Houghton, Emma
(2025)
Acceptance and commitment therapy for older adults who hear voices: a hermeneutic single case efficacy design (HSCED) series.
DClinPsy thesis, University of Nottingham.
Abstract
Background
The ageing population is growing (United Nations, 2022), with 20% of this cohort anticipated to experience mental health and/or neurological difficulties (World Health Organisation, 2017). Hearing voices (HV) is a common and transdiagnostic symptom within the older adult (OA) population (Cort et al., 2021) that can be associated with increased psychological distress (van der Gaag et al., 2003) and significant morbidity and mortality (Tampi et al., 2019). The dominant treatment for these symptoms for OAs are antipsychotic medications, however, given the increased risks of complications for OAs who use these medications, there are recommendations that such interventions should be avoided if possible (Badcock et al., 2020). Therefore, calls have been made for alternative treatments to be explored.
Acceptance and Commitment Therapy (ACT) has been shown to be an effective intervention for psychotic symptoms such as HV amongst the working-age adult population (Morris et al, 2024). ACT aims to reduce psychological distress through enhancing psychological flexibility (Hayes et al., 2005). ACT is well suited to facilitate more helpful and effective ways of responding to voices that can reduce voice-related distress (Stephanie et al., 2018) and is believed to be an approach that is well-suited to OAs (Petkus & Wetherell, 2013). However, there is not currently any research that explores this. Therefore, this study explores the efficacy of ACT for OAs whose experience of HV is psychologically distressing, using an adjudicated Hermeneutic Single Case Efficacy Design (HSCED) series.
Methods
Two participants aged 65 and above who experienced voice-related distress completed a 12-session ACT intervention. HSCED methodology was used to examine the presence and mechanisms of meaningful change. A range of quantitative and qualitative data was collated and critically analysed by a panel of three independent expert judges. Conclusions were drawn about the outcome for each client.
Results
Meaningful changes were indicated for both participants, including in measures of psychological flexibility, anxiety, and depression. These changes were attributed to therapy processes, with ACT-specific processes appearing the most dominant mechanisms of change, however generic therapy-factors were still concluded as influential in therapeutic change. The therapeutic relationship was identified as a mediating factor, whilst client motivation, openness, and familial support were identified as moderating factors.
Discussion/Conclusion
This study is the first of its kind in exploring the effectiveness and acceptability of ACT for OAs who HV. HSCED methodology allowed a nuanced approach to examining change mechanisms. Findings offer support for the use of ACT for OAs who HV, aligning with literature for the working-age population. However, given the small sample size and lack of research within this area, these claims remain tentative and require more extensive research.
This study contributes to the limited evidence base supporting the use of psychological interventions for OAs whose experience of HV is psychologically distressing.
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