Barriers to Engaging in Self-Help CBT for Voice Hearing

Individuals with lived experience and clinicians share about barriers and facilitators to guided self-help CBT for voice hearing


A recent article, published open-access in PLoS ONE, explores facilitators and barriers to engaging Cognitive Behavior Therapy (CBT) for individuals who hear voices. The article reviews two studies conducted with (1) individuals with lived experience and (2) mental health clinicians. Results suggest that factors related to voice hearing (e.g., psychosis symptoms) and lack of resources can be barriers to engaging in a brief, guided self-help version of CBT. Having a compassionate and skilled therapist facilitates engagement. The authors, led by Cassie Hazell, a research fellow at the University of Sussex in the UK, write:

“The findings from both study 1 and 2 demonstrate that both clinicians and people who hear voices anticipate a number of barriers and facilitators to the implementation of guided self-help CBTv. Identifying these barriers, from each perspective, will enable all parties to openly and collaboratively consider the possible solutions.”

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The authors define psychosis as “a range of unusual experiences that cause distress or impede functioning i.e. delusions, hallucinations, or disorganized thoughts and behaviors.” The authors report that CBT is the only type of psychotherapy recommended to treat psychosis in Clinical Practice Guidelines, which are often used by mental health and primary care providers to determine treatment options. CBT has also been found more effective than antipsychotics in treating other disorders, such as Obsessive-Compulsive Disorder.

Many voice hearers experience barriers to accessing CBT, often due to limited resources. Research suggests that symptom-specific therapies may be more beneficial than broader therapies for psychosis. Therefore, the researchers are developing a guided self-help CBT program that specifically targets voice hearing.

They write, “As part of the therapy development process we wanted to learn about the potential facilitators and barriers to therapy implementation from the stakeholders who deliver (mental health clinicians) and receive (people who hear voices) therapy.” The researchers conducted two studies. The first was a qualitative study, interviewing individuals who hear voices in focus groups. The second study was a questionnaire completed by mental health clinicians.

Study 1: Lived Experience Perspective

Twenty-one individuals who hear voices participated in the group interviews. Prior to the focus group, each individual was provided with the self-help guide that is being developed by the authors and asked to read at least one chapter. The authors present themes identified by participants, focusing on two themes related to barriers and facilitators of psychotherapy for psychosis.

Theme 1: Therapist

The participants expressed that the personal qualities of theTwenty-one are important, especially having a therapist who develops a strong therapeutic relationship and is genuine and compassionate. They also identified the importance of the therapist being skilled in both CBT and working with voice hearers. Lastly, participants wanted therapy to be confidential and for any limits to confidentiality to be clearly discussed.

Theme 2: Presenting Problem

Participants reported that voices themselves could be a barrier to engaging in CBT, or that talking about their voices may make them worse. For example, one participant stated, “If I’m focussing on something that is specifically about hearing voices and how to help that situation, my voices will not like that. And they will try and distract me from that.” Participants also identified that challenges concentrating or other cognitive difficulties may make it hard to engage, especially in reading the self-help book.

Study 2: Clinical Perspective

The authors also report on the qualitative data collected via questionnaires from 124 mental health clinicians. They identify two main themes relevant to barriers that limit engagement in CBT. The clinicians who participated in the questionnaire did not identify any factors that may facilitate treatment engagement.

Theme 1: Presenting Problem

Many clinicians expressed that clients’ symptoms may be a barrier to engaging in guided CBT, often suggesting that this therapy may be less appropriate for individuals with more severe symptoms. The authors state, “This may lead to clinicians’, rightly or wrongly, acting as gatekeepers for their clients.” The authors also note:

“It appears that hearing voices in itself is not necessarily a barrier to engagement. Instead it is what the clinicians associate with the experience of hearing voices that may be the barrier i.e. lack of ‘insight’ and ‘chaotic lifestyles’. These clinicians however do not explain the basis for these associations or how these factors may act as barrier.”

Similar to individuals with lived experience, clinicians suggested that cognitive abilities could be a barrier to engagement and motivation. Sometimes cognitive difficulties were not connected to voice hearing itself, but to other factors such as medication side effects.

Theme 2: Practical Barriers

Most commonly, clinicians reported concerns that they would not have the resources to carry out the guided self-help CBT. “This subtheme demonstrates the high workload that current mental health practitioners have and how this workload can prevent the dissemination of psychological interventions,” state the authors.

Clinicians also expressed concern that the intervention would not be supported by higher level staff (e.g., managers) because it is not the dominant treatment model and may be challenging to demonstrate meeting target goals. One participant stated, “It seems to me that as psychosis does not produce results or turnover suitable to corporate organisations it [treatment provision] will remain the poor relation within services.”

The authors conclude, “The most pertinent clinical application that can be taken from these results is the impact of the shared perception (both clinicians and lived experience) that the presenting problem could be a barrier to guided self-help CBTv.”

The researchers suggest ways to combat barriers to engagement, such as offering the self-help guide in multiple formats (e.g., images and text) and supplemented with in-person support. Voice hearers deserve quality, judgment free supports and alternatives to medication. However, the authors state:

“The somewhat negative attitudes of clinicians towards the efficacy of therapy for people distressed by hearing voices is further demonstrated by the continued dominance of the medical model, to the detriment of psychological services.”



Hazell, C. M., Strauss, C., Cavanagh, K., & Hayward, M. (2017). Barriers to disseminating brief CBT for voices from a lived experience and clinician perspective. PloS ONE, 12(6), e0178715. (Full Text)

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Shannon Peters
MIA Research News Team: Shannon Peters is a doctoral student at the University of Massachusetts Boston and has a master’s degree in mental health counseling. She is particularly interested in exploring the impacts of medicalization and pathologizing the experiences of individuals who have been affected by trauma. She is engaged in research on the effects of institutional corruption and financial conflicts of interest on research and practice.


  1. Shannon,
    this article leaves me a little discouraged with the prevailing attitude of the ‘experts’ on voice hearing. When my wife began ‘hearing voices’, I didn’t pathologize it. My attitude was ‘since they weren’t audible, then they were ‘in her head’ which means the voices are a part of her, and just because she hadn’t ever ‘heard’ them before, didn’t mean they weren’t ‘real’ or anything else pathological.’

    The longer we were in the journey together, the more I reflected on how she functioned, but also how I did as I learned how ‘voice hearing’ works: her experience taught me to ‘listen’ to the voices in my head. I realized that because of our culture’s stigmatizing of ‘voice hearing’ it teaches us to dread ‘hearing voices’ and so we learn to ignore what I would contend is a very normal mental process.

    So if it only took me a few years of helping my wife to realize how normal it is to hear voices, why is it so incomprehensible to the experts who work with people all the time? I would contend that we ALL hear voices, but like breathing air or paying attention to other autonomous body functions, it’s something we’ve always experienced and so until someone says, ‘slow down…listen…yes, that’s it’ we just go on blithely ignorant of what’s happening and for those few who can’t ignore it because of the internal turmoil happening, then we put them in a ‘special’ category of ‘voice hearers’.

    That’s my biggest problem with this entire study and even the ‘voice hearers’ movement. I could be wrong, but I firmly believe we all do it and the movement would better serve themselves and us to help everyone understand that this experience is as natural as breathing, rather than acting like ‘voice hearing’ is some impediment or something only ‘the few’ experience. Learning to hear voices ought to be one of the first things taught to a person in distress. It’s kind of like getting your temperature taken. Those voices are the mind’s way of bringing attention to issues that haven’t been dealt with or integrated as well as they should, or quite honestly, they can simply be part of one’s ability to see things from multiple perspectives (something that our hyper-polarized society clearly needs to relearn to do), and so the voices keep ‘popping’ up, but our cultural fear of them means we desperately ignore them rather than embrace them and see them for the great value they could bring to each of us.

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  2. I have found CBT to be very helpful with the voices and with delusional thoughts but my therapist had said that she had been told to not bother using it with schizophrenics. They’re told only drugs work on schizos. Not true.

    So, I ended up buying CBT textbooks and reading them on my own. I also bought DBT textbooks, Mindfulness textbooks, and ACT textbooks and they have all been helpful for me.

    So if your therapist won’t help you, go buy the books and help yourself.

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