be incorrect, and it may prompt unwarranted treatment with antipsychotic medication. We therefore argue that a DSM-5 diagnosis of Schizophrenia Spectrum Disorder (or any other type of psychotic disorder) characterized by AH should require at least one more symptom listed under the A-criterion (i.e. delusions, disorganized speech, disorganized or catatonic behavior or negative symptoms). Adhering to these more stringent criteria may help to distinguish between individuals with persistent AH which are part of a psychotic disorder, for whom antipsychotic medication may be helpful, and individuals with AH in the absence of such a disorder who may benefit from other approaches (e.g. different pharmacological interventions, improving coping style, trauma-related therapy).

Recognition of negative emotions is impaired in behavioral-variant frontotemporal dementia (bvFTD). Less is known about the identification of positive emotions. One limitation likely arises from the stimulus sets used in previous studies. The widely used Ekman 60 Faces Test, for example, consists of four negative emotions (anger, fear, disgust and sadness) but only one positive emotion (happiness). Here, patients with bvFTD (n = 9), AD (n = 9), and controls (n = 15) recognized a range of experimentally-validated positive and negative non-verbal vocalizations (e.g., cheers for triumph; retching for disgust) that have recently become available. The bvFTD group was impaired in the recognition of both positive and negative vocalizations. In contrast, performance in the AD cohort was comparable to that of controls. Findings in the bvFTD group point to a global emotion recognition deficit in this syndrome. These results are consistent with a growing body of research showing that deficits also extend to positive emotions. (JINS, 2013, 19, 1–5)

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.

This article presents the initial implementation and adaptation of a group for people who hear voices in a psychiatric intensive care unit (PICU) using a cognitive behavioural therapy (CBT) approach. It highlights the lack of evidence-based psychosocial group interventions designed specifically for the PICU environment and challenges the traditional medical-model of PICU care. It also highlights national policy and guidelines advocating the implementation of CBT approaches for severe and enduring mental illness. An overview of the group sessions is described, with particular focus on adaptations of the group content and delivery for PICU populations. The authors note that twenty three clients have attended the PICU voices groups to date, demonstrating the feasibility of voices groups in PICU environments. Further work is currently being undertaken including formal evaluations of group outcomes using standardised measures.

Background: There is a small body of research indicating that mindfulness training can be beneficial for people with distressing psychosis. What is not yet clear is whether mindfulness effects change in affect and cognition associated with voices specifically. This study examined the hypothesis that mindfulness training alone would lead to change in distress and cognition (belief conviction) in people with distressing voices. Method: Two case studies are presented. Participants experienced long-standing distressing voices. Belief conviction and distress were measured twice weekly through baseline and mindfulness intervention. Mindfulness in relation to voices was measured at the start of baseline and end of intervention. Results: Following a relatively stable baseline phase, after 2–3 weeks of mindfulness practice, belief conviction and distress fell for both participants. Both participants' mindfulness scores were higher post treatment. Conclusion: Findings show that mindfulness training has an impact on cognition and affect specifically associated with voices, and thereby beneficially alters relationship with voices.

Background: The clinical literature cautions against use of meditation by people with psychosis. There is, however, evidence for acceptance-based therapy reducing relapse, and some evidence for clinical benefits of mindfulness groups for people with distressing psychosis, though no data on whether participants became more mindful. Aims: To assess feasibility of randomized evaluation of group mindfulness therapy for psychosis, to replicate clinical gains observed in one small uncontrolled study, and to assess for changes in mindfulness. Method: Twenty-two participants with current distressing psychotic experiences were allocated at random between group-based mindfulness training and a waiting list for this therapy. Mindfulness training comprised twice-weekly sessions for 5 weeks, plus home practice (meditation CDs were supplied), followed by 5 weeks of home practice. Results: There were no significant differences between intervention and waiting-list participants. Secondary analyses combining both groups and comparing scores before and after mindfulness training revealed significant improvement in clinical functioning (p = .013) and mindfulness of distressing thoughts and images (p = .037). Conclusions: Findings on feasibility are encouraging and secondary analyses replicated earlier clinical benefits and showed improved mindfulness of thoughts and images, but not voices.

The past decade has seen considerable growth in the evidence base of cognitive behavioural therapy for psychosis. Consistent reports of moderate effect sizes have led to such interventions being recommended as part of routine clinical practice. Most of this evidence is based on a generic form of CBT for psychosis applied to a heterogeneous group. An increase in the effectiveness of cognitive behavioural interventions may require new protocols. Such therapeutic developments should be based on the theoretical understanding of the psychological processes associated with specific forms of psychotic presentation. The current evidence base of CBT for psychosis is reviewed, and barriers that have held back the development of this research are discussed.

The concept of safety (seeking) behaviours has been very important in cognitive behavioural models of anxiety disorders. Morrison (1998) considered how a similar process may be involved in the development and maintenance of auditory hallucinations; however there has been no research that specifically explores safety behaviours in people who hear voices. The S-REF model (Wells and Matthews, 1994) proposed that compensatory beliefs mediate the choice of coping mechanism. The aim of this study was to explore whether people who hear voices have interpretations about the experience of hearing voices and if this interpretation threatens their physiological or psychological wellbeing, do they engage in safety behaviours to prevent this feared outcome. The study also considered whether the choice of behaviour was cognitively mediated. Twelve participants who had heard voices in the previous 2 weeks completed the study; 11 participants reported catastrophic interpretations and 12 reported using safety behaviours. The theoretical and clinical implications are discussed.