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

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1 Clinical Psychology Review 27 (2007) Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies and therapeutic interventions John Farhall a,, Kenneth Mark Greenwood a,b, Henry J. Jackson c a School of Psychological Science, La Trobe University, Victoria 3086, Australia b School of Health Sciences, Science, Engineering and Technology Portfolio, RMIT University, PO Box 71 Bundoora, Victoria 3083 Australia c Department of Psychology, 12th Floor, Redmond Barry Building, University of Melbourne, Parkville 3010, Victoria, Australia 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 Elsevier Ltd. All rights reserved. 1. 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. Corresponding author. Tel.: ; fax: addresses: j.farhall@latrobe.edu.au (J. Farhall), ken.greenwood@rmit.edu.au (K.M. Greenwood), henryjj@unimelb.edu.au (H.J. Jackson) /$ - see front matter 2007 Elsevier Ltd. All rights reserved. doi: /j.cpr

2 J. Farhall et al. / Clinical Psychology Review 27 (2007) 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. 2. 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 were not separated from other symptoms, and a further 14 studies were identified where data about auditory hallucinations were reported. The following section reviews the first of these two groups; subsequent sections review the hallucination-specific studies Natural coping with psychotic symptoms (studies without hallucination-specific data) Table 1 outlines the studies where data about coping with hallucinations were not reported separately. All but one (Dittman & Schuttler, 1990) draw their convenience samples from patients in the community. All employ interview methodology or both interviews and questionnaires (Carr & Katsikitis, 1987). Sample sizes range from 10 for the grounded theory study of McNally and Goldberg (1997), to 200 for the survey of Carr and Katsikitis (1987). Table 1 Studies of natural coping with psychotic and other symptoms Authors n Sample Method Results Cohen and Berk (1985) 86 Outpatients Semi-structured interview Strategies grouped into nine categories. For psychotic symptoms, fighting back was most frequent category, then acceptance. Carr and Katsikitis (1987) 200 Community residing Self-report questionnaire Similar frequencies of use of coping strategies observed across the range of symptoms. Arousal reduction most common. Tarrier (1987) 25 Community residing Semi-structured interview 72% identified a coping strategy. Cognitive and behavioural strategies were more commonly reported. Thurm and Haefner (1987) 37 Community residing Semi-structured interview Strategy groups: ask for help; intrapsychic coping; take extra medication; behavioural change. Asking for help was most frequent. Kumar, Thara, and Rajkumar (1989) 30 Outpatients Semi-structured interview Most common strategies: internal dialogue (43%); talk to relative/friend (23%); adjust medication (13%) Dittman and Schuttler (1990) 50 Mainly inpatients (92%) Semi-structured interview 86% described a strategy. Withdrawal was the most frequent helpful strategy. 14% gave symptomatic behaviour as the most helpful strategy McNally and Goldberg (1997) 10 Community residing Grounded theory interviews 19 coping categories identified: 14 X cognitive (incl. 9 effective forms of self-talk); 4 X medical, social and interpersonal ;1Xbehavioural Boschi et al. (2000) 95 Community residing, early psychosis Structured interview Mean of 9.75 strategies endorsed. Active-behavioural strategies claimed as most helpful, but active-cognitive strategies were more frequently used. Bak et al. (2001) 21 Community residing Structured interview Mean of two strategies endorsed per symptom group. Five clusters of coping: active problem-solving; passive illness behaviour; active problem-avoiding; passive problem-avoiding; symptomatic behaviour. Latter was most frequent.

3 478 J. Farhall et al. / Clinical Psychology Review 27 (2007) Together, these studies illustrate that natural coping efforts directed at psychotic symptoms are common in people diagnosed with schizophrenia. Where data were reported, at least 70% of patients could identify a coping behaviour. There was little consistency in the number of strategies identified for symptom groups or overall: for example, Bak et al. (2001) reported a mean of two strategies per symptom group whereas Boschi et al. (2000) reported a mean of 9.75 strategies for psychotic symptoms. The studies, particularly through their examples, give a picture of great diversity in the nature of coping. Patients may fight back against, or accept, symptoms (Cohen & Berk, 1985). They may talk to themselves: McNally and Goldberg (1997) identified nine effective forms of self-talk. Treatment-oriented coping, such as asking for help and taking additional medication, as well as symptomatic coping, such as acting in accordance with the symptoms (Thurm & Haefner, 1987), were observed. Despite this diversity in strategies, there is little evidence that they are tailored to the type of symptom: Carr and Katsikitis (1987) reported that similar frequencies of specific coping strategies were claimed for a number of different symptoms, although whether individuals used the same strategies for different symptoms was not reported Natural coping with hallucinated voices Fourteen studies provided reports of natural coping with auditory hallucinations by people who have a diagnosis of schizophrenia. Table 2 summarises information about the sample, methods, and results for each study. A further study was identified (Kumar, Thara, & Rist, 1994) but no copy was available for review Incidence of natural coping with hallucinations A fundamental question for both descriptive psychopathology and treatment is whether many or few hallucinators employ natural coping methods. All of the studies summarised in Table 2 (except Carr, 1988) address this question in some way. None appeared to select their sample on the basis of coping, thus, the proportion of participants with identified coping methods is of interest. In five studies (Falloon & Talbot, 1981; Frederick & Cotanch, 1995; Lee, Chong, Chan, & Sathyadevan, 2004; Ramanathan, 1984; Singh, Sharan, & Kulhara, 2003) all participants reported coping, and this is implied in a sixth study (Tsai & Ku, 2005). Four studies report lesser proportions (Johns, Hemsley, & Kuipers, 2002; Nayani & David, 1996; O'Sullivan, 1994; Wahass & Kent, 1997), the lowest, 71%, being from a small sample (n = 14). Two studies illustrate that the method of enquiring about natural coping may influence the rates of reported coping (Farhall & Gehrke, 1997; Farhall & Voudouris, 1996). Every participant in both samples claimed a coping strategy when presented with a prompt list; however, asking, Is there anything you deliberately do to cope when you hear a voice you don't like? prior to presentation of the prompt list, elicited a strategy from far fewer participants. Two limitations of some of these studies have been addressed by other studies. The possibility that some of the reported strategies were not attempts to cope in response to stress is raised by O'Sullivan's (1994) study which recorded substantial numbers of coping strategies for voices categorised by participants as pleasant, as well as for voices that were unpleasant. Nonetheless, the two studies that specifically limited their enquiries about coping to those who were stressed by voices (Carter, Mackinnon, & Copolov, 1996; Farhall & Gehrke, 1997), each reported high rates of coping in response to open-ended questions (84% and 68% respectively). In addition, the assumption that most of the coping reported by participants was natural, rather than being actions suggested by mental health workers or family, was only tested by two studies. O'Sullivan (1994) reported that 78% of strategies were attributed by patients to themselves, and Tsai and Ku (2005), in a much larger Taiwanese sample, reported that 50% of strategies were attributed to the self. In summary, despite differences in method, quality and culture across these studies, it seems clear that many, if not all, hallucinators, of their own volition, attempt to cope with the experience of voices Extent of natural coping with hallucinations If natural coping is almost universal amongst hallucinators, how extensive are their coping repertoires? The five studies addressing this question (Carr & Katsikitis, 1987; Farhall & Gehrke, 1997; Frederick & Cotanch, 1995; O'Sullivan, 1994; Singh et al., 2003) give mean numbers of coping strategies per person ranging from 2.2 to One reason for variation across studies may be the use of prompt list vs. open question methods. It is also plausible that

4 Table 2 Research studies of natural coping with auditory hallucinations by people who have a diagnosis of schizophrenia a Authors Sample size Sample/diagnosis/hallucinations status Methods/analysis Results Falloon and Talbot (1981) 40 Community residing (USA)/RDC schizophrenia/daily hallucinations for N12 months Ramanathan (1984) 30 Outpatients (India)/Feighner criteria/hallucinated in previous 24 h Carr (1988) 28 Community residing (subsample of Carr and Katsikitis (1987) who reported hallucinations strategies additional to main coping checklist) (Australia)/clinician-diagnosed schizophrenia/ symptoms in past 12 months: O'Sullivan (1994) 40 Depot medication clinic attendees (UK)/file diagnosis: schizophrenia (n=32), schizoaffective (n =3), other (n=5)/73% heard voices in past 12 months Frederick and Cotanch 33 Outpatients (USA)/DSM-III-R schizophrenia or (1995) schizoaffective disorder/hallucinating 3 5 times per week Carter et al. (1996) 100 Community residing and inpatients (69%) (Australia)/DSM-IIIR Schizophrenia (n=52), schizophreniform (n=15), schizoaffective (n=7), Mood disorders (n=18), Other (n=8)/current and past hallucinators Farhall and Voudouris (1996) Nayani and David (1996) Farhall and Gehrke (1997) Wahass and Kent (1997) 35 Inpatients (Australia)/DSM-IIIR Schizophrenia (n=33), schizoaffective disorder (n=2) Hallucinations persisting despite minimum of 8 weeks antipsychotic medication. 100 Community residing and inpatients (55%) (UK)/ICD-10 Schizophrenia disorders (73%), Mood and other (27%)/ Hallucinations within past 3 months. 81 Community residing and inpatients (52%) (Australia)/Clinician diagnosis of schizophrenia (n=78), Mood disorder (n=2)/70% hallucinated in 6 weeks prior. 70 Inpatients (n=?) and outpatients from Saudi Arabia (n=37) and UK (n=33)/icd-10 schizophrenia/hallucinations persisting N4 years. Johns et al. (2002) 14 Outpatients (UK)/?clinician diagnosis of schizophrenia/9 had current auditory hallucinations, 5 in remission Singh et al. (2003) 75 Outpatients (India)/ICD-10 schizophrenia N2 year illness duration/current or recent (last 3 months) hallucinations, clinically stable for 3 months. Lee et al. (2004) 20 Inpatients (Singapore)/DSM-IV schizophrenia and no history of psychotherapy/heard a command hallucination at least once in past 6 months Tsai and Ku (2005) 200 Non-acute inpatients (Taiwan)/DSM-IV schizophrenia/daily voices for at least 6 months plus minimum inpatient stay of 3 months a Studies included if at least 70% participants had diagnosis of schizophrenia. Several interviews over 6 months/open-ended responses about strategies classified (method unstated). Interviewed with family/coping style scored on 6 theoreticallyderived coping themes from Ray et al. (1982); Usefulness of themes in interrupting or reducing voices was scored Semi-structured interview/strategies for all symptoms classified into 5 major categories (& sub-categories) according to apparent commonality. Semi-structured interview including coping checklist (Carr & Katsikitis, 1987)/factor analysis of the 13 most frequent strategies Semi-structured interview/verbatim reports of coping were classified into a priori categories Comprehensive structured schedule including a card sort of 25 coping techniques/groups identified by multidimensional scaling from use and efficacy ratings. Structured interview including 29-item coping strategy checklist/ descriptive results and comparison of frequency ratings with Falloon and Talbot (1981) Open-ended phenomenology questions; insight schedule. Coping schedule not described/descriptive results. Structured interview including unprompted reports and check list of general and hallucination-specific strategies/factor analysis. Semi-structured interview/elicited strategies categorized (method not stated) Semi-structured interview using the MHRI Unusual Perceptions Scale/Responses compared with 16 tinnitus sufferers Used Thurm and Hafner's (1987) interview/classified into four a priori groups of Kumar et al. (1994). Semi-structured interview given to 100 patients reporting voices to identify those (n=53) with command hallucinations (CHs)/One coping strategy recorded for those not complying with the command (n=20) Self-report and semi-structured questionnaires developed by the authors. Asked for 3 self-management strategies for the most frequent hallucination/strategies classified by consensus as physiological (reducing or increasing stimulation); cognitive (only involving a mental process); behavioural (changing behaviours) All reported coping. Classified into 16 categories and 3 themes: behavioural, physiological or cognitive. 1+ strategy from each theme was used by 73% All reported coping. Data on specific strategies not reported. Patients could be classified according to coping style. Those using fewer themes did better. Some differences in effectiveness across strategies; e.g., self-distraction helpful, aggression not. Behaviour change and cognitive control more frequent than socialization, medical, or symptomatic. Observed both adaptive and maladaptive coping in same persons. 39/40 reported coping strategies. Common strategies: telling voices to go away, seeking company, taking medication. Factors: active hopeful engagement; passive despairing rejection; active ambivalent acceptance; active hopeful rejection. Each person used 1 4 techniques. Percent of sample using physiological; cognitive; and behavioural strategies was 90; 66 and 57, respectively Of 81 worried by voices, 68% reported 1+ coping strategies (M=10). Yelling or talking back was the most common strategy. Three groups of strategies identified: competing auditory stimulation, active/vocalizing, and constructive alternative focus. 55% reported strategies in response to an open-ended question; 100% when prompted by the coping checklist. Each strategy claimed by N1/3 patients. Most successful: sleeping; prayer/meditation/yoga; doing a task to divert attention 76% identified 1+ coping strategy. Most successful strategies: Talking to somebody; sleeping; thinking of something else. Poor control over voices associated with distress. Of 76 with stressful voices, 84% gave unprompted strategies. Both general and hallucination-specific coping used. Three checklist factors: active acceptance; passive coping; resistance coping. N85% reported 1+ strategy. Six themes: Religious; Distraction; Physiological; Social; Individualistic; Cessation. Groups differed in total strategies used and type, esp. religious (more SA) vs. distraction (more UK). 71% reported a coping strategy. Six strategies reported effective by both groups: talking to someone, humming, watching TV, listening to music, focusing/concentrating on something, and repeating numbers subvocally Shouting at voices to stop was least effective. Mean of four strategies endorsed. Of the coping strategy groups, help-seeking was most frequently used, followed by Diversion, Problem-solving and Avoidance. Hallucination severity and Problem-solving strategies were associated with distress. Coping strategies used: prayer (25% of subsample), medication, listen to music, think about something else, talk to someone, sleep, do housework, put cotton wool/fingers in ears and go to the beach. 36 self-management strategies identified. The most frequently reported strategies were: ignore them (n=155), cover ears (n=55), and watchtv (n=37). Behavioural strategies were the most commonly reported category. J. Farhall et al. / Clinical Psychology Review 27 (2007)

5 480 J. Farhall et al. / Clinical Psychology Review 27 (2007) longer prompt lists will, on average, lead to a greater number of strategies claimed, either because the strategies themselves are more narrowly defined, or because more prompts give a greater aid to memory. At a minimum, these results suggest that people troubled by hallucinations have typically tried more than one strategy The nature of coping strategies Summarising the coping behaviours reported by these studies is difficult given the lack of consistency in measurement and the diversity of specific strategies reported. Nonetheless, three simple observations can be made. Firstly, it is clear that coping strategies for voices include much diverse behaviour that cover behavioural, cognitive and physiological domains. Ten of the 14 studies categorised specific strategies elicited by interview or checklist into a taxonomy or schema, but the only similarity was use of a physiological/behavioural/cognitive schema (Falloon & Talbot, 1981; Frederick & Cotanch, 1995; Tsai & Ku, 2005). Post hoc categories based on content themes were identified in three studies (Carr, 1988; Carr & Katsikitis, 1987; Wahass & Kent, 1997), but showed little similarity. Only three studies used empirical methods. Carter et al. (1996) used multidimensional scaling to group strategies according to both frequencies of use and efficacy. The groupings were interpreted as possible mechanisms of action, e.g. competing auditory stimuli; vocalisation; distraction. O'Sullivan (1994) conducted a principal components analysis identifying four themes interpreted as coping styles (e.g. active ambivalent acceptance). Farhall and Gehrke (1997) also employed a principal components analysis, identifying three factors that may also reflect coping style or orientation (Active acceptance; Passive coping; and, Resistance coping). The second observation about the nature of coping behaviours is that most strategies reported are not specific to the stressor of hallucinations; many were also reported as ways of coping for psychotic symptoms generally (see Table 1). Neither are the strategies specific to schizophrenia, being similar to those reported for other disorders (Breier & Strauss, 1983), for hallucinations in people without schizophrenia (Romme & Escher, 1989), or for life stressors (Farhall & Gehrke, 1997). The third observation is that the bulk of strategies used are not culture bound. The coping strategies reported in samples from India (Ramanathan, 1984; Singh et al., 2003) and Taiwan (Tsai & Ku, 2005) are similar to those reported by hallucinators from Western cultures, although the cross-cultural comparison of Wahass and Kent (1997) shows there may be different emphases in strategy use across cultures. In summary, a large range of behaviours are reported as coping strategies for voices by people with schizophrenia, but most are not specific to voices, or to psychosis. The factor analytic studies suggest that coping style or orientation may be fruitfully explored Efficacy of natural coping strategies for hallucinated voices The effectiveness of natural coping may determine its usefulness in therapeutic interventions as well as being of interest in its own right. No longitudinal studies could be found assessing the outcomes of coping strategy use for voices. A confounding feature of the cross-sectional studies is that sample selection was confined to those currently or recently hallucinating, raising the likelihood that the samples were biased towards unsuccessful copers, with those successfully stopping voices being excluded. Despite this limitation, we have reported below, in turn, four types of outcome data: general adaptation; efficacy of specific strategies; efficacy of strategy groups; and, outcome as a function of the number of strategies reported. Falloon and Talbot (1981) reported that despite considerable coping actions by many patients, only one-third had good or fair adaptation. There was a large overlap of strategies used by better adapted patients with those used by more poorly adapted patients suggesting that strategy choice may not be the primary determinant of outcome. Carter et al. (1996) reported indirect evidence that hallucinators may have difficulty in learning from their attempts at coping; more effective strategies were not used more frequently, and the number of strategies did not increase with age. Five of the studies report information about strategy effectiveness. In those using rating methods (Carter et al., 1996; Farhall & Voudouris, 1996; Tsai & Ku, 2005), no strategies stood out as frequently or highly effective; most had at least moderate endorsement. Those mentioned as relatively effective in two or more of the five studies were: Shifting or focussing attention (4 studies); Listening to music, Prayer, and Talking to others (3 studies); Sleep, Compliance with command and Games (2 studies). As well as this overlap in results there are apparent inconsistencies, e.g., Yell or argue back was a relatively ineffective strategy in three studies (Carter et al., 1996; Farhall & Voudouris, 1996; Tsai & Ku, 2005), but not in a fourth (Nayani & David, 1996). Despite some commonality, the perceived (or actual) effectiveness

6 J. Farhall et al. / Clinical Psychology Review 27 (2007) of different strategies may differ widely across individuals (O'Sullivan, 1994), matching the great variability in choice of strategies. Two studies identified coping strategy groups and related these to outcome using hierarchical regression. In Farhall and Gehrke's (1997) study, active acceptance was associated with perceived control over hallucinations, passive coping predicted reduced distress and resistance coping predicted greater distress. This latter finding is supported by Singh et al. (2003) who found that problem-solving strategies predicted increased hallucinations distress. The association of distress with active attempts to resist or deal with the voice in these studies rather than with passive coping styles, was not expected, and raises the possibility that direct attempts to change or resist voices may be distressing. Note however, that the opposite inference cannot be ruled out distressing voices may lead to the hallucinator persisting with ineffective resistance coping. Further, even if active coping strategies are associated with distress at a single point in time, it does not mean that such strategies are ineffective in the longer term: A longitudinal study (Boschi et al., 2000) found that active (vs. avoidant) coping for positive symptoms (not voices specifically) predicted improved psychosocial functioning 24 months later. Clearly, the association between active coping and distress requires further investigation. Some studies have related the number of coping strategies (coping repertoire) to outcome. Ramanathan (1984) asserted that patients who used fewer coping themes had better results (p. 235) but reported no supporting analysis. Although Falloon and Talbot (1981) also asserted that better copers used fewer strategies more consistently, this referred only to the 5 best copers. If their data on frequency of strategy use for the whole sample is considered, the opposite is apparent. Ten of the 16 strategies were more often reported by the bgood/fair copers" (n=14) than by the Poor copers (n = 26). Tarrier (1987) provided additional evidence that a repertoire of strategies may be beneficial: patients reporting just one coping strategy for positive symptoms were less likely to have a (self-rated) effective strategy than those reporting more than one strategy. Nayani and David (1996) related the number of strategies reported to distress, showing an association between a greater number of strategies and less distress, however, Singh et al. (2003) reported the opposite. On balance, there are more indications for an association between greater size of coping repertoire and better outcome than the opposite, but it is plausible that consistent application of effective strategies, as well as a breadth of coping repertoire to choose from, may both be beneficial. In summary, the presence, but limited effectiveness, of natural coping strategies in many people who have persisting hallucinations, suggests there is scope to implement psychological interventions aimed at bolstering this natural process. 3. 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 Behavioural methods Aversive conditioning, in the form of electric shocks, noise or imaginal stimuli, was investigated in several single case experiments, all of which reported success (Alford & Turner, 1976; Fonagy & Slade, 1982; Moser, 1974; Turner, Hersen, & Bellack, 1977). Two case reports investigated thought stopping and diversionary activities (Allen, Halperin, & Friend, 1985; Erickson, 1978): diversion reduced hallucination frequency whereas thought stopping affected the duration. A controlled trial of thought stopping (Lamontagne, Audet, & Elie, 1983) reported reduction of delusions but no significant effect on hallucinations. However, there was no information about how frequently the technique was used for hallucinations. Each of these studies has limitations. Most techniques were not pure, involving additional mechanisms to those being tested (e.g., attention switching). None controlled for self-monitoring, which may reduce hallucination frequency, but together they suggest that behavioural methods can lead to change in reported hallucinations, at least for some patients Vocalisation and subvocalisation Verbal hallucinations may be unrecognised or misattributed internal stimuli such as memories or subvocal speech (Slade, 1994). Although this mechanism has not been definitively clarified (Green & Kinsbourne, 1990), treatment

7 482 J. Farhall et al. / Clinical Psychology Review 27 (2007) techniques directed at control of subvocalisation, for example by humming or counting, have been shown by some small trials to be moderately effective in inhibiting of verbal hallucinations (Bick & Kinsbourne, 1987; Gallagher, Dinan, & Baker, 1995; Green & Kinsbourne, 1989, 1990; Nelson, Thrasher, & Barnes, 1991) Auditory competition methods Several small experimental trials also demonstrate the efficacy of auditory techniques in reducing voices, and suggest that meaningful stimuli (e.g., speech vs. noise), and familiar stimuli (e.g., favourite music vs. news reader) are more effective. Margo, Hemsley, and Slade (1981) compared 10 different auditory stimulation conditions. Several of the meaningful auditory input conditions (listening to interesting and boring speech, music) led to significantly fewer reported hallucinations compared with sensory restriction or non-aversive white noise. The main findings have been broadly replicated (Collins, Cull, & Sireling, 1989; Feder, 1982; Gallagher, Dinan, & Baker, 1994; Johnston, Gallagher, McMahon, & King, 2002), however, as with natural coping methods, the effectiveness of any strategy across individuals may vary greatly (Hustig, Tran, Hafner, & Miller, 1990). Nelson et al. (1991) compared the acceptability and uptake of subvocalisation and auditory competition techniques in a sample of 15. Listening to music via a personal cassette player was superior in terms of uptake, reported effectiveness and continued use at follow-up. 4. 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 coping has been incorporated into psychological interventions for hallucinations. In this section we focus on treatments where coping is the main focus, then in Section 5 we turn to hallucination-specific therapies where coping is one of several components. Finally, in Section 6, we consider the place of coping strategies in broader CBT for psychosis therapies A rationale for coping as the focus of treatment Although natural coping strategies are widely used for hallucinated voices, this review suggests that the typical benefit is, at best, modest. To some extent, poor outcome is associated with a small natural coping repertoire, and a failure to implement more effective strategies at the expense of less effective strategies. These observations imply that coping might be improved by: a) encouraging growth in coping repertoires, where patients have few strategies; b) helping patients prioritise more efficacious strategies from their existing repertoire; c) teaching patients additional strategies that have known efficacy; and, d) providing information to patients about natural strategies used by other hallucinators, and their reported efficacy, to encourage further self-discovery of personally effective strategies. Such interventions could be expected to be acceptable, and perhaps empowering, because they build upon the natural coping of the patient. In addition, this approach maximises outcomes through an emphasis on efficacious techniques from the experimental literature Interventions that systematically teach coping strategies for voices The growing use of coping interventions in clinical practice prompted a recent Cochrane review of distraction treatments for hallucinated voices (Crawford-Walker, King, & Chan, 2005). Distraction was defined as any coping strategies that diverted attention away from hallucinations. Of five completed randomised controlled trials identified, only three (Buccheri, Trygstad, Kanas, Waldron, & Dowling, 1996; Lamontagne et al., 1983; Tarrier, Sharpe et al.,

8 J. Farhall et al. / Clinical Psychology Review 27 (2007) ) included interventions that could be considered personal coping strategies directed at voices, and there was little data in total available for analysis. No conclusions about efficacy were drawn. Haddock, Bentall, and Slade (1996) described a systematic approach for helping patients to build a repertoire of suppression and distraction techniques, in which new techniques were introduced in each session. This distraction therapy was compared with focussing therapy in which the patients were gradually made aware of the possibility that their voices could be explained as misattributed, internally-generated, mental activity. Patients in both groups improved over the treatment period on measures of hallucination frequency, distress, and disruption to life; however, the groups did not differ on these measures either at end of treatment or at 2-year follow-up (Haddock, Slade, Bentall, Reid, & Faragher, 1998). There was some evidence that self-esteem rose over treatment for focusers and reduced for distracters; however, it had fallen substantially in both groups by follow-up. Buccheri et al. (1996) devised a group program to systematically introduce 11 empirically-supported behavioural strategies for managing persisting hallucinations. Outcomes did not differ across treatment and control groups; however, complete data were only available for six participants per group. The effectiveness of any strategy varied across participants but all found at least one of the introduced strategies helpful. Qualitative data seemed to demonstrate both the viability, and specific benefits, of a systematic introduction of coping strategies in a group treatment context. A second study (Buccheri et al., 2004) evaluated a similar group treatment program involving 60 participants, but without a controlled design. The intervention was acceptable to participants, and reductions from baseline levels of hallucination were sustained for up to 1 year post-treatment. A further group intervention directed primarily at implementation of coping strategies for voices has been reported (Perlman & Hubbard, 2000), but with no controls and a small n Interventions that enhance natural coping for positive symptoms Coping Strategy Enhancement (CSE) is the only published coping-focussed treatment that explicitly adopts the rationale of recognising and building upon natural coping. CSE was originally developed by Tarrier and his co-workers (Tarrier, Beckett et al., 1993; Tarrier, Harwood, Yusopoff, Beckett, & Baker, 1990), and was later combined with problem-solving and relapse prevention into a broader CBT for psychosis (Tarrier, Yusupoff et al., 1998). The original CSE (Tarrier, 1992) consisted of 10 sessions over 5 weeks during which a behavioural analysis of distressing symptoms was made, a priority symptom chosen, natural coping assessed as helpful or not, and enhancements to natural coping made using a variety of behavioural techniques. In one of the two initial cases (Tarrier et al., 1990), hallucinations were a target symptom and the patient showed considerable reduction in overall symptoms; however, hallucination-specific data were not reported. A randomised controlled trial (Tarrier, Beckett et al., 1993) compared CSE with behavioural problem-solving. Both treatments led to significant improvements in delusions but not hallucinations. Further analyses (Tarrier, Sharpe et al., 1993) supported the CSE rationale, in that use of positive coping strategies was associated with a reduction in the number and severity of symptoms, but again, no hallucination-specific outcomes were reported. The later trial of Tarrier and colleagues (Tarrier et al., 1999; Tarrier, Yusupoff et al., 1998), in which CSE was combined with problem-solving and relapse prevention in a broader CBT for psychosis package, did report specific results for hallucinations (Tarrier et al., 2001), but to what extent these were attributable to the CSE component as opposed to the problem-solving or relapse prevention components is unknown. Further, although at the end of the treatment period, severity of hallucinations was significantly less for the CBT group compared with supportive counselling, surprisingly, there were no significant differences between the CBT and the routine care groups. Farhall and Cotton (2002) piloted implementation of a CBT intervention for symptoms in which coping enhancement was the most frequently used component. The therapy was acceptable to patients and symptom frequency, distress and preoccupation improved, but separate results for hallucinations were not reported, and there was no control group. In summary, coping has rarely been the primary focus of published treatments. CSE may be effective in reducing overall symptom severity, but the effect on hallucinations of enhancing coping has not been isolated in a well-designed trial. 5. 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.

9 484 J. Farhall et al. / Clinical Psychology Review 27 (2007) Hallucinations integrated therapy Hallucinations Integrated Therapy (HIT) is a multi-modal family therapy developed in the Netherlands for patients with persisting hallucinations (Wiersma, Jenner, van de Willige, Spakman, and Nienhuis, 2001). The manualised, 20- session treatment is implemented flexibly and largely replaces routine care. It encompasses six main components: psychoeducation; medication; CBT; coping training; family treatment; and, rehabilitation. The coping training, delivered to patients and their relatives, includes anxiety management, distraction, and focussing elements, with exercises and daily monitoring. A randomised trial of HIT versus routine care (Jenner, Nienhuis, Wiersma, & van de Willige, 2004) demonstrated reductions in distress about hallucinations, and in symptom scores. Jenner et al. were unable to say what contribution, if any, the coping component made to the overall benefit. One aim of the coping component, to encourage consistent use of fewer strategies, was not well achieved. The aim is not supported by the small number of studies reviewed earlier, where better outcome was more often associated with use of a broader repertoire of strategies Group CBT for voices Wykes and colleagues (Wykes, 2005; Wykes, Parr, & Landau, 1999) have developed a group program for voices that includes psychoeducation, behavioural coping strategies and cognitive restructuring components. The program improved social functioning, and reduced hallucination severity in groups conducted by more experienced therapists (Wykes, 2005). A small increase in the number of coping strategies employed following treatment was not statistically significant. No other measure of the specific effect of coping strategy component was reported. 6. CBT for psychosis therapies that incorporate a coping strategy component Over the past two decades, cognitive therapy and cognitive behaviour therapy treatments for psychosis 1 have been developed. Recent reviews (Dickerson & 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 (Tarrier & Wykes, 2004) that methodological rigour was inversely associated with effect size, and by Gaudiano's conclusion that neither the efficacy of components of these packages nor their superiority compared with alternative therapies has yet been established. CBT for psychosis therapies are diverse, and only some include coping techniques for hallucinations in their treatment packages (Fowler, Garety, & Kuipers, 1995; Herrmann-Doig, Maude, & Edwards, 2003; Hogarty et al., 1995; Kingdon & Turkington, 1994; Liberman, 1988; Pinto, La Pia, Mennella, Georgio, & DeSimone, 1999; Tarrier, Yusupoff et al., 1998). Coping is not a significant element of Focussing Therapy (Bentall, Haddock, & Slade, 1994), Cognitive Therapy for positive symptoms (Chadwick, Birchwood, & Trower, 1996; Drury, Birchwood, Cochrane, & Macmillan, 1996; Rector & Beck, 2002), Language Therapy (Hoffman & Satel, 1993) or Rational Emotive Behaviour Therapy for schizophrenia (Olevitch, 1995; Perris, 1989; Svensson, Hansson, & Nyman, 2000). Inclusion of coping strategy work in some CBT for psychosis packages illustrates a therapeutic context in which it may be useful, but none of these outcome studies report data on the efficacy of the coping components, either in general or for hallucinations. Typically, the primary outcome variables have been broader measures of positive symptoms, or overall symptom severity. 7. Issues concerning the structure and focus of treatment Practice and research issues raised by the review are discussed in this and the following section The place of coping enhancement in current psychological treatments for voices It could be argued that Coping Strategy Enhancement, as originally outlined by Tarrier et al. (1990), was a historical step in the development of CBT for psychosis, and that the field has moved on from this focus on coping. To some 1 In this review, cognitive therapy and cognitive behaviour therapy treatments are both referred to as CBT.

10 J. Farhall et al. / Clinical Psychology Review 27 (2007) extent this is true: the core CSE idea of assessing and building upon patients' natural coping was a significant conceptual and practical advance; yet recent theoretically-driven research has emphasised the role of cognitive, rather than coping, factors (Beck & Rector, 2003; Morrison, 2001), and the emphasis of current hallucination treatment practice within CBT for psychosis is on modification of beliefs about voices (e.g., Chadwick et al., 1996; Nelson, 1997). Does this mean that coping strategies are no longer an important focus of intervention? We argue that coping is still prevalent in clinical practice, and has broad application. Although research has moved away from examining coping with hallucinations, coping seems to have become an established part of most CBT for psychosis therapies. In Australia, Herrmann-Doig et al. (2003) list coping strategies as one of the three types of interventions in their treatment handbook. In the UK, Nelson (1997) devotes a chapter of her practice manual to practical interventions for voices; Fowler et al. (1995) outline specific coping approaches for voices and explain the value of CSE as encouraging behavioural change and feelings of control (Fowler, Garety, & Kuipers, 1998); and, although belief modification is more central to their approach, coping is included in the approach of Kingdon and Turkington (Kingdon & Turkington, 1994; Sensky et al., 2000). In the Netherlands, coping training is one of two main components (the second is CBT) of HIT (Jenner & van de Willige, 2001; Jenner, van de Willige, & Wiersma, 1998; Wiersma et al., 2001). In the USA, a longstanding component of the intensive Social and Independent Living Skills training developed at UCLA (Liberman, Kopelowicz, & Young, 1994) is a Symptom Management Module (Liberman, 1988) that trains patients to cope with relapse prodromes and persisting symptoms, and coping is also a significant element of Personal Therapy for schizophrenia (Hogarty, Greenwald et al., 1997; Hogarty et al., 1995; Hogarty, Kornblith et al., 1997). The presence of a coping component in these diverse CBT treatments suggests that the idea of bolstering coping may be broadly applicable across a number of treatment contexts. For example, coping enhancement may be the central focus of behaviour change, or it may be simply a concrete starting point, designed to strengthen engagement prior to a more challenging process of belief modification. Given that coping is a natural process, the therapist's support and strengthening of it may be experienced as empowering. Further, given that identification of natural coping by patients, and engagement in improving coping, require no confrontation of psychotic beliefs, coping enhancement may be an accessible and realistic focus for group treatments for voices, and for psychological interventions in acute inpatient settings, where short length of stay and symptom severity may preclude belief modification. Given the prevalence of coping in current treatments and these practical reasons for its continued use, the absence of any efficacy data about such interventions specifically for voices is a significant gap The relative effectiveness of coping versus other components of CBT for psychosis The cognitive emphasis in CBT for psychosis reflects a wider trend in the CBT field (Nathan & Gorman, 2002), but as Gaudiano (2005) points out, it is not based on any evidence about relative efficacy of cognitive and behavioural components. In this view, behavioural aspects of therapy are as effective as cognitive elements, and possibly sufficient for clinical change (Gaudiano, 2005). Whether this analysis holds for CBT for psychosis is not known: the effective elements have not been isolated, and some authors doubt the practicability of doing so (Tarrier, 2005a). Haddock et al. (1996) found little difference between focussing therapy and coping enhancement centred on distraction both led to useful improvements suggesting that both belief-oriented and coping-oriented treatments may be useful. A similar implication arises from the differentiation by Romme and Escher (1996) of their survey respondents into those who coped with voices and those who did not. Both better relationships with the voice and better coping strategies distinguished the copers. In short, there is currently no evidence that either cognitive (belief change) or coping interventions (i.e., predominantly behavioural) are superior Mindfulness and coping with voices Mindfulness is the cognitive skill of being aware of, or observing, experiences as they occur, including physical sensations, cognitions, and perceptions (Kabat-Zinn, 2003). Mindfulness practices have been incorporated into some CBT therapies (Linehan, 1993; Segal, Williams, & Teasdale, 2001) and their central elements acceptance and disengagement from a stressor appear to be relevant to the treatment of auditory hallucinations. Some coping strategies, such as yelling back to voices or drowning them out with loud music (Falloon & Talbot, 1981; Tarrier, 1987), imply an intention of resisting the voice, a theme also identified by Chadwick and Birchwood

11 486 J. Farhall et al. / Clinical Psychology Review 27 (2007) (1994) as a fundamental response orientation. However, resistance to voices may have emotional costs for the person. Fight and flight responses have been associated with depression (Gilbert et al., 2001) and resistance coping has been associated with negative emotional outcomes (Farhall & Gehrke, 1997). An alternative to resisting voices is acceptance of their presence. Although this may seem antithetical to treatment, some reports suggest it may be an adaptive form of coping. Firstly, some hallucinators incorporate their voices into their lives without resistance or suppression, apparently without adverse outcomes. These people include voice-hearers without a psychiatric diagnosis such as Freud (Liester, 1996), as well as those recovering from psychosis (Davies, Thomas, & Leudar, 1999). Secondly, in their community sample of voice-hearers, Romme and Escher (1989) observed that; coping success appears to entail reaching some sort of peaceful accommodation and acceptance of the voice as part of me (p.213). Further, in the Farhall and Gehrke (1997) study, the Active Acceptance factor (items such as listen to the voices and accept what they say p.260) was associated with perceived control of voices whereas the resistance and passive coping factors were not. However, a risk of accepting the presence of voices may be a greater preoccupation with them (Benjamin, 1989). Shawyer, Farhall, Sims, and Copolov (2005) argue that in order for acceptance to be adaptive it needs to include some degree of disengagement from the voice experience, as in the practice of mindfulness. In these circumstances, the voice is noticed, accepted as an experience that occurs, and coping action taken if required. The absence of disengagement in Falloon and Talbot's (1981) coping theme of passive acceptance (defined as listening attentively, repeating the content, accepting guidance, p.334) may explain why this acceptance theme was prominent in the poor copers rather than good copers. Two studies have directly applied a mindfulness therapy to voices. Bach and Hayes (2002) implemented a foursession version of Acceptance and Commitment Therapy (ACT Hayes, Strosahl, & Wilson, 1999) with inpatients. It aimed to help patients work towards valued goals through developing an attitude of willing exposure to, rather than avoidance of, voices, whilst not being drawn in by them. The treatment group had fewer rehospitalisations by 9-month follow-up, and lower levels of voice believability, despite similar levels of symptom frequency and distress. A similar trial (Gaudiano & Herbert, 2006) also showed hallucination-specific benefits compared with treatment as usual. A controlled trial of a new treatment for command hallucinations, combining elements of ACT and belief modification, is currently underway (Shawyer et al., 2005; Shawyer, Mackinnon, Farhall, Trauer, & Copolov, 2003), with similar goals of disengagement and acceptance Collaboration with service users The theme of coping enhancement provides a valuable point of contact between evidence-based psychological treatments and the growing recovery movement. Service users (Deegan, 1988; Frese & Davis, 1997), and some rehabilitation models (e.g., Anthony, 1993), have adopted a notion of recovery in which the goal is for the patient to get on with life despite any continuing symptoms and disabilities, thus living outside mental illness (Davidson, 2003). In recovery approaches, the service user is central to setting the goals for change in their mental health problem, and assistance is provided by peers and service providers who foster coping and coming to terms with having a disorder. Structured peer support programs may include mutual help groups, and recovery workbooks (Coleman & Smith, 1997) emphasising coping and acceptance. These resources for service users typically are an amalgam of research-based material and the accumulated wisdom of voice-hearers. In the emerging interplay between service users, providers, and researchers (Davidson, 2005) the goal of better coping constitutes a valuable common ground for shared initiatives Clinical implications Some of the observations made in this review have implications for clinical assessment. Firstly, differences in the size and nature of coping repertoires elicited by open questions (i.e., unprompted) versus use of checklists of coping strategies, suggest a two-step approach for assessment of coping repertoire. A first step, asking what, if anything, the person does to stop voices or to feel better, may elicit strategies that are prominent and allow mention of idiosyncratic behaviours, but the responses may be limited by recall and the person's awareness of coping. Adding a second step using prompt lists of strategies reported by others may overcome these limitations, although it may risk over-reporting. Secondly, reduction in voice frequency the primary criterion for coping success evident in the experimental literature can be augmented in the clinical setting to include assessment of other relevant outcomes. A particular