People Suffering Mental Disorder Auditory Hallucinations

Published Date: 23 Mar 2015 Last Modified: 02 May 2017

Auditory hallucinations for some people suffering mental disorder are frequently experienced as alien and under the influence of some external force. These are often experienced as voices that are distressing to the individual and can cause social withdrawal and isolation. Although auditory hallucinations are associated with major mental illnesses such as schizophrenia, they also occur in the general population (Coffey and Hewitt 2008). The annual incidence is estimated between 4-5 percent (Tien 1991), with those experiencing voices at least once, estimated between 10-25 percent (Slade & Bentall 1988).The standard professional response to voice hearing has been to label it as symptomatic of illness and to prescribe anti-psychotic medication (Leudar & Thomas 2000). An alternative is suggested by Romme and Escher (1993), who view the hearing of voices as not simply an individual's psychological experience, but as an interaction, reflecting the nature of the individual's relationship with his or her own social environment. In this way, voices are interpreted as being linked to past or present experiences and the emphasis is on accepting the existence of the voices. Romme and Escher (1993) see hallucinatory voices as responsive to enhanced coping and found that those who coped well with voices had more supportive social environments than those who found it difficult to cope.

This dissertation will aim to discuss the experience and management of auditory hallucinations in schizophrenia looking into therapeutic relationship, helping approaches, and working towards the ending of a therapeutic relationship discussing discharge.

First chapter will aim to explain what schizophrenia is, the cause of schizophrenia, its symptoms and types with particular focus on auditory hallucinations. The chapter will then discuss what auditory hallucinations are in the diagnosis.

Therapeutic relationship between service user and the nurse is paramount in mental health nursing and is seen to prove long term outcome such as social functioning (Svensson and Hansson 1999). Chapter two will aim to discuss the building of therapeutic relationship in the management of auditory hallucinations using Peplau's interpersonal relations model (1952).

The importance of holistic assessment using a variety of tools, scales and questionnaires that will identify symptoms, risks, management of risk and address the service users needs will be discuss in chapter three.

Chapter four of this dissertation will discuss helping approaches. Gray et al (2003) states that pharmacological and psychosocial interventions have been heavily researched to find the most up to date literature and recommendations for the management of auditory hallucinations in schizophrenia with medication and Cognitive Behavioural Therapy (CBT).. The final chapter will aim to discuss the ending of the therapeutic relationship between the nurse and the service user looking into discharge planning process and conclusion.

Chapter one

What is Schizophrenia and Auditory Hallucinations?

Introduction to chosen topic

Schizophrenia is one of the terms used to describe a major psychiatric disorder (or cluster of disorders) that alters an individual's perception, thoughts, affect and behaviour. Individuals who develop schizophrenia will each have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their particular circumstances (NICE 2010).

Allen et al (2010) define schizophrenia as a chronic and seriously disabling brain disorder that produces significant residual cognitive, functional and social deficits. Schizophrenia is considered the most disabling of all mental disorders (Mueser and McGurk, 2004), it occurs in about 1% of the world population, or more than 20 million people worldwide (Silverstein et al., 2006).

The DSM -IV - TR (APA 2000) defines schizophrenia as a persistent, often chronic and usually serious mental disorder affecting a variety of aspects of behaviour, thinking, and emotion. Patients with delusions or hallucinations may be described as psychotic. However, Tucker (1998) argues that the system of classification developed by the DSM-IV does not actually fit many patients as a whole; the syndromes outlined in DSM-IV are free standing descriptions of symptoms. He said unlike diagnoses of diseases in the rest of medicine, psychiatric diagnoses still have no proven link to causes and cures; Tucker argues that there is no identified etiological agents for psychiatric disorders.

Schizophrenia is characterized by clusters of positive symptoms (e.g. hallucinations, delusions, and/or catatonia), negative symptoms (e.g. apathy, flat feet, social withdrawal, loss of feelings, lack of motivation and/or poverty of speech), and disorganized symptoms (e.g. formal thought disorder and/or bizarre behaviours). In addition, individuals with schizophrenia often experience substantial cognitive deficits including loss of executive function, as well as social dysfunction (Allen et al., 2010). It is estimated that nearly 75% of people with schizophrenia suffer with auditory hallucinations (Ford et al., 2009).

Positive and negative symptoms are mentioned briefly because the dissertation is primarily focused on auditory hallucinations.

Auditory hallucinations in diagnosis

Auditory hallucinations are often considered symptomatic of people diagnosed as suffering from schizophrenia (Millham and Easton, 1998). APA (1994, p.767) defines hallucinations as "a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations range from muffled sounds to complete conversations and can be experienced as coming either from within or from outside ones self (Nayani & David, 1996). However, Stanghellini and Cutting (2003) argue that APA definition of hallucinations is false, they believe an auditory hallucination is not a false perception of sound but is a disorder of self consciousness that becomes conscious. Hearing voices is not only linked to a person's inner experience but can reflect a person's relationship with their own past and present experiences (Romme and Escher, 1996). Beyerstein (1996) suggests that voices are anything that prompts a move from word based thinking to imagistic or pictorial thinking predisposes a person to hallucinating.

Auditory hallucinations, or hearing sounds or voices are the most common and occur in nearly 75 percent of individuals diagnosed with schizophrenia (Ford et al., 2009). Auditory hallucinations are often derogatory or persecutory in nature, and can be heard in the third person, as a running commentary, or as audible thoughts. Some individuals with schizophrenia also experience useful or positive voices that give advice, encourage, remind, and help make decisions, or assist the person in their daily activities (Jenner et al., 2008).

Voice hearer can work with their voices and either choose what to listen to or can completely ignore them (Romme et al., 1992). Sorrell et al (2009) states that some individuals experience positive voices which do not affect the way they function or go about their daily living, these hearers also find that their voices may offer advice and guidance. The hearer's voice can be reported as a little distressful or some go on to report no distress at all (Honig et al., 1998). However Nayani and David (1996) argues that individuals who experience a constant negative voice found them less difficult to control, they found the voice more powerful and attempt to ignore the voice. Chadwick et al (2005) said that those who resist voices or feel the need to argue or shout back are termed malevolent, those who think voices are good and engage with them are benevolent, they see voices are helping them so they tend to listen and follow advice.

Swanson et al (2008) suggests that people who hear voices are more likely to be victims of violence than be violent themselves. However Soppitt and Birchwood (1997) argue that voices are more commonly linked to depression, voice hearers can also have a history of suicidal thoughts, paranoia and abuse.

Not all auditory hallucinations are associated with mental illness, and studies show that 10 to 40 percent of people without a psychiatric illness report hallucinatory experiences in the auditory modality (Ohayon, 2000). A range of organic brain disorders is also associated with hallucinations, including temporal lobe epilepsy; delirium; dementia; focal brain lesions; neuro- infections, such as viral encephalitis; and cerebral tumours intoxication or withdrawal from substances such alcohol, cocaine, and amphetamines is also associated with auditory hallucinations (Fricchione et al., 1995)

The phenomenological characteristics of auditory hallucinations differ on the basis of their etiology, and this can have diagnostic implications. People without mental illness tend to report a greater proportion of positive voices, a higher level of control over the voices, less frequent hallucinatory experiences, and less interference with activities than people who have a psychiatric illness (Lowe, 1973).

There is also evidence that delusion formation may distinguish psychotic disorders from non clinical hallucinatory experiences. In other words, the development of delusions in people with auditory hallucinations significantly increases the risk of psychosis when compared with individuals who have hallucinations but not delusions. Auditory hallucinations may be experienced as coming through the ears, in the mind, on the surface of the body, or anywhere in external space. The frequency can range from low (once a month or less) to continuously all day long. Loudness also varies, from whispers to shouts. The intensity and frequency of symptoms fluctuate during the illness, but the factor that determines whether auditory hallucinations are a central feature of the clinical picture is the degree of interference with activities and mental functions (Waters, 2010)

The most common type of auditory hallucinations in psychiatric illness consists of voices. Voices may be male or female, and with intonations and accents that typically differ from those of the patient. Persons who have auditory hallucinations usually hear more than one voice, and these are sometimes recognized as belonging to someone who is familiar (such as a neighbour, family member or TV personality) or to an imaginary character (God, the devil, an angel). Verbal hallucinations may comprise full sentences, but single words are more often reported. Voices that comment on or discuss the individual's behaviour and that refer to the patient in the third person were thought to be first-rank symptoms and of diagnostic significance for schizophrenia (Schneider, 1959). Studies show that approximately half of patients with schizophrenia experience these symptoms (Waters, 2010).

Waters (2010) says a significant proportion of patients also experience non verbal hallucinations, such as music, tapping, or animal sounds, although these experiences are frequently overlooked in auditory hallucinations research. Another type of hallucination includes the experience of functional hallucinations, in which the person experiences auditory hallucinations simultaneously through another real noise (e.g., a person may perceive auditory hallucinations only when he hears a car engine). The content of voices varies between individuals. Often the voices have a negative and malicious content. They might speak to the patient in a derogatory or insulting manner or give commands to perform an unacceptable behaviour. The experience of negative voices causes considerable distress. However, a significant proportion of voices are pleasant and positive, and some individuals report feelings of loss when the treatment causes the voices to disappear (Copolov et al., 2004).

The exact processes that underlie auditory hallucinations remain largely unknown. There are two principal avenues of research: one focuses on neuro anatomical networks using techniques such as positron emission tomography and functional Magnetic Resonance Imaging (MRI). The other focuses on cognitive and psychological processes and the exploration of mental events involved in auditory hallucinations. A common formulation suggests that auditory verbal hallucinations represent an impairment in language processing and, particularly, inner speech processes, whereby the internal and silent dialogue that healthy people engage in is no longer interpreted as coming from the self but instead as having an external alien origin. There is support for this language hypothesis of auditory hallucinations from neuro imaging studies. These show that the experience of auditory hallucinations engages brain regions, such as the primary auditory cortex and broca area, which are associated with language comprehension and production. This suggests that hallucinatory experiences are associated with listening to external speech in the absence of external sounds (Waters, 2010)

An explanation of why these experiences are not perceived as self-generated posits that auditory hallucinations arise because persons who have the hallucinations fail to distinguish between internal and external events. This arises because of deficits in internal self-monitoring mechanisms that compare the expected with the actual sensations that arise from the patient's intentions. This abnormality also applies to inner speech processes and leads to the misclassification of internal events as external and misattribution to an external agent (Frith, 2005).However, Bentall and Slade (1985) suggest that individuals with hallucinations use a different set of judgment criteria from healthy people when deciding whether an event is real, and they are more willing to accept that a perceptual experience is true. This bias essentially involves a greater willingness to believe that an event is real on the basis of less evidence.

According to the context memory hypothesis of auditory hallucinations, the failure to identify events as self-generated arises because of specific deficits in episodic memory for remembering the details associated with particular past memory events. These specific deficits in memory cause confusion about the origins of the experience (Nayani and David, 1996). Patients with auditory hallucinations tend to misidentify the origins and source of stimuli during ongoing events and during memory events (Waters et al., 2006). The lack of voluntary control over the experience is a key feature of auditory hallucinations, which might explain why self-generated inner speech is classified as external in origin (Copolov et al., 2003). Hallucinations are experienced when verbal thoughts are unintended and unwanted. Because deficits in cognitive processes, such as inhibitory control, are thought to render people more susceptible to intrusive and recurrent unwanted thoughts, studies have linked auditory hallucinations with deficits in cognitive inhibition (Waters et al., 2006).

Recent advances in the neurosciences provide clues to why patients report an auditory experience in the absence of any perceptual input. Spontaneous activity in the early sensory cortices may in fact form the basis for the original signal. Early neuronal computation systems are known to interpret this activity and engage in decision-making processes to determine whether a percept has been detected. A brain system that is abnormally tuned in to internal acoustic experiences may therefore report an auditory perception in the absence of any external sound (Deco and Romo, 2008). Ford et al., (2009) suggested that patients with auditory hallucinations may have excessive attentional focus toward internally generated events: the brains of persons who have auditory hallucinations may therefore be over interpreting spontaneous sensory activity that is largely ignored in healthy brains.

Cognitive impairments are not the only factors responsible for auditory hallucinations. Psychological factors such as meta-cognitive biases, beliefs, and attributions concerning the origins and intent of voices also play a critical modulatory role in shaping the experience of hallucinations. The role of environmental cues and reinforcement factors through avoidance strategies must also be incorporated in any explanations of auditory hallucinations. These factors do not explain how hallucinations occur in the first place, but they have strong explanatory power when accounting for individual differences in how the voices are experienced (Baker and Morrison, 1998).

Patients suffering from auditory hallucinations sometimes can not distinguish between what is real and what is not real, it is very important to build a trusting therapeutic relationship with the sufferer. This dissertation will go on to explore the importance of building a therapeutic relationship with a patient; To explore the extent of auditory hallucinations a patient may be experiencing it is important that an appropriate assessment and risk management are carried out, exploring the need for assessment and risk management in auditory hallucinations, It will also look into helping approaches discussing pharmacological and psychosocial approaches in the management of auditory hallucinations and how to end the therapeutic relationship between a service user and the nurse, looking into discharge planning.

CHAPTER TWO

DEVELOPMENT OF THERAPEUTIC RELATIONSHIP

Development of the Therapeutic Relationship

Peplau's theories laid the ground for ascendancy of the relationship as the key context for all subsequent interventions with patients (Ryan & Brooks, 2000). Although the idea of the relationship endures as the paradigm for psychiatric nursing (Barker, Jackson, & Stevenson, 1999a; 1999b; Krauss, 2000; Raingruber, 2003), it does not appear there is any universal consensus on exactly how to frame this relationship. The nurse-patient relationship can be defined as an" ongoing, meaningful communication that fosters honesty, humility, and mutual respect and is based on a negotiated partnership between the patient and the practitioner" (Krauss, 2000, p. 49).

Peplau describes nursing as a therapeutic interpersonal process that aims to identify problems and how to relate to them (Peterson and Bredow 2009). Forster (2001) defines therapeutic relationship as a trusting relationship developed by two or more individuals. However, Jukes and Aldridge (2006) says at first sight therapeutic nursing and the therapeutic relationship may seem relatively easy to define, but once we scrape the surface we find a complex range of ideas and concepts that stem from philosophies, ideologies and individual therapies. Sometimes there are difficulties in applying these definitions to our own work. Not least of these difficulties is the relevance of the concept of 'therapy as healing' to nursing. This begs the question of whether a therapeutic relationship always entails the use of a therapy, or whether there is something more universal and fundamental in therapeutic relationships. It seems important therefore to attempt a workable definition of the therapeutic relationship that has currency within nursing as a whole. Additionally, it seems that therapeutic nursing has two facets. The first of these, and probably the most apparent, is the emotional and interpersonal aspect, which we might call 'therapeutic nursing as an art'. The second is the more logical and objective aspect, which we might call 'The therapeutic nursing as a science'. Arguably, there is a synergy between the two that leads to a gestalt, and therefore a need to address both aspects if our nursing is to be truly therapeutic in a holistic sense.

Peplau's theory focuses on the nurse, the patient and the relationship between them and is aimed at using interpersonal skills to develop trust and security within the nurse-patient relationship. Therapeutic relationships are the corner stone of nursing practice with people who are experiencing threats to their health, including but not restricted to those people with mental illness (Reynolds 2003). The relationship of one to one of nurse - patient has potential to influence positive outcome for patients. Hildegard Peplau interpersonal relations overlap over four phases namely: Orientation, Identification, Exploitation and Resolution.

Peplau also identify that during the four overlapping phases nurses adopts many roles such as- Resource person: giving specific needed information that aids the patient to understand his/her problem and their new situation. A nurse may function in a counselling relationship, listening to the patient as he/she reviews events that led up to hospitalization and feeling connected with them. The patient may cast the nurse into roles such as surrogate for mother, father, sibling, in which the nurse aids the patient by permitting him/her to re-enact and examine generically older feelings generated in prior relationships. The nurse also functions as a technical expert who understands various professional devices and can manipulate them with skill and discrimination in the interest of the patient (Clay 1988).

The orientation phase is the initial phase of the relationship where the nurse and the patient get to know each other. The patient begins to trust the nurse. This phase is sometimes called the stranger phase because the nurse and the patient are strangers to each other (Reynolds 2003).

Peplau's (1952) suggest that during this phase early levels of trust are developed and roles and expectation begin to be understood. It is important that during this time that the nurse builds a relationship with the patient by gaining their trust, establishing a therapeutic environment, developing rapport and a level of communication expectable to both the patient and the nurse. During the orientation phase trust and security is supposed to be developed between the nurse and the patient.

Co-ordination of care and treatment of patient while using an effective communication between the MDT is a nurse role. The nurse also acts as an advocate/surrogate for a patient and promotes recovery and self belief. Essential communication skills are deemed to be listening and attending, empathy, information giving and support in the context of a therapeutic relationship (Bach and Grant 2009). Building a therapeutic relationship needs to focus on patient -centred rather than nurse-task focus.

Bach and Grant (2009) say interpersonal relationship describes the connection between two or more people or groups and their involvement with one another, especially as regards the way they behave towards and feels about one another. Communication is to exchange information between people by means of speaking, writing or using a common system of signs or behaviour. Faulkner (1998) suggested that Rogers (1961) client centred approach conditions can be seen as important factors that contributes to a therapeutic relationship. Rogers (1961) three core conditions are: congruence, empathy and unconditional positive regards.

Congruence means that the nurse should be open and genuine about feelings towards their patient. Having the ability to empathise with the patient would show that the nurse has the ability to understand the patient's thoughts and feelings about their current problem. Unconditional positive regards is viewing them as a person and focusing on positive attributes and behaviour (Forster 2001). The orientation phase also gives the nurse the chance to asses the patient's current health and once the assessment has been carried out the can then move the relationship forward to the identification phase. The identification phase is where the patient's needs are identified through various assessment tools. Assessment will be discussed in detail in the next chapter. Butterworth (1994; DH 1994a; DH 2006a) says that during the identification phase the nurse and the patient will both work together discussing the patient's identified needs, needs that can be met and those that cannot be met. They will also identify risks and how to manage the risks and aim to formulate a care plan. Butterworth said the care plan should focused on the patient's individual needs, long and short term goals and their wishes, whilst being empowered at all times to make informed decisions and choices that matter in their care.

Collaborative working between multi-agencies ensures the needs of the patient are being met through appropriate assessment and treatment under the Care and Treatment Plan (CTP). The Care and Treatment Plan is one of a number of new rights delivered by the Mental Health (Wales) Measure (2010). The Measure also gives people who have been discharged from secondary mental health services the right to make a self referral back for assessment and it extends the right to an Independent Mental Health Advocate to all in-patients. A care co-ordinator must ensure that a care and treatment plan which records all of the outcomes which the provision of mental health services are designed to achieve for a relevant patient is completed in writing in the form set out (Hafal, 2012).

The Sainsbury Centre for Mental Health (Rose 2001) found that patients are often not involved in the care planning process and many service users were not even aware of having a care plan.

The exploitation phase is where interventions are implemented from the needs and goals set out in the identification phase which enables the service user to move forward, these interventions will assist in managing auditory hallucinations, whilst educating the patient and family members about the illness. Helping approaches will be discussed in detail in the next chapter looking at various up to date interventions available for the management of auditory hallucinations.

A trusting relationship can help with recovery and during these interlocking phases is what the nurse and the patient are aiming for (Hewitt and Coffey, 2005). Building of a trusting therapeutic relationship is essential for nursing interventions to work (Lynch and Trenoweth, 2008). Nurses need to be sensitive, show compassion at all times and understanding to a patient's needs. Nursing interventions needs to address physical, psychological and social needs; this involves having holistic approach (Coleman and Jenkins, 1998). Nurses need to work with the best evidence based therapeutic treatment available, this then being a positive approach to care (NMC 2008). The Chief Nursing Officer (CNO) review of the Mental Health Nursing (2006) noted that to improve quality of life, service users risks need to be managed properly, whilst promoting health, physical care and well being. However, Hall et al., (2008) argues that the CNO review does not take into consideration the great pressure nurses are under and also the complex needs of the service user.

Therapeutic interventions are an important aspect of recovery (Gourney 2005). Recovery can be described as a set of values about the service user's right to build a meaning life for themselves without the continuous presence of mental health symptoms (Shepherd et al., 2008). The purpose of recovery is to work towards self determination and self confidence (Rethink 2005). National Institute for Mental Health in England (NIMHE, 2005) described recovery as a state of wellness after period of illness. Nurse need to provide a holistic view of mental illness with a person centred approach that can work towards the identification of goals and offer the patient appropriate support through interventions like CBT, family therapy and coping skills, this will enable the patient to be at the centre of their own care, thus taking responsibility for their own illness and improve quality of life. Service user who have a full understanding and accept their illness can engage more with therapies and interventions with the necessary support from professionals, this then leads to self determination and better quality of life (Cunningham et al., 2005). However, Took (2002) says it is important to remember that with a service user experiencing auditory hallucinations, their mood and engagement can fluctuate and also the side effect of prescribed medication can affect this which may slow down the recovery process.

Early intervention is also recognised to improve long term outcomes of auditory hallucinations in schizophrenia (McGorry et al., 2005: NICE 2009). However, not all service users will seek advice when first experiencing symptoms, due to stigma attached to mental illness and fear of admission to hospital (French and Morrison 2004). Some service users have also complained that the hospital has a non therapeutic environment and that they also feel unsafe and in an orison like setting (SCMH 1998, 2005; DoH 2004b). Drury (2006) says that service users felt that some professionals lacked compassion. Mental health nurses are encouraged to adopt a client centre approach, some research suggests nurses lack empathy and have general uncaring attitude (Herdman 2004).

The final phase of Peplau's theory is the resolution phase. This is where the nurse and the service user will end their professional relationship. The relationship can end either through discharge or death. For the purpose of this dissertation the ending of the relationship that will be discussed at a later chapter will be discharge.

Therapeutic relationship is seen as paramount during these interlocking phases of peplau's interpersonal relations theory, nurse's needs to promote the service users independence whilst treating them with respect, privacy and dignity. By identifying treatment goals, implementing and evaluating treatment plans the service user can move on to interventions that will help them manage and cope with auditory hallucinations.

Chapter 3

Assessment of a patient with Auditory Hallucinations

Assessment of Auditory Hallucinations

Assessment is the decision making process, based upon the collection of relevant information, using a formal set of ethical criteria, that contributes to an overall estimation of a person and his circumstances (Barker 2004). Hall et al (2008) described assessment as one of the first steps to the nursing process; it is also part of care planning and a positive foundation for building a relationship and forming therapeutic alliance. It is an ongoing process that enables professional to gather information that allows them to understand a person's experience.

Most assessments have similar aims. However, how assessments are conducted can vary enormously. Such differences are very important and can influence greatly the value of the information produced (Barker 2004). In Wales CTP was introduced under the Mental Health (Wales) Measures 2010. CTP means a plan prepared for the purpose of achieving the outcomes which the provision of mental health services for a relevant patient is design to achieve and ensures service users have a care plan, risk assessment and a care co-ordinator to monitor and review their care (see appendix one). NICE (2010) suggest that assessment should contain the service user's psychiatric, psychological and physical health needs and also include current living arrangements, ethnicity, quality of life, social links, relevant risk and other significant factors that may affect the service user's quality of life.

Assessment of a patient relies upon the collection of information through interviewing: the patient, member of their family, direct observation of the nurse, questionnaire, rating scales, and previous history (Previous records). However, Barker (2004) argues that despite the importance of the history, if relied upon as the sole method of assessment, not only may the final picture of the patient be of a doubtful accuracy but it may also lack the fine detail necessary for the planning of care or evaluating progress.

Direct observation is an important assessment skill; during observation the nurse can identify a service user hearing or responding to voices, this would be observed through non-verbal communication and behaviours (Trevithick 2005). Lamph (2010) suggested that engaging with a service user who is experiencing voices maybe difficult due to them being preoccupied with the voices or suspicious of the nurse's motive. It is understandably a difficult and distressing time for the service user; open ended questioning techniques can work towards holistic assessment. It is not only distress that is caused through hearing voices but additionally the beliefs the service user may hold about them (Chadwick and Birchwood 1994; 1995). A service user experiencing voices maybe thinking that the nurse does not understand what it is like to hear them, it is therefore essential for the nurse to empathise with them at all times throughout assessment.

There are different types of tools and aid that can assist in identifying auditory hallucinations but before discussing them, the importance of risk assessment and risk management will be discussed first.

Risk can be defined as the probability that negative consequences will follow an action or as the likelihood of adverse outcome after a particular event (Woods 2001). Identifying risk is the ability to assess the likelihood of an event occurring, rate severity if event occurs and take appropriate action whilst evaluating the identified risk and re-assessing (Doyle 1999). However, Baker (2004) argues that risk assessment is driven by fear of litigation, or a professional or institutional obligation to abide by specific legislative requirements; what the behaviourist called negative reinforcement. He said the risk is that staff will become overburdened by paperwork, lose sight of the person, the vogue for using standardized risk assessments or checklist are but two examples of this unfortunate although, given the political climate, understandable shift in organizational priorities.

Risk can include harm to self (deliberate or accidental), suicide, self neglect, harm to others, alcohol, substance related misuse and social vulnerability (DH 2007).

Risk assessment is an integral part of assessing, planning, reviewing the risk of patients and risk they may pose to other people (DOH, 2008). The Mental Health Policy Implementation Guide (DOH, 2007) specifies the importance of service user centred assessment of needs and risks carried out using established methods and procedures for measuring symptoms, risk and social functioning; Risk assessment should contain a full multidisciplinary assessment of the service user's full history, needs, risk management, crisis and contingency planning. Risk assessment should also work within the Department of Health best practice guidelines (DOH 2007).

Although there is no statutory risk assessment with the CTP, however there are many tools, variety of rating scales and interviews that can be used to assess the severity of auditory hallucinations, symptoms of psychosis, risks and how to manage them. Gamble and Brennan (2000) says questionnaires for psychotic symptoms have been developed through research and are seen as valid tools of measurement, however they said questionnaires should be used selectively and not primarily because they are there, if there is a particular need or symptom to assess then a relevant tool should be appropriately used.

Auditory Hallucinations Rating Scale (AHRS) (Haddock 1994, appendix two) is an additional questionnaire used by professionals during assessment primarily designed to identify voices individuals are experiencing over a period of time, frequency, duration, loudness and amount of distress or intensity are discussed including the number of voices a person maybe experiencing.

Another tool to aid assessment of person hearing voices is the Beliefs about voices Questionnaires revised (BAVQ-R) (Chadwick and Birchwood 1994, appendix three). The BAVQ-R is an assessment tool used in reviewing what the service user thinks about the voices they experience. During the assessment the service user is questioned about their belief on the voice they are hearing and the information gather from the service user is used to get an accurate picture of the voice they hear. Chadwick and Birchwood (1995) suggests that this tool is cause the least distress with voice hearers when engaging with them and it improves communication with the professional as the questions are not so intrusive and challenging.

The KGV scale (Krawiecka, Goldenberg and Vaughan Manchester 1977) (appendix four) is another tool used to aid assessment of auditory hallucinations; it is a structured interview that focuses on fourteen areas of symptoms to discuss ranging from symptoms that includes hallucinations, anxiety, depression that is measured on a scale ranging from 0-5 from absent to severe.

Another tool to aid assessment is the Psychiatric Symptom Rating Scale (PSYRATS) (Haddock et al., 1995, appendix five) is a tool that measures severity and intensity of dimensions in auditory hallucinations. It comprises of 11 items on hallucinations and 6 items on delusions. They are rated on a scale 0-5. Drake et al., (2007) says that this scale is commonly used in psychiatry and can review outcomes of interventions; it is also well tested for validity and well researched.

The Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987 appendix six) this scale can be used to assess the severity of auditory hallucinations. The scale has 30 items that includes 7 positive and 7 negative symptoms and 16 general psychopathology items; these are then scored on a 1-7 point severity scale, 1 being absent and 7 being severer (Kay, Opler and Lindenmayer 1989).All the tools mentioned are the most common ones used in the aid of assessing auditory hallucination but there are many others too.

Through good communication and interaction service user can begin to work towards common goals and that through these interactions, an agreement can be made which assists in achieving these goals (Lafferty and Davidson 2006). Once all necessary assessments have been carried out a CTP can be formulated. Assessment is a constant process and has become an important part of clinical practice (WAG 2005). Harrison et al., (2004) says plan of care will have to be regularly evaluated to identify a change in needs. Care plans should also indicate who was responsible for implementing the treatment required within a specified time frame.

Townsend (2007) said assessment tools can be used to re-assess the level of voices an individual is experiencing; this will then identify whether there has been a reduction in voices and whether current care plans in place are effective. Nurses have a responsibility to deliver care on the best available evidence or best practice (NMC 2008). For a care plan to be effective there needs to be relevant evidence based treatment and interventions to assist in alleviating auditory hallucinations. The purpose of treatment is to improve the service the service user's quality of life and prevent relapse (APA 2000).

Chapter 4

Helping Approaches

(Interventions for the Management of Auditory Hallucinations)

Pharmacological Interventions

The treatment of Schizophrenia and psychosis is complex and requires the involvement of a multidisciplinary team of professionals (Rubin et al., 2010). Ettinger (2012) states that the majority of the newer generation antipsychotic medications have been claimed to have worked on schizophrenic patients or at least improved some of their symptoms. Guidelines from the National Institute for Health and Clinical Excellence (NICE 2010) recommend that antipsychotic medication continues to be the primary treatment for schizophrenia. However, Kaufman and Gorman (1996) state that there are comparative possibilities that certain antipsychotic medications are known to cause extra pyramidal side effects such as akathisia, metabolic side effects including weight gain and other side effects such as unpleasant subjective experiences causing patients to not adhere with their treatment plan. It is estimated 25 percent of people diagnosed with schizophrenia still continue to suffer with positive symptoms such as auditory hallucinations even when taking antipsychotic medication (Davis and Casper 1997). Early intervention is the key to treating auditory hallucinations, it is important to use antipsychotics during early onset of psychosis, it is necessary to prevent suffering of the individual; it is more effective in treating the episode and long-term outcomes. Early introduction of antipsychotics should improve individual attitudes if treatment is not causing any untoward side effects or distress (Bebbington 2000).

The class of drugs used to treat schizophrenia and other psychotic illnesses is known as antipsychotics (the terms 'neuroleptics' and 'major tranquillisers' are also sometimes used although neither is strictly correct). The antipsychotic potency of most antipsychotics is directly proportional to their ability to block dopamine receptors in the brain, although the exact mechanism by which they exert their antipsychotic effect is probably complicated than this. They vary greatly in their selectivity for dopamine receptors, many also having significant effect on acetylcholine, noradrenaline, histamine and 5HT pathways (Taylor et al., 2003). Antipsychotics are in two groups; first being typical antipsychotic medications called first-generation antipsychotics (FGAs). Typical antipsychotics formed the basis of treatment and recovery for people with schizophrenia (McCann et al., 2008) although they are cost effective and work in managing positive symptoms including auditory hallucinations they have a range of unpleasant and damaging side effects (Gillam and Williams 2002). Breggin (2007) agrees that typical antipychotics come with common and disabling side effect. Tardive dyskinesia is most common one that is experienced, and its symptom develops in around 20 percent of patients known to be using these types of antipsychotic medications. Hence the attributable to the restricted potency and wide ranging side effects experienced with using these first generation antipsychotics a lot of work and research has gone into developing treatments that are more effectual and where patients experience no negative or less disabling effects from using the medication (Aschenbrenner and Venable, 2008).

The second group of antipsychotics are known as atypical antipsychotics (second generation antipsychotics). Atypical antipsychotics produce lesser side effects than the typical antipsychotics and reported to be better tolerated. However, research has shown them to be less effective than the older typical antipsychotics (Gillam and Williams 2002). This makes treating auditory hallucinations slightly difficult for professionals as they have to weigh up the pros and cons in what are more tolerable and the risks involved. Aronson (2008) states that the foremost benefit of the new 'atypical' antipsychotics give the impression that they have a reduced incidence of chronic extrapyramidal side effects and tardive dyskinesia. However, in comparison this should be weighed against other side effects, such as weight increase and metabolic difficulties. NICE (2009) recommends that typical antipsychotics can be used for 4 to 6 weeks to screen for treatment-resistant schizophrenia, after which treatment with clozapine may be considered as a last pharmacological option. Moncrieff (2003) stated that in a review of comparative randomised trials concurred that clozapine is to a higher degree effective than other established antipsychotics for all patients with schizophrenia and that the comparative benefits of clozapine are greater in patients whose conditions are categorised as treatment-resistant. However, Shim (2009) argues that although clozapine is considered the standard pharmacological therapy and the last resort in the management of treatment-resistant schizophrenia, 40 to 70 percent of patients with treatment-resistant schizophrenia fail to respond to clozapine treatment. Overall antipsychotics are seen as the most effective for the treatment of auditory hallucinations in the diagnosis of schizophrenia (Heinssen et al., 2000). However, Shergill et al (1998) said it is estimated 25- 30 percent of people may not respond to pharmacological treatments and voices will continue to remain present.

The nurse's role in pharmacological interventions is to aim for concordance, this can be done by educating the service user about the biological side of their illness and discuss the benefits of medication and how it can help (NICE 2009). The nurse has an important role monitoring physical health as antipsychotics are known to cause an increase in developing cardiovascular disease and also diabetes. The nurse's observation skills also come into use when administering medication as they can observe for any side effects and discuss any concerns the patient has with the Responsible Clinician (RC). They may also use the Liverpool University Side Effect Rating Scale (LUNSERS) to carry out assessment if any side effects are reported by the patient (Appendix 7).

It is estimated as much as 50 percent of out-patients within the first year of hospital discharge will not adhere to medication (Zygmunt 2002). Olfen et al (2006) suggest that the primary reason for non-adherence to medication is lack of insight and awareness of having mental illness. If medication for schizophrenia is discontinued, the relapse rate is about 80 percent within 2 years. With continued drug treatment, only about 40 percent of recovered patients will suffer relapses (Fenton et al, 1997). Morken et al (2008) suggests that most psychotic relapses are due to non-compliance with treatment plans and medication, long acting injectable antipsychotic medication or commonly known as depot medication is a valuable alternative to oral mediation. Breggin and Cohen (1999) argue that withdrawing from psychiatric drugs can be agonising and in some cases extremely unsafe to do without clinical guidance. Medication withdrawal should normally be done slowly over a period of time and reduced down with the guidance of an experienced, informed clinician. Kemp et al (1996) state that a particular cognitive behavioural conceptualisation with the main purpose of enhancing conformation with treatment was formulated in 1990s to combat non-compliance, this is commonly known as adherence therapy.

It is acknowledged that being dependent on medication; therapists often fail to challenge the humanistic, empirical perspective of human characteristics. In failing to do this the tasks of learning to live by values and by higher beliefs, such as autonomy, individual responsibility, and emotion are not reinforced (Breggin, 2008). This endeavour is a necessary part of the psychotherapeutic procedures and life as a whole. Breggin (1991) states that not only does this first attempt of treatment to medicates retract from these values of life but the effects of the medication themselves blunt and distort in many cases the patients quality of life and their abilities of higher functioning. Conversely, that the avoidance of the use of transpersonal, mystical, and religious techniques may sometimes help some clients to live and accept their disturbed thinking but at the same time impede on the full development of flexible, open, and scientific positions which, according mental health professionals are core characteristics of optimal and sustained mental health (Ellis, 2007). Newton et al (2005) articulate that 20 to 50 percent of people with a diagnosis of schizophrenia continue to hear voices despite taking antipsychotic medication. This is reiterated by Blom and Sommer(2011) who come to the conclusion by using clinical trials, published that there are no specific antipsychotic medication that compare the efficiency of different antipsychotic medications and their effect on hallucinations exclusively.

Antipsychotics is recommended as a front-line treatment in schizophrenia, however the general consensus is that about 25 to 60 percent of persons continue to have persistent positive and negative symptoms despite medication management. Thus, medications are not a cure-all for schizophrenia, but only part of a comprehensive treatment approach needed for recovery (Rubin et al., 2010). The effects of medication are further attenuated by high rates of medication non-compliance, which range between 50-70 percent of individuals who discontinue their medication against medical advice (Buchanan, 1992).

Currently, there is a renewed interest in psychosocial therapies for schizophrenia (Rubin et al., 2010). Although medication may help in the treatment of auditory hallucinations in schizophrenia there is no known cure for the symptoms, the sufferer will need to develop coping strategies along with talking therapies like CBT, family groups, psycho-education like coping skills training and relapse prevention training. These treatments are considered evidence-based treatment so the author will look into the application of all these treatments.

Psychosocial Interventions

Medication adherence is necessary if treatment goals are to be achieved. However, medication alone is insufficient for ensuring that problems related to social functioning, employment, and families will be adequately addressed. Treating schizophrenia does just not mean addressing hallucinations, it also means providing psychosocial interventions that address the social skills of the patient, support their families and give care givers the skills they will need to cope with and support the individuals (Rubin et al., 2010).

Psychological therapies and psychosocial interventions in the treatment of schizophrenia have gained momentum over the past 3 decades. This can be attributed to at least two main factors. First, there has been growing recognition of the importance of psychological processes in psychosis, both as contributors to onset and persistence, and in terms of the negative psychological impact of a diagnosis of schizophrenia on the individual's well-being, psychosocial functioning and life opportunities. Psychological and psychosocial interventions for psychosis have been developed to address these needs. Second, although pharmacological interventions have been the mainstay of treatment since their introduction in the 1950s, they have a number of limitations. These include limited response of some people to antipsychotic medication, high incidence of disabling side effects and poor adherence to treatment. Recognition of these limitations has paved the way for acceptance of a more broadly-based approach, combining different treatment options tailored to the needs of individual service users and their families. Such treatment options include psychological therapies and psychosocial interventions. Recently, emphasis has also been placed on the value of multidisciplinary formulation and reflective practice, particularly where psychologists and allied mental health professionals operate within multidisciplinary teams (British Psychological Society, 2007).

NICE (2010) recognised the need for psychosocial interventions for the management of auditory hallucinations in schizophrenia. Although there have been limited studies that directly focus on the treatment of targeting auditory hallucinations. However, Thomas et al (2010) suggest that psychosocial approaches can minimise positive symptoms and reduce voices.

Nurses can improve symptoms with a cognitive approach (Turkington et al., 2006). Gumley et al (2006) also suggests that these approaches can lead to a reduction in negative voices and low self esteem.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is considered a front-line treatment in the United Kingdom, and it is recommended that CBT is offered to all persons with schizophrenia (NICE, 2009). Chadwick et al., (1996) states that the goal of CBT is to reduce the symptoms of schizophrenia by targeting the underlying deficits and biases in information processing that lead to the formation of hallucinations.

CBT is based on the relationship between a person's feeling, thought and behaviour. It was first founded and developed by Albert Ellis in the 1960s and was then adapted by Aaron T Beck for the treatment of depression in the 1970s (Beck 1979). CBT) can help people with schizophrenia manage the symptoms of their hallucinations or delusions more effectively (Hersen and Rosqvist, 2005). Chadwick et al (1996) suggest that cognitive behavioural therapy for hallucinations comprehends the considerations of several other strategies of cognitive therapy but anticipates that distress and coping behaviour are effects not of the hallucination specifically, but of the sufferer's principles concerning the hallucination.

The effectiveness of CBT depends on the development of a therapeutic relationship (Roth et al., 1996) engagement, developing good rapport, trust and empathy (Rubin et al., 2010). Chadwick et al (1996) suggests that hallucinations can be understood using the ABC model (Antecedent-belief-consequences model. See appendix 8). The hallucination is considered the A or activating event that leads to beliefs about voice (B), which is then followed by an emotional or behavioural consequence (C). Hallucination represents an odd or unusual experience in the ABC model that the person must make sense of or assign meaning to understand the voice. They begin to search for the meaning of voice, why they are experiencing this voice, and what this voice means about them as person. The end result is a sense of closure (Rubin et al., 2010).

Romme et al (1992) states that people who cope with their voices do not often complain or use distraction techniques; these are referred to as copers as they believe the voice is talking about beliefs held by them. In support of this Chadwick and Birchwood (1995) says that people who cannot link their voices to their beliefs can be seen as non copers, they often find the voice annoying and distressing and would require more support to understand the meaning of their beliefs. These two arguments validated the ABC models and seen as a beneficial tool in CBT combating the voices in sufferers of auditory hallucinations.

The goals of CBT for hallucinations are to weaken the voices activity, change the person's beliefs about their voices (i.e. omnipotence etc) (Rubin et al., 2010). CBT helps the patient ascertain the thinking patterns that are causing them to have unwanted emotions and behaviour, and help learn to substitute this thinking with more pragmatic and constructive thoughts (Sampl and Kadden, 2006). Valmaggia et al (2005) states that cognitive-behavioural therapy showed modest short-term benefits for treatment-refractory positive symptoms of schizophrenia. Wiersma et al (2004) report that there are many direct and subsidiary advantages of the cognitive-behavioural conceptualisation these have been conveyed by the following ways, the patients report experiencing enhanced quality of life, lessening of their general anxiety and depression, vast improvements in their self-esteem, empowerment and a greater sense of personal control, and a lessening of inappropriate behaviours. However, Byrne et al (2006) states that there are in some cases substantial diminutions in conformity to CBT due to hallucinatory voice commands.

Wiersma et al (2004) argues that patient's with a good pre-morbid situational quality of life, could be a facilitation or catalyst for the encouraging effects of therapy using mindfulness. Beck and Rector (2003) express that cognitive behavioural therapy and mindfulness have a momentous and imperishable consequence to client's insight in relation to their hallucinations and to the root of their delusions. Garety (1991) agrees and suggests that the bulk of the therapeutic perceptions and central principles in the management of the disorder require the patient's recognition that their hallucinations and delusions were the product of their minds and did not arise from an extraneous provocation. However, Baer (2006) conflicts this, proposing that although mindfulness and CBT can be of a great use to professionals, it cannot be used in the midst of a psychotic episode as a treatment basis, thus medication in some cases is the only option. Rathus (2010) echoes this and suggests that with the use of this type of treatment, therapists must be careful and cautious when they challenge delusional and distorted behaviours of client's with schizophrenia. This is because schizophrenia tends to make a person resistant to challenges. Thus why it is advisable that cognitive reorganisation is implemented with the extreme care in order to avert emotional distress that could jeopardise or hinder the therapeutic process completely (MIND, 2005).

Although CBT is recommended as a treatment in first episode psychosis (NICE 2010) and research suggests its effectiveness. However, there is no single agreed upon set of methods for CBT, too often clinicians and researchers use their own set of techniques and procedures. This makes it hard to find commonalities across these approaches (Rubin et al., 2010).

The proper use of CBT is in conjunction with antipsychotic medication, general medical care and case management services (Rubin et al., 2010). NICE (2010) echoes this recognising that CBT works more effectively when used alongside antipsychotic medication. Pinkham et al (2004) argues that at present, there is more research to support the use of CBT with individual patient rather than in groups, but more research is being conducted on group based CBT approaches.

Family Interventions

NICE (2009) states that the carers, relatives and friends of individuals with schizophrenia are important both in the method of assessment and engagement, and in the long-term the deliverance of successful interventions. Beck et al (2011) agrees stating that the families of sufferers of schizophrenia regularly have an essential role in the treatment and care of that person, and with the right support from agencies and professionals can positively contribute to the promotion of that relative's recovery. Family can become actively involved in the treatment process with the implementation of family therapy. NICE (2010) recommends that family intervention should be at least ten sessions, this would involve the patient's main carer or closest relative. However, Atkinson (1986) argues that whilst family involvement in care and treatment can have a positive impact on the sufferer, it is just important that families and carers also receive support for themselves, because they can become physically and psychologically affected by caring for someone with schizophrenia, as it can be an emotionally and physically draining experience on times. They may become fearful, distressed and isolated, and these feelings can have a significant impact on the quality of the relative or carer life and it can ultimately impact on the support and care the family member with schizophrenia receives. Lukens and Thorning (1998) agrees stating, that when a person respond to hallucinations, is preoccupied with highly improbable or impossible beliefs, or acts in a bizarre fashion, the impact on close relatives and friends is particularly disturbing.

Herman et al (2007) states that service user may find themselves back in hospital or homeless if there is no adequate support from family or mental health professionals. Family therapy can help work with the service user and family members to treat symptoms as a group rather than the service user being left to deal with voices on their own. Family therapy help relatives gain a better understanding of the illness and improve communication within the family group.

PSYCHOEDUCATION

Psychoeducation was designed to give information and teaching about any particular mental disorder. It involves using teaching strategies such as lectures and discussions, workshops, reading books, watching films and reviewing handouts to aid knowledge of illness (Anderson, Reiss, and Hogarty 1986; Goldman and Quinn 1988). Psychoeducation aim to equip service users diagnosed with auditory hallucination in schizophrenia with basic information they need about their mental illness, management of it and treatment.

Research on psychoeducation has consistently showed that people with severe mental illness are capable of learning and retaining basic information about the management of their mental disorder and treatment (Bauml, Kissling and Pitschel-Walz 1996; Goldman and Quinn 1988). However, Musser et al (2002) argues that psychoeducation alone has limited effect on reducing relapses, reduction in symptoms or re-hospitalisation.

Relapse Prevention

Relapse prevention training was developed based on the understanding that relapses usually starts gradually over several weeks and often preceded by subtle changes in the service users thinking, social behaviour and mood. Relapse prevention in service user suffering from auditory hallucinations in schizophrenia usually involves teaching the service user how to recognize common triggers of relapse and identifying their own individual unique early warning signs like stressful situations, anxiety, lack of sleep, depression and formulating a plan on how to deal with the early warning signs should they occur (Rubin et al., 2010).

Coping Skills Training

Coping skills has been found to help alleviate anxiety caused through hearing voices. Coping skills look at ways to minimise the severity of symptoms by using coping, distraction and focusing techniques (Yanos, 2001). Coping skills training involve assessing the service user's current coping strategies, increasing the use of effective coping strategies the service user currently uses, reviewing and selecting additional coping strategies to teach the service user, modelling a new coping strategies for the service user, engaging the service user in practicing the strategies in sessions, develop assignment for the service user to practice the coping skills on their own (Tarrier, 1992).

Nelson et al (1991) did a study looking into psychological procedures and found that the use of headphones whilst listening to music during voice hearing can decrease the symptom; this is because the music might distract the voices hearer and takes their mind of the voices. The study also found that music distraction is more beneficial when used alongside antipsychotic medication.

Psychosocial and pharmacological interventions are an important part of managing auditory hallucinations and there is a great need for these interventions to be place within our health system (British Psychological Society, 2007).

All the interventions discussed will not work unless a therapeutic relationship is established, the role of the nurse and other health care professionals is to assist in the management of symptoms of auditory hallucinations in schizophrenia and implement the interventions.

This dissertation has discussed the recommended evidence based helping approaches to the management of auditory hallucinations in schizophrenia.

All the interventions discussed can help service users manage their symptoms whilst gaining independence and help move towards recovering. The next chapter will discuss ending of relationship with reference to discharge planning.

Chapter 5

The Ending of the Relationship

The Ending of the Relationship and Discharge Planning Process

The ending of the relationship can be for many reasons e.g. transfer of care due to stability in mental health which does not require further treatment in the hospital; this can mean that the service user is ready for discharge. With appropriate interventions and resources in the community they will be able to manage without any unnecessary further stay in hospital.

The resolution phase is described as the ending or termination of the nurse/patient relationship (Peplau 1952). This phase of peplau's interpersonal relation is identified as the patient becoming independent and able to move on when goals have been met in the ide