Whispers of progress: innovative apps to cope with distressing voice experiences

The purpose of this research was to help people experiencing frequent, distressing voices by developing and evaluating the effects of a smartphone app called Temstem. CHAPTER 1 reviews existing treatments for voice hearing. Antipsychotic medication reduces symptoms but can cause severe side effects. Cognitive Behavioral Therapy for psychosis (CBTp) is effective but not widely accessible. Unguided app interventions offer new treatment possibilities, though initial studies show mixed effectiveness. Temstem, created with input from voice hearers, features language-based games. The 'Silencing' function aims to suppress voices temporarily, while the 'Challenging' function uses dual-tasking to reduce the emotional impact and credibility of negative voices. An avatar named 'Tim' provides positive feedback to boost self-esteem. CHAPTER 2 details the protocol for the Temstem Randomized Controlled Trial (RCT) aimed at evaluating the app’s effectiveness in reducing distress and improving social functioning among people with frequent, distressing voices. CHAPTER 3 reports on a Virtual Reality (VR) study exploring the impact of self-esteem on responses to social stress. Ninety-four participants with low psychosis liability and seventy-five with high psychosis liability were exposed to stressors in a virtual café. Results showed negative self-esteem heightened paranoia and distress, especially under multiple stressors, while positive self-esteem mitigated these responses. These findings suggest that improving self-esteem could help reduce distress and paranoia in social settings. CHAPTER 4 presents network analyses from the Temstem trial’s baseline Experience Sampling Method (ESM) data, examining the interplay between voice hearing and various mental state factors. Voice hearing was predominantly auto-regressive, persisting without external triggers. This suggests that interventions should initially target potential triggers or, if voices are self-sustaining, focus on altering responses to voices. CHAPTER 5 describes a side study testing the effectiveness of dual-tasking in managing voice hearing experiences. Thirty-seven participants were asked to recall negative voice hearing experiences and engage in a language game. The dual-tasking condition significantly reduced the emotionality, vividness, and credibility of the experiences compared to a recall-only condition. This suggests that the Challenging function may help manage distressing voices. CHAPTER 6 reports on a naturalistic study assessing Temstem’s effects on voice hearing distress and emotionality. Data from 1,048 frequent users indicated significant reductions in distress and emotionality after using the Silencing and Challenging functions. Although effects diminished with frequent use, they remained clinically significant. However, the study lacked a control condition, leaving the specific impact of Temstem uncertain. CHAPTER 7 analyzes the Temstem RCT data on the app's unguided use. Eighty-nine participants were divided into two groups: one used Temstem and monitored their voices, while the other only monitored their voices. No significant differences in distress and social functioning were found between the groups, suggesting that unguided Temstem use may not effectively reduce distress or improve functioning in severe cases. CHAPTER 8 reflects on the findings, highlighting positive self-esteem as a protective factor and supporting the effectiveness of Temstem’s Silencing and Challenging functions. However, the RCT results indicate that unguided app use alone is insufficient for significant symptom reduction, aligning with other research showing limited effectiveness of apps in clinical settings. This suggests that some patients may need therapist support to benefit from app interventions. Continuous involvement of voice hearers in developing and adapting interventions is crucial for their relevance and effectiveness. In conclusion, while the study did not demonstrate significant effectiveness for unguided Temstem use, it underscores the potential of app interventions when integrated into broader therapeutic practices. Ongoing research, active patient involvement, and addressing research challenges are essential for developing effective interventions for those experiencing distressing voices.