‘Like jumping off a ledge into the water’: A qualitative study of trauma‐focussed imaginal exposure for hearing voices

Abstract

Objective There is growing evidence of a link between the experience of hearing voices and past traumatic events, and trauma‐focussed psychological interventions are being applied to hearing voices as an emerging treatment direction. To inform the ongoing development and implementation of this application, there is a need to understand clients’ therapy experiences. Design Qualitative study exploring the experience of people who received an intervention for voices linked to a previous traumatic event. Method Ten participants experiencing voices with some connection to a previous traumatic event participated in individual semi‐structured interviews following six sessions of imaginal exposure, an exposure‐based trauma‐focussed intervention. Participant responses were analysed using thematic analysis. Results Participants reported a range of benefits from the intervention, including improved mental health, reduction of distressing voice‐hearing experiences, and increased clarity of the traumatic event. The therapy was perceived as distinctly different to previous therapy experiences, and participants noted that therapy could be intense and challenging, yet helpful later. Participants also reported that outside circumstances impacted on their progress in therapy and their voice‐hearing experience. Conclusions The findings suggest that exposure‐based trauma‐focussed therapies may be beneficial for people who hear trauma‐related voices. However, this intervention can be intense and clinicians and consumers need to consider the timing of delivery, and pay attention to internal and external resources that can increase participants’ sense of safety. Practitioner points Imaginal exposure may be an effective intervention for people who hear voices that they perceive to be associated with a past traumatic event. Positive changes associated with the intervention may be highly variable between individuals, and encompass changes in sense of self, changes to internal states, and changes to voice‐hearing experience. Imaginal exposure interventions may involve some temporary discomfort and symptom exacerbation, which may affect the acceptability of the intervention. This needs to be considered in both future research and clinical delivery.

Eye-movement desensitisation and reprocessing therapy (EMDR) to prevent transition to psychosis in people with an at-risk mental state (ARMS): mixed method feasibility study

“…some did not have a secure place to live), or that they might have needed more preparatory work before moving to the trauma-processing stage. Consistent with our results, a qualitative study exploring the experiences of trauma-focused imaginal exposure for voice hearing found that people's therapy experience can be negatively affected by outside circumstances, 52 and highlighted the need for a supportive environment outside of therapy. Others have also highlighted the importance of offering trauma-focused interventions in a multidisciplinary setting.…”

“… 48 One reason for this is that clinicians fear that addressing trauma may lead to an increase in the severity of positive symptoms or suicidal behaviour. 49 Our findings expand the research available so far on the application of trauma-focused therapies in people with psychotic symptoms 50 , 52 and show that EMDR can be acceptable and helpful for people with ARMS.…”

“It hurt but it helped”: A mixed methods audit of the implementation of trauma- focused cognitive-behavioral therapy for psychosis

“…The risk of ongoing victimization was also highlighted by two cases, with psychosocial stressors in the form of actual or threatened reoccurrence of their index traumas leading to a clinically significant deterioration in PTSD, undermining previous gains and thus emphasizing the need for ongoing safety management. Similarly, Brand et al ( 69 ) conducted a qualitative analysis of a case series of PE for voice hearing ( 16 ) and recommended monitoring and adaptions to therapy where indicated, after finding the therapy experience was negatively impacted by aversive external circumstances. Social work and safeguarding interventions may be necessary in these cases, further highlighting the value of delivering tf-CBTp in a multidisciplinary setting.…”

Voice hearers' explanations of trauma‐related voices and processes of change throughout imagery rescripting: A qualitative exploration

“…This finding is consistent with those from a randomised controlled trial ( n = 40) of ImRs for post‐traumatic nightmares that found significant reductions in perceived incompetence, which compared to other trauma‐related beliefs, was most strongly associated with PTSD symptom reduction (Long et al, 2011). Furthermore, preliminary evidence suggests that negative affect, emotion regulation deficits and dissociative coping mediate the pathway from trauma to hallucinatory experiences (Strachan, Paulik, Preece et al, 2023), and past qualitative findings suggest trauma‐focussed treatments enhance skills to constructively cope with distress (Feary et al, 2022) and stand up for oneself (Bosch & Arntz, 2021). Bandura (1997) suggests that encouragement from credible others, experiences of successful performance and physiological feedback influence self‐efficacy.…”