Systematic review of interactive digital interventions for voices & a grounded theory exploration of how voice-hearers relate to their voices socially: a mentalisation theory perspective

Abstract

BACKGROUND: Auditory Hallucinations (AHs) or ‘hearing voices’ can be linked to high levels of distress, depression and anxiety (Chadwick & Birchwood, 1994; Hartley et al., 2013). They are relatively common for people diagnosed with a schizophrenia spectrum disorder, with around 70% of individuals reporting them (Waters et al., 2012). Voices have largely been understood from a cognitive perspective, which suggests that the beliefs an individual holds about their voices, in terms of their power, purpose and identity impacts the distress they cause (Chadwick & Birchwood, 1994; Close & Garety, 1998).

Cognitive behavioural therapy for psychosis (CBTp) has been demonstrated to be effective in treating AHs (Van der Gaag et al., 2014). Recently, more psychological therapies aiming to address the relationship between hearer and voice have been developed. These therapies increasingly highlight the importance of psychological formulation that encompasses the voice identity, content and the voice-hearer’s significant life events (Longden et al., 2021). This indicates the necessity of understanding factors that lead to more positive and negative voice relationships, including the consideration of how voice-hearers relate to their voices socially, and what aspects of the voice they consider important. However, there can be barriers to accessing face to face treatments, and online therapies have been suggested as a way of addressing this.

PURPOSE: The systematic review aimed to systematically synthesise the characteristics, modes of delivery and clinical outcomes of interactive digital interventions for AHs. The grounded theory empirical study explored how voice-hearers relate to their voices as social agents, from a mentalisation theory perspective.

METHODS: For the empirical study, seven voice-hearers were interviewed about their relationship with their voices, as well as their early attachment relationships using the Adult Attachment Interview (AAI; George et al., 1996). The transcribed interviews were coded according to grounded theory processes concurrently with recruitment and interviewing. Additionally, the AAI was coded for reflective functioning scores using the Reflective Functioning Scale coding manual (Fonagy et al., 1998). Voice-hearing severity and distress was also evaluated using the Psychotic Symptom Rating Scale (PSYRATS; Haddock et al., 1999).

The systematic review involved searching four databases systematically for peer-reviewed journals, and empirical studies of interactive digital interventions for AHs were extracted. Effect sizes on clinical outcomes were reported and a meta-analysis was completed for avatar therapies featuring an active control.

RESULTS: The systematic review included 18 studies involving 1730 participants. Overall, evidence appeared to be strongest for avatar therapies, with six RCTs reporting improvements in voicehearing distress with large effect sizes. App-based RCTs that included an ecological momentary assessment (EMA) component also demonstrated some positive improvements in voice-hearing distress. There was limited evidence supporting the use of computerised interventions for AHs.

The theory developed from the grounded theory exploration was that voice-hearers relate to their characterised voices as they would ‘real’ people. The core process through which they do this was by Trying to Understand the voice, with two categories influencing the core processes: 1) Ascribing Agency and 2) Making Comparisons. Seven subcategories were also constructed: 1) Evidence of Realness 2) Characterisation 3) Affective Experience 4) Changing over time and place 5) Social Comparison 6) Goal Congruency 7) External Relationships. These factors related to participants’ overall understanding of their voice and the valence of their relationship.

DISCUSSION: Overall, this portfolio confirms the importance of incorporating an understanding of how people relate to their voices into clinical practice. The encouraging results of avatar therapies suggest that digital interventions that consider the relationship with the voice are proving promising. Further high-quality research into digital interventions for AHs are required before they become established, including safety considerations.

Voice-hearers appear to develop their understanding of their voices by ascribing an identity to them, and develop very real relationships with them. This in many ways mirrors our external social relationships, including that voice-hearers develop an understanding of their voices’ mental states. Further exploration into links between mentalisation and hearing voices would be merited.