Stage 2 Developing a Revised Model of Voice Hearing over Time

The themes developed in stage 1 were mapped onto the integrated model of voice hearing over time to generate a revised model (see Figure 14). A preliminary revised model corroborates and expands upon the integrated model. Specifically, three sub-themes highlight the idiosyncratic journeys beyond a common pathway which implied that recovery was not a linear or universal experience for the participants.

Prior to accessing help, a “common pathway” was followed by all participants. The preliminary revised model subsequently divides into three pathways representing different experiences of voice dis/continuity that appeared to be influenced by beliefs about voices. Two of the pathways involve the changing of beliefs about voices. For both the “Voices continue but beliefs change” and “Voices stop” pathway, belief modification seemed to play a role in the recovery process, irrespective of the

continuation or dis-continuation of voice hearing experiences. By contract, the “Voices continue but beliefs do not change” pathway describes the journey of participants who do not seem to experience belief modification, and consequently felt trapped in a cycle of voice negativity and accessing help.

6.5 Discussion

This study aimed to compare findings from a longitudinal (retrospective and prospective) study of a cohort of patients distressed by hearing voices with existing models of voice hearing over time (de Jager et al., 2016; Milligan et al., 2013; Romme & Escher, 1989).

Four higher-order themes emerged from the analysis of the accounts of twelve participants who were interviewed over a three-year period. The analysis proposed a “Common pathway” that was experienced by all participants – whereby a journey was travelled from voice onset through to disclosure and the accessing of help that was necessitated by a worsening of voices. Subsequently, pathways diversified in a manner that seemed to result from an interaction between voice continuation/dis-continuation and belief modification. The ‘common pathway’ was developed from participants’ retrospective accounts. The three novel pathways emerged during the period of data collection. The pathways did not appear to differ systematically according to time since onset of voice hearing. Although the duration of the ‘common pathway was more protracted for those with longer-term recall than those who were in the early stages of voice hearing and help-seeking, this pathway did not differ according length of time.

Within the “Voices stop” pathway, participants experienced a cessation of voice hearing experiences. Despite the likelihood of voices stopping after a first episode following the establishment of an anti-psychotic medication regime (Sommer et al., 2012), participants attributed this cessation to a variety of sources - medication, therapy and the opportunity to discuss voice hearing experiences. Cessation prompted a time of reflection and sense-making that facilitated the modification of beliefs about voices and the accessing of further help if voices returned. For participants whose voices continued, the modification of beliefs (or lack thereof) seemed to play a role in what happened next. Both groups experienced stages of heightened voice negativity resulting in an increased need for help. For the participants whose “Voices continue but beliefs change”, a process of enquiring facilitated by CBT and supportive discussions with significant others enabled re-evaluation and modification of beliefs about voice

omnipotence, control and origin. Participants within this group changed from a passive response style (accepting voice comments and commands) to a more active response style (challenging voice comments and commands) to voices. Alternatively, those who’s “Voices continue but beliefs do not change” remained in a cycle of intensifying voice negativity and the continued need to access services. Unlike the group whose

voices continued but beliefs changed, this group did not have access to supportive non- judgemental conversations about voices.

The integrated model of voice hearing (see Figure 13) has been expanded to include three novel sub-group pathways (see Figure 14). The preliminary revised model corroborates the existence of the significant challenges that can be faced by patients prior to disclosure (Bogen-Johnston et al., 2017). Following disclosure, beliefs about voices seem to exert an influence, with modification being associated with acceptance, meaning making and recovery (whether voices continue not), and a lack of modification being associated with ongoing struggles with voices. Several [5] participants ascribed changes in beliefs about voices to CBTp based therapeutic intervention. Through therapy, participants questioned the control and power of voices, and for those whose voices continued, learnt to re-address the imbalance. Outcomes implied that therapy (as an adjunct to medication) influenced the recovery pathway. Beliefs regarding voice origin (external or internal), omnipotence and omniscience have been prominent within the empirical literature (Birchwood & Chadwick, 1997; Chadwick & Birchwood, 1994) and their modification is a central aim of CBT (Smailes et al., 2015). Our findings suggest that the exploration and evaluation of the accuracy of these beliefs may be an important part of therapeutic conversations about voice hearing experiences that occur after disclosure. Whilst the preliminary revised model of voice hearing over time does not identify the precise timing of these conversations and how formal they need to be, there is no suggestion within the data that these conversations would benefit from being delayed after disclosure. Whilst patients may not be ‘ready’ for formal psychological therapy immediately following disclosure, therapeutic conversations that encourage patients to explore and evaluate voice hearing experiences may lay the foundations for subsequent belief modification. However, engagement with these conversations may be influenced by both the recovery style of the patient and their willingness to explore voice hearing experiences(de Jager et al., 2016) and the ability and confidence of clinicians to start and continue a conversation about voice hearing (Coffey & Hewitt, 2008).

Whilst we accept that the preliminary revised model cannot be generalised beyond the experience of this study’s participants, we propose that it offers insights that can augment the existing voice hearing literature. The preliminary revised model builds upon previous recovery models and suggests three novel pathways. The identified pathways offer new insights into hearers’ trajectories with voices and are the

groundwork for future clinical research. Research examining the suggested pathways may further clinical understandings between the relationship of voice appraisals, readiness for therapy and the timing of therapy.

6.5.1 Limitations

This study had a number of limitations. Firstly, participants were engaged with Early Intervention in Psychosis services and therefore findings cannot be extrapolated to patients who hear voices beyond a first episode of psychosis or people who have never accessed mental health services. Future research should explore the preliminary revised model with differing populations of voice hearers and seek to triangulate qualitative and quantitative data. Secondly, participant views prior to engagement with services were retrospective and reflections may have been influenced by attenuated recall. Future longitudinal research could address this issue by deploying novel methodologies (e.g. experience sampling methodology) which, supported by digital technologies, could capture data ‘in-the-moment’. Thirdly, differences in duration of voice hearing meant that, with respect to the early course, some participants were reporting more distant experiences than others. However, despite the heterogeneity, time since onset did not affect course of voice hearing. Fourthly, our analysis did not reach the point of saturation, suggesting that some possible experiences of voice hearing over time may not have been captured by this study. Future studies could adopt methodologies (e.g. Grounded Theory) that could be more comprehensive in this respect. Fifthly, a limitation of this study was the lack of diversity within the sample. We did attempt to partly address this problem by recruiting from two EIP services: a metropolitan borough located in the North of England (Manchester) and coastal towns located in the South East of England (Brighton and Eastbourne). However, the sample was limited, for example in terms of age, ethnicity and geography. Consequently, future research should explore the utility of the preliminary model in samples that are more diverse.

7. General Discussion and Conclusions