Coping training
A talking therapy that helps people with persistent voices find the ways of coping that work for them, and use them more deliberately.
At a glance
- Type
- Talking therapy
- Used for
- People whose voices or other psychotic symptoms persist despite medicine
- Status
- In treatment guidelines, as part of CBT for psychosis
- First used
- 1993, in a trial in Manchester
- Evidence
- EmergingHow evidence is rated
- Format
- One to one with a therapist. A brief version has 4 sessions; the Groningen programme lasted 9 months and included the family
- Starts to work
- In the brief version, distress from voices fell over 4 sessions
- Possible downsides
- Voices rarely stop altogether, the evidence comes from small studies, many people in the first trial did not complete it
- In Europe
- Offered at the voices outpatient clinic (Stemmenpoli) in Groningen and in an NHS service for distressing voices in Sussex. Also part of CBT for psychosis
Clinical summaryFor health professionals
- First trial (Tarrier 1993, 27 completers): coping training and problem solving both reduced psychotic symptoms compared with waiting. No effect on negative symptoms.
- Groningen trial (63 patients, voices for over 10 years): better quality of life and social functioning than routine care at 18 months, a moderate effect (Wiersma 2004).
- Groningen follow-up (40 patients, 4 years, no control group): 60% kept their gains; voices stopped in 18%.
- Brief 4-session version in NHS practice: less distress from voices in 125 patients with psychosis (no control group; Morrice 2022).
- NICE lists promoting alternative ways of coping among the components of CBT for psychosis.
What it is
Coping training is a talking therapy for people whose voices, or other psychotic symptoms, persist despite medicine. With a therapist, the person finds out which of their own ways of coping help, and learns to use them more deliberately.1,2 In studies, it was given alongside medicine and usual care.3
How it works
Almost everyone who hears voices finds some way of coping with them, and the strategies are similar across cultures.4 A study of 40 people with persistent voices, published in 1981, described the most common ones: changing activity, seeking contact with other people, calming down or becoming more alert, and shifting attention. Those who coped well used such strategies systematically.5
Coping training builds on this. The person and the therapist look at what the person already does when the voices come, and which strategies help. They then practise the strategies that help, so that the person uses more of them, and to better effect. In the first trial, the more a person’s coping improved, the more their symptoms fell.2
In Groningen, coping training is combined with CBT and involves the person’s family.6
History
Coping training grew out of studies, such as the one from 1981, showing that people with persistent voices develop their own ways of coping.5 In 1993, a team in Manchester tested it in a trial, under the name coping strategy enhancement.1 In the 1990s, the voices outpatient clinic of the University Hospital Groningen combined coping training with CBT, and tested the combination in a trial published in 2004.3,7
Coping methods have since become part of CBT for psychosis.4 NICE lists “promoting alternative ways of coping with the target symptom” among the components of CBT for psychosis.8
How well it works
In the Manchester trial, people whose symptoms had persisted despite medicine had either coping training or training in problem solving. Both groups had fewer psychotic symptoms than while they were waiting for treatment, and coping training may have helped slightly more. Neither treatment improved negative symptoms or social functioning.1
In the Groningen trial, 63 people who had heard voices for more than 10 years, despite medicine, had either the combined treatment or routine care for 9 months. The burden of the voices and other symptoms improved most in the treatment group.7 At 18 months, quality of life and social functioning were better than with routine care.9
An earlier group of 40 people treated in Groningen was followed for 4 years. Sixty in 100 kept their improvement, and a third improved further. The voices stopped altogether in 18 in 100.6 This study had no comparison group.
A brief version, with four sessions, is used in an NHS service for distressing voices in Sussex. Among 125 people with psychosis, distress from voices fell after treatment. There was no comparison group.10
A 2007 review found some evidence that coping training helps, but concluded that its benefit for voices in particular was not yet known.4
Possible downsides
In the Manchester trial, 49 people were recruited, but only 27 started and completed treatment.1 Voices rarely stop altogether: in Groningen, they disappeared in 18 in 100 people after 4 years.6 The evidence comes from small studies.
Format
One to one with a therapist. The brief version in Sussex has four sessions.10 The Groningen programme lasted 9 months and included the person’s family.7,6 When coping training is part of CBT for psychosis, NICE recommends at least 16 sessions.8
Contraindications and cautions
In studies, coping training was given alongside medicine and usual care, not instead of them.3 The 1981 study noted a high risk of suicide among people with persistent voices.5
Alternatives
CBT for psychosis (opens in a new tab) uses coping strategies among other methods. AVATAR therapy (opens in a new tab) and Talking With Voices (opens in a new tab) work on the person’s relationship with the voice. The Maastricht interview (opens in a new tab) maps a person’s voices and links them to their life story.
What we don’t know yet
- Whether coping training helps more than other talking therapies for voices.
- Which strategies work best, and for whom.
- Whether the brief four-session version works when tested against a comparison group.
