Community Mental Health Journal https://doi.org/10.1007/s10597-018-0294-0

ORIGINAL PAPER

Experience Focussed Counselling with Voice Hearers as a TraumaSensitive Approach. Results of a Qualitative Thematic Enquiry J. K. Schnackenberg1,2 · M. Fleming3 · C. R. Martin4 Received: 27 May 2017 / Accepted: 6 June 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract The individual approach of the Hearing Voices Movement, Experience Focussed Counselling or Making Sense of Voices, claims a strong life context and trauma focus. This qualitative study represented the first to explore whether Experience Focussed Counselling with voice hearers, when compared to Treatment As Usual, could be considered trauma-sensitive. Twenty-five semi-structured interviews with voice hearers and mental health professionals in routine German mental health settings were analysed as part of an Applied Thematic Analysis. Overall themes identified were: trauma related; dealing with emotions; process of working with voices; intra- and interpersonal life; and coping related. Experience Focussed Counselling was considered helpful in understanding and working on unresolved trauma-related areas of distress. The same did not apply to Treatment As Usual. Findings support Experience Focussed Counselling as a trauma-sensitive intervention in hearing voices. Frontline mental health staff can potentially support voice hearers in identifying and working on traumarelated voices and emotions. Keywords  Experience Focussed Counselling (EFC) · Making Sense of Voices · Trauma-sensitive intervention · Voices related to life context · Psychosis

Introduction As estimates of the prevalence of hearing voices from general population studies suggest a median 13.2% (Beavan et al. 2011), current thinking increasingly understands hearing voices as a non-pathological experience in itself (Corstens et al. 2014). A newly emerging understanding suggests that distressed voice hearer(s) (VH) may benefit Please note: care was taken to use non-pathologising language in line with Hearing Voices Movement suggestions,i.e. using voice hearing instead of auditory hallucinations or non-shared reality instead of delusions. * J. K. Schnackenberg info@efc‑institut.de 1



EFC Institute, Westende 3, 24806 Hohn, Germany

2



Stiftung Diakoniewerk Kropp & St Ansgar gGmbH, Kropp, Germany

3

DHSC Education and Training Centre/Cabinet Office, Learning and Development (LEaD) Team, Keyll Darree, Strang, Isle of Man

4

Faculty of Health Sciences, Institute for Clinical and Applied Health Research (ICAHR), University of Hull, Hull, UK





from support toward an improved way of relating to voices (Bak et al. 2003). This may include resolving trauma, related emotional conflicts, or even identity or similar conflicts, on their way to recovery (Read et al. 2005; Romme et al. 2009; Varese et al. 2012; Thomas et al. 2014; Steel 2015). Within a trauma framework voices may be conceptualised as dissociative expressions, the externalisation of memories, decontextualised trauma flashbacks (Read et al. 2005; Steel 2015) or even as metaphorical, psychodynamic or historical expressions of trauma (Romme and Escher 2000). Importantly, multiple, rather than single-event, adversities or traumas are more likely to predict psychosis risk (Longden et al. 2015). These are not new concepts to the Hearing Voices Movement (HVM) (Corstens et al. 2014). Its individualised approach, Making Sense of Voices or Experience Focussed Counselling (EFC) (Romme and Escher 2000, 2008/2013), is distinct from other novel approaches, such as Cognitive Behavioural Therapy in Psychosis (CBTp) (Steel 2017) or Relating Therapy (Hayward et al. 2018). EFC focusses on trauma not just as a general stressor which may contribute to the outbreak of an underlying vulnerability to psychotic symptoms or the interpretation of voice hearing experiences, as may be the case in CBTp (Steel 2017). It proposes instead

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that the nature, relationship with, and content of voices may be both directly expressive of, and pointing at, unresolved life conflicts, including trauma (Corstens and Longden 2013). Voices may thus represent non-pathological sources of useful knowledge (Schnackenberg and Martin 2014) independently of diagnoses (Moskowitz and Corstens 2007). Direct engagement with, and exploration of, the contents, life context and potentially positive meaning of voices within a non-pathologising, non-judgemental, meaning-seeking and active-listening process is thus encouraged (Corstens et al. 2009; Steel 2017). This may establish a link between unresolved past trauma (only if considered relevant by the VH) and current voices (Read et al. 2005). Voices may thus be revealed as understandable experiences (Romme and Escher 2000). Such thinking is, however, contrary to the general mental health discourse, which is dominated by attempts to objectify the experience into psychopathological paradigms (Moskowitz 2009; Thomas 2015). Here, voices in psychoses are assumed to be not understandable and in need of medical treatment (Beer 1996). The EFC process consists of the sequential use of the Maastricht Interview, Report and Construct (Romme and Escher 2000). The interview process specifically allows VH to explore current and past expressions and impact of the voice hearing experience. It also provides space to share past traumatic or adverse events. Following a summary of the interview in report form, the ‘Construct’ provides a structured format to help the VH identify who and what the voices may represent within his/her life’s context. It may identify voices as potentially pointing towards current difficulty with emotions or boundaries which in turn may be rooted in past traumatic (e.g. abusive, etc.) experiences (Romme and Escher 2008/2013, 2010). When engaging and respectfully talking, enquiring and listening to voices directly as part of this process, they may regularly also reveal their positive intention, or they may be used in overcoming such adverse events (Corstens et al. 2012). Thus, an aggressive voice may be trying to encourage the VH to express anger, something they may struggle with as a result of e.g. childhood abuse. Such understanding frequently develops as part of a collaborative, but VH-led, EFC process and should never be imposed by professionals (Corstens et al. 2014). Importantly, an openness towards life context and trauma connections exists but is of course not mandatory. The explanatory framework of the VH should ultimately remain decisive (Corstens and Longden 2013) and be worked within (Romme and Escher 1993). EFC thus also conceptualises related experiences like anxiety, low mood, etc. as potentially understandable, non-pathological reactions to voices and unresolved trauma or socioemotional conflicts. It is therefore explicit in not representing therapy, even if it may have therapeutic benefits (Romme and Escher 2008/2013). It’s normalising and de-pathologising approach uniquely

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understands the possibility of using voices to potentially help overcome trauma. The focus is thus on a need to develop a balanced more understanding relationship with the voices, rather than just learning to assert oneself towards the voices, as is suggested in Relating Therapy (Hawyward et al. 2018) or AVATAR Therapy (Craig et al 2017). A selection of 50 recovery stories (Romme et al. 2009), which did not use a recognised qualitative methodology, and 100 clinical cases, primarily applying the construct element of EFC only (Corstens and Longden 2013), indicated a trauma-sensitive and sense making nature in the application of elements of EFC. Beyond this, a review of the literature confirmed that no additional qualitative or quantitative studies existed specifically addressing the full application of EFC or the potential of EFC as a trauma-sensitive intervention (Schnackenberg and Martin 2014). There also appears to be a lack of qualitative studies within psychosis related research more generally (Corstens et al. 2014; Thomas et al. 2014) and a need for trauma-sensitive interventions in psychosis (Romme 2009b; Johnstone and Boyle 2018). There is therefore a need to evaluate EFC specifically for its potential trauma-sensitive credentials as it may address an important shortfall in current mental health service provision. To our knowledge this paper represented the first qualitative study with the specific research aim to explore whether the use of a full EFC intervention in routine psychiatric settings was indeed experienced as trauma-sensitive when compared to Treatment As Usual (TAU). TAU included a primary focus on medication, medical-model psychoeducation, regular supportive counselling one-to-ones, and support in work-related and daily living skills. The main difference between the groups consisted of the focus of the one-to-one support, which was aimed to be a minimum of 2 × 45 min/ month in either group.

Method Design Theoretical Framework This paper presents a qualitative enquiry, using semistructured interviews and an inductive explanatory model approach of Applied Thematic Analysis (Guest et al. 2012). To enhance validity of findings, various sources of data were used (Guest et  al. 2012), including mental health professional(s) (MHP) and VH. They had respectively provided, or engaged in, either EFC or TAU interventions over a period of 44 weeks as part of a randomised study design (Schnackenberg et al. 2017). The inclusion of MHP as a qualitative data source also served to reflect the experience

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of psychiatric support where VH are regularly exposed to the evaluations of MHP. Comparison with the COREQ checklist (Tong et al. 2007) indicated adherence to qualitative research guidelines.

Ethics Ethical approval from the University of the West of Scotland, the collaborating German University of Applied Sciences Hanover, Germany, and the respective German research sites was gained between June 2011 and December 2012. Prior to the intervention study interested MHP had attended a halfday information session with the first author. Interested VH off MHP’ caseloads, who were meeting eligibility criteria, read through a study information sheet. Both VH and MHP were invited to discuss questions in more detail with the first author of the study prior to signing a written voluntary consent form. All study participating VH continued to be accompanied by their supporting mental health team, to deal with any potential distress or worsening of experience.

Participant Selection Sampling VH inclusion criteria for the intervention study included no alcohol or drug dependency in the past 3 months, aged between 18 and 65, IQ of over 70, and no organic brain disease, such as dementia. A minimum level of voice hearing related distress, in line with help-seeking criteria by Bak et al. (2003), included study entry distress levels reaching a minimum severity rating of ≥ 4 on the Brief Psychiatric Rating Scale—Expanded Version 4.0 (Lukoff et al. 1986) hallucinations item. VH and MHP [i.e. pedagogues (a term describing both academically and non-academically trained educators with similarities to social workers or social work assistants), mental health nurses, social workers and psychologists who had provided the respective EFC or TAU interventions] were recruited from the two study participating psychiatric service sites in Germany. Description of Sample All VH had long-term experience of mental health support and most had diagnoses of psychosis (see “Findings” section). Participating MHP ranged from newly qualified to over 20 years of experience. None had been trained in trauma therapy before.

wanted to be interviewed. If an interest in the interview existed, VH and MHP were contacted by the interviewer, reminded of voluntary participation and face-to-face or phone contact was arranged, depending on preferences and logistics. Sample Size and Non‑participation All VH and MHP who were available were contacted and most agreed to take part in the interviews. Two TAU VH were not interviewed (one had moved away and the other declined). These respective VHs’ mental health or trauma disclosures were reported by their MHP to not have changed in a significant way during the study. One TAU MHP was on long-term sick leave. One EFC VH (had moved away) and his respective EFC MHP (long-term sick) did not engage in the interviews. This EFC VH’s mental health distress and trauma disclosure and processing was informally reported by his MHP to have slightly improved. As the non-interviewed VHs’ mental health distress and trauma disclosure did not differ significantly from interviewed study participants and there was only one EFC VH for which no interview existed, the subsequent analysis was not unduly biased by selection or drop-out. Overall, this resulted in 25 interviews. Nine VH and their respective nine MHP reflected on their experience with EFC as part of the 44-week intervention study. In the TAU group two VH and their respective two MHP, one additional VH and two additional MHPs were interviewed. This resulted in a total of seven interviews pertaining to five different TAU clients reflecting on their experience of TAU as part of the 44-week intervention study.

Setting Setting of Data Collection Suitable times and places chosen by the interviewees, to ensure as open and free an exchange as possible (Moriarty 2011), were primarily in their home, work, and clinical settings. Presence of Non‑participants 2 TAU VH and 3 EFC VH wanted someone present (4 keyworkers; 1 friend).

Data Collection

Method of Approach

Interview Guide Development

At the end of the 44-week intervention study participating VH were first contacted by their MHP and asked if they

The development of the interview schedule included feedback by two experts-by-training (Romme and Escher)

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and one recovered expert-by-experience (and trainer in EFC). Research aim specific questions focussed on detecting changes in life context and trauma related domains (Romme 2009a) compared to the year before the study. There was an attempt to determine attribution of change (i.e. the result of EFC, TAU or other elements). The complete interview schedule also included questions pertaining to recovery (paper undergoing review process) and trans-diagnostic (Schnackenberg et al. 2018) elements of EFC, discussed elsewhere. These domains were, however, not considered in this paper. The interview schedule was essentially the same for interviewees from both intervention groups. It was group, VH or MHP specifically worded to afford comparability between EFC and TAU group and VHs’ and MHPs’ views. A trial run with two VH and one MHP ensured good comprehension levels and a limit of interview length to 75 min (Guest et al. 2012). Interviews were conducted by one interviewer familiar with the topic.

Repeat Interviews

Interview Guide

Duration

Questions posed were asking interviewees to compare the development in the respective intervention group compared to the year before the study. Prompters helped interviewees to focus and clarify. MHP were asked to reflect on any changes noted in the respective VH they were interviewed about. Questions were formulated in line with the research aim:

Interviews lasted between 30 and 95 min.

• Did you develop a new understanding about what your •

•

•

•

voice hearing experience was about? (if so, what and who do you feel the voices represent?) Did you identify unresolved and undisclosed issues in your life which you felt were connected to your experience of voice hearing? (What helped to identify these? Was it helpful or unhelpful to make such connections? Did sharing influence how distressed you were by your voices and related experiences?) If you disclosed anything traumatic or similar did you feel your professional was able to handle it in a good way? (Yes? Only partially? Not at all?—In which way? What hindered the process?) Did you become more or less or in the same way able to recognise and accept your own emotions, particularly in relation to traumatic or similar experiences? (please explain how). Did you feel more or less or in the same way able to talk about difficult emotions (i.e. like fear or anger, etc.) and talk through and deal with conflicts?

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As these were exit-interviews at the end of the intervention, designed to reflect on the experience of either EFC or TAU, no repeat interviews were organised. Audio Recordings, Transcription and Translation Process All interviews were audio recorded. Simple transcription guidelines were applied (Dresing et al. 2012). Translations for English publications were done by the first author. No expert panel translation process (Harkness 2003) was needed as the first author had conducted all of the interviews and was an experienced translator. Field Notes A debriefing note tool (Guest et al. 2012) was applied following each interview.

Saturation and Development of Content Codes The overall process of content code development applied guidelines by Guest et al. (2012) and focussed on ‘discovering themes’, ‘winnowing themes’, ‘creating an effective codebook’, and ‘linking themes to theoretical models’. Working iteratively on one interview at a time helped to avoid any conflation of source texts (Guest et al. 2012). A circular process allowed to re-visit earlier coded interviews with themes discovered in later interviews (Braun and Clarke 2006). Following familiarisation with all texts, the process of identifying themes combined a surface-level semantic approach on overt themes and a latent approach, focussing on underlying themes (Braun and Clarke 2006). Specifically, a section of text would be coded as having an overall ‘trauma related’ theme. Theme-specific codes might then further distinguish into ‘disclosure—impact on mood’, ‘—impact on recovery’, etc. Finally, a series of subcodes denoted whether MHP or VH felt these areas to have remained the same, improved or worsened. The constant refinement of brief distinguishable code descriptions and definitions allowed for a consistent application throughout the coding process (Guest et al. 2012). The process of code definition revision saw, for example, “…control over … voices has increased…” change to “… control over … voices has increased …., as evidenced by being more able to influence…”. Code creation saturation was achieved after two rounds of code application to all interviews. Coding application saturation was achieved in the third coding process.

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Transcripts Returned No transcripts were returned for comment or correction to keep the demands on the researcher and the participants at an acceptable level. However, participants were given opportunities to summarise at the end of the interview and asked whether the interviewer’s own summary had been accurate. No need for corrections of the transcripts was consequently indicated, which should increase confidence in the subsequent analysis (Guest et al. 2012). Data Analysis Preparation Reducing and comparing the data corpus of over 1200 transcribed typed pages to highlight structures, patterns and relationships across interviews (Braun and Clarke 2006) was achieved by using a combination of relative rather than absolute code frequency summaries and code by stakeholder group matrices. This allowed for an easy comparison of response between EFC and TAU and VH and MHP interviewees (Guest et al. 2012). An analysis of the structural codebook found a very good 98–100% saturation rate of questions being answered. Finally, an analysis of potential areas of bias towards EFC (i.e. through EFC VH and MHP or by the interviewer) were felt to have been kept low, as balanced reflections included negative and deviant responses (not in favour of EFC; and unexpected findings).

Findings Description of VH Demographic information included age, diagnosis, length since diagnosis and gender (Tables 1, 2). None of the VH were in employment. Both groups included VH of non-German origin (two in the TAU and one in the EFC group). At the beginning of the intervention, five of nine in the EFC group and three of five in the TAU group were living in 24-h supported residential settings. One EFC and one TAU VH respectively were living semi-independently. Three EFC VH and one TAU VH were living independently with psychiatric support. In summary, both groups were fairly similar in background information.

Themes A final theme map provided an overview of the identified five overall themes related to the research question. These were: ‘trauma related’, ‘process of working with voices’, ‘intra- and interpersonal life’, ‘dealing with emotions’ and ‘coping related’ themes. Overall themes were further divided

Table 1  TAU group VH demographics and characteristics (n = 5) Characteristic

Results

VH

Age in years, mean (SD) Years of continuous psychiatric contact, mean (SD) Primary diagnosis  Schizophrenia  Schizoaffective disorder Years since diagnosis, mean (SD) (n = 4) Gender  Male  Female

43.80 (7.89) 19.60 (8.62)

All All

4 1 19.75 (10.37)

All but Sally Sally Sally’s not traceable

2 3

Ian, Bertie Paula, Alice, Sally

Terms explained: Alice, Bertie, Ian, Paula, Sally—anonymised names used to denote individual TAU VH participants SD standard deviation

into subthemes and the source, direction and nature of any potential change taking place. Subthemes were marked in either single inverted commas in the text.

Theme One: Trauma Related Eight out of nine EFC group VH ‘disclosed past trauma for the first time’, compared to two out of five in the TAU group. All EFC group VH reported a noticeable ‘relief following disclosure’. The one TAU group VH who reported relief, felt this in relation to having confided to a friend. There had clearly been a number of traumatic conflicts for VH. //For example,// that I was being forced to eat. … even when I was … not hungry. By my parents. …And it [the food] would then come back up. And that is when I would also get spanked. I thought that was bad. [EFC VH Ben] One reason why trauma may not have been listened to so much in the past was the concern of professionals whether they were suitably prepared to deal with trauma. However, a little encouragement and guidance on good validating listening as part of the EFC training appeared sufficient to listen well. Ben’s MHP:… And that is when I thought [after guidance on validating listening]: „Of course. You can do that, too. …"…[I] //Was then// no longer afraid …And then he really did talk there, and/ Interviewer: And basically, he was simply talking and you would //ask// and //listen.// Ben’s MHP: //Yes.// //Exact//ly. [Ben’s EFC MHP] Unsurprisingly, all EFC group interviewees felt that EFC trained MHP’ current ‘response’ to disclosures of past

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Table 2  EFC group VH demographics and characteristics (n = 9)

Characteristic

Results

VH

Age in years, mean (SD) Years of continuous psychiatric contact, mean (SD) Primary diagnosis  Schizophrenia  Schizoaffective disorder  Emotionally unstable personality disorder Years since diagnosis, mean (SD) Gender  Male  Female

43.89 (9.61) 16.78 (9.81)

All All

7 1 1 17.44 (6.95)

All but Vince & Gail Vince Gail

4 5

Rob, Ben, Theo, Vince Amy, Gail, Mo, Wendy, Xenia

Terms explained: Amy, Ben, Gail, Mo, Rob, Theo, Vince, Wendy, Xenia—anonymised names used to denote individual EFC VH participants SD standard deviation

trauma had been ‘good’ and ‘responsive’, whereas on the minority of occasions when VH had tried to disclose in prestudy settings, most had felt that MHP’ reactions had not been responsive. Disclosure of Past Trauma: Impact Disclosure of past trauma, which primarily pertained to childhood trauma, was at times accompanied by an understandable brief initial reaction of withdrawing or discomfort by VH. However, it did not lead to a destabilising effect of overall mental health necessitating a hospital or similar intervention. Gail’s MHP: … she did show a little tendency to withdraw to start off with. But she did also manage to come back into the one-to-one. Interviewer: Withdrawal yes, but no relapse. Gail’s MHP: Exactly. [Gail’s EFC MHP] Disclosure was felt to have a positive impact on ‘anxiety’ and ‘depression’ related distress across groups. Ben: It [talking about past trauma] was not nice. … after a certain period I did feel better [reported to also pertain to anxiety and depression domains elsewhere in the interview]. [This was] after the conversation [about trauma] with Mrs X [Name of EFC trained MHP]. [EFC VH Ben] About half of the EFC group VH felt that disclosure did, in fact, have an improving impact on ‘voice hearing related distress’ or ‘recovery’. Theo’s MHP: … he moved out [from 24-hour supported to independent living with supportive visits, which he had not felt able to imagine before] after that [after trauma/adverse events disclosure]. …he is think-

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ing, ‘that [life as a chronic patient] cannot have been all’. … then [after disclosing trauma and linking it to some voices] they [the voices] did not say anything anymore. … “it was quiet then.” [Theo’s EFC MHP]. Only the TAU client disclosing to a friend, noted a greater confidence in her ability to recover. Trauma Processing and Current and Past Ways of Dealing with it Although most EFC group interviewees felt that the newly disclosed trauma had already been ‘worked with’ during the 44-week intervention period and this had been ‘beneficial’, almost all felt that ‘more work was needed’ to fully process the impact of the trauma. A latent analysis of the transcripts indicated that about half of EFC VH became ‘constructive’ in their way of dealing with trauma following exposure to EFC. In contrast, about half of TAU group VH remained ‘avoidant’ and half ‘avoidant and constructive’. ‘Avoidant’ ways were defined by trying to avoid memories, thoughts, feelings, and triggers in relation to past traumatic events. Gail: … [when hearing about other persons’ traumas] I had to go. … the accepting [is difficult]. … Interviewer: What was … particularly difficult to accept? Gail: [11] Interviewer:… Did this have anything to do with difficult live events? … Gail: //Yes.// //Yes.// [EFC VH Gail] ‘Constructive’ ways were defined by being more prepared to look at, talk and think about, and feel trauma-related themes (Briere et al. 2010). Importantly, this is not to say that avoidant ways cannot also have an important role to play in dealing with trauma-related themes.

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An empathetic, non fear-based, active listening process by the accompanying EFC professional during the disclosure process appeared to lead to a significant difference in distress for VH. Xenia: //She [EFC professional] did// react well. … That is, she was calm. She said … that it had happened to a lot of young women. And that is when I said: “Yes. Me, too.” … when X [EFC professional] was there, I did to her open myself up. …And she did effectively heal part of my soul. Interviewer: Simply by you //being able to share it//, too. Xenia: … Yes. Correct. … something normalised again inside of me. Relief was there. [EFC VH Xenia] The experienced relief had a lasting positive impact for some. Amy’ s MHP: Well, that she did expose herself to that situation [talking about trauma]. … But there were really big sobs here. And she does not do that anymore. …But she has rather put that behind her. [Amy’s EFC MHP]

Theme Two: Process of Working with Voices A majority of 61.5% of EFC group interviewees felt that VH had been able to make a ‘connection between their voices and their lives’, whereas only one VH in the TAU group was certain to have made a connection. Only two VH in the EFC group were felt to have been ‘distressed’ by making such connections, though one of these felt relief at the same time and the other was also felt to have experienced no discernible overly negative impact from the respective professional’s point of view. For EFC VH Theo making the connection between his voices and his life history meant he no longer used nonshared reality views to explain his voices. Theo: … well, since the [Maastricht] construct it had become clear to me, … how idiotic it is, really, you know. Because I … had attributed these voices to the real person. I somehow had the feeling ‘that is all nonsense’. [EFC VH Theo] For some, making connections facilitated a sense of being able to affect change themselves, as it provided a situation which could more actively be affected (resolution of trauma) instead of a more passive way of making sense (biological illness). Ben’s MHP: …he …no longer feels so …threatened. Instead, it is clear to him now, why the voices are there. …they do now have a cause [related to abuse]. … he knows … it is not his fault. And in this way he

is much more self-confident and more courageous …. [Ben’s EFC MHP].

Theme Three: Intra‑ and Interpersonal Life Most EFC group interviewees felt that VH had improved their ability to be ‘assertive’, had an increased ‘interest in their voices’ and an increased sense of ‘active explanations’ (that is, related to life-context) for their voices, mirrored by most feeling that professionals were now more ‘accepting of VHs’ ‘voices as real’. About half felt that VHs’ ability to ‘make choices’ had improved, their ability to recognise ‘voices as belonging to themselves’ and ‘accept themselves as VH’ had increased, and VHs’ sense of feeling ‘accepted by others as VH’ had increased, too. This contrasted to the TAU group, where corresponding themes had largely been felt to have remained the same. Being ‘more in charge of one’s recovery’ and increased ‘assertiveness’ often went hand in hand for EFC clients. Amy’s MHP: … she has moved on… she is always actively involved. …. She has responsibility. And she has a plan. [Amy’s EFC MHP] Interestingly, for Rob, given that the voices had actually significantly reduced, he was more interested now in coming to terms with underlying conflicts, as became clear during the interview. Rob’s MHP: Well interest in his voice hearing experience … has got considerably less. … Because they did reduce, //you know.// [Rob’s EFC MHP]

Theme Four: Dealing with Emotions ‘Accepting’ and ‘talking about difficult emotions’ (i.e. fear, guilt, shame, anger, etc.) did improve for most in the EFC group and stayed the same in the TAU group. Openness by MHP to ‘talk about trauma’ and ‘voice hearing related distress’ played an important role, it seemed, for clients to open up about difficult emotions. Amy’s MHP: … she would compare herself with her mother, ‘but I, too, am such a shit mother.’’… And that has changed. That she has been able to accept, ‘I have looked out for my child’. And … has forgiven the mother. And …that helps her to recover. [Amy’s EFC MHP] It is clear here how such a talking process did contribute to the acceptance of difficult emotions, such as feelings of guilt. This in turn was also related to her own ability to get on better with her life. Importantly, VH also felt a need to improve their ways of accepting and dealing with difficult emotions in particular.

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Rob: Sometimes I would really like to … scream out or something like that. … Interviewer: Would that help you, to be able to deal with your life better, too? Rob: Yes. [EFC VH Rob] Not surprisingly, dealing with difficult emotions was identified as being linked to unresolved traumatic conflicts, too. Gail’s MHP: … the thing that we have now got into very gently, is, of course, trauma work, … dealing with her fears, … anger. … shame, //guilt.// … [Gail’s EFC MHP]. Interestingly, life problems and traumatic problems were often mirrored in the content of the voices, whether the VH was aware of this or not. Paula: … And … when I get annoyed, then the voices become annoyed with me [TAU VH Paula] Amy, who as a child had been sent by her mother to work the streets as a sex worker, similarly points at how her ongoing conflicted relationship with her mother also appeared to be evident through the on-going hearing of her mother’s voice. Amy: But I do want to have a good contact with my mother at some point, too … [I] hear [the] voice of my mother out in the wood… much more now. [EFC VH Amy]

Theme Five: Coping Related The EFC group appeared to have a strong sense of VH accessing ‘new external and internal resources’, which were generally connected with the newly learned EFC material. Importantly, using existing resources differently, i.e. reducing antipsychotic medication, was also felt to be helpful by some. Ben’s MHP: … And we did also always feed back to him, that the less medication he had, [the] much more clearly, and more awake, and more actively [he] would partake in life. … [Ben’s EFC MHP]. This medication reduction had been preceded by a process of Ben increasingly taking charge of, and an interest in, his voice hearing experience and how to cope with it. A different openness towards trauma within the team as a direct result of the ‘EFC training’ had also improved Gail’s own ability to ask for help. Gail’s MHP:… this whole abuse thing is more open within the team. … Where she carries a lot of feelings

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of guilt around … and [therefore for her] to notice, ‘okay, but I am not … a bad human being …’, does make it simply (.) easier for her, to then go on and get herself support. [Gail’s EFC MHP]. Not surprisingly, ‘constructive’ as opposed to ‘symptomatic coping’ (Bak et al. 2003), characterised by not just trying to avoid the voice but making a reflected decision on how to react to it, had increased for all but VH Mo in the EFC group. The EFC group also reported the strengthening of existing coping strategies. Ben’s MHP: …Every time when these bad voices would appear to him … he would get through it with a bible verse … and … say a prayer. [Ben’s EFC MHP] Paula of the TAU group also found that deciding to change her attitude towards the voice hearing experience was helpful. Paula: … And he [the voice] then sits there … and … that is quite good for me for a change that I can laugh about it. [TAU VH Paula].

Discussion Although this study used several sources of data for methodological reasons, this should not be confused with the purity of the EFC intervention, within which the VH’s view should remain decisive.

Implications for Mental Health Practice Following their training in EFC, MHP felt more equipped than within a TAU intervention only, to deal in a traumasensitive manner both with voices and related unresolved life problems and traumas. This led to most EFC VH disclosing trauma for the first time, which contrasted to the TAU group. In most cases, and in line with EFC training-based trauma-awareness raising, this meant taking an active, listening, non-judging, available-in-crisis, interest in trauma or unresolved life problems as relevant to the person’s life history and potentially to their current levels of distress (Read et al. 2007). EFC trained MHP now felt more able to facilitate discussions that were open, structured, understanding, constructive, open to past trauma, and able to take VH more seriously than before. These are considered important recovery promoting qualities by the HVM (Romme 2009a). Talking about trauma in this way was generally felt to be relieving and to be offering a way of partial resolution. Making connections between the nature, content of, and relationship with voices and life context, including trauma or socioemotional conflicts, within a meaning-seeking, listening,

Community Mental Health Journal

normalising and non-pathologising EFC paradigm did in fact lead to improvements in the domains of anxiety, depression, recovery and voices related distress. This mirrored accounts found in recovered VH within the HVM (Romme et  al. 2009). These findings suggest, not only is making such a life context connection with voices possible with minimal training, but the process of creating meaningful relationships between voices and life context may be much more powerful. It may also include more experience or symptom domains, than is commonly understood (Romme and Escher 2000). Importantly, EFC also appeared to support VH more in dealing with difficult trauma-associated emotions, such as fear, anger, guilt, and shame; and taking active, assertive charge of one’s life and recovery process. These findings thus add further support to calls for mental health services to better facilitate meaning-making processes for distressed VH within non-judgemental, active-listening, non-pathologising relationships (Romme 2009a, b). The de-pathologising focus of EFC, which is open to positively including voices in the process of recovery, sets it apart from other approaches, like CBTp (Steel 2017), Relating Therapy (Hayward et al 2018), AVATAR Therapy (Craig et al. 2017) or Metacognitive Training (Jiang et al. 2015). In fact, dependency on services, underpinned by biological or problematising paradigms within which trauma-informed and meaning-making interventions in psychosis do not routinely take place, represents an impetus that contributed to the rise of the Recovery Movement in the first place (Amering and Schmolke 2009; Johnstone and Boyle 2018).

Implications for Mental Health Staff These findings provided early support that mental health frontline practitioners could provide safe and trauma-sensitive support with minimal EFC training. This confirms advice by Read et al. (2007), that it does not need many years of trauma-specific training. As social workers and psychiatric nurses in various psychiatric settings are often the main professions dealing with mental and emotional crises in non-medical ways already, they may fulfill a key role in the provision of trauma-sensitive service provision to VH.

Implications for the Concept of Hearing Voices and Psychosis The common perception of voices as meaningless (Dowbiggin 1990), non-understandable, primary symptoms of psychosis (Beer 1996; Bentall 2004), whose engagement would make things worse (Bentall 2009) was questioned by this study. MHP and VH felt it was possible to make sense of voices within the VH’s life context, despite the majority of interviewed VH, bar one, having had schizophrenia spectrum diagnoses (see Tables 1, 2), thus confirming findings

in related studies (Corstens and Longden 2013). Traditional psychosis definitions may therefore in fact be based on incorrect, untested inferences (Romme and Escher 2000; Wykes et al. 2008). Considering voices as direct sources of information and knowledge about the person (Schnackenberg and Martin 2014), often pertaining to unresolved trauma, was supported by this study instead. If these findings were found to be confirmed in future studies it would lend further support for a necessary re-focussing of existing psychosis related services to be much more trauma-informed and in support of sense-making processes (Johnstone and Boyle 2018).

Limitations and Strengths These findings would benefit from replication in future qualitative and quantitative studies, as generalised conclusions cannot be drawn from a single qualitative study. Using several interviewers and analysts might also address potential areas of bias. The provision of a specific trauma-sensitive one-to-one intervention as part of TAU would also allow for a greater understanding of specific factors at work. Informal feedback by her MHP provided a rough estimate that the missing data for ‘Sally’ (TAU group) (see Table 1) on ‘years since diagnosis’ was similar to the rest of the group and therefore was unlikely to have impacted on the findings. The discrepancy in numbers in TAU and EFC interviewees was particularly owed to the fact that less TAU VH than EFC VH completed their intervention, as they had felt no benefit. Their interview inclusion might therefore have resulted in less favourable findings for TAU. Finally, using all consenting VH and MHP participants of both interventions from a randomised cohort means that the trustworthiness of these findings must be considered strong (Guest et al. 2012).

Conclusion This study identified supporting qualitative evidence towards EFC being a trauma-sensitive and safe intervention for potential use by various mental health frontline practitioners. This would need replicating in future studies. It also supports the call of the HVM (Romme and Morris 2009) and others (Johnstone and Boyle 2018) for a complete overhaul of both the set up and focus of formal mental health support service provision towards meaning-making traumasensitive trans-diagnostic interventions (McCarthy-Jones and Longden 2015). Author Contributions  JS co-designed the study, undertook data collection and drafted the manuscript. CM co-designed the study, supervised

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the project and checked the text for accuracy; MF supervised the project and checked the text for accuracy.

Compliance with Ethical Standards  Conflict of interest  No financial support was received and this research was instead based largely on the good will of participating mental health professionals and persons who hear voices at the participating research sites. The first author conducted the study as part of a selffunded PhD at the University of the West of Scotland (in collaboration with the University of Applied Sciences, Faculty V, Hanover, Germany). He is a freelance trainer at the efc Institut, specialising in the provision of training and supervision in Experience Focussed Counselling. He received no fees for the provision of EFC training and supervision during the study. Following completion of the study he was unexpectedly  offered and accepted employment with the St Ansgar gGmbH, Kropp, which had taken part in the study. No financial gain was expected.

References Amering, M., & Schmolke, M. (2009). Recovery in mental health. Reshaping scientific and clinical responsibilities. Chichester: Wiley-Blackwell. Bak, M., Myin-Germeys, I., Hanssen, M., Bijl, R., Vollebergh, W., Delespaul, P., & van Os, J. (2003). When does experience of psychosis result in a need for care? A prospective general population study. Schizophrenia Bulletin, 29(2), 349–358. Beavan, V., Read, J., & Cartwright, C. (2011). The prevalence of voicehearers in the general population: A literature review. Journal of Mental Health, 20(3), 281–292. Beer, M. D. (1996). Psychosis: A history of the concept. Comprehensive Psychiatry, 37(4), 273–291. Bentall, R. (2004). Madness explained: Psychosis and human nature. London: Penguin Books Ltd. Bentall, R. (2009). Doctoring the mind. Why psychiatric treatments fail. London: Penguin Books Ltd. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(1), 77–101. Briere, J., Hodges, M., & Godbout, N. (2010). Traumatic stress, affect dysregulation, and dysfunctional avoidance: A structural equation model. Journal of Traumatic Stress, 23(6), 767–774. Corstens, D., Escher, S., & Romme, M. (2009). Accepting and working with voices: The Maastricht approach. In A. Moskowitz, I. Schäfer & M. J. Dorahy (Eds.), Psychosis, trauma and dissociation. Emerging perspectives on severe psychopathology. Chichester: Wiley-Blackwell. Corstens, D., & Longden, E. (2013). The origin of voices: Links between life history and voice hearing in a survey of 100 cases. Psychosis: Psychological, Social and Integrative Approaches, 5(3), 270–285. Corstens, D., Longden, E., & May, R. (2012). Talking with voices: Exploring what is expressed by the voices people hear. Psychosis: Psychological, Social and Integrative Approaches, 4(2), 95–104. Corstens, D., Longden, E., McCarthy-Jones, S., Waddingham, R., & Thomas, N. (2014). Emerging perspectives from the hearing voices movement: Implications for research and practice. Schizophrenia Bulletin, 40(suppl. 4), S285–S294. Craig, T. K. J., Rus-Calafell, M., Ward, T., Leff, J. P., Huckvale, M., Howarth, E., Emsley, R., & Garety, P. A. (2017). AVATAR therapy for auditory verbal hallucinations in people with psychosis: A single-blind, randomised controlled trial. The Lancet Psychiatry, 5(1), 31–40.

13

Community Mental Health Journal Dowbiggin, I. (1990). Alfred Maury and the politics of the unconscious in nineteenth-century France. History of Psychiatry, 1(3 pt 3), 255–287. Dresing, T., Pehl, T., & Schmieder, C. (2012). Manual (on) transcription. transcription conventions, software guides and practical hints for qualitative researchers (2nd English ed.). Marburg. Retrieved from http://www.audio​trans​kript​ion.de/engli​sh/trans​ cript​ion-pract​icalg​uide.htm. Guest, G., MacQueen, K. M., & Namey, E. E. (2012). Applied thematic analysis. London: Sage Publications Ltd. Harkness, J. (2003). ‘Questionnaire translation’. In J. A. Harkness, F. J. R. van de Vijver & P. P. Mohler (Eds.), Cross-cultural survey methods. New Jersey: Wiley. Hayward, M., Bogen-Johnston, L., & Deamer, F. (2018) Relating Therapy for distressing voices: Who, or what, is changing?. Psychosis. Psychological, Social and Integrative Approaches. https​ ://doi.org/10.1080/17522​439.2018.14690​37. Jiang, J., Zhang, L., Zhu, Z., Li, W., & Li, C. (2015). Metacognitive training for schizophrenia: A systematic review. Shanghai Archives of Psychiatry, 27(3), 149–157. Johnstone, L. & Boyle, M., with Cromby, J., Dillon, J., Harper, D., Kindermann, P., Longden, E., Pilgrim, D., & Read, J. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society. Longden, E., Sampson, M., & Read, J. (2015). Childhood adversity and psychosis: Generalised or specific effects?. Epidemiology and Psychiatric Sciences https​://doi.org/10.1017/S2045​79601​50004​ 4X. Lukoff, D., Nuechterlein, K., & Ventura, J. (1986). Manual for the Expanded Brief Psychiatric Rating Scale. Schizophrenia Bulletin, 12(4), 594–602. McCarthy-Jones, S., & Longden, E. (2015). Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: Common phenomenology, common cause, common interventions? Hypothesis and Theory, 6, Frontiers in Psychology. https​://doi. org/10.3389/fpsyg​.2015.01071​. Moriarty, J. (2011). Qualitative methods overview. Methods review, 1. National Institute for Health Research. London. Retrieved October 5, 2013 from http://eprin​ts.lse.ac.uk/41199​/ Moskowitz, A. (2009). Association and dissociation in the historical concept of schizophrenia. In A. Moskowitz, I. Schäfer & M. J. Dorahy (Eds.), Psychosis, trauma and dissociation. Emerging perspectives on severe psychopathology (pp. 35–49). Chichester: Wiley-Blackwell. Moskowitz, A., & Corstens, D. (2007). Auditory hallucinations: Psychotic symptoms or dissociative experience. Journal of Psychological Trauma, 6(2–3), 35–63. Read, J., Hammersley, P., & Rudegeair, T. (2007). Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13(2), 101–110. Read, J., van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112(5), 330–350. Romme, M. (2009a). Important steps to recovery with voices. In M. Romme, S. Escher, J. Dillon, J., D. Corstens & M. Morris (Eds.), Living with voices. 50 stories of recovery. Ross-on-Wye: PCCS Books. Romme, M. (2009b). Psychotherapy with hearing voices. In M. Romme, S. Escher, J. Dillon, J., D. Corstens & M. Morris (Eds.), Living with voices. 50 stories of recovery. Ross-on-Wye: PCCS Books. Romme, M., & Escher, S. (1993). Accepting voices. London: Mind Publications.

Community Mental Health Journal Romme, M., & Escher, S. (2000). Making sense of voices. London: Mind Publications. Romme, M., & Escher, S. (2008/2013). Stimmenhören verstehen. Der Leitfaden für die Arbeit mit Stimmenhörern. Köln: Psychiatrieverlag. Romme, M., & Escher, S. (2010). Personal history and hearing voices. In F. Laroi & A. Aleman (Eds.), Hallucinations. A guide to treatment and management. Oxford: Oxford University Press. Romme, M., Escher, S., Dillon, J., Corstens, D., & Morris, M. (2009). Living with voices. 50 stories of recovery. Ross-on-Wye: PCCS Books. Romme, M., & Morris, M. (2009). Introduction. In M. Romme, S. Escher, J. Dillon, J., D. Corstens & M. Morris (Eds.), Living with voices. 50 stories of recovery. Ross-on-Wye: PCCS Books. Schnackenberg, J., Fleming, M., & Martin, C. (2017). A randomised controlled pilot study of experience focussed counselling with voice hearers. Psychosis, 9(1), 12–24. Schnackenberg, J. K., Fleming, M., Walker, H., & Martin, C. R. (2018). Experience focussed counselling with voice hearers: Towards a trans-diagnostic key to understanding past and current distress. A thematic enquiry. Community Mental Health Journal. https​://doi. org/10.1007/s1059​7-018-0280-6. Schnackenberg, J. K., & Martin, C. R. (2014). The need for experience focussed counselling with voice hearers in training and practice: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 21(5), 391–402. Steel, C. (2015). Hallucinations as a trauma-based memory: Implications for psychological interventions. Frontiers in Psychology. https​://doi.org/10.3389/fpsyg​.2015.01262​.

Steel, C. (2017). Psychological interventions for working with trauma and distressing voices: The future is in the past. Frontiers in Psychology. https​://doi.org/10.3389/fpsyg​.2016.02035​. Thomas, N. (2015). What’s really wrong with cognitive behavioral therapy for psychosis? Frontiers in Psychology, 6(Article 323), 1–4. 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., García-Montes, J. M., Waters, F., Dodgson, G., & McCarthyJones, S. (2014). Psychological therapies for auditory hallucinations (voices): Current status and key directions for future research. Schizophrenia Bulletin, 40(suppl. 4), S202–S212. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., Read, J., van Os, J., & Bentall, R. P. (2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38(4), 661–671. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behaviour therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34(3), 523–537.

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