‘I just want an explanation’: A qualitative investigation of how people with psychosis make sense of their visual hallucinations

Objectives: Visual hallucinations (visions) in people with psychosis are common and often distressing. Cognitive theory emphasises a central role of appraisals in determining distress. We explored how people made sense of their visions to inform the development of targeted cognitive treatments for visions.

Design: Semi-structured interviews were conducted with 12 participants with psychosis recently reporting visions.

Methods: Reflexive thematic analysis was utilised.

Results: There was an overarching theme that participants lacked convincing and acceptable explanations as to why they saw visions. The absence of credible explanations led people to rely on two types of themes of how to make sense of their experiences. Theme one was 'Unconvincing but acceptable' appraisals-such as visions were internally generated in some way, perhaps owing to poor sleep or stress. These were unconvincing as they did not account for the complexity and life-like reality of visions. Theme two was 'Convincing but unacceptable' appraisals. These were typically threat-based interpretations-such as 'It's real' or 'It's here to harm'. These appraisals were often more believable, yet incurred higher levels of distress. Appraisals were not static. They changed in response to dynamic factors such as the presence of visions and the participants' emotional state.

Conclusions: Participants described a need to understand why they see visions. Yet, the most convincing explanations often led to high levels of distress. Generating credible and acceptable ways to explain visions and understanding the dynamic factors that drive vision-specific appraisals may provide a potential route to improve cognitive treatments for these.