Hearing voices is seen as a bad thing – but what do patients think?

• Before we begin, watch this video on what it’s like to suddenly hear voices + why it’s not always a bad thing! 

🗣️What do we know about voices? 

Psychosis occurs when people lose contact with reality and show symptoms like hallucinations.

• Hearing voices, aka Auditory Verbal Hallucinations (AVH), is the most common type of hallucination in psychosis.

👂Ever wondered what hearing voices feels like? Click here for a Simulation! 

• Traditionally, AVH have been viewed as a detrimental symptom of psychosis, and many people share how scary and distressing hearing voices can be.

🤔 But people experience Positive AVH too!

•  Some people experience voices as gifts that bring comfort and guidance  
• A study found that around half of psychotic patients report hearing positive and useful voices. Why? Because the voices: 

1. 1. Protected patients 
   2. Gave patients advice 

⭐ In fact, some patients even resist treatment aimed at reducing AVH because they miss and are afraid of losing their voices.

Pretty cool right? 

👣 Positive AVH in Psychotic populations is a novel and upcoming research field with lots more to discover… 

❓ What don’t we know about Positive voices? 

1. Research hasn’t uncovered how common they are in specific populations, like people with a First Episode of Psychosis.

• These people are usually referred to Early Intervention Services to receive treatment, after experiencing symptoms like AVH for at least 1 week.
• Knowing whether patients experience Positive AVH is important to understand their experiences. This could determine the treatment they receive and affect how their illness develops.  

2. We don’t know what these Positive voices are saying. Experiencing AVH is subjective, meaning there is a lot of variation in what each patient hears from their voice. Whilst some scales are used to measure what voices say, these questions are not:

❎ Specifically about Positive voices 

❎ Tested in patients with a First Episode of Psychosis 

❎ Categorised in a way that’s easy to understand 

3. We don’t know what predicts Positive AVH experiences. These predictors can help us identify who hears Positive voices and may be less likely to engage with treatment. If we know this, we can help improve services to address their needs.

🔍 So, our project wanted to investigate:  

1. Out of everyone who experiences AVH, how many people hear Positive ones? 
2. What are these Positive voices saying, and how common are they? 
3. Can we predict whether someone experiences a Positive AVH?

🖥️What did we do?

“We” are a team of assistant psychologists, contributing to a wider project aimed at improving treatment within an Early Intervention in Psychosis Service. Patient data for this investigation is drawn from this initiative and consists of National Health Service progress notes, which document patient illness progression. 

 1️⃣ Defined “Positive” – a voice helping the patient gain a goal, either based on what the voices say (Positive Content) or how the person interprets them (Positive Interpretation).

💡Here’s an example of a Positive AVH: 

 “The voice tells me I will die soon and go to heaven.” 

This is not seen as Positive Content BUT if a progress note reports a patient interpreting this as achieving their goal of reuniting with their deceased family member, it would be a Positive Interpretation.

2️⃣ Looked through NHS progress notes of 740 patients with AVH. Counted the number of patients experiencing Positive AVH. 

3️⃣ Classified each patient’s Positive AVH into 11 categories and 62 subcategories. Categories included: Biological, Social and Psychological Gains, Positive Content and Positive Interpretation 

4️⃣ Counted the number of Positive AVH that fit into each category and subcategory  

5️⃣ Used a statistical test called a logistic regression to determine whether patient characteristics (e.g. gender, age) could predict experiencing Positive AVH  

📊What did we find? 

1. 181 out of 740 patients experienced Positive AVH.

2. 120 out of 181 patients experienced a Psychological Gain, making it the most common category of Positive AVH.

Happiness and self-esteem were subcategories within this category. Patients commonly reported these as increasing after experiencing Positive AVH.

A paraphrased example from a patient:

“The voices encourage me and say everything will be ok.”

4. Psychosis Illness Length predicted Positive AVH – having psychosis for longer meant patients were more likely to experience Positive AVH.

 👀 Why is this so interesting? 

✅ We know how common hearing Positive AVH is for First Episode Psychosis patients

✅ We understand what Positive voices are about. This helps us understand patients’ experiences. 

✅ We know that a longer diagnosis of Psychosis predicts experiencing Positive AVH. 

🏆The bonus?

This research uses the largest, most culturally diverse sample to investigate Positive AVH in patients to date!

• As of this blog’s publication and to the best of our knowledge, this is the most comprehensive information about Positive AVH in First Episode Psychosis patients out there – we know more now than ever! 
• This means our results are relevant and applicable when investigating Positive AVH in patients outside this study.    

‼️The important thing is..

These results challenge the view that all AVHs are bad. It highlights that voices provide social support, making patients feel protected and even happy. 

Increasing our awareness of Positive AVH and understanding patient experiences gets us asking questions going beyond the scope of this investigation… 

It makes us wonder – is removing all AVH experienced by patients still the best focus when treating Psychosis?

🏥 If patients are unwilling to get treated because they’re afraid of losing their voices, this tells us that treatment plans need to change. 

Our findings encourage us to rethink how current treatments align with patients’ experiences and suggest that treatments may need improvement to better reflect what patients want and need.

⏰What’s next?

• Test how common Positive AVH and people’s experiences of them are in other populations, e.g. those with long-lasting Psychosis (>3 years).
• Test if other sample characteristics predict Positive AVH, e.g. culture, which can influence what voices say 
• If you’re interested to learn more about Psychosis, check out these further resources! 

999 words 

Credits: 

1. Video from YouTube https://www.youtube.com/watch?v=syjEN3peCJw 
2. Video from YouTube https://www.youtube.com/watch?v=NyUqhbPD2tc 
3. Both Artworks were obtained from Melvin et al.(2021), the first by Dr Fiona Blake and the second by a participant https://doi.org/10.1080/13546805.2021.1993807 
4. Meme self made from meme generator https://imgflip.com/memegenerator  

References: 

1. Hearing voices. What Does “Hearing Voices” Mean? (2022). https://www.rethink.org/advice-and-information/about-mental-illness/mental-health-symptoms/hearing-voices/
2. Lorente-Rovira, E., Grasa, E., Ochoa, S., Corripio, I., Peláez, T., López-Carrillero, R., Morano-Guillén, M., Gutiérrez-Gea, Á., Villagrán, J. M., Llácer, B., & Sanjuán, J. (2020). Positive and useful voices in patients with schizophrenia. Journal of Nervous & Mental Disease, 208(8), 587–592. https://doi.org/10.1097/nmd.0000000000001183 (Open access article) 
3. Thomas, N., Hayward, M., Peters, E., van der Gaag, M., Bentall, R. P., Jenner, J., Strauss, C., Sommer, I. E., Johns, L. C., Varese, F., Garcia-Montes, J. M., Waters, F., Dodgson, G., & McCarthy-Jones, S. (2014). Psychological therapies for auditory hallucinations (voices): Current status and Key Directions for future research. Schizophrenia Bulletin, 40(Suppl 4). https://doi.org/10.1093/schbul/sbu037 (Open access article)