Our research

The aim of this research is to increase access to effective psychological interventions for psychosis patients who are distressed by hearing voices.

The 'Feeling Heard' study will explore the feasibility and acceptability of offering choices within a pathway of brief and targeted interventions, delivered by a wider workforce of therapists.

Background

Cognitive Behaviour Therapy (CBT) has been the psychological intervention recommended for the ‘positive symptoms’of psychosis (delusions and voice hearing) for the past two decades. However, CBT has experienced two barriers to progress during this time:

1. CBT has only been able to generate small-medium amounts of benefit (relative to control groups) for patients, and adaptations have been unable to break through the barrier. A recent response to this barrier has been to target CBT at one psychotic symptom at a time (the ‘single-symptom approach’) and results havebeen encouraging with enhanced benefits being reported.
2. There has been limited access to CBT with only a minority of patients being offered treatment. The reasons for limited access include a lack of resources as CBT istypically delivered by highly trained therapists who are in short supply. Our response to this barrier has been to evaluate CBT for distressing voices when offered by briefly trained therapists, with preliminary findings offering encouragement. Having made progress regarding both patient benefit from CBT and increased access to CBT, we now wish to combine these approaches to maximise access and benefits. Additionally, we want to offer patients greater choice over the length and content of CBT.

See more about the study here

Who can participate?

Adults over 18 years, with a diagnosis of psychosis and experiencing voice-hearing.

What does the study involve?
Participants will have a baseline assessment and a pathway of interventions offered over a maximum of 20 sessions with monthly assessments.

The study will be recruiting until September 2023.

Our research aims to give more people with a diagnosis of psychosis the chance to receive a helpful talking therapy. 

People with a diagnosis of psychosis may experience distressing delusional beliefs and hearing voices. The National Institute for Health & Care Excellence recommend Cognitive Behaviour Therapy for psychosis (CBTp) as one of the best treatments for people with a diagnosis of psychosis. But only 26% of people with a diagnosis of psychosis have the chance to receive this talking therapy. CBTp is scarce because it can take a long time to deliver and needs to be delivered by highly trained therapists.

We have adapted CBTp in several ways to reduce its length and make it less resource intensive:

1. We have targeted CBTp at only one of the problems commonly associated with psychosis – hearing voices.
2. This targeted approach has enabled us to reduce the number of sessions over which the therapy is conducted (from the recommended minimum of 16 sessions, down to 10 sessions).
3. We have structured the therapy in the form of a workbook to enable briefly trained therapists to guide people through the therapy. Our therapy is called Guided self-help CBT intervention for distressing voices (also known as the GiVE intervention). Our briefly trained therapists are called Assistant Psychologists. They have a degree in psychology and usually work in NHS Mental Health Services under the supervision of highly trained therapists.

Building on the GIVE 1 and 2 studies, the lessons that we learnt have helped us to design this larger study.

We will include 130 people with a diagnosis of psychosis in our study:

• 65 people will be offered the GiVE intervention over 10 sessions, delivered by an Assistant Psychologist

• 65 people will continue to receive the usual support and treatments offered by their mental health team

Our findings will tell us if the GiVE intervention is helpful to people with a diagnosis of psychosis who hear voices, when delivered by Assistant Psychologists.

Timelines

The study will open on 30th April 2022 and conclude on 30th October 2024.

The recruitment of participants is planned for the 12-month period from October 2022 to September 2023

For more details, please email: mark.hayward@spft.nhs.uk

Click here for the Give3 Plain language summary

The range of outcomes and measures that have been used in trials of Cognitive Behavioural Therapy (CBT) for distressing voices suggests that there is a lack of consensus among professionals about what should be measured. Additionally, these outcomes have mostly been determined by professionals in the field, with little to no focus on lived experience perspectives. Consequently, the outcomes may not be representative of the changes or benefits sought by the voice hearers themselves. For that reason, the MOTIVE study seeks to explore views and perspectives of service users and practitioners about what the outcomes of CBT for distressing voices should be. This involves conducting individual interviews with service users and focus groups with practitioners.

Service users can take part if they are 18 years of age or older, have attended at least 50% of a course of CBT and are able to talk about their experience. Practitioners can take part if they have experience of delivering of CBT for distressing voices. 

The findings will be used to improve clarity around the outcomes of CBT for distressing voices in both research and routine clinical practice.

This study finished recruiting in January 2022 and results will be available soon.

PREFER aims to better understand how, when and where patients most want to receive therapy for voice-hearing.

PREFER is a questionnaire study in which patients who hear voices meet with a researcher to complete a set of questionnaires about their therapy preferences, mental health, and thoughts about themselves and the future. The study will help us learn how to best design and offer voice-hearing therapies to maximise their suitability for patients who hear distressing voices.

For more information please visit the Sussex Psychosis Research (SPRiG) website or see the flyer

 To be eligible, patients must:

• be aged 16 years or over,
• have heard voices for at least six months irrespective of diagnosis,
• be under the care of secondary mental health services with a designated care co-ordinator or lead practitioner, and
• be able to read English in order to complete the consent form and questionnaires

For more information please contact Hazel Frost: hazel.frost@sussexpartnership.nhs.uk or voices.clinic@sussexpartnership.nhs.uk

Many people sometimes hear a voice or voices that other people do not hear. Hearing these voices is often distressing which can make it difficult to go about daily life activities.

Psychological research suggests that distress can be reduced by changing the way the voice hearer relates to his or her voices. In particular if the hearer can change from relating in a passive and subordinate manner to relating assertively.

Building on this research, a novel approach called Relating Therapy teaches assertive responses to voices using experiential role-plays. A small pilot study in the United Kingdom with twenty-nine participants showed promising effects of Relating Therapy in reducing voice hearing related distress. The findings from this study have been published and can be found here.

The current trial is funded by the German Research Foundation and will be conducted at the Universität Hamburg in Germany under the lead of Professor Tania M. Lincoln.

In this trial, we aim to recruit seventy-five participants and to examine whether it is feasible and effective to add a module of Relating Therapy in the routine care for patients with distressing voices across different outpatient and inpatient mental health service settings in Germany.

The results of this research are expected in late 2023. If the findings are encouraging, we plan to conduct a subsequent larger multi-centre trial on Relating Therapy, which is needed in order to draw final conclusions about the benefit of Relating Therapy for patients who hear distressing voices.  

For more information please contact Dr Matthias Pillny (MSc.) Email: matthias.pillny@uni-hamburg.de

See the study protocol here

Auditory hallucinations in the form of spoken language (i.e., hearing voices) often first occur in adolescence or young adulthood. Hearing voices can be associated with emotional distress and impairment in everyday life. To date, there are hardly any evaluated therapy programmes for young people who hear voices. Our study aims to investigate whether smartphone-assisted psychological therapy for adolescents and young adults helps to reduce voice-related distress.

An 8-week, smartphone-based Ecological Momentary Intervention (EMI), in addition to treatment as usual, will be compared to treatment as usual in this randomised controlled trial. 

The study is aimed at young people between the ages of 14 and 25 with distressing voices, regardless of their mental disorder or whether or not they meet the criteria for a psychiatric diagnosis.

Study participants are randomly assigned to one of two conditions: In the therapy condition, study participants receive a text message twice a day for 8 weeks with a suggested exercise to learn a helpful way to manage their voices. In the control condition, the study participants do not receive any study-specific intervention. The effectiveness of the intervention will be assessed by means of clinical interviews and (online) questionnaires immediately before and after the intervention phase and again at a later time (6 months after the start of the study). The study participants will have the chance to receive a highly specialised psychological therapy for hearing voices. We assume that this therapy can help young people who hear voices to be less troubled and to cope better in their lives again. In order to find out whether this is actually the case, we are conducting this study. In doing so, we intend to make a contribution to early intervention of mental disorders.

154 adolescents and young adults aged between 14 and 25 years with distressing voices will be recruited from psychiatric hospitals and the general population in Switzerland. 

For more information, please contact: mark.hayward@sfpt.nhs.uk

1. Guided self-help cognitive-behaviour intervention for voices (GiVE): Results from a pilot randomised controlled trial

The GiVE study involved consultations with clinicians and people who hear voices to develop a brief, intervention based upon the ‘overcoming distressing voices’ self-help book. The team developed a workbook to guide participants through an eight-session intervention with opportunities to get involved in cognitive behavioural therapy-based self-help activities.

Data has been analysed and has found that GiVE is helpful in significantly reducing the distress caused by voices.

See a paper about the patient experience of GiVE therapy here

Full text 

2. Mindfulness for voices (M4V)

Group mindfulness-based intervention for distressing voices: A pragmatic randomised controlled trial. 

Being distressed by hearing voices (‘auditory hallucinations’) is common for people diagnosed with schizophrenia. Cognitive Behaviour Therapy offered on a one to one basis is the recommended treatment, but is rarely available in practice. One solution is to offer therapy in groups so patients can receive therapy at the same time. In 2008, a pilot study (funded by Heads On, Sussex Partnership’s charity) led by Professor Paul Chadwick and Dr Mark Hayward, assessed the effectiveness of a group therapy for voices that combined mindfulness and cognitive behavioural therapy. The results suggested the therapy was beneficial. However, pilot studies often show benefits that can’t be replicated in studies with more rigorous methodologies. Consequently, the research team needed to evaluate the therapy further and successfully applied to the Department of Health’s National Institute for Health Research to fund a randomised controlled trial. 108 patients took part in this. Half of the patients received the group therapy and their usual care, and the other half received only their usual care (the control). The results indicated that the therapy can reduce the distress caused by voices, enhance mood, improve personal control and promote recovery. However, some of the findings were not maintained over the follow-up period of six months, suggesting that further work needs to be done to strengthen the benefits.

Full text

3. Relating to voices: relating therapy for distressing auditory hallucinations (R2V)

The Relating to Voices (R2V) study looked at the effect of relating therapy for people who experience distressing voices. Auditory hallucinations are a common and distressing experience and patients report distress reduction to be a priority. Relating therapy adopts a symptom-specific and mechanism-focused approach to the reduction of auditory hallucinations distress. Participants were randomly allocated to receive therapy or to be part of the control group.

The therapy offered 16 weeks of individual psychological therapy to help participants to relate and respond differently to their voices and other people in their social lives. The distress caused by these relationships is often maintained by the passive and/or aggressive responses of the participant. Relating therapy teaches people to relate assertively, standing-up for themselves, whilst respecting the needs of others.

Dr Mark Hayward and Dr Clara Strauss led the study and were part of the team that delivered the therapy. The study finished in 2015.

 Full text

4. Voice impact scale (VIS)

There are several psychological therapies that we know can be helpful for people who hear distressing voices - many of these therapies are currently on offer within the Voices Clinic.  More research is needed on the ways in which these therapies are helpful so that they can be made more readily available in the NHS.  We have ways of measuring whether these therapies help people to feel less depressed, less anxious, and feel better about themselves - but we do not have a comprehensive way of measuring the impact that voices have on people, and whether psychological therapies can improve this.

We have developed a questionnaire, with help from researchers, clinicians, and people who hear voices themselves, that we think can accurately measure the impact of voices on the person hearing them.

To request a copy of the Voice Impact Scale contact Clara Strauss: clara.strauss@nhs.net

5. Use of smartphones for coping therapy

This project is a collaboration between local researcher Dr Mark Hayward and researchers at the Voices Clinic in Swinburne, Australia. The project will evaluate if smartphones could enhance the benefit of the Level 1 coping therapy. Patients were given a smartphone at the beginning of therapy and asked to enter data about their voice-hearing experiences when prompted by the phone. The data generated by the patient can be used in the therapy sessions to provide accurate information about the patient’s current coping strategies. The success of any adapted strategies can also be accurately captured and assessed.

Case illustrations from the study detail how digital technologies such as ecological momentary assessment and intervention (EMA/I) may be used in future as clinical tools to enhance therapy, and demonstrated support for the clinical utility of the integration of smartphone EMA/I with traditional face-to-face therapy for improving coping with distressing voices.  See the preliminary outcomes about a pilot randomised control trial of a brief coping-focussed intervention for hearing voices with smartphone-based ecological momentary assessment and intervention (SAVVy) here

6. Increasing access to Cognitive Behavioural Therapy for Voice-hearing (GiVE2)

The National Institute for Health & Care Excellence (NICE) recommends Cognitive Behavioural Therapy (CBT) as one of the best treatments for psychosis. However, only a minority of people with psychosis have the chance to receive CBT as delivery takes time and it needs to be delivered by highly trained therapists, such as clinical psychologists. We want to find out if a shorter version of CBT that is delivered by therapists with less training (such as Assistant Psychologists) is helpful for people who hear distressing voices.

We were awarded £250k by the National Institute of Health Research (NIHR) to evaluate this form of CBT by comparing it to two control groups – one group who received supportive counselling and another group who received no additional interventions.

If it proves to be cost-effective, this shorter version of CBT could be made available to more people. This study has finished recruiting and results are being analysed.

See a paper about the study here

For more information please contact Mark Hayward: mark.hayward@spft.nhs.uk.

7. Voices in Borderline Personality Disorder Explored (ViBe)

We are investigating the psychological and brain mechanisms underlying voices hearing experiences in people with a diagnosis of Borderline Personality Disorder (BPD). We know that voices hearing is common in people who receive a BPD diagnosis, but unfortunately this is often not recognised by mental health professionals. Very little research has been done to understand what these experiences are like for people with BPD.

We hope this research will increase our understanding of voice hearing, and lead to the development of new therapies for voice hearers with a BPD diagnosis. 

See a publication about the study here

See another publication here

8. Attitudes 2 Voices (A2V)

Many people sometimes hear a voice or voices that other people do not hear. Some of these individuals might seek help from mental health services for voice-hearing or for other difficulties they might be facing. However, there has been little research on the views and experiences of clinical staff about voice-hearing.

The A2V Project seeks to understand more about clinicians' thoughts, feelings and approaches to working with patients who hear voices. It involves collecting clinicians' views and attitudes towards voice-hearing and the assessment of this experience in patients. The findings may be used to inform training on ways of working with this patient group in the future. We are currently analysing data and hope to share findings soon. 

9. Voice-hearing in young people: distress factors and social relating (Vista)

Vista is a youth mental health study looking at the social lives, relationships and activities of young people who do and do not hear voices. We are interested in better understanding what voice-hearing is like, what might make it upsetting for young people and how it might influence young people's social lives.

Many young people hear a voice or voices that other people cannot hear. Although in most cases voice-hearing will follow a transient course and can be considered part of typical development, for some young people hearing voices can be complex, persistent and be associated with numerous mental health problems later in life. Additionally, young people most at risk of long-term mental health and social disability present with social decline, in the context of non-specific symptoms. These symptoms usually include anxiety and depression and often, but not always, psychotic like experiences (e.g. hearing voices). However, we don't know much about voice-hearing in young people and how this might affect their social lives and activities. 

The goal of this study is to find out more about social relationships and activities of young people who do and do not hear voices, to find out more about voice hearing in young people and better understand when voice hearing might be upsetting for young people, and to hear about the expereinces of care / support of young people distressed by hearing voices.

Research implications will focus on informing developmentally appropriate interventions for young people, including those who hear distressing voices. 

This research study has now closed for recruitment. We would like to express gratitude to everyone that has contributed. We are currently analysing data and hope to share findings soon.

10. Assertive Responding to Voices (AppRoVe)

The AppRoVe study evaluated the psychometric properties of new measures of responding to distressing voices and other people. Several psychological therapies are currently being developed to help people respond more assertively to the distressing voices they hear. Responding assertively means to stand-up for yourself, but in a way that is respectful of the voice or person that you are talking to. There are currently no reliable questionnaires that measure assertive responding – so we cannot be sure that a therapy is helping people to develop assertive responses.

This study aimed to develop two questionnaires – one that can measure assertive responding to voices, and another that can measure assertive responding to other people. We developed initial drafts of these questionnaires with help from researchers, clinicians and people who hear voices. For us to find out if our questionnaires were good measures, we needed people who heard voices to complete them, along with some other measures.

This research study recruited 402 participants across 14 Mental Health Trusts within the NHS in the UK. We would like to express our gratitude to everyone who contributed to the study.

The findings from the study have been published and can be found here.  We have created two questionnaires – one that assesses relating to voices (‘Approve-Voices’) and one that assesses relating to other people (‘Approve-Social’) . We are pleased to make the questionnaires available for use by clinicians, researchers and people who hear voices.

The questionnaires can be downloaded here:

Approve-Voices

Approve-Social questionnaires

For more information please contact Professor Mark Hayward: mark.hayward@spft.nhs.uk.

Open access papers in peer review journals 

Therapy evaluations

Commentaries and reviews

Measure development