The Acceptability and Impact of a Video on Compassion Focused Therapy as a Psycho-Educative Tool to Deepen Awareness around Voice-Hearing

Tara Hickey ^{1,2, 3}, Sarah Strohmaier ⁴, Ellie Fossey ⁵, Charles Heriot-Maitland ^{6, 7, *}

1. Southern Synergy, Monash University, Melbourne, Australia

2. Centre for Rural Health, University of Sydney, Lismore, Australia

3. Centre for Youth Mental Health, The University of Melbourne, Australia

4. Psychology Discipline, Institute for Health and Sport, Victoria University, Melbourne, Australia

5. Department of Occupational Therapy, Monash University, Melbourne, Australia

6. Department of Psychology, King’s College London, UK

7. Balanced Minds, London, UK

* Correspondence: Charles Heriot-Maitland

Academic Editors: Syd Hiskey and Neil Clapton

Special Issue: Compassion Focused Therapy (CFT) – Advances and Innovations

Received: December 21, 2023 | Accepted: April 10, 2024 | Published: April 25, 2024

OBM Integrative and Complementary Medicine 2024, Volume 9, Issue 2, doi:10.21926/obm.icm.2402023

Recommended citation: Hickey T, Strohmaier S, Fossey E, Heriot-Maitland C. The Acceptability and Impact of a Video on Compassion Focused Therapy as a Psycho-Educative Tool to Deepen Awareness around Voice-Hearing. OBM Integrative and Complementary Medicine 2024; 9(2): 023; doi:10.21926/obm.icm.2402023.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Experiences of psychosis are prevalent in society, with up to 15 percent of the population reporting that they have previously had or are currently experiencing psychosis-related symptoms [1]. Although hearing voices can be common in the general population, there is often no need for psychiatric care [2]. However, for those who hear voices which seem uncontrollable, frequent, and overly negative, this can be very distressing and severely disrupt everyday life [3]. Therapeutic interventions for voice-hearing have included various approaches, such as antipsychotic medication and cognitive behavior change therapies [4]. Alternatively, other approaches include conceptualizing distressing voices as being a protective part of the person themselves and focusing on learning to respond to voices in a more peaceful and compassionate manner thus minimizing dissociations [5,6]. One such approach to working with distressing voices is compassion focused therapy (CFT). CFT is an evolution-informed approach that aims to help people activate the patterns in their bodies, minds, and social environments that support attachment and caregiving/receiving relationships. By building a ‘compassionate mind/self’, CFT helps voice-hearers to extend more compassionate understandings towards the functions of their voice-hearing experiences, and often a more collaborative relationship with the voices themselves [7].

CFT for use in mental health services has increased steadily in the past two decades and has been found to improve clinical symptomatology across outcomes for individuals struggling with their mental health [8]. CFT has been found helpful in addressing shame and self-criticism along with fear of self-compassion [9] which are particularly prevalent in individuals experiencing psychosis [10]. During CFT, voice-hearers learn to identify different motivational systems and understand their purpose in the context of their lives, and then learn to switch motivational systems from those which are threat-focused to those linked more closely to supportive and caring systems, therefore approaching voices with compassion [11]. Compassionate mind training has previously been found helpful in reducing malevolent voices, along with depression, anxiety, and paranoia, among others [12]. Research exploring change processes in group CFT discovered that after participating in CFT, individuals with psychosis had significantly greater levels of self-compassion, which in turn related to significantly lower depression and perceived social marginalization [13]. Furthermore, group CFT was found helpful in decreasing distress and increasing calmness in a study with acute inpatients, with individuals stating that participating in CFT improved their understanding of relating to voices with compassion, and their experiences of common humanity [14]. Similarly, in a case report of a person with distressing voices along with comorbid mental health difficulties such as depression, agoraphobia, and anxiety for most of her life, individual CFT was found helpful in approaching voices with compassion and soothing inner critics, resulting in the client feeling an improvement in depressive symptoms and a reduction in the intensity of distressing voices [15]. Therefore, CFT has been found to benefit in the treatment of and recovery from psychosis, by addressing difficulties such as shame, self-criticism, and low self-compassion [16].

Although CFT has been conducive in treating symptoms related to psychosis, one of the potential barriers for individuals experiencing psychosis to engage with mental health programs such as CFT however, is the perception of the individual in not being able to understand what a particular therapy is and does, and whether they feel that participating in such therapy would be helpful in addressing their specific difficulties [17,18]. This issue is in addition to the general difficulty in engaging in talking therapies many individuals experiencing psychosis-related symptoms face [19]. Similarly, in addition to furthering knowledge of therapeutic processes for the individuals experiencing psychosis, it is important to further understanding of psychosis-related experiences and how therapeutical interventions such as CFT can help for friends and family of the person hearing distressing voices [20]. Even beyond this, increasing public understanding of psychosis and treatment programs have been found helpful to reduce stigma and improve psychoeducation in the general public [21,22,23].

Therefore, it is important to provide accessible psychoeducational tools to further understanding of mental health difficulties, and how certain therapies such as CFT can help with this. In 2015, a five-minute educational animated video titled "Compassion for Voices: a tale of courage and hope” was created by the collaboration of professionals in the fields of mental health and the creative arts, with the aim of providing a de-stigmatizing tool to further understanding of compassionate responding to distressing voices for use in education and therapy [24]. In the video, a person called Stuart describes his experiences of hearing voices, how it disrupts his life and social interactions, followed by his experiences of engaging in CFT and the changes in his life after starting CFT. At the time of writing, this video has been viewed over 300,000 times on YouTube. However, despite the large number of views gained on YouTube, it is important to have a more tangible understanding of consumer feedback on the Stuart video in order to be able to fully conceptualize the perceived accessibility of mental health interventions for individuals experiencing difficulties resulting from the video as well as its perceived impact and acceptability for use in psychoeducation. Receiving feedback directly from voice-hearers is important in order to test the accuracy of the content created. In addition, it is valuable to be able to have consumer feedback from the users of the video, including individuals experiencing psychosis, their loved ones, as well as for public understanding and educational purposes. Other therapeutic approaches have previously researched the impact of psycho-educational materials. For instance, interventions which involve social contact-based video interventions have previously been found effective in reducing public stigma of psychosis [25]. In a study of 1203 young adults, a brief (90 second) video intervention was found to be more effective at reducing stigma than a written vignette or a control condition [26] a finding that was later replicated in another large sample of 1055, which also had the additional benefit of a 30-day follow up to demonstrate that the stigma-reducing impact of video was sustained over time [27]. Whether the same is true for the Stuart video now needs to be explored.

This project aimed to obtain public feedback about the acceptability and perceived impact of the Stuart video as a psycho-educative tool to help deepen awareness around voice-hearing and reduce stigma and/or shame around hearing voices.

2. Materials and Methods

2.1 Compassion for Voices Film

The Compassion for Voices (CFV) film was designed as a public engagement tool to help people understand the key elements of compassion focused therapy for psychosis (CFTp). The animation follows a young man, Stuart, who starts using CFTp to develop a compassionate relationship with his voices. It was funded by four sources (a Medical Research Council public engagement grant, a King’s College London cultural innovation grant, a Compassionate Mind Foundation CFT development grant, and a Balanced Minds engagement grant).

2.2 Procedure

The CFV film was released on YouTube in February 2015. An anonymous online survey posted with the Compassion for Voices film on the web was used to obtain public feedback about the film. Given the survey was open to the general public and anonymous, ethical approval and consent were not sought. The Research Excellence Framework [28] criteria for measuring impact of research was used to guide the selection of questions. The survey involved specific questions about the impact of watching the film. For example, has it changed your understanding about voices? Has it changed your attitude or approach towards people who hear voices? Has it encouraged you to think about, or to do, something in a different way? There was also space to share “any additional feedback/comments/thoughts”. Questions also asked whether the respondent identified as a person who hears voices, a family member or friend of a person who hears voices, or someone who works with voice hearers. No other demographic information was sought. The survey was open for completion between February 2015 and February 2018. The aim was to use the feedback to ascertain the acceptability of the CFTp approach. Traditionally, mainstream understanding of how to relate to voices is to reduce or eliminate them, rather than to develop a compassionate relationship with voices. The CFTp approach may therefore not only be novel but also potentially controversial, so that understanding public responses to its messaging is important.

2.3 Data Analysis

The qualitative data was analysed using a hands-on guide to Content Analysis [29]. A deductive approach based on the survey questions was taken. There were six steps, the first of which involved cleaning and transferring the qualitative data as text into an excel spreadsheet. There were 140 respondents, 3 were removed due to duplications which left a sample of 137. Next, the lines of text were condensed while preserving the core meaning in each statement. The condensed statements were then each assigned a descriptive label or code - usually one or two words long - to characterise its meaning. Codes that related to each other through their content or context were then grouped together into categories, and in turn named descriptively. To further synthesize the main ideas across the data, the analysis was taken one step further to create themes that express an underlying meaning, i.e. latent content found across two or more categories. These steps involved an iterative process of going back and forth between the data itself, coding and grouping of codes into categories to check each step as the analysis progressed. The initial coding and analysis was undertaken by the first author (TH), then discussed with a second researcher (EF), before proceeding with the subsequent theme development. Descriptive statistics were also calculated for questions that gathered categorical data.

3. Results

One hundred and thirty-seven individuals completed the survey; 20 identified as ‘a person who hears voices’, 16 as ‘a family member of a person who hears voices’ and 14 as ‘a friend of a person who hears voices’, and 87 as ‘someone who works with people who hear voices.’

3.1 Main Impact of the Film

The most common theme in relation to the impact of the film for all participants was the attainment of knowledge. This knowledge covered several domains including learning about a ‘Compassion for Voices’ approach or compassion focused therapy, voice hearing, the impact on voice hearers and a non-medical approach to voice hearing. One voice hearer commented ‘I haven’t heard of this strategy’ with another commenting the ‘film has made me understand in a positive way how to be compassionate to my voices.’ A few individuals indicated they were already informed on this topic. Watching the film appeared to have reinforced their knowledge. The second most common impact was a change of attitude or approach. Participants were more hopeful about the outcome for voice hearers, including voice hearers themselves, and there was a sense of empowerment among some - ‘providing an alternative approach and perception of self as capable, competent, having goals, succeeding.’ Participants commonly reported they had shared the film or were planning to share the film. Over ten percent of participants specifically commented on the medium of communication chosen to share this information. It was seen as powerful, educational, and more striking than written information. A few health professionals wanted to find out more about the approach. And a few voice-hearers wanted to access compassion focused therapy. They identified with the film content ‘it nailed my experience’ and felt a sense of community humanity ‘it has also made me understand that I’m not the only one.’ (See Table 1).

Table 1 Main impact of the film, illustrated by examples coded in transcripts.

3.2 Impact on Health and Welfare

Over 98% of participants thought the film has, or could potentially have, an impact on health and welfare. Most thought the main impact was or could be a change in approach or attitude. This was particularly related to reducing stigma, changing relationships with voices, developing self-compassion and self-acceptance. And an increase in acceptance from the general public. One family member commented ‘different way of looking at things’ with a friend commenting ‘gives more choice on possible ways to understand and be with the experience of hearing voices.’ Voice hearers expressed a sense of hope for recovery, a new perspective on voices, a normalization of voice hearing, a reduction of stress, anxiety, depression, and an increase in self-awareness. Participants also felt that the film could result in an improvement in both physical and mental health outcomes with a few participants suggesting adopting a ‘Compassion for Voices’ approach would result a less dependence on medication resulting in less risk and side-effects associated with taking medication (see Table 2).

Table 2 Impact on health and welfare, illustrated by example coded in transcripts.

3.3 Impact on Health Service Policy and Service Provision

Over 78% of participants thought the film has or could potentially have an impact on health service policy. While 88% and 78% thought it has or could impact health and non-health service provision respectively. Health workers thought the film could impact treatment provision providing voice hearers with more treatment options, increased access to compassion focused therapy, access to a non-medical, non-pathologizing intervention and an improvement in treatment effectiveness. Voice hearers also commented on having access to more non-medical interventions, increase awareness among the general public, health workers and policy makers with one commenting ‘it can help policymakers see things from another perspective.’ Several participants commented it was a good educational resource and could be used in schools and advertisements. Voice hearers, family, friends, and health works all recognised it would be used as a training tool for practitioners which could change attitudes and approaches to working with voice hearers. A health worker explained it ‘allows health professionals to look at voices from a different lens.’ Another health worker thought it might influence an increase in funding with another suggesting it should become part of a greater strategic mental health engagement policy. The most common potential impact on non-health service provision considered was a change of approach or attitude. Notably, an increase in awareness and understanding, a reduction in stigma and an increase in positive attitudes as well as normalizing voice hearing (see Table 3).

Table 3 Impact on health service policy and service provision, illustrated by example coded in transcripts.

3.4 Impact on Public Understanding and Societal Impact

The areas the film could potentially make most impact was deemed to be public understanding (96%) and social impact (94%). The main public impact was deemed to be increasing knowledge that could lead to changes in attitudes and approaches to voice hearing and voice hearers. Participants felt the film explained complex concepts clearly with a health worker suggesting the film could play a role in ‘increasing public understanding in a clear, easy to follow and interesting way.’ With a voice hearer commenting it may - ‘may show family members how it really is.’ Participants also thought the film could change public attitudes and approach taken to voice hears - including a reduction in fear of voice hearers, a decrease in stigma and isolation and an increase in tolerance and empathy - and have an impact on a societal level. Many participants commented on the possibility of creating a more caring, compassionate, kind, and inclusive society. A health care worker reflected the film could impact society ‘by helping increasing understanding/reduce stigma around hearing voices and therefore letting everyone be more included in society rather than ostracised.’ This sentiment was shared by voice hearers - ‘that people would not be in isolation secluded but become an active part of the community they live’ and their family members - ‘brings ideas about inclusion through tolerance and understanding.’ (See Table 4).

Table 4 Impact on public understanding and society impact, illustrated by example coded in transcripts.

3.5 Economic Impact

Participants reported being less convinced of the film having an economic impact (55%). The main areas of potential impact described were service usage, cost of services and improved functioning for voice hearers. Many mentioned a possible reduction in overall service use, hospital stays and need for medication which would result in less cost. And voice hearers could benefit from increase coping skills, improved relationships both at home and at work allowing more voice hearers to return to work or study. A member of the general public noted ‘those who can integrate their challenging aspects positively into their whole being are more able to be financially independent, thus needing less "care." And friend of a voice hearer commented ‘more understanding of compassion-based approaches and flexibility in the workplace and reasonable adjustments that allow people flexibility to put compassion-based learning into practice- people can deal with what they are dealing with then get back to their working day.’ (See Table 5).

Table 5 Economic impact, illustrated by example coded in transcripts.

3.6 Impact - Other

The overwhelming response to the film was one of support with many participants expressing appreciation of the work involved. While many thought the film running time made it accessible to more people and included key messages a few individuals would have liked more information and a longer running time. There were many suggestions and requests for the film to be made available in other languages, for more films to be created either on other symptoms of psychosis or another mental health difficulty. A summary of the results by subgroup of responders can be found in Table 6 below.

Table 6 Perceived impact - subgroups of responders for whom film has direct relevance to their life or work.

4. Discussion

This project sought to provide an understanding around the acceptability and impact of a psycho-educative video on compassion focused therapy for voice-hearing. The main impact of the video was thought to be the attainment as well as reinforcement of knowledge, with participants indicating the video giving a strong sense of empowerment and common humanity, something which was believed to be superior to written information. This finding further expands previous research with the Stuart video, where individuals who hear voices found it helpful in understanding their compassionate voice [11]. Additionally, given the Stuart video was designed to increase awareness, accessibility and information of how CFT can be helpful for individuals experiencing psychosis-related symptoms it might have a role to play in reducing the perceived barrier to engaging in talking therapies many individuals face as described in the literature e.g. [17,19]. Increasing general understanding of experiences of psychosis not only for the person themselves, but also for their family and friends has been found to be of significant importance [20].

Furthermore, participants in this study also expressed the potential impact the Stuart video could have not only on health and welfare systems, but also on society as a whole, for a more caring and compassionate society. This corresponds with recent research by [25] where social contact-based video interventions were found to be helpful in reducing public stigma of psychosis. Similarly, participants’ views on the potential impact of videos such as the Stuart video on health service policy makers was expressed, as a tool to change the perspective and attitude of the general public towards those experiencing psychosis, which has also been expressed as valuable in previous research [21,22,23].

4.1 Limitations

Findings of this study should be interpreted in the context of the study’s limitations. First of all, the vast majority of the study’s sample identified as ‘someone who works with people who hear voices’, with much smaller numbers of participants identifying as ‘a person who hears voices’, ‘a family member of a person who hears voices’ and ‘a friend of a person who hears voices.’ The knowledge and experiences of those who regularly work with people who hear voices is likely very different to those who hear voices themselves or are a friend or family member of someone who hears voices, and again very different from someone without any direct knowledge or experience of someone hearing voices, such as a lay person from the general population. Therefore, there are limitations around the generalisability of the findings to populations other than those who participated in this sample. Similarly, at the time of video launch in 2015 (when many respondents accessed the survey), only the English language version was available, which may have limited the cultural accessibility and generalisability of these findings. However, over the first few months, several other languages were uploaded as subtitles (Dutch, French, German, Greek, Italian, Japanese, Portuguese, Russian, Slovenian, Spanish) to extend the accessibility across cultures.

Furthermore, participants provided relatively brief feedback on the video, which does not allow for as much depth as longer, individual participant interviews would have done. However, the aim of this study was to further understand immediate thoughts on the impact and acceptability of a psycho-educative video for voice-hearing, rather than a more in-depth analysis of the video’s content.

4.2 Clinical and Research Implications

Despite the limitations on what can be concluded from this study, there are clear clinical and practical implications as well as opportunities for future research resulting from this study. Practical implications of this video are evident: there can be barriers to awareness of mental health struggles such as voice-hearing and understanding processes involved in therapy. Feedback suggests the Stuart video can be a helpful psychoeducational tool for greater accessibility of talking therapies not only to those experiencing voice-hearing, but also their loved ones, and the general population as well as for educational and training purposes of healthcare providers.

Participants in this study expressed their appreciation for the work involved in making the video, in particular its accessible format and length. It would be prudent for future research to repeat this study with representatives from the general population with limited or no experience of hearing voices, or knowing someone who hears voices, as participants. This would be helpful to further understanding of the acceptability and impact of a video on CFT as therapy for hearing voices as a psycho-educative tool in the general population to increase awareness.

The present study focused on acceptability and impact from a general public point of view while a future focus could involve questions specifically related to symptoms and compassion. Additionally, future research could examine the impact and accessibility of this video when translated into other languages and adapted for other cultures, to determine whether similar results would be found in different contexts.

5. Conclusions

The Stuart video, designed to be a psycho-educative tool to deepen awareness on voice-hearing, was found in an anonymous online feedback survey to be impactful, providing greater accessibility of how CFT can be helpful as a therapy for hearing voices not only to individuals themselves, but also their friends and family, welfare providers, and society as a whole.

Acknowledgments

The authors would like to acknowledge the film animator, Kate Anderson, and the four organisations that contributed to funding it’s production: Cultural Institute at King’s College London, Compassionate Mind Foundation, Balanced Minds, and Medical Research Council.

Author Contributions

Charlie Heriot-Maitland conceptualized and developed the ‘Compassion for Voices’ video alongside a film animator. He developed and conducted a public survey to ascertain feedback. Tara Hickey completed the qualitative data analysis. Ellie Fossey provided guidance and checked the coding of the analysis. Sarah Strohmaier and Tara Hickey contributed to writing of the manuscript. All authors proofread and finalized the manuscript.

Competing Interests

The authors declare that no competing interests exist.

Additional Materials

The following additional materials are uploaded at the page of this paper.

1. Video S1: Compassion for Voices video.
2. Feedback survey.
3. Figure S1: Perceived impact - All responders (n = 137).
4. Figure S2: Perceived impact - Responders who are voice-hearers (n = 20).
5. Figure S3: Perceived impact - Responders who are family and friends of voice-hearers (n = 30).
6. Figure S4: Perceived impact - Responders who work with voice-hearers (n = 87).