A tale of two outcomes: Remission and exacerbation in the use of trauma‐focused imaginal exposure for trauma‐related voice‐hearing. Key learnings to guide future practice

ObjectiveMany people who hear voices (also termed auditory‐verbal hallucinations) have experienced traumatic or adverse life events. There is growing evidence that, for a number of people, these events are an important contributing factor to voice‐hearing experiences. Psychological mechanisms implicated in the trauma‐voice‐hearing relationship overlap with those involved in posttraumatic stress disorder, giving a strong rationale for the use of exposure‐based trauma‐focused therapies for distressing voices. There is currently limited clinical guidance in this area and, despite preliminary evidence of effectiveness, clinicians report reluctance to deliver these therapies. We believe that two key questions will be important in informing the delivery of exposure‐based trauma‐focused therapies for distressing voices; namely, what influences their acceptability and tolerability, and who is most likely to benefit?MethodWe present two case illustrations from an ongoing pilot trial in which people with trauma‐related voices received six sessions of imaginal exposure.ResultsThe clients “Tara” and “Laura” had very different therapy outcomes and we believe their experiences provide some initial insights into processes and factors that may impact on the delivery of exposure‐based trauma‐focused therapies for voice‐hearing.ConclusionsWe highlight the potential for symptom exacerbation in early sessions and consider how this might influence acceptability, including the possibility that exposure therapy may be less tolerable when clients have persecutory appraisals of their voice‐hearing experience. We also explore the potential therapeutic importance of associations between trauma and voices, suggesting exposure therapy is particularly indicated when there is a direct link between the content of voices and the index trauma.