The simulation of hallucinations to reduce the stigma of schizophrenia: A systematic review

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Abstract

Background/objectives

Many people with schizophrenia face stigmatisation. Several methods have been produced to simulate the auditory and visual hallucinations experienced by people with schizophrenia in order to increase empathy and understanding about the condition. However, there has been no review of such methods. This systematic review aims to determine whether and how simulated hallucinations are effective in reducing stigma, and if simulated hallucinations are safe and acceptable.

Methods

Medline, Embase, PsycInfo, the Cochrane Library, CINAHL, and Worldcat Dissertations and Theses were searched from 1980 to September 2010. Reference checking, hand-searching, and contacting of experts in the field were also performed. A narrative synthesis of quantitative studies was conducted, and qualitative studies were synthesised using meta-ethnography.

Results

Ten studies were included. Simulation tools varied in context, but consistently increased both empathy towards, and desire for social distance from, people with schizophrenia whilst findings for other attitudes were inconsistent. Participants reported physical, cognitive and emotional discomfort. Qualitative data suggest that these discomforts give participants an ‘insider's perspective’ which produced empathy and respect. Simulated hallucinations sometimes produced concurrent negative affect, and physical and emotional distress, but were considered a highly acceptable learning tool.

Discussion/conclusions

Simulated hallucinations have contradictory effects on stigma, increasing empathy but also the desire for social distance. They should therefore be used with caution. Further research is required to discover if there is a way of using simulated hallucination interventions that increases empathy without increasing the desire for social distance from people with mental illness.

Introduction

Many people with schizophrenia experience stigma. A survey in 27 countries showed that approximately half of the 732 people with schizophrenia interviewed reported negative discrimination when making or keeping friends, 43% from family members, and 29% when finding a job (Thornicroft et al., 2009). A recent postal survey examined the level of self-stigma and perceived stigma reported by people with schizophrenia or other psychotic disorders across 14 European countries. Almost half (42%) reported moderate or high levels of self-stigma and 69% moderate or high perceived discrimination (Brohan et al., 2010). In a survey of 1737 adults in the UK, it was found that more than 70% of the general public viewed people with schizophrenia as dangerous and/or unpredictable (Crisp et al., 2000). Stigmatisation of individuals who have schizophrenia is also prevalent in medical and nursing students. A survey of medical and nursing undergraduates showed that 78% thought that patients with schizophrenia are dangerous or violent, and 40% of them rejected or felt ambivalent about accepting them in a social situation (Llerena et al., 2002).

In the field of physical disability there has been a long history of using simulated experience in attempts to increase understanding and destigmatise disability (French, 1992). In recent years simulated experience has begun to be used in the mental health field with various aims. For example interventions that simulate hallucinatory experience have been used with patients with schizophrenia as part of exposure therapy to desensitise them to their hallucinations (Tichon and Banks, 2006). However such interventions have most commonly been developed with the aim of reducing the stigma associated with psychosis. For instance the widely-used “Hearing Voices that are Distressing: A Training Experience and Simulation” developed by the National Empowerment Center, Boston (Deegan, 1996). This comprises of a 45-minute recording of benign and derogatory voices typical of those heard in psychosis which participants hear through headphones whilst undertaking a variety of tasks at workstations and in the local area. Further components are an audiotaped presentation about the experience of psychosis and a post-simulation debriefing discussion. Other simulations use virtual reality techniques to re-create both audio and visual illusions in the 3-dimensional environment (Radio, 2002, Banks et al., 2004), the most widely used being headphones and goggles headset developed by a pharmaceutical company (Tabar, 2007). These interventions were expected to prompt understanding and bolster empathy, therefore have been used as an anti-stigma intervention (Brown et al., 2010a). However, to our knowledge, there is limited evidence and no review investigating the effectiveness of simulated hallucinations in reducing stigma. This review aims to elucidate the effects of hallucination simulations on stigma, as well as the processes that may underlie any effects on stigma, and evidence on possible harm and acceptability among the general public.

Section snippets

Objectives

This systematic review addresses four specific research questions:

  • 1)

    What is the effect of simulated hallucinations on the stigma associated with schizophrenia?

  • 2)

    What processes underlie any effects of simulated hallucinations on stigma?

  • 3)

    Do simulated hallucinations cause any harm or distress to those who participate in the simulation?

  • 4)

    How acceptable are simulated hallucinations to participants?

Inclusion and exclusion criteria for studies

In order to collect a wide range of relevant evidence, we used a broad set of inclusion criteria and relatively few exclusion criteria. Studies were included if they used any simulation that created the experience of auditory, visual, olfactory, and/or tactile hallucinations with the aim of reducing stigma. Included studies could be on any population including students, professionals, informal caregivers or the general public of any age. In line with our research questions, studies were

Search results

The results of the search are shown in Fig. 1. A total of 6690 titles were identified by the electronic database search, 39 full papers were assessed for eligibility, and 2 were found from forward citation checking. As a result, eleven papers met inclusion criteria. Two papers reported one study (Dearing and Steadman, 2008, Dearing and Steadman, 2009), the latter being an analysis of reflective writing undertaken by a subset of the participants in the former. The characteristics of these ten

Effects on stigma

The synthesis indicates that although simulated hallucinations increase empathy towards people with schizophrenia, they also increase the desire for social distance from them. The evidence on attitudes was inconsistent. Therefore, the effects on stigma are mixed and complex. The simulation may influence various aspects of stigma differently. Furthermore no studies have examined the effects of simulated hallucinations on behavioural stigma outcomes. Consequently it is not currently known whether

Role of funding source

This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1053). GT is also funded through a NIHR Specialist Mental Health Biomedical Research Centre at the Institute of Psychiatry, King's College London and the South London and Maudsley NHS Foundation Trust. SA is funded through unrestricted scholarship The GlaxoSmithKline International Scholarship Charitable Trust Fund. None of

Contributors

SA, SC and EB designed the study and wrote the protocol. SC and GT supervised the study. SA managed the literature searches and initial screening of abstracts, and SC independently rated a subsample. SA and SC made inclusion decisions for all potentially relevant papers with EB as arbiter. SA and EB undertook data extraction and quality rating for the qualitative studies, and SA and EB did this for the quantitative studies. SA undertook the statistical analyses and meta-ethnographic synthesis.

Conflict of interest

All the authors have declared that there are no conflicts of interest in relation to this study.

Acknowledgement

This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1053). GT is also funded through a NIHR Specialist Mental Health Biomedical Research Centre at the Institute of Psychiatry, King's College London and the South London and Maudsley NHS Foundation Trust. SA is funded through unrestricted scholarship The GlaxoSmithKline International Scholarship Charitable Trust Fund. None of

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