Centre for Youth Mental Health - Research Publications

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    Enhancing Self-Management of Distressing Voices Hearing Experiences Using Ecological Momentary Assessment and Intervention
    Bell, I ( 2019)
    Voice hearing experiences, otherwise known as auditory verbal hallucinations, involve the perception of sounds or voices in the absence of external stimuli. These experiences are a common occurrence across many mental health conditions and can be distressing, impairing, and are associated with poor quality of life. Whilst some people can effectively manage their voices independently, or even experience them positively, many seek help from mental health services. For these individuals, evidence-based treatment approaches typically include a combination of medication and psychological therapy. Psychological therapy can help people to gain a greater understanding of these experiences, improve self-management, and minimise their impact on daily living. However, existing psychological therapies show only moderate effectiveness, and can be difficult to access, with long wait times, geographical barriers, and prohibitive costs. Many individuals with persisting mental health problems face these difficulties, highlighting a need for novel and innovative interventions that are more effective and accessible for those who need them. When used in conjunction with standard therapies, otherwise known as blended therapy, digital technologies have potential to support delivery and improve the efficacy of therapeutic components. Smartphones are particularly promising given ownership is becoming ubiquitous and they tend to be carried on the person; offering an opportunity to extend the therapeutic domain to everyday life. Ecological momentary intervention (EMI) is one application of this, involving the use of mobile devices to deliver interventions at specified moments in daily life. A related approach called ecological momentary assessment (EMA) uses mobile devices to assess clinically-relevant phenomenon as it arises in natural environments. When blended with standard face-to-face therapies, EMI and EMI (EMA/I) might enhance assessment and promote the implementation of intervention strategies beyond the therapeutic context. This might lead to more potent interventions that help support people to self-manage distressing experiences, such as hearing voices. As such, the focus of this thesis was to examine the potential to harness these technologies as tools within a blended therapy for hearing voices. Specifically, an intervention was developed that used EMA to assess predictors of fluctuations in the intensity of voices in their natural environment. EMA-derived feedback was discussed during face-to-face therapy sessions to inform clinical formulation. Based on this formulation, tailored, individualised coping strategies were selected, with personalised EMI prompts then sent to individuals in their daily life. The aim II of this research was to examine the feasibility, acceptability, and preliminary clinical efficacy of this approach. To establish the evidence-base and inform the development of the intervention, the first thesis paper involved a systematic review of existing literature on the clinical application of EMA/I in the treatment of psychotic disorders. Findings demonstrated the early stage of this research, with a small number of studies supporting the feasibility and acceptability of these approaches for a variety of purposes, and promise for improving outcomes. Following the systematic review, which provided a rationale for the current research and details on the typical design of EMA/I studies, an initial prototype of the intervention was developed, which was also informed by consultation with lived experience consultants and experts in the field. An initial pilot study with a small number of participants was conducted to test procedures. Key findings led to refinement of the intervention and trial protocol, including technical issues that were solved in the next stage of the research. As an outcome of this piloting, a single case study was published to illustrate the approach and describe the development. Following this, a trial protocol was published, outlining the background and details of the methodology used in the main study conducted as part of this research, namely a pilot randomised controlled trial (RCT). In line with the overall aim of this thesis, findings from the pilot RCT supported the feasibility and acceptability of the intervention, with good engagement and satisfaction rates. Clinical outcomes were promising, showing the intervention has potential to improve outcomes related to voices, coping, and awareness, however potentially not overall emotional distress. This research is the first to examine the use of EMA and EMI within a blended therapy for psychotic experiences. These technologies were successfully used to support therapeutic components and ultimately assisted people to more effective self-manage distressing voice hearing experiences in their daily life. Beyond the potential to enhance psychological treatments for voices specifically, the model of blending EMA/I with standard therapies has broader clinical potential beyond psychosis, justifying further research and development