Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies and therapeutic interventions

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Abstract

This article reviews the state of knowledge about strategies used by people with a diagnosis of schizophrenia to cope with hallucinated voices, and considers the role of coping in psychological treatments for persisting symptoms. The use of self-initiated (‘natural’) coping strategies appears almost universal amongst voice-hearers. These strategies are similar across cultures, and include diverse behaviours, only a minority of which is specific to hallucinations. Most strategies are reported by at least some users to be effective, but more sophisticated outcome studies are lacking. Some evidence for the efficacy of certain behavioural techniques of coping, for the manipulation of auditory input, and for strategies involving subvocalisation, is available from experimental studies. Therapeutic enhancement of natural coping strategies for persisting symptoms has demonstrated some efficacy, but its benefit for voices is unknown. Despite this, it has become an established part of some CBT interventions for psychosis. Further advances in knowledge and practice may come from utilisation of coping models in research, longitudinal and ideographic methods of study and a movement away from descriptive coping lists to investigations of coping styles, mechanisms of action, and the process of coping.

Introduction

The observation that symptoms of schizophrenia may be subjectively experienced as a stressor, and trigger coping actions, is as old as the disorder itself (Jaspers, 1913/1963), although scientific study of coping has only emerged in the past two decades. Evidence that coping strategies for voices can be learned has led to their inclusion in cognitive behaviour therapy for psychosis treatments, and has stimulated their dissemination by training programs (Tarrier, Haddock, & Barrowclough, 1998), and by the self-help literature (Baker, 1996, Watkins, 1993). Given widespread acceptance of coping as a principle in the treatment of persisting positive symptoms, our purpose is to review the state of knowledge about coping strategies for voices, to consider their place in psychological treatments, and to identify issues and future directions.

Slade and Bentall (1988) reviewed in detail the early literature, and more recently, Shergill, Murray, and McGuire (1998) included five studies of natural coping in their review of treatments for hallucinations. Knudson and Coyle's (1999) review has a useful focus on observing possible theoretical mechanisms, however, the studies are not confined to schizophrenia, and coping with other symptoms is not distinguished from coping with voices in some included studies. Wykes (2004) summarises the literature on behavioural and cognitive interventions for hallucinations in schizophrenia, in the context of their theoretical underpinnings, but only briefly addresses the natural coping literature. We could find no other recent reviews.

This review addresses coping with auditory verbal hallucinations (‘voices’) in people with a diagnosis of schizophrenia. Coping was rarely defined in this literature, thus we accepted at face value the responses each study included as coping. The review firstly assesses descriptive studies of ‘natural’ coping (Section 2) and experimental studies of strategy efficacy (Section 3). The next three sections consider how coping strategies have been included in CBT for psychosis treatments, either as the primary focus (Section 4) or as one therapeutic component for voices therapy (Section 5) or within a more general CBT for psychosis treatment (Section 6). Section 7 raises some practice issues, and Section 8 considers research issues arising from the review.

Section snippets

Studies of ‘natural’ coping

In this review, ‘natural’ coping is defined as actions taken to ameliorate the symptom or to regulate emotion that are assumed to have been chosen and implemented without assistance from professionals. We undertook PsychLIT and MEDLINE searches using keywords of voices, hallucinations, schizophrenia, psychosis and coping, and identified further reports from reference lists of relevant studies. Nine research reports of natural coping with psychotic symptoms were identified where hallucinations

Experimental investigation of coping techniques

Experimental studies designed to reduce or remove auditory hallucinations can help to clarify the effective elements in coping; knowledge that can aid understanding of natural coping and suggest priority strategies for therapies. The bulk of this work was conducted in the 1970s and 1980s and has been reviewed by Slade and Bentall (1988) and Shergill et al. (1998). This section briefly outlines the main themes of this literature.

Therapies centred on enhancing the coping strategy repertoire

So far, in this review, we have shown that most patients with schizophrenia try out ways of coping with distressing or unwanted symptoms, and that most report some benefit. In addition, the efficacy of a number of specific strategies has been confirmed by experimental studies which have demonstrated reductions in the duration of hallucinatory episodes, and sometimes in the frequency of recurrence of the voice. In this section and the two sections that follow, we now review the way in which

Hallucination-specific therapies that incorporate a coping strategy component

We found two therapeutic programs for persisting hallucinations that differ significantly from those reviewed in Section 4 because, in addition to a component designed to build coping strategies, other substantive treatment elements are included as well.

CBT for psychosis therapies that incorporate a coping strategy component

Over the past two decades, cognitive therapy and cognitive behaviour therapy treatments for psychosis1 have been developed. Recent reviews (Dickerson and Lehman, 2006, Gaudiano, 2005, Tarrier, 2005b) concur that, in general, the approach has efficacy for the treatment of positive symptoms, particularly as an adjunct to usual care. However, caution is raised by the observation (

Issues concerning the structure and focus of treatment

Practice and research issues raised by the review are discussed in this and the following section.

Research issues

Research to date has been primarily descriptive and is hampered by a number of definitional, design and measurement problems.

Conclusions

It seems clear that many, possibly all, patients develop natural ways of coping with distressing hallucinations. Most strategies are not unique to hallucinations, overlapping considerably with those used for other symptoms and with those reported by non-clinical populations for other stressors. The effectiveness of these natural coping strategies is variable across individuals and the more effective strategies are not necessarily used. Only about a third of hallucinators are rated as having

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