Received: 29 January 2021 Revised: 21 May 2021 Accepted: 28 June 2021

DOI: 10.1002/cpp.2647

RESEARCH ARTICLE

Brief coping strategy enhancement for the treatment of

distressing voices in the context of borderline personality
disorder: A comparison with outcomes in the context of
psychosis

Frankie Morrice1 | Anna-Marie Jones2 | Vincenzo Burgio3 | Clara Strauss1,2 |

Mark Hayward1,2

1
School of Psychology, University of Sussex,
Brighton, UK
2
Research and Development Department,
Sussex Partnership NHS Foundation Trust,
Hove, UK
3
Faculty of Medicine, University of
Southampton, Southampton, UK
Correspondence
Mark Hayward, School of Psychology,
University of Sussex, Brighton BN1 9RH, UK.
Email: m.i.hayward@sussex.ac.uk
Abstract
Background: Voice hearing in the context of Borderline Personality Disorder (BPD)
has traditionally been regarded as transient and an experience that lacks legitimacy.
Consequently, there are no evidence-based treatments for the voices reported by
BPD patients. Contrary to the traditional view, there is a growing literature
suggesting that voice hearing in the context of BPD can be an enduring and
distressing experience which shares similarities with voice hearing in the context of
psychosis. Given these similarities, the aim of this study was to explore whether brief
Coping Strategy Enhancement developed in the context of psychosis can be used to
treat distressing voice hearing in the context of BPD.
Method: This was a service evaluation carried out in a specialist NHS service deliver-
ing psychological therapies for distressing voices. Patients with either a BPD (n = 46)
or a psychosis diagnosis (n = 125) received four sessions of Coping Strategy
Enhancement (CSE). The primary outcome was voice-related distress. The pre-post
outcomes for BPD patients were explored and compared with those achieved by the
psychosis patients.
Results: Both the BPD and psychosis groups experienced a significant reduction in
voice-related distress after CSE compared with baseline. The interaction between
diagnosis group and time was small and statistically non-significant.
Conclusion: These findings suggest a brief CSE intervention developed in the context
of psychosis can be an effective starting point in the treatment of distressing voice
hearing in the context of BPD. Such interventions have the potential to be integrated
into broader BPD treatment programmes for those who hear voices.

KEYWORDS
auditory hallucinations, borderline personality disorder, cognitive behavioural therapy, coping
strategy enhancement, distress, hearing voices

Clin Psychol Psychother. 2021;1–12. wileyonlinelibrary.com/journal/cpp © 2021 John Wiley & Sons, Ltd. 1
2 MORRICE ET AL.
1 | I N T RO DU CT I O N
Hearing a voice of someone who is not physically present is a com-
mon experience among people with and without psychiatric diagno-
ses. Voice hearing is the perceptual experience of hearing a voice in
the absence of external stimuli (McCarthy-Jones et al., 2014). A key
predictor of clinical caseness when voice hearing is experienced is the
level of distress (Waters & Fernyhough, 2016). Voices may provoke
particular fear and distress if they are interpreted by the hearer as
malevolent, powerful and all knowing (Chadwick & Birchwood, 1994).
Distressing voice hearing is usually considered as indicative of a psy-
chotic disorder such as schizophrenia, schizoaffective disorder or brief
psychotic disorder (American Psychiatric Association, APA, 2013—
hereafter, collectively referred to as ‘psychosis’). However, it is
becoming increasingly apparent that distressing voice hearing
is observed among other diagnostic groups such as bipolar disorder,
post-traumatic stress disorder and borderline personality disorder
(Waters & Fernyhough, 2016).
Borderline Personality Disorder (BPD), also termed as emotionally
unstable personality disorder, is characterised by patterns of instabil-
ity in one's self-image, affect and interpersonal relationships
(APA, 2013; Leichsenring et al., 2011). Voice hearing in the context of
BPD has traditionally been regarded as a transient experience which
causes little distress (Zanarini et al., 1990; Zonnenberg et al., 2016)
and was often considered to be within the person's voluntary control
(Pope et al., 1985; Zanarini et al., 1990). Terminology such as
‘pseudohullucinations’, ‘quasi-psychotic symptoms’ or ‘factitious
experiences’ has been used to differentiate voice hearing in BPD from
the ‘true’ hallucinations experienced in psychosis (Pope et al., 1985;
Zanarini et al., 1990). Voice hearing as a symptom within BPD con-
tinues to be met with scepticism by some professionals (Adams &
Sanders, 2011). Furthermore, the latest diagnostic and statistical man-
ual of mental disorders (DSM-5) only recognizes psychotic symptoms
in BPD, such as voice hearing, as brief, stress-related experiences
(APA, 2013). However, growing research into these experiences sug-
gests that the prevalence of voice hearing in BPD could be between
50% and 90% (Kingdon et al., 2010; Pearse et al., 2014). These experi-
ences are found to be enduring and distressing (Pearse et al., 2014;
Slotema et al., 2012; Zonnenberg et al., 2016). When voice hearing is
experienced within the context of BPD, there can also be higher
instances of self-harm (Cavelti et al., 2019) and suicide attempts
(Slotema et al., 2017).
Emerging research suggests that voice-hearing experiences in the
context of BPD and psychosis are phenomenologically indistinguish-
able (Cavelti et al., 2019; Hepworth et al., 2013; Tschoeke
et al., 2014). Studies have found no differences between BPD and
psychosis patients in the frequency and duration of voice hearing
(Kingdon et al., 2010; Slotema et al., 2012), the familiarity and number
of voices heard (Tschoeke et al., 2014) or their perceived location
(Kingdon et al., 2010; Slotema et al., 2012; Tschoeke et al., 2014).
Voice content in both groups has been found to be predominantly
negative and persecutory in nature (Merrett et al., 2016). Similarities
are also found in the appraisal of, and behavioural responses to,
Key Practitioner Messages
• BPD patients who hear voices can experience high levels
of voice-related distress, anxiety and depression.
• Brief Coping Strategy Enhancement targeting distressing
voices in the context of psychosis may reduce voice-
related distress for BPD patients who are distressed by
hearing voices.
• Coping Strategy Enhancement for voices offered in a
brief format may be appropriate for those with BPD
when offered as part of a wider package of care.
voices; BPD and psychosis voice hearers show no significant differ-
ences in their beliefs regarding the omnipotence or malevolence of
voices or whether they are more likely to engage with or try to ignore
the experience (Cavelti et al., 2020; Hepworth et al., 2013). The onset
of voice hearing has been found to be significantly earlier for those
with BPD (Tschoeke et al., 2014), which may be expected given the
tendency for the emergence of BPD symptoms to be earlier
(Leichsenring et al., 2011) than the onset of psychosis (Miettunen
et al., 2019).
One particular area of difference which has been highlighted is
the affective responses to voices (Hepworth et al., 2013). BPD
patients have been found to experience higher levels of voice-related
distress (Kingdon et al., 2010; Merrett et al., 2016) and receive higher
scores on depression and anxiety measures in comparison to psycho-
sis voice hearers (Cavelti et al., 2019; Kingdon et al., 2010; Tschoeke
et al., 2014). They have been found to experience higher degrees of
negative voice content (Cavelti et al., 2019; Kingdon et al., 2010;
Merrett et al., 2016) and are more likely to feel controlled by the
voices (Tschoeke et al., 2014). Recently, Cavelti et al. (2020) found
that BPD voice hearers report more negative beliefs about themselves
and others than those with psychosis which contributes to the
negative appraisal of voices and subsequent distress.
Despite emerging evidence of its clinical prevalence and dis-
tressing nature, there is limited evidence to inform the treatment of
distressing voices in BPD (Hepworth et al., 2013; National Institute
for Health and Care Excellence, NICE, 2009). Furthermore, BPD
patients can be excluded from evidence-based treatment for voice
hearing due to having a non-psychosis diagnosis (Hepworth
et al., 2013). However, the similarities in voice-hearing experiences
suggest that voice-hearing interventions developed for those with
psychosis may also be beneficial for BPD voice hearers.
Cognitive Behavioural Therapy (CBT) is recommended for all
those with a psychosis diagnosis (NICE, 2014). Randomized control
trials have widely shown CBT for psychosis to have a small to
moderate effect on psychotic symptoms (Bighelli et al., 2018).
Furthermore, adapting CBT to be specific to the psychotic symptom,
such as voice hearing, has been shown to increase its efficacy
MORRICE ET AL.
(Lincoln & Peters, 2019). Evidence highlighting similarities in BPD and
psychosis patient's appraisals and behavioural responses to voice
hearing suggests that voice hearing in BPD could be understood and
treated within a cognitive behavioural model (Cavelti et al., 2019;
Hepworth et al., 2013). Coping Strategy Enhancement (CSE) is a form
of CBT for psychosis which puts greater emphasis on its behavioural
aspects and uses a functional analytic framework to identify and
enhance naturally occurring strategies for coping with psychotic
experiences (Tarrier et al., 1990, 1993, 1998). At the Sussex Voices
Clinic, CSE has been adapted into a briefer format (four sessions),
specifically for coping with distressing voice hearing. Whilst outcomes
have been reported for a cohort of trans-diagnostic patients (Hayward
et al., 2018), no attempt has been made to focus specifically on BPD
patients and compare their experiences and outcomes with psychosis
patients. Therefore, the current study considered whether brief CSE
can generate benefits for BPD patients distressed by hearing voices.
This was an uncontrolled evaluation of CSE for distressing voices,
carried out in a naturalistic setting of routine clinical practice. This
evaluation has three key areas of interest: (1) to profile the BPD
patients in terms of their demographics and clinical baseline scores;
(2) to explore pre-post voice-related distress outcomes of CSE for a
group of patients with a BPD diagnosis and test the primary hypothesis
that there will be a reduction in voice-related distress post therapy; and
(3) to compare this reduction to that observed in the psychosis patient
group by carrying out a secondary hypothesis test that the ‘difference
in reductions’ will be non-zero.
2 | METHODS
2.1 | Study design
This study is a service evaluation exploring pre-post clinical outcomes
after a course of brief CSE delivered at a single NHS site—the Sussex
Voices Clinic (SVC). The evaluation involves the secondary analysis of
patient data which is collected as part of routine clinical practice. Two
naturally occurring groups were evaluated, a subsample of patients
with a BPD diagnosis and a subsample with a psychosis diagnosis. As
this study is an evaluation of routine, clinical practice approval from
the NHS Research Ethics Committee was not required (Department
of Health, 2017). Approval to carry out a service evaluation was
gained from the Clinical Audit department of the Sussex Partnership
NHS Foundation Trust. All patients included in this study consented
to the use of their data for the purpose of a service evaluation.
2.2 | Setting and participants
SVC is a specialist psychological therapies service within the
secondary care services of Sussex Partnership NHS Foundation Trust
(SPFT), a provider of mental health services within the UK's National
Health Service. SVC seeks to increase access to evidence-based
interventions by engaging a wider workforce in the delivery of
3
low-intensity interventions for patients distressed by hearing voices,
irrespective of diagnosis (https://www.sussexpartnership.nhs.uk/
sussex-voices-clinic).
The study population comprises of patients who were referred
to SVC through clinical services within SPFT. The eligibility criteria
for SVC were a score of 3 or more on a distress item of
the Psychotic Symptoms Ratings Scale–Auditory Hallucinations
(Haddock et al., 1999) or a score of 8 or more on the negative impact
subscale of the Hamilton Program for Schizophrenia Voices
Questionnaire (Van Lieshout & Goldberg, 2007). Between May 2014
and September 2019, 536 patients were assessed within SVC—of
whom 82 had a BPD diagnosis and 227 had a psychosis diagnosis
(diagnosis was verified by the treating psychiatrist). Of the BPD
patients, 53 (65%) started CSE, and 46 (56%) completed the
intervention by attending all 4 sessions. Of the psychosis patients,
156 (69%) started CSE, and 125 (55%) completed the intervention.
The current study included patients who had completed the full
course of CSE. See Figure 1 for full details of the flow of patients
through the assessment and therapy process.
2.3 | Reasons for non-commencement or
non-completion of CSE
Of the 82 BPD patients initially assessed, 17 (21%) did not start
CSE despite being eligible (non-commencers). Reasons for non-
commencement were as follows: no reason given/recorded (n = 10),
did not attend the first appointment and could not be contacted to re-
book (n = 3), opted to pursue a different treatment or therapy (n = 2),
not interested in therapy at this time (n = 1) and passed away before
the start of treatment (n = 1).
The proportion of non-commencers was similar for the psychosis
sample, as 227 patients were initially assessed and 42 (19%) were eli-
gible for CSE but did not start the intervention. The reasons for non-
commencement were as follows: no reason given/recorded (n = 22),
did not attend the first appointment and could not be contacted to
rebook (n = 9), deterioration of mental health preventing engagement
(n = 4), not interested in therapy at this time (n = 2), dissatisfaction
with the distance or location of the clinic (n = 2), opted to pursue a
different treatment or therapy (n = 2) and non-engagement due to
substance misuse (n = 1).
Of the 53 BPD patients who started CSE, 7 (13%) withdrew after
completing between 1 and 3 sessions. Reasons for withdrawal were:
did not attend multiple appointments and could not be contacted to
rebook (n = 3), no reason given/recorded (n = 3), and passing away
before the end of treatment (n = 1).
A higher proportion of the psychosis group withdrew during CSE
as 20% of patients (31/156) withdrew after attending between 1 and
3 sessions. Reasons for withdrawal were as follows: no reason given/
recorded (n = 19), did not attend multiple appointments and could
not be contacted to rebook (n = 3), misunderstanding of what CSE
would entail (n = 2), dissatisfaction with location or distance of clinic
(n = 1), deterioration of mental health preventing engagement (n = 1),
4 MORRICE ET AL.

F I G U R E 1 Flow chart showing final

sample selection

opted to pursue another type of therapy or treatment (n = 2), no depression, anxiety and stress subscales. It was used as a measure of
longer interested (n = 1), lack of engagement due to substance use depression and anxiety at SVC until November 2016. Each subscale
(n = 1) and dissatisfaction with treating practitioner (n = 1). rates 7 items on a 4-point Likert scale (0–3) in terms of frequency and
severity over the last week, leading to a total score of 0–21 separately
for anxiety and depression (Lovibond & Lovibond, 1995). The DASS-
2.4 | Measures 21 has been reported to have excellent internal consistency in terms
of the Depression subscale (a = 0.94) and Anxiety subscale (a = 0.87)
Baseline assessments were completed by clinic assistants within and overall acceptable concurrent validity (Antony et al., 1998).
4 weeks prior to the commencement of CSE, and post-intervention General Anxiety Disorder screener-7 (GAD-7; Spitzer et al., 2006) is
measures were collected within 4 weeks of its completion. The a 7-item self-report measure in which respondents rate the frequency
following measures were administered to assess clinical outcomes. of anxiety symptoms during the previous 2 weeks. Items are scored
on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day), with
total scores ranging from 0–21. Spitzer et al. (2006) reported the
2.5 | Baseline clinical measures GAD-7 has good construct validity and test–retest reliability
(intraclass correlation = 0.83) and excellent internal consistency
The Depression Anxiety Stress Scale (DASS-21)—Short-Form (a = 0.92). The GAD-7 has been used to measure anxiety at SVC since
(Lovibond & Lovibond, 1995)—is a self-report instrument with November 2016.
MORRICE ET AL.
The Patient Health Questionnaire-9 (PHQ-9; Kroenke
Spitzer, 2002) is a 9-item self-report measure of the presence and
severity of depression symptoms. Items are scored from 0 (not at all)
to 3 (nearly every day) resulting in a total of 0–27 (Kroenke &
Spitzer, 2002). The PHQ-9 reportedly has excellent test–retest and
inter-rater reliability and good internal consistency (a = 0.89; Kroenke
et al., 2001). The PHQ-9 has been used to measure depression at SVC
since November 2016.
2.5.1 | Primary measures
Psychotic Symptoms Ratings Scale–Auditory Hallucination (PSYRATS-
AH; Haddock et al., 1999) is an observer-rated measure of
auditory hallucinations. The 5-item distress scale of the PSYRATS-AH
was used to measure voice-related distress at SVC until November
2016. Items measure the amount and degree of negative voice
content, distress and controllability of the voice(s) (Woodward
et al., 2014). Items are scored on a 5-point Likert scale (0–5), leading
to a total distress score of 0–20 (Haddock et al., 1999). The distress
scale of the PSYRATS-AH has been found to have excellent
inter-rater reliability (intraclass correlation coefficient = 0.93;
Woodward et al., 2014).
Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ;
Van Lieshout & Goldberg, 2007) is a self-report measure of auditory
hallucinations. The 4-item negative impact subscale was used to mea-
sure voice-related distress at SVC after November 2016. Items cover
voice content, life interference, distress and the emotional impact of
the voice(s). Items are scored on a 5-point Likert scale from 0 (least
severe/impairing) to 4 (most severe/impairing), leading to a total distress
score of 0–16 (Van Lieshout & Goldberg, 2007). The HPSVQ has been
found to have excellent test–retest reliability (a = 0.84; Kim
et al., 2010) and good internal consistency (Kim et al., 2010; Van
Lieshout & Goldberg, 2007). Most recently, the HPSVQ has been
found to have structural and measurement invariance across
diagnoses (Berry et al., 2021).
2.6 | Intervention
CSE is offered at SVC as the first treatment within a stepped care
approach to treating distressing voices; it can lead to further, more
intensive interventions where appropriate.
CSE is composed of four 1-hour sessions, delivered weekly on an
individual basis. The intervention is manualized, and a workbook is
completed in each session (available to download from https://www.
sussexpartnership.nhs.uk/sussex-voices-clinic). All therapists received
training in CSE from the last author.
Session 1 involves establishing the antecedents of voice-hearing
experiences. Session 2 explores the patient's behavioural and emo-
tional responses to voices. Information about antecedents and
responses are used to identify and adapt existing coping strategies.
Sessions 3 and 4 explore the effectiveness of using the adapted
5
& coping strategies and problem solve any obstacles to their use (for fur-
ther details, see Hayward et al., 2018).
Throughout CSE, patients received their usual treatment. This is
normally composed of regular appointments with their care team and
psychotropic medication, and occasionally other psychological
therapies.
2.7 | Statistical analysis
2.7.1 | Sociodemographic and clinical
characteristics
Descriptive statistics, count (n), percentage (%), mean (M), standard
deviation (SD) and minimum and maximum (range) were used to sum-
marize the sociodemographic (gender, employment status, education,
ethnicity, first language, social capital, age, age at onset of voice
hearing and duration of voice hearing) and clinical measures, as
appropriate. To provide insight into any notable baseline diagnostic
differences, significance tests were carried out using a Pearson's
chi-squared test (for categorical variables) or an independent t test
(for continuous variables).
2.7.2 | Transformation
The two clinical measures of distress were transformed for analysis so
that they were comparable, using a method described in Jones
et al. (2020). The PSYRATS-AH distress scale and the HPSVQ nega-
tive impact scale were converted into z scores using the baseline
means and standard deviations of the corresponding scales, within
each diagnosis group, to make a single voice-related distress variable
(at baseline and post-CSE). We combined these measures in this way
as we were confident the paired scales both measured the same
construct and were equally effective at detecting change (Jones
et al., 2020). By combining the data, we aimed to increase the statisti-
cal power of the analysis (Jones et al., 2020).
2.7.3 | Covariates
It was expected that there would be a higher proportion of females in
the BPD group than in the psychosis group given the typical gender
profiles of these clinical populations (Castillejos et al., 2018; Lieb
et al., 2004). To control for the effect of gender, it was added as a
covariate variable to all baseline comparisons and the primary analysis.
2.7.4 | Baseline comparison of psychosis and BPD
groups
Analyses of Covariance (ANCOVA) models were used to
examine whether there were any significant between-diagnosis
6 MORRICE ET AL.
group differences in baseline anxiety or depression, with
gender added as a covariate. For the baseline analyses, only the
raw data were used to profile characteristics of voice hearing in
BPD compared with voice hearing in psychosis; i.e., there was no
use of transformed data. PHQ-9, DASS depression, GAD-7 and
DASS anxiety were all separately used as dependent variables in the
ANCOVAs.
2.7.5 | Voice-related distress analysis
A linear mixed model was used to predict voice-related distress from
time point (baseline or post-CSE) and diagnosis (BPD or psychosis),
with gender added as a controlling variable. An interaction term for
diagnosis group and time point was added to see if there was a signifi-
cant between-group difference in the change in distress over time.
After running the model, the marginal effects were examined using
contrasts to explore the difference in distress between the diagnostic
groups at each time point, after adjusting for the effect of gender. For
the within-group comparisons, the marginal effects for distress at
baseline compared with post-CSE were looked at for each diagnostic
group. Our primary analysis to address our first hypothesis was a test
for pre-post reduction in the BPD group. Our secondary analysis
tested the hypothesis that the pre-post reductions in the BPD and
Psychosis groups were different. This involved checking the
diagnosis-group  time interaction. All other analyses on voice-
related distress were exploratory to help us understand the patterns
in the data. As we have stated a single primary analysis, there was no
correction for multiple testing.
2.7.6 | Missing data
All sociodemographic and baseline clinical characteristics were
analysed with missing values excluded given the low level of expected
missing data. For the voice-related distress analysis, missing data were
treated using Multiple Imputation for Chained Equations (MICE; Van
Buuren & Groothuis-Oudshoorn, 2011). All missing data were
assumed to be missing at random (Jakobsen et al., 2017). The imputa-
tion model included the variables in the linear mixed model (voice-
related distress score and diagnosis) and auxiliary variables. The initial
pool of auxiliary variables were education, employment, social capital,
gender, age, ethnicity, age of voice-hearing onset, voice-hearing dura-
tion, anxiety and depression. An auxiliary variable was included in the
final imputation model if it correlated with outcome (voice-related dis-
tress score), or its missingness, and if the largest absolute value of
either of these correlations exceeded a Pearson's r of 0.1 (Van Buuren
et al., 1999). A sensitivity analysis was carried out by comparing the
results from the multiple imputation model (adjusted analysis) to those
obtained using only cases with complete data (complete case
analysis).
All statistical tests were considered significant if p < 0.05, and
95% confidence intervals were created for all estimates. For
between-group comparisons, the standardized effect size, Cohen's d,
was calculated with weights for the sample sizes to correct for posi-
tive bias in the pooled standard deviation due to the unequal group
sizes (Ellis, 2010). For the within-group comparisons, Cohen's d was
calculated taking in to account the correlation between pre- and
post-CSE distress scores and using the standard deviation of the
pre-test condition (Morris, 2008). Cohen's d effect sizes are inter-
preted as small = 0.2, medium = 0.5 and large = 0.8 (Cohen, 1988).
All analyses were carried out using the statistical software R
(version 3.6.1), and all categorical variables were dummy coded in R
for analysis.
3 | RE SU LT S
3.1 | Patient characteristics
One-hundred and seventy-one patients were included in this
evaluation; 46 (26.9%) of these patients had a BPD diagnosis and
125 (73.1%) a psychosis diagnosis. A descriptive summary of
sociodemographic and clinical characteristics for both subsamples is
presented in Table 1. For both groups, the majority of patients were
unemployed (psychosis: 73.1%, BPD: 66.7%) and did not have a part-
ner (psychosis: 77.7%, BPD: 67.4%). Education level was varied, with
the highest frequency category for both groups being educated up to
college level (psychosis: 31.4%, BPD: 30.2%). Consistent with the
demographic characteristics of the South East of England, the majority
of both subsamples identified as White British (psychosis: 79.0%,
BPD: 93.2%), with English as a first language (psychosis: 90.3%, BPD:
95.4%).
As expected, the BPD subsample was disproportionately female
(86.7%), whereas females made up just less than half (46.4%) of the
psychosis group. These proportions are consistent with the gender
profiles of these clinical populations within the literature (Castillejos
et al., 2018; Lieb et al., 2004). A chi-squared test found a significant
association between gender (male and female) and diagnosis group, X2
(1, N = 170) = 20.3, p = < 0.001. With regards to gender, a very small
number identified themselves using another term; however, they were
excluded from the chi-squared test due to the resulting small cell
count.
The psychosis subsample was slightly older than the BPD sub-
sample (M = 41.7, SD = 12.0 years, range = 15–76 compared with
M = 37.8, SD = 11.7 years, range = 18–57) and had a marginally
longer duration of voice hearing (M = 17.3, SD = 14.3 years, ran-
ge = 0–61 compared with M = 15.6, SD = 12.4 years, range = 0–43);
however, both these comparisons were non-significant (p = 0.06 and
p = 0.05, respectively). Based on differences highlighted in previous
research, diagnostic differences in age at onset of voice hearing were
explored in more detail. Despite the psychosis group having an
older age of voice-hearing onset (M = 24.2, SD = 12.4 years,
range = 2–53) than the BPD group (M = 21.3, SD = 12.4 years,
range = 5–50), the effect of diagnosis was not statistically significant,
t(72) = 1.3, p = 0.20; 95% CI [ 0.6, 0.1].
MORRICE ET AL. 7

TABLE 1 Sociodemographic and clinical characteristics of patients at baseline

Diagnostic group

Psychosis (N = 125) BPD (N = 46)

Baseline characteristic n (%) n (%)
Gender
Female 58 (46.4) 39 (86.7)
Male 67 (53.6) 6 (13.3)
a a
Identify as another term
Employment status
Unemployed 87 (73.1) 28 (66.7)
Employedb 18 (15.1) 9 (21.4)
Student 6 (5.0) 2 (4.8)
Retired 4 (3.4) 0 (0)
Other 4 (3.4) 3 (7.1)
Education
Left school before 16 19 (15.7) 7 (16.3)
Left school at 16 24 (19.8) 8 (18.6)
Left school at 17/18 15 (12.4) 7 (16.3)
Completed college 38 (31.4) 13 (30.2)
Completed university 25 (20.7) 8 (18.6)
Ethnicity
Asian 5 (4.0) 0 (0)
Black/Caribbean/African 3 (2.4) 0 (0)
Mixed ethnicity 5 (4.0) 1 (2.3)
White British 98 (79.0) 41 (93.2)
White other 7 (5.7) 2 (4.6)
Other/prefer not to say 6 (4.8) 0 (0)
Social capitalc
Without a partner 94 (77.7) 29 (67.4)
In a relationship 27 (22.3) 14 (32.6)
M (SD) M (SD)
Age (years) 41.7 (12.0) 37.8 (11.7)
Age at onset of voice hearing (years) 24.2 (12.4) 21.3 (12.4)
Duration of voice hearing (years) 17.3 (14.3) 15.6 (12.4)
n; M (SD) n; M (SD)
Pre-CSE
DASS anxiety 52; 8.9 (5.3) 25; 15.2 (4.3)
GAD-7 68; 13.9 (5.5) 21; 20.6 (4.5)
DASS depression 52; 10.7 (4.7) 24; 12.9 (4.7)
PHQ-9 63; 16.4 (6.3) 20; 16.8 (3.9)
PSYRATS distress scale 49; 15.1 (4.3) 24; 17.5 (1.8)
HPSVQ negative impact scale 73; 11.8 (3.2) 20; 13.3 (2.1)
Post-CSE
PSYRATS distress scale 41; 13.3 (5.2) 19; 16.1 (2.5)
HPSVQ negative impact scale 43; 9.8 (4.1) 14; 11.3 (4.6)

Note: Anxiety, depression and voice-related distress scales are expressed using the raw data. Percentages are based on all available data for the variable.
Data missing for characteristic: employment (psychosis: n = 6, BPD: n = 4), education (psychosis: n = 4, BPD: n = 3), ethnicity (psychosis: n = 1, BPD:
n = 2), first language (psychosis: n = 1, BPD: n = 3), social capital (psychosis: n = 4, BPD: n = 3), age (psychosis, n = 1, BPD: n = 1), age of voice hearing
onset (psychosis: n = 9, BPD: n = 4) and voice-hearing duration (psychosis: n = 7, BPD: n = 3).
8 MORRICE ET AL.

Abbreviations: BPD, Borderline Personality Disorder; CSE, Coping Strategy Enhancement; DASS, The Depression Anxiety Stress Scale; GAD-7, General
Anxiety Disorder screener-7; HPSVQ, Hamilton Program for Schizophrenia Voices Questionnaire; M, Mean; n, count; PHQ-9, The Patient Health
Questionnaire-9; PSYRATS, Psychotic Symptoms Ratings Scale; SD, Standard Deviation.
a
These results are suppressed to protect anonymity as only a small number of patients identified using another term.
b
Without a partner includes single, separated and widowed. In a relationship includes married, civil partnership, cohabiting and long-term relationship.
c
Includes full, part-time, voluntary and paid employment (for both subsamples).

3.2 | Baseline comparison of psychosis and BPD
groups
Table 1 displays the descriptive statistics of baseline anxiety and
depression across the two groups. The ANCOVA results showed
that after adjusting for gender, the between diagnostic group
effects for both baseline anxiety scores were statistically signifi-
cantly higher for the BPD group compared with the psychosis
group: DASS anxiety (b = 6.8, 95% CI [4.1, 9.5], p = < 0.001) and
GAD-7 (b = 5.6, 95% CI [2.9, 8.3], p ≤ 0.001). The depression
ANCOVA results showed that the between diagnostic group effects
for baseline DASS depression scores were statistically significantly
higher for the BPD group compared with the psychosis group, after
adjusting for gender (b = 2.9, 95% CI [0.4–5.5], p = 0.03). The
PHQ-9 baseline depression scores were also higher for the BPD
group compared with the psychosis group; however, this difference
was marginal and not statistically significant (b = 0.7, 95% CI
[ 3.8, 2.4], p = 0.68).
3.3 | Voice-related distress analyses
A descriptive summary of the original voice-related distress measures
(PSYRATS Distress and HPSVQ Negative impact) is provided in
Table 1. The two variables were combined into a single voice-related
distress variable using z-score transformation before analysis. For the
clinical outcomes, data were missing in the following number of cases
(n and %): baseline voice-related distress (5; 3.0%), post-CSE voice-
related distress (54; 46.2%), anxiety (5; 3.0%) and depression (12;
7.6%). Voice-related distress post-CSE had the highest level of mis-
singness; 92.6% of this missing data was due to the patient not
attending the post-intervention feedback session after CSE. The final
imputation model included diagnosis and voice-related distress score
(pre and post), and as auxiliary variables: gender, depression and anxi-
ety. Data were imputed for 76 missing data points (out of a total of
1,026; 7% missingness). Seven imputations were used to match the
percentage of total missing data points (White et al., 2011). The seven
data sets were combined for inference leading to one pooled set of

TABLE 2 The within-group and between-group voice-related distress comparisons

Effect Est 95% CI Cohen's d 95% CI

Effect Est (b) LL UL SE p value Cohen's d LL UL

Within-group (baseline to post)
Complete case analysis
BPD 0.9 1.4 0.3 0.27 0.001 0.8 1.4 0.3
Psychosis 0.6 0.9 0.2 0.29 0.001 0.5 0.8 0.2
Interaction between group and time 0.3 1.0 0.5 0.38 0.46
Adjusted analysis
BPD 0.8 1.3 0.3 0.27 0.003 0.8 1.2 0.4
Psychosis 0.6 0.9 0.3 0.29 <0.001 0.5 0.8 0.3
Interaction between group and time 0.3 1.1 0.6 0.41 0.51
Between-group (psychosis to BPD)
Complete case analysis
Baseline 0.2 0.7 0.4 0.27 0.52 0.0 0.4 0.2
Post-CSE 0.4 1.0 0.1 0.29 0.14 0.2 0.7 0.2
Adjusted analysis
Baseline 0.2 0.7 0.4 0.27 0.53 0.0 0.3 0.4
Post-CSE 0.4 1.0 0.1 0.27 0.16 0.2 0.5 0.2

Note: Complete case: BPD: n = 31, psychosis: n = 81. Adjusted: n = 46 and 125. Voice-related distress expressed in z scores created from scores on the
HPSVQ negative impact subscale and the PSYRATS-AH distress subscale (see Table 1 for descriptive statistics using the raw scores). Negative Cohen's ds
indicate a reduction in distress z scores in favour of the post-CSE condition.
Abbreviations: BPD, Borderline Personality Disorder; CI, confidence interval; CSE, Coping Strategy Enhancement; Est, estimate; LL, lower level; SE,
standard error; UL, upper level.
MORRICE ET AL.
results. These adjusted results are those reported in the text below;
all within-group and between-group comparison results for both the
complete case and adjusted analyses are presented in Table 2.
3.4 | Primary analysis
The within-group comparisons (see Table 2) from the linear mixed
model found a statistically significant pre-post effect for the BPD
group, b = 0.8, 95% CI [ 1.3, 0.3], p = 0.003, showing a large
standardized effect size of d = 0.8, 95% CI [ 1.2, 0.4]. This evi-
dence in support of our primary hypothesis indicated that voice-
related distress in the BPD group significantly reduced following four
sessions of CSE, compared with baseline, after controlling for gender.
3.5 | Secondary analysis
Similarly, within the psychosis group, voice-related distress was lower
post-CSE when compared with baseline (see Table 2). This pre-post
difference was statistically significant (b = 0.6, 95% CI [ 0.9, 0.3],
p < 0.001) and represented a medium standardized effect, d = 0.5,
95% CI [ 0.8, 0.3]. In comparison to the BPD group, the psychosis
group experienced a smaller reduction in distress. Our secondary
hypothesis test of a non-zero ‘difference in reductions’ showed that
the interaction between diagnosis group and time was in fact small
and non-significant, b = 0.3, 95% CI[ 1.1, 0.6], SE = 0.41, p = 0.51
(complete case results: b = 0.3, 95% CI[ 1.0, 0.5] SE = 0.38,
p = 0.46). This implies that the difference in distress reduction post-
CSE between the psychosis and BPD group is negligible.
3.6 | Exploratory analysis
At baseline, the BPD group had marginally higher voice-related
distress compared with the psychosis group. This difference was not
significant after adjusting for the effect of gender, b = 0.2, 95% CI
[ 0.7, 0.4], p = 0.53, and represented a negligible effect of d = 0.01,
95% CI[ 0.33, 0.35]. At the post-CSE time point, the BPD group had
higher voice-related distress than those with psychosis. Similarly, this
difference was not statistically significant b = 0.4, 95% CI [ 1.0,
0.1], p = 0.16, after adjusting for gender and also signified a negligible
effect size of d = 0.2, 95% CI [ 0.5, 0.2].
3.7 | Sensitivity analysis
All voice-related distress analyses were carried out first using
complete cases and then compared with the adjusted results from
the multiple imputation model (see Table 2). It was noted that in all
analyses the differences between the two sets of effect estimates
were marginal and all conclusions of statistical significance were
consistent.
9
4 | DI SCU SSION
An emerging literature is suggesting that voice hearing experiences
for patients with diagnoses of psychosis and BPD have many similari-
ties. However, evidence-based psychological treatments exist only for
patients with a psychosis diagnosis. This study explored the outcomes
for BPD patients who received brief CSE for voices, an intervention
designed and evaluated in the context of psychosis that has been
adapted for the trans-diagnostic treatment of distressing voices. We
found that the majority of patients with BPD engaged with CSE and
reported a significant reduction in voice-related distress after the
intervention, compared with baseline. This reduction in voice-related
distress was not significantly different from that achieved by the
psychosis group.
The findings from the current study extend the emerging litera-
ture which suggests that the voice hearing experiences of both BPD
and psychosis patients can be associated with high levels of distress.
This similarity suggests that psychological interventions informed by
CBT principles targeted at the reduction of voice-related distress
might be relevant to both groups of patients. CSE is an example of
such an intervention and the levels of engagement and outcomes for
the BPD patients within the current study suggest this brief interven-
tion is an acceptable and beneficial intervention for this patient group.
Levels of engagement were similar for both BPD and psychosis
patient groups, with just over half of the assessed patients within each
group completing the intervention. Outcomes were also similar as
both groups reported a significant reduction in voice-related distress.
The difference in distress reduction between the groups was
negligible.
Differences between the patient groups were also noted. As pre-
viously reported, levels of voice-related distress were higher at base-
line for the BPD patients. However, these differences were not
significant when controlling for gender, corroborating previous find-
ings that gender can be associated with differing responses to voices
(Hayward et al., 2016; Schlier et al., 2021). Voice-related distress was
also higher for the BPD patients post-CSE; however, again, this differ-
ence was not significant after controlling for gender. BPD patients
reported higher levels of baseline anxiety and depression, and this dif-
ference was found to be statistically significant for both anxiety scales
and the DASS depression scale but not for the PHQ-9 depression
measure. Largely, these findings corroborate the literature suggesting
that BPD patients experience higher levels of negative affect per se
(APA, 2013), and this can generalize to the negative affect related to
voice hearing experiences (Kingdon et al., 2010; Merrett et al., 2016).
However, although statistically significant, the difference found on
the DASS depression scale is unlikely to represent a clinically signifi-
cant difference. Therefore, group differences in depression should be
interpreted with caution. More in-depth exploration of group differ-
ences in depression and anxiety is an area for future research.
Differences were also found regarding the onset of voices, with
BPD patients reporting earlier onset. However, the age of onset for
BPD patients was not as early as reported elsewhere (Tschoeke
et al., 2014). Amidst the growing literature suggesting that voice
10
hearing experiences can be similar for patients with BPD and psycho-
sis, attention should be focussed upon the differences as they may
have implications for the types and targets of other psychological
interventions that are offered as part of a pathway of intervention for
BPD patients distressed by hearing voices.
4.1 | Clinical implications
The current findings suggest that psychological interventions devel-
oped in the context of psychosis, informed by CBT principles and
targeted at voice related distress, such as CSE, can be a beneficial
starting point in the treatment of distressing voice hearing in BPD.
This finding has the potential to increase access to evidence-based
treatment as some BPD voice hearers may be excluded from psycho-
logical therapies for distressing voices due to having a non-psychosis
diagnosis (Hepworth et al., 2013). Given the higher levels of voice-
related distress, anxiety and depression reported by the BPD group,
these patients are still likely to require a focus on emotional regulation
within their treatment plan. Consequently, CSE could be integrated
into broader BPD treatments such as Dialectical Behaviour Therapy
(Linehan, 2018) as an additional treatment component for those who
hear voices.
As CSE is intended as a first step in pathways of psychological
interventions for distressing voices, future research could explore the
most appropriate and effective way for the psychological treatment of
distressing voices to be continued for BPD patients. Given the similar
ways in which BPD and psychosis patients appraise their voice hear-
ing experiences (Cavelti et al., 2019; Hepworth et al., 2013), cognitive
interventions exploring appraisals of voices may build upon the
behavioural focus of CSE (e.g., Guided self-help CBT for voices; Hazell
et al., 2018). Emerging evidence suggests that, compared with those
with psychosis, BPD patients have more negative beliefs about the
self and others which leads to negative appraisals of voices and subse-
quent distress (Cavelti et al., 2020). Therefore, CBT-based interven-
tions which address concepts of self could be a target for further
investigation. In the context of the significant relationship difficulties
experienced by BPD patients, one of the emerging relationally based
interventions for distressing voices may also be indicated (e.g., Avatar
Therapy, Craig et al., 2018; Relating Therapy, Hayward et al., 2017).
4.2 | Limitations
There are several limitations to this study which mean the results
must be interpreted with caution. First, the diagnoses of the patients
were not derived from structured clinical interviews conducted within
the study, creating the possibility that some patients may have been
misdiagnosed. Second, as an evaluation conducted in an uncontrolled
clinical setting, the BPD and psychosis groups may systematically dif-
fer in ways which could affect voice-related distress. Additionally,
without a control group it cannot be conclusively established that
changes in voice-related distress were attributable to CSE rather than
MORRICE ET AL.
unrelated factors. Observed changes may also be subject to regres-
sion to the mean bias. Third, usual treatment for SVC patients may
have varied, with some patients undertaking other psychological ther-
apies which could have affected distress within the timeframe of the
CSE pre-post measures. Fourth, without follow-up data beyond
4 weeks, there is no indication as to whether reductions in distress
were maintained over time. Fifth, those who did not fully complete
CSE therapy were excluded from this evaluation. These patients may
have been a sub-population who found CSE less helpful (Jakobsen
et al., 2017). Therefore, the results may be an overestimation of CSE's
benefits, and this study could have been strengthened by analysing
patterns of drop out. Finally, the conducting of the service evaluation
within a single site with limited ethnic diversity will hinder the
generalizability of findings.
The principal strength of this study was its novel focus on the
treatment of distressing voice hearing in BPD, an area in which
research evidence and guidance is sparse. The naturalistic clinical set-
ting, although posing methodological limitations, means the findings
have high ecological validity, increasing their generalizability to clinical
practice (Andrade, 2018).
This study is the first to provide evidence from routine clinical
practice of the beneficial treatment of voice hearing in BPD using an
intervention developed in the context of psychosis. Our findings sug-
gest that brief CBT-informed voice-hearing interventions can be an
appropriate and beneficial treatment for BPD voice hearers in terms
of the management of voice-related distress, which previous research
has highlighted to be a significant and unmet clinical need for this
patient group. Interventions targeting distressing voices have the
potential to be integrated into wider BPD treatments for those who
hear voices.
AC KNOW LEDG EME NT S
We would like to express our thanks to the many therapists and clinic
assistants within the Sussex Voices Clinic who delivered therapy and
collected data for this study. Thanks are also due to Warren Leaver
for his contribution to an earlier draft of this manuscript.
CONFLIC T OF INT ER E ST
There is no conflict of interest to declare.
DATA AVAILABILITY STAT EMEN T
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
OR CID
Mark Hayward https://orcid.org/0000-0001-6567-7723
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How to cite this article: Morrice, F., Jones, A.-M., Burgio, V.,
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