Managing dissociation in imagery rescripting for voice hearers with trauma: lessons from a case series

Trauma, voice hearing and dissociation tend to be closely linked. Cognitive models of voice hearing largely agree that traumatic events may predispose people to voice hearing via dissociative processes. While treating trauma in voice hearers may help to reduce voice distress and frequency, dissociation may be a barrier to this therapeutic work. This case series reports on the dissociative experiences of a sub-sample of voice hearing clients who reported dissociation during Imagery Rescripting (ImRs) for trauma (N=6, 50% of original sample) in the case series study reported on previously (Paulik, Steel & Arntz, 2019). The aims in the current paper were to explore the impact of dissociation on outcomes, the type of dissociative experiences encountered, where in the ImRs protocol they occurred, and the use of therapeutic techniques to address them. We found that clients who dissociated during therapy showed reductions in their trauma intrusions and voice-related distress and frequency. However, when compared to non-dissociators, these benefits took more sessions to achieve. The most common types of dissociation were flashbacks, losing control over the image, emotional detachment and trance/absorbed state. These were most likely to occur at points during the therapy where negative affect was heightened. Grounding and soothing techniques, as well as strategies to reduce the level of negative affect were reported effective by participants in preventing or interrupting dissociation. We recommend that dissociation should not be a barrier to implementing imagery rescripting with this group.