Clinical Psychology and PsychotherapyClin. Psychol. Psychother. (2010)Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.729

Copyright © 2010 John Wiley & Sons, Ltd.

Assessment

Auditory Hallucinations: A Review of Assessment Tools

Kirk Ratcliff,1,2* John Farhall1,2 and Frances Shawyer1

1 School of Psychological Science, La Trobe University, Melbourne, Australia2 Northern Area Mental Health Service, Melbourne, Australia

Auditory hallucinations are a common and troubling symptom in psychotic disorders. We aimed to identify measures that could be used by clinicians and researchers to assess the experience of auditory hallucinations. A literature review was conducted to identify auditory hallucination measures that were developed since the last such review in 1998. We identifi ed 10 tools: eight self-report measures and two clinical interviews. The scales measured diverse constructs and are divided into four categories for review: multidimensional assessment, coping strategies, rating of beliefs and acceptance or mind-fulness. Evidence of the measures’ reliability, validity and sensitivity to change are discussed. There has been an expansion in the range of instruments available, particularly in self-report questionnaires and in measures that focus on psychological aspects such as attitudes and beliefs regarding voices. Copyright © 2010 John Wiley & Sons, Ltd.

Key Practitioner Message:• A wide variety of measures of auditory hallucinations has been developed in recent years.• The majority of measures reviewed here are relevant to psychological therapies.• This paper provides a resource to help practitioners select appropriate measures to assess auditory

hallucinations and their sequalae.

Keywords: Auditory Hallucinations, Instruments, Assessment

* Correspondence to: Kirk Ratcliff, Northern Area Mental Health Service, 131 Wood Street, Preston, VIC, Australia 3072.E-mail: kirk.ratcliff@mh.org.au

INTRODUCTIONAuditory hallucinations (AHs) experienced in psychotic illness contribute signifi cantly to distress and disability. Substantial individual differences in specifi c characteris-tics and impact of hallucinations have been shown (Copolov, Mackinnon, & Trauer, 2004; Nayani & David, 1996) and thus require careful exploration. Hearing voices is an internal experience; it cannot be directly observed. Although sometimes accompanied by observable behav-iours such as addressing an unseen speaker, investigation of AHs fundamentally relies on the voice hearer’s reports. Structured interviews and self-report instruments provide the most systematic means of assessment.

In 1998, Frederick and Killeen (Frederick & Killeen, 1998) reviewed 10 instruments that measure AHs in schiz-ophrenia; three were global psychopathology measures and seven were hallucination-specifi c measures. They noted that the psychometrics of AH specifi c measures

were not adequately explored, that small samples had typically been used in validation studies and that only a single instrument had been used in research by anyone other than the instrument’s author. They recommended that new instruments be developed to provide a more complete understanding of AHs.

Since that time, a variety of instruments have been developed to explore diverse elements of AHs. Although Aleman and Laroi (Aleman & Laroi, 2008) have described some of the main instruments available to assess a range of hallucinatory experiences, we could fi nd no review of developments in the measurement of AHs in psychosis since Frederick and Killeen’s. We aimed to review instru-ments published in the last decade that were designed to measure auditory verbal hallucinations in psychosis for adults.

MATERIAL AND METHODSSelection of Instruments for Review

We searched the MEDLINE and PsycINFO databases for articles published between 1998 and December 2009. Key terms included auditory hallucinations, instrument, scale

K. Ratcliff et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2010)

and measure. The search was limited to articles published in English. We read abstracts and hand-searched refer-ence lists from key articles to identify further studies.

The following inclusion criteria were used to screen papers:

1. The instrument was designed to measure AHs in psy-chosis rather than in non-clinical samples.

2. The scale was developed in English or a validated English version has been published.

RESULTSTen instruments met the inclusion criteria. These meas-ures were quite diverse, ranging from broad characteris-tics of the hallucinatory experience, such as frequency and duration, to attitudes, beliefs and reactions to the voices. Some measures incorporated several aspects. In order to facilitate comparison and selection of appropriate mea-sures by researchers and clinicians, the measures are grouped according to their primary focus. They are pre-sented under the following headings: multidimensional; coping; beliefs; and acceptance and mindfulness of AHs.

Multidimensional Rating Scales

Our search found four English language instruments designed to provide a broad assessment of the phenom-enology of hearing voices. Two structured interviews are reviewed: the Psychotic Symptom Rating Scales (PSYRATS; Haddock, McCarron, Tarrier, & Faragher, 1999) and the Auditory Hallucinations Rating Scale (AHRS; Hoffman et al., 2003), followed by two self-report questionnaires, the Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ; Van Lieshout & Goldberg, 2007) and the Characteristics of Auditory Hallucinations Questionnaire (CAHQ; Buccheri et al., 2004). Table 1 pres-ents reliability data for all measures reviewed.

The Psychotic Symptom Rating ScalesThe PSYRATS was designed to be more easily admin-

istered than lengthy hallucination interviews (Carter, Mackinnon, Howard, Zeegers, & Copolov, 1995) but to provide a more detailed examination of both voices and delusions than broad inventories such as the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987). We will review only the auditory hallucina-tions scale (PSYRATS-AH). This structured interview examines 11 dimensions: frequency; duration; location (inside head or external); loudness; conviction in beliefs about origin; amount of negative content; degree of nega-tive content; amount of distress; intensity of distress; dis-ruption; and controllability. Each is rated on a fi ve-point ordinal scale; for example, duration ranges from 0 = Voices not present to 4 = Voices last for hours at a time.

It can be administered in approximately 15 minutes and requires a trained interviewer.

Reliability and Validity. Two studies have reported relia-bility statistics (Table 1) indicating generally strong inter-rater reliability of the PSYRATS-AH and adequate test-retest reliability (Drake, Haddock, Tarrier, Bentall, & Lewis, 2007; Haddock et al., 1999). Haddock and col-leagues (Haddock et al., 1999) considered that the dimen-sions measured by items were largely independent and found few signifi cant correlations between items. However, a more recent study has suggested it to be more internally consistent (see Table 1; Drake et al., 2007).

In its validation study (Haddock et al., 1999) the PSYRATS-AH total score modestly correlated (r = 0.33) with the hallucinations item of the Psychiatric Assessment Scale (Krawiecka, Goldberg, & Vaughan, 1977), suggest-ing some convergent validity. Steel and colleagues (Steel et al., 2007) explored the validity of the PSYRATS using several measures. The total PSYRATS-AH scores corre-lated with the PANSS (Kay et al., 1987) AH item (r = 0.47), the Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984) AH scale (r = 0.27), and Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996) score (r = 0.46). The correlations presented as evidence of con-vergent validity of the scale’s total score are modest. This is likely to be infl uenced by its multidimensional nature which limits the total score’s correlations with other mea-sures (Steel et al., 2007). More objective dimensions of the PSYRATS-AH, particularly frequency, showed higher correlations with PANSS and SAPS hallucination items (r = 0.57–0.68).

Factor analyses have suggested three- (Drake et al., 2007; Haddock et al., 1999) and four-factor structures (Jenner, Nienhius, Wiersma, & van de Willige, 2004; Steel et al., 2007), suggesting that the factor structure may vary across populations, or is unstable.

The PSYRATS total score was shown to be sensitive to change in a sample of 124 participants with fi rst episode psychosis, as evidenced by associated changes in the PANSS (Drake et al., 2007). A strength of the scale is its broad multidimensional nature—however, this compli-cates its use as an outcome measure because it combines elements that can be targeted in treatment (e.g., distress) with those that are unlikely to change (e.g., loudness). Steel and colleagues (Steel et al., 2007) argue that the total score should not be used as an outcome, but that indi-vidual dimensions should instead be used.

Comment. The PSYRATS-AH is a brief and multidimen-sional measure that has been employed in diverse projects including studies of neural correlates of AHs (Garcia-Marti et al., 2008; Plaze et al., 2006), the genetics of AHs (Sanjuan et al., 2004) and in various treatment trials (Jandl et al., 2006; Wykes et al., 2005).

Assessment of Auditory Hallucinations

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2010)

Tabl

e 1.

Su

mm

ary

of s

tati

stic

s an

d r

elia

bilit

y fo

r in

stru

men

ts

Stud

ySc

ale

No.

item

sA

dm

inis

trat

ion

mod

eIn

tern

al c

onsi

sten

cyIn

ter-

rate

r re

liabi

lity

Test

-ret

est

relia

bilit

y

Had

doc

k et

al.,

199

9PS

YR

AT

S-A

H11

Stru

ctur

ed

inte

rvie

w–

Ind

ivid

ual i

tem

s IC

C =

0.

79–1

. Six

rat

ers

of

six

pati

ents

–

Dra

ke e

t al

., 20

07PS

YR

AT

S-A

H11

Stru

ctur

ed

inte

rvie

wN

on-p

aram

etri

c co

rrec

ted

item

tot

al

corr

elat

ion

(Ken

dal

l’s

tau)

= 0

.63–

0.76

, ex

cept

con

trol

of

voic

es (

0.16

)

PSY

RA

TS-

AH

tot

alIt

em I

CC

= 0

.99–

1. I

CC

=

0.74

–1, e

xcep

t lo

cati

on (

0.42

).T

hree

rat

ers,

13

pati

ents

ICC

= 0

.70

one

wee

k in

terv

al (

n =

103)

Hof

fman

et

al.,

2005

AH

RS

7St

ruct

ured

in

terv

iew

Cro

nbac

h’s

α =

0.60

ICC

= 0

.80–

0.98

(n

= 50

)In

div

idua

l ite

ms

ICC

s >

0.70

exc

ept

real

ness

0.

51 a

nd le

ngth

0.5

7 (n

= 5

0)V

an L

iesh

out

&

Gol

dbe

rg, 2

007

HPS

VQ

13Se

lf-r

epor

tC

ronb

ach’

s α

= 0.

74–0

.85

over

3 t

est

occa

sion

s (n

= 2

0)

N/

AIC

C =

0.7

2 on

e w

eek

inte

rval

(n

= 19

)

Tryg

stad

et

al.,

2002

CA

HQ

7Se

lf-r

epor

tN

/A

N/

AN

/A

Man

n &

Pak

enha

m,

2006

RA

HQ

18Se

lf-r

epor

tSu

bsca

le’s

Cro

nbac

h’s

α =

0.69

–0.7

6 (n

= 1

25)

N/

AW

ithd

raw

al c

opin

g r

= 0.

81, s

uppr

essi

on

copi

ng r

= 0

.44,

act

ive

copi

ng r

= 0

.32;

test

-ret

est

inte

rval

= 2

–9

mon

ths

(n =

20)

Bir

chw

ood

et

al.,

2000

VPD

6Se

lf-r

epor

tC

ronb

ach’

s α

= 0.

85

(n =

59)

N/

Ar

= 0.

82 o

ver

1 w

eek

inte

rval

(n

= 25

)C

had

wic

k et

al.,

200

0B

AV

Q-R

35Se

lf-r

epor

tSu

bsca

le’s

Cro

nbac

h’s

α =

0.74

–0.8

8 (n

= 7

1)N

/A

N/

A f

or B

AV

Q-R

; ho

wev

er, t

he B

AV

Q

has

high

tes

t-re

test

re

liabi

lity

(IC

Cs

> 0.

80)

(Cha

dw

ick

&

Bir

chw

ood

, 199

5)H

ayw

ard

et

al.,

2008

VA

Y29

Self

-rep

ort

Subs

cale

’s C

ronb

ach’

s α

= 0.

78–0

.92

(n =

30)

N/

A3

wee

ks in

terv

al

r =

0.72

–0.9

1 (n

= 1

7)C

had

wic

k et

al.,

200

7SM

VQ

12Se

lf-r

epor

tSM

VQ

tot

al C

ronb

ach’

s α

= 0.

84 (

n =

59)

N/

A–

Shaw

yer

et a

l., 2

007

VA

AS

31Se

lf-r

epor

tSu

bsca

le’s

Cro

nbac

h’s

α =

0.76

–0.8

5V

AA

S to

tal C

ronb

ach’

s α

= 0.

90 (

n =

41)

N/

AIC

Cs:

Ful

l-sc

ale

= 0.

73;

subs

cale

s =

0.72

–0.8

2 (4

-mon

th p

erio

d)

(n =

17)

Not

e: T

he s

ymbo

l—in

dic

ates

tha

t no

dat

a w

ere

foun

d.

N/

A =

not

app

licab

le. P

SYR

AT

S-A

H =

Psy

chot

ic S

ympt

om R

atin

g Sc

ales

-Aud

itor

y H

allu

cina

tion

. IC

C =

Int

racl

ass

Cor

rela

tion

Coe

ffi c

ient

. AH

RS

= A

udit

ory

Hal

luci

nati

ons

Rat

ing

Scal

e. H

PSV

Q =

Ham

ilton

Pro

gram

for

Sch

izop

hren

ia V

oice

s Q

uest

ionn

aire

. C

AH

Q =

Cha

ract

eris

tics

of

Aud

itor

y H

allu

cina

tion

s Q

uest

ionn

aire

. R

AH

Q =

Res

pons

es t

o A

udit

ory

Hal

luci

nati

ons

Que

stio

nnai

re. V

PD =

Voi

ce P

ower

Dif

fere

ntia

l. B

AV

Q-R

= B

elie

fs A

bout

Voi

ces

Que

stio

nnai

re-R

evis

ed =

VA

Y =

Voi

ce a

nd Y

ou S

cale

. SM

VQ

= S

outh

ampt

on M

ind

fuln

ess

of V

oice

s Q

uest

ionn

aire

. VA

AS

= V

oice

s A

ctio

n an

d A

ccep

tanc

e Sc

ale.

K. Ratcliff et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2010)

Further refi nement of the scale may increase its utility. For example, the sensitivity of the conviction in beliefs about origin subscale could be enhanced. With the current scoring anchors, a change from 99% conviction in the externality of the voice to 51% conviction results in no change in rating on this dimension. Furthermore, the dis-ruption scale combines impact on daily living, on social functioning, family relationships and need for hospitali-zation in a fi ve-point scale ranging from no disruption to severe disruption. Thus, for outpatients, the scope for change is very limited. Disaggregating these domains may improve the scale’s sensitivity and breadth.

Auditory Hallucinations Rating ScaleThis is a brief structured clinical interview used in

repetitive transcranial magnetic stimulation (rTMS) trials (Hoffman, et al., 2003; Hoffman et al., 2005). It measures frequency, reality, loudness, number of voices, length, attentional salience (how demanding of attention the voice is) and distress. Items are rated on 5–10-point scales, each with unique anchors.

Reliability and Validity. The authors report adequate inter-rater reliability and temporal stability, and moderate internal consistency given the diverse aspects measured (Table 1). Published studies have used both individual items and the sum score as outcomes.

Comment. The AHRS has only been used by Hoffman and colleagues. It provides a slightly shorter alternative to the PSYRATS but has not been used and explored to the same degree. The AHRS includes two dimensions not covered by the PSYRATS, attentional salience and perception of reality of voices, but excludes PSYRATS dimensions neg-ative content and beliefs regarding origin. These differ-ences refl ect the scale’s development to measure the effects of rTMS rather than psychological therapy.

The Hamilton Program for Schizophrenia Voices Questionnaire

The HPSVQ (Van Lieshout & Goldberg, 2007) covers similar domains to the PSYRATS-AH, but in a self-report format. The scale is worded simply and can be completed in approximately four minutes. It is a unitary index of severity that comprises nine items, each rated on a fi ve-point scale of impairment or severity. The anchors for each item are unique. The nine items included in the scale score refer to frequency, negative content, loudness, dura-tion, interference with life, distress, impact on self-appraisal, clarity and compliance with commands. The four remaining items examine the time of day and situa-tions in which voices occur, the location of the voice and whether the week that is rated is typical.

The scale covers three domains not covered by the PSYRATS: clarity, impact on self-esteem and compliance

with commanding voices. However, the scale only measures compliance with commands and not their presence alone.

Reliability and Validity. Table 1 shows that the HPSVQ’s test-retest reliability was acceptable over one week. Internal consistency was found to be adequate. Correlation with the PSYRATS-AH indicated adequate convergent validity (r = 0.76; Van Lieshout & Goldberg, 2007).

Comment. This brief self-report measure may prove useful but requires further validation beyond the initial report on 20 participants. Its sensitivity to change is yet to be established.

Characteristics of Auditory Hallucinations QuestionnaireThe CAHQ (Trygstad et al., 2002) examines the

broad characteristics of AHs in the past 24 hours. It is a self-report questionnaire that covers similar domains to those in the measures discussed above: frequency, loudness, controllability, clarity, tone, distraction and distress (Buccheri et al., 2004). Each item uses a unique six-point scale. An expanded instrument with two addi-tional items measuring commands to harm self and others has been used (Buccheri, Trygstad, & Dowling, 2007).

Reliability and Validity. The psychometrics and validity of the scale have not been investigated. The items have good face validity. All dimensions but loudness were rated lower after a group intervention (Buccheri et al., 2004). Similar results were found for a specifi c group programme for command hallucinations (Buccheri et al., 2007).

Comment. This measure is brief and easily understood. However, very little information is available on its relia-bility and validity. The use of a 24-hour time span is likely to lead to more reliable reporting but it may be too brief for some purposes.

Multidimensional Measures Developed in Other Languages

Three tools developed in languages other than English were identifi ed. They are not reviewed in detail because although an English translation is available for each, we could fi nd no validation of the translated scale. They are the Delusion and Voices Self-Assessment, a brief self-report tool developed in Italian (Pinto, Gigantesco, Morosini, & La Pia, 2007); the Matsuzawa Assessment Schedule for Auditory Hallucinations developed in Japanese, which offers a broad assessment of multiple dimensions of AHs (Hayashi, Igarashi, Suda, & Nakagawa, 2004); and the Characteristics of Auditory Hallucinations rating scale, a broad clinical interview developed in Greek (Oulis et al., 2007).

Assessment of Auditory Hallucinations

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2010)

Coping with AHs

The review will now move from measures of the charac-teristics of voices to attempts to cope with the experience. The majority of people who experience AHs report that they attempt to cope in some way (Farhall, Greenwood, & Jackson, 2007). Assessment of coping is important clini-cally in that it can help determine the distress and dys-function caused by AHs (Falloon & Talbot, 1981).

We found a single instrument that met criteria for inclu-sion in the current review, the Responses to Auditory Hallucinations Questionnaire (RAHQ; Mann & Pakenham, 2006). One Dutch scale was also found, the Auditory Hallucinations Coping List (Jenner, Willige, & Wiersma, 1998), a 49-item structured interview that does not have a validated English version.

Responses to Auditory Hallucinations QuestionnaireThe RAHQ is a self-report questionnaire comprising

three subscales: active coping, withdrawal coping and suppression coping (Mann & Pakenham, 2006). Lazarus and Folkman’s (Lazarus & Folkman, 1984) stress-appraisal-coping model informed its development. Semi-structured interviews were used to develop a questionnaire that was refi ned via factor analysis. The language is simple and the authors report that it was easily com-pleted by participants. The questionnaire uses a four-point scale, from 1 = Never to 4 = Almost always (Mann & Pakenham, 2006).

Reliability and Validity. Three factors form the basis of the subscales: active coping, which measures activities and distraction; withdrawal coping, which measures attempts to reduce emotional arousal via escape or avoidance; and suppression coping, which measures efforts to block out voices. Table 1 shows that all three subscales have accept-able internal consistency. The test-retest consistency was adequate for withdrawal coping but poor for the other two subscales. However, the test-retest interval of between 2 and 9 months was both too variable and too long to judge the reliability of the instrument.

Modest correlations with criterion variables were reported. Higher active coping scores were associated with favourable appraisal (r = 0.20). Higher withdrawal coping scores were associated with greater hallucination severity, negative appraisal of the AHs, depression and anxiety (r = 0.20–0.34). Suppression scores were not sig-nifi cantly related to any criterion variables.

A series of regressions showed that the withdrawal coping scores predicted an additional 7–9% in anxiety and depression after controlling for voice appraisal and sever-ity. The remaining two subscales did not signifi cantly contribute to the prediction of these outcomes.

Comment. The RAHQ provides a brief assessment of common coping strategies and reports initial data from a

larger than usual sample (n = 125). The authors acknowl-edge that the use of an entirely male sample to generate items was a weakness of the development process. Another limitation of the scale is that RAHQ does not measure maladaptive coping such as self-harming and also excludes strategies rated as prevalent in other studies such as sleeping or praying (Farhall et al., 2007). Examination of the RAHQ in further samples will clarify its utility.

Beliefs about AHs Rating Scales

Below, we explore measures of interpretations of voices, the beliefs that individuals form as they attempt to make sense of these aberrant experiences. Beliefs are important in determining the sequelae of hallucinatory experiences (Chadwick & Birchwood, 1994). The Beliefs About Voices Questionnaire-Revised (BAVQ-R; Chadwick, Lees, & Birchwood, 2000), the Voice Power Differential (VPD; Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000) and the Voice and You Scale (VAY; Hayward, Denney, Vaughan, & Fowler, 2008) are presented below. The reader may also be interested in the Interpretation of Voices Inventory which was developed for a non-clinical population (Morrison, 2002) and is thus not reviewed here although it has been employed with patients (Morrison et al., 2004).

The Beliefs about Voices Questionnaire-RevisedThe BAVQ-R (Chadwick et al., 2000), a revision of the

original BAVQ (Chadwick & Birchwood, 1995), is a self-rating scale of beliefs about AHs and emotional and behavioural responses. The scale is based on a cognitive model wherein emotional consequences and behavioural reactions to voices are strongly linked to the meaning attributed to the voices (Chadwick & Birchwood, 1994). It measures beliefs in the voices’ malevolence, benevolence and omnipotence. Emotional and behavioural responses are assessed via two subscales, resistance and engagement.

The revised version features two changes. In order to improve the sensitivity of measurement, the yes/no response format was replaced with a four-point Likert scale ranging from disagree to strongly agree. Five items were added to strengthen measurement of omnipotence, which was measured by a single item in the original scale (Chadwick et al., 2000). The scale can be completed in approximately 15 minutes.

Reliability and Validity. Internal consistencies for each subscale are high, but test-retest reliability has not been reported for the revised scale. In the validation study (Chadwick et al., 2000), 58 participants completed the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983). Malevolence, omnipotence and resistance

K. Ratcliff et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2010)

were all associated with anxiety and depression (r = 0.30–0.44) and engagement was negatively associated with depression (r = −0.42) and with anxiety (r = −0.36).

The authors hypothesized that, in line with their model, malicious voices would be resisted and friendly voices would be engaged with. Malevolence and resistance sub-scales are strongly related (r = 0.68) and benevolence scores and engagement scores are also strongly associated (r = 0.80). Omnipotence was positively related to malevo-lence (r = 0.70) and resistance (r = 0.50), and negatively relative to engagement (r = −0.26; Chadwick et al., 2000).

Further evidence of construct validity comes from several recent studies. BAVQ-R omnipotence and malevolence scores were related to perception of threat, the use of safety-seeking behaviours and distress (Hacker, Birchwood, Tudway, Meaden, & Amphlett, 2008). BAVQ-R omnipo-tence scores have been found to be associated with compli-ance with threatening command hallucinations (Shawyer et al., 2008). Omnipotence, malevolence and resistance have been found to be associated with depression, hope-lessness and suicidal ideation (Simms, McCormack, Anderson, & Mulholland, 2007). Furthermore, those with a diagnosis of psychosis have higher scores than non-clinical voice hearers (Andrew, Gray, & Snowden, 2008; Sorrell, Hayward, & Meddings, 2009). A principal compo-nents analysis was performed on the original version of the scale (Chadwick & Birchwood, 1995) but we could fi nd no factor analysis of the revised measure.

Trower and colleagues (Trower et al., 2004) found that omniscience scores were signifi cantly reduced following an intervention that specifi cally targeted beliefs about power and control. Pinkham, Gloege, Flanagan and Penn (2004) found a decrease in the BAVQ-R sum score in a cognitive behaviour therapy (CBT) for voices group. Interestingly, Penn and colleagues (Penn et al., 2009) found a reduction in malevolence and resistance in an enhanced supportive therapy group compared to a CBT group.

Comment. The BAVQ and BAVQ-R have proved valuable for researching the cognitive model of AHs. The BAVQ-R’s test-retest reliability and factor structure need further exploration.

The Voice Power DifferentialPeople who hear voices often believe the voice to be

powerful and see themselves as powerless (Birchwood et al., 2000; Gilbert et al., 2001). The VPD, a self-report scale, was developed to provide a measure of the respondent’s perception of the disparity of power between themselves and the voice (Birchwood et al., 2000). The elements of power addressed by the scale are constructs from social rank theory, which examines subordination and domi-nance in social relationships (Gilbert & Allan, 1998; Gilbert et al., 2001).

Respondents compare themselves and the voices on six constructs: strength, confi dence, respect, ability to harm, superiority and knowledge. Each item has a fi ve-point scale (e.g., strength ranges from 1 = I am much stronger than my voice to 5 = My voice is much stronger than me).

Reliability and Validity. Table 1 shows that the VPD is both internally and temporally consistent. We could fi nd no papers that explicitly set out to validate the VPD. However, evidence of its validity comes from its use in several studies. VPD scores are strongly associated with depression (Birchwood et al., 2000; Gilbert et al., 2001). Birchwood and colleagues (Birchwood et al., 2004) found that perceptions of rank and power in social relationships determine appraisals of the voices’ power as measured by the VPD, which in turn contributes to depression.

The VPD was used in a trial of the effi cacy of cognitive therapy for command hallucinations (Trower et al., 2004). There was a signifi cant reduction in VPD scores in the experimental group and no change in the control condi-tion. Moreover, the reduction in compliance with com-mands appeared to be mediated by a reduction in VPD scores (Trower, e al., 2004), demonstrating the importance of perceived power and the usefulness of the VPD in measuring it.

Comment. The VPD is a brief and reliable measure that targets a key driver of distress and risk.

The Voice and You ScaleThe relationship between the voice hearer and the voices

often has characteristics of an interpersonal relationship (Benjamin, 1989; Thomas, McLeod, & Brewin, 2009; Vaughan & Fowler, 2004). Consistent with Birtchnell’s (Birtchnell, 2002) relating theory, the VAY (Hayward et al., 2008) examines the hearer’s relationship with the most dominant voice in terms of intersecting axes representing power and intimacy. The VAY has four scales: voice domi-nance, voice intrusiveness, hearer distance and hearer dependence. Items are self-rated on a four-point scale.

Reliability and Validity. The four subscales were found to have adequate internal consistency and also showed ade-quate test-retest reliability (see Table 1). Voice hearers’ perceptions of the voice relating dominantly and intru-sively were strongly correlated with BAVQ-R malevo-lence (r = 0.87 and r = 0.76, respectively) and omnipotence (r = 0.59 and r = .64, respectively). Voice dominance and voice intrusiveness were also signifi cantly correlated with PSYRATS distress (r = 0.70 and r = 0.48, respectively).

VAY voice hearer distance was related to BAVQ-R resistance (r = 0.77) and PSYRATS distress (r = 0.61). Hearer dependence was positively correlated with BAVQ-R engagement (r = 0.63) and benevolence (r = 0.55), and negatively related to distress (r = −0.37).

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VAY voice dominance and intrusiveness were corre-lated (r = 0.66), voice dominance and hearer distance were strongly correlated (r = 0.79), as were voice intrusiveness and hearer distance (r = 0.58), and a negative correlation was found between hearer distance and hearer depend-ence (r = −0.56).

Comment. The VAY provides a well-developed measure of the perceived relationship with voices. Further explora-tion is needed of the construct measured by the VAY, including the distinction of subscales from each other and from beliefs about voices.

Acceptance and Mindfulness of AHs

Intervention studies of mindfulness and acceptance of voices have shown promising results (Bach & Hayes, 2002; Gaudiano & Herbert, 2006) but have lacked tar-geted measures of the putative mechanisms of change. To date, two scales have appeared in the literature: the Southampton Mindfulness of Voices Questionnaire (SMVQ; Chadwick, Barnbrook, & Newman-Taylor, 2007) and the Voices Action and Acceptance Scale (VAAS; Shawyer et al., 2007).

Southampton Mindfulness of Voices QuestionnaireThe SMVQ is a self-report scale that measures four con-

structs: (1) clarity of awareness of the present moment versus being lost in responding to the voice; (2) allowing attention to remain on an unpleasant voice versus avoid-ing it; (3) acceptance of the diffi cult situation and of oneself, versus judgement of the situation and self; and (4) letting go versus struggle and rumination. Items are rated on a seven-point scale from strongly disagree to strongly agree (Chadwick et al., 2007).

Reliability and Validity. The scale was found to be inter-nally consistent but the test-retest reliability of the measure is yet to be assessed. The SMVQ was negatively correlated with Positive Affect Negative Affect Schedule (PANAS) negative affect (r = −0.69) and distress (r = −0.63), and the BAVQ-R malevolence, omnipotence and resistance (r = −0.45–65) scales.

Comment. The SMVQ provides a new dimension of meas-urement of the experience of hearing voices. However, the scale is at an early stage of its use and needs further exploration.

The Voices Acceptance and Action ScaleThe VAAS (Shawyer et al., 2007), a self-report scale,

was developed to measure two constructs: (a) acceptance of having the experience of AHs and (b) action, the ability to act autonomously (Shawyer et al., 2007). The VAAS was constructed for patients with command hal-

lucinations (Shawyer et al., 2007), but also has a general voices scale called Section A which is designed for use with any AH.

Reliability and Validity. Internal consistency was high and temporal consistency was adequate over a 4-month period (see Table 1). Confi dence in coping with the voices was signifi cantly correlated with the total score and the subscales (r = 0.35–0.40). VAAS action subscale scores were signifi -cantly lower in those who had acted on dangerous command hallucinations than in those who had not. A signifi cant cor-relation was found between BAVQ-R omnipotence and the action subscale (r = −0.49). BAVQ-R engagement scores were negatively correlated with the action subscale (r = −0.33) and unrelated to other subscales. The other BAVQ-R subscales were unrelated to the VAAS and its components.

Calgary Depression Scale (Addington, Addington, Maticka-Tyndale, & Joyce, 1992) scores were negatively related to the VAAS total score and subscale scores (r = −0.40–−0.57). The subjective feelings subscale of the Quality of Life Enjoyment and Satisfaction Questionnaire (Endicott, Nee, Harrison, & Blumenthal, 1993) was also related to the total score and subscale scores (r = 0.34–0.61). A hierarchical regression indicated that VAAS pre-dicted an additional 38% of variance in depression, 23% of variance in confi dence in coping, and 38–46% in quality of life measures after controlling for the BAVQ-R, sug-gesting that VAAS scores provide unique information relevant to important outcomes.

Comment. The VAAS addresses aspects of the relation-ship of a person to their voice that are both theoretically and clinically important. However, it has only been used by its authors and with a sample experiencing high symptom severity (Shawyer et al., 2007); data on sensitiv-ity to change has yet to be published.

DISCUSSIONThis review explored 10 measures of AHs developed in the last decade. These measures provide a means of exploring previously neglected domains of individuals’ experiences of AHs. Compared with the instruments reviewed by Frederick and Killeen (Frederick & Killeen, 1998), two notable trends are evident. First, there has been a growth in scales designed for measurement of beliefs, interpretations and attitudes towards AHs. Second, self-rated measures have become more common than clinician-administered measures; eight of the 10 instruments reviewed here are self-report measures.

Trend towards Measurement of Beliefs and Attitudes

Cognitive theories of distress in relation to voices (Chadwick & Birchwood, 1994; Morrison, 1998) have led

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Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2010)

to the development and refi nement of instruments to operationalize theoretical constructs, the most developed of which is the BAVQ-R. The original scale (BAVQ) was revised in order to increase its sensitivity and to better measure beliefs about the power of the voices. There have been some indications that the revised version can detect change (Penn et al., 2009; Pinkham et al., 2004; Trower et al., 2004). The BAVQ and BAVQ-R have played a pivotal role in elaborating the cognitive model of AHs and have been used in research examining the role of beliefs about voices in determining distress, compliance with command hallucinations, impact on social function-ing, and the association between trauma symptoms and beliefs. This body of knowledge has led to innovations in psychological treatments such as targeting key beliefs about command hallucinations (Trower et al., 2004). The VPD is a more focused measure that has enabled the exploration of subordination in relation to voices (Birchwood et al., 2000; Gilbert et al., 2001) and the impor-tance of addressing it in therapy (Trower et al., 2004). The VAY offers insight into the relationship between voice hearer and voice with a well developed measure.

Acceptance and mindfulness have been topics of increasing interest to psychotherapy researchers (Baer & Krietemeyer, 2006). Recent measures such as the SMVQ and the VAAS aim to play a similar role to the BAVQ-R in elaborating processes that facilitate adaptation and other outcomes of treatment. The SMVQ and VAAS have shown promising results, but have thus far been used only by their authors and require further use and exploration.

Trend towards Self-Rated Measures

All measures reviewed here, except the PSYRATS and AHRS, were self-rated. By contrast, Frederick and Killeen’s review (Frederick & Killeen, 1998) included seven clinician-rated measures and just three self-rated measures. Time and resource effi ciency appears to be one reason for the move towards self-report measurement. A further reason is that, given most of the scales reviewed measure beliefs or attitudes about AHs, a Likert self-report format is probably a more appropriate format. Many of the measures in Frederick and Killeen’s review were concerned with description and quantifi cation of symptom dimensions, constructs considered better mea-sured by clinical interview.

Several of the scales’ authors noted that self-report measures were acceptable to clients and generally easily completed. Nonetheless, cognitive defi cits in schizophre-nia are well known (Tandon, Keshavan, & Nasrallah, 2008) and may infl uence responding on self-report mea-sures through limiting the ability to concentrate, to men-tally synthesize material prior to answering (e.g., level of distress or frequency per week), to keep motivated and to

make abstract judgements as part of a rating. In our expe-rience with questionnaires, this patient group often requires support from an interviewer to clarify the meaning of words and to check for basic errors such as inadvertently skipping items. Clinicians and researchers should exercise caution in using self-report measures, and be prepared to provide support to clients, especially for those whose cognitive functioning may be impaired by acuity of symptoms or cognitive defi cits.

Validation of Measures

The current review shows considerable progress over the past decade in both expanding the range of measures that is available and in the psychometric exploration of some measures. The PSYRATS is clearly the most thoroughly explored of the instruments presented here. Several studies have provided evidence of its reliability and validity (Drake et al., 2007; Haddock et al., 1999; Steel et al., 2007). The BAVQ-R been used extensively in research and has strong support for its convergent valid-ity with several other constructs (Andrew et al., 2008; Birchwood et al., 2000; Chadwick et al., 2007; Shawyer et al., 2003; Simms et al., 2007). Less is known about the psychometric properties of the other measures reviewed.

Measuring change is a fundamental requirement for use in clinical trials and assessing progress in routine treat-ment. The sensitivity to change of the PSYRATS has been explicitly investigated (Drake et al., 2007) and evidence of change in trials is available for the AHRS, BAVQ-R, VPD and CAHQ. We could fi nd no published evidence of the sensitivity to change of the other measures.

Several of the scales reviewed are in an early stage of development. The HPSQ, VAAS and SMQ were all devel-oped with few participants. Recruitment of large samples for scale validation is perhaps an arduous task. People who experience persisting voices may be suspicious, guarded and disinclined to participate in research. For some, the belief system about the voice may preclude the disclosure of details about their experience. Given such diffi culties in recruitment, researchers may be more inclined to progress to treatment trials or exploration of theoretical questions rather than undertake scale develop-ment and refi nement. However, the value of research is dependent on the measurement of constructs and out-comes. Clinical trials are likely to present misleading fi nd-ings if they use insensitive or unreliable measures and theoretical explorations are likely to be fl awed without solid measurement of constructs.

The importance of development and further refi nement of scales should not be underrated. Their use and refi ne-ment is likely to bring new insights and highlight therapeutic opportunities for psychological treatments and more comprehensive assessment of the impact of biological treatments. The importance of measurement to

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theoretical elaboration is illustrated by the use of the BAVQ-R.

The strengths and weaknesses of the measures reviewed suggest some specifi c recommendations. The impact of voices on the individual, including both distress and their infl uence on behaviour are not suffi ciently assessed by measures that are currently available: the PSYRATS has two items measuring distress and one rating disruption, and the VAAS provides an autonomous action subscale. However, given that this is a dimension of considerable clinical and theoretical importance, the development of a more complete measure would provide an important variable for outcome measurement.

We also suggest that there is value in further refi ne-ment of the PSYRATS, especially given the demand for such an instrument and the accumulated knowledge about its strengths and weaknesses. Specifi cally, alterna-tive formats to the current fi ve-point ordinal scale could be trialled in order to improve both its sensitivity to change and its usability in statistical analyses. In addi-tion, the various dimensions that are combined to measure disruption are likely to be more adequately assessed on separate items.

A fi nal recommendation relates to the process of devel-oping measures. The growing involvement of mental health consumers in research (Trivedi & Wykes, 2002) has not yet reached this domain of measurement. Hallucinated voices are strikingly internal and fundamentally diffi cult to understand from the outside. The fi rst-hand knowl-edge of voice hearers could be used to inform more com-plete assessment. Measurement may be brought closer to the domains that are valued by those we are trying to understand and assist (Greenwood et al., 2009). Recently, consumer input has led to innovation in measurement in other domains (Greenwood et al., 2009; Neil et al., 2009) and the same may apply to measurement of AHs.

The last decade has seen considerable progress in the measurement of AHs. Frederick and Killeen’s earlier review (Frederick & Killeen, 1998) suggested that the development of new instruments was needed in order to support the refi nement in treatment of AHs. The PSYRATS and BAVQ-R have fulfi lled this prediction with their sig-nifi cant contribution to measurement. Many of the mea-sures presented here provide new insights into the experience of AHs. Further validation and refi nement of these measures is recommended and will provide an important contribution to the ongoing development of treatments for AHs.

ACKNOWLEDGEMENTSWe would like to thank Dr Neil Thomas and Ms Jessica Stephens for their valuable assistance in the preparation of the manuscript.

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