Janssen, Hella, van den Berg, Karin C., Keijsers, Ger P.J., Paulik, Georgie, Newman-Taylor, Katherine, Taylor, Christopher D.J., Steel, Craig and Marcelis, Machteld C. (2025) Imagery-focused cognitive behavioral therapy techniques for auditory verbal hallucinations in psychosis spectrum disorders: four experimental case series. Schizophrenia Bulletin, 51 (6), 1702-1717, [sbaf033]. (doi:10.1093/schbul/sbaf033).
Abstract
Background: in psychosis spectrum disorders, maladaptive mental imagery is associated with auditory verbal hallucinations (AVHs). This study evaluates the feasibility, acceptability, and effectiveness of the following 4 imagery techniques in targeting mental imagery and AVHs severity: Imagery Rescripting (ImRs), Promoting positive Imagery de novo (Pos-Im), Metacognitive Imagery techniques (Meta-Im), and playing Tetris.
Study design: four replicated single-case series experimental designs were used. Participants were randomized to 1 of the 4 treatment conditions. Primary, we measured the severity of mental imagery and AVHs thrice daily on an 11-point VAS scale during a 2-week baseline, throughout 3 weeks of therapy, and during a 2-week follow-up phase. Randomization tests were used to examine whether daily severity levels of momentary mental imagery and AVHs decreased post-therapy. Secondary, questionnaires assessing the severity of AVHs, mental imagery characteristics, and levels of mood, anxiety, and functioning were administered at baseline, before, and posttreatment.
Results: twenty-eight participants completed all treatment sessions. Mental imagery significantly decreased after ImRs (P < .001, d = 1.13) and Pos-Im (P = .039, d = 0.22), with no significant effects observed following Meta-Im or Tetris. AVHs significantly decreased with all treatment conditions, with largest effects for ImRs (P = .001, d = 1.39) and Pos-Im (P < .001, d = 1.99). Secondary results demonstrated reductions in the severity of AVHs, mood, anxiety, imagery frequency, and appraisals.
Conclusions: imagery techniques appear feasible and acceptable for addressing mental imagery and AVHs in the psychosis continuum and may be valuable additions to current treatment for AVHs.
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