Mark Hayward

• PhD (Surrey), DClinPsy (Leicester), BA (Sussex)
• Honorary Professor of Psychology at University of Sussex

Purpose To present a treatment protocol for Relating Therapy—a novel psychological intervention which supports adults to respond assertively to their distressing voice hearing experiences. Method This paper reports the background to the development of Relating Therapy. Thereafter, the four phases of the therapy are described: (1) exploring the hea...

Background Hearing voices is a common experience for young people and can cause significant distress. There are no evidence-based psychological interventions for distressing voices in young people, although a focus on coping strategies has been suggested as a useful approach. We have developed and evaluated a brief 1:1 coping intervention for young...

Background: There is a need to identify and to better understand key processes involved in voice hearing, which can inform the targeting and development of psychological interventions for distressing voices. The current study aimed to examine interrelations between the negative impact of voices, voice characteristics, emotional distress and recover...

Introduction: There is a significant demand for interventions that reduce distress related to auditory verbal hallucinations (AVHs). AVH distress is associated with the way voice hearers relate with AVHs. We aimed to establish the feasibility of a randomized controlled trial to demonstrate that adding "Relating Therapy" (RT) to treatment as usual (...

Background: The outcomes of Cognitive Behavioural Therapy for distres-sing voices and their measurement have mostly been determined by professionals, with little focus on the outcomes that matter to people who hear voices. The aim of this qualitative study was to explore views about the outcomes of Cognitive Behavioural Therapy for distressing voic...

Voice hearing experiences are commonly reported by patients with anorexia nervosa (AN) and are associated with negative outcomes. The “eating disorder voice” (EDV) can be understood within relational frameworks. Relating therapy (RT) has offered encouraging outcomes when targeted at voice hearing experiences transdiagnostically but has not been eva...

Limited research has explored the specific impact of voice-hearing experiences upon the social relating of adolescents. This study examined the associations of voice-hearing in youth with social relating, and putative explanatory factors. An observational, cross-sectional design using a clinical comparison group was employed to examine historical a...

Background The National Institute for Health and Care Excellence (NICE) recommends that cognitive behaviour therapy (CBT) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBT. This is attributable, in part, to the resource-intensive nature of CBT. One response to...

Background: Hearing voices is a common experience in young people and can be associated with distress, self-harm, and an increased risk of attempting suicide. Many parents lack confidence in supporting young people who are distressed by voices. However, there are currently no evidence-based interventions to support the parents of young voice heare...

Introduction Due to the general psychopathological vulnerability of young people who hear distressing voices, research has stressed the importance for clinicians to assess this experience in youth. Nonetheless, the limited literature on the topic comes from studies with clinicians in adult health services and it primarily reports that clinicians do...

Background: Research into hallucinatory experiences has focused primarily upon hallucinations within the auditory modality, to the relative neglect of other modalities. Furthermore, the exploration of auditory hallucinations (or 'voices') has focused primarily upon the experiences of people with a diagnosis of psychosis. The presence of multi-moda...

Auditory verbal hallucinations (AVH) are often multiple distressing experiences. Emerging evidence suggests that interventions informed by the principles of cognitive behavioral therapy, such as brief Cognitive Strategy Enhancement (brief-CSE), can reduce the distress related to AVH. The benefits of brief-CSE have been demonstrated for English-spea...

Background Personal recovery literature has been influential in the conceptualization of emotional distress and service provision. While personal recovery in psychosis has been well‐studied, voice hearing literature has not been reviewed to elucidate recovery processes. Method Five databases were systematically searched to identify relevant qualit...

Background Older adult carers of people who experience psychosis are at increased risk of developing physical and mental health problems due to the compounding factors of supporting their care-recipient and the health changes associated with ageing. Effective interventions exist but can be difficult to access and maintain prolonged engagement. Self...

Background The long-standing view that auditory verbal hallucinations (AVH) or hearing voices is a sign of schizophrenia has been challenged by research demonstrating that they lie on a continuum ranging from normal to pathological experience related to distress and need for care. Hearing voices is more prevalent in adolescence than in later life,...

Aims This service evaluation aimed to compare the outcomes for interventions for distressing voices that were delivered face-to-face (F2F) or remotely. It was hypothesised that F2F interventions would generate greater reductions in the primary outcome of the negative impact of voices, relative to remote delivery. Methods Sixty-three patients (33 F...

Background Voice-hearing is a common, phenomenologically diverse, experience across different mental health diagnoses. Patient preferences for psychological therapies are helpful in informing treatment commissioning and provision, especially in the context of complex and variable experiences like voice-hearing. There is, however, very limited evide...

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course...

Objectives Little is known about the factors that can maintain the distress related to voice‐hearing experiences in youth. Building upon understandings developed with adults, this study aimed to explore the associations between negative relating between hearer and voices, persecutory beliefs about voices and voice‐related distress in a clinical sam...

Background: First responders (i.e. police and ambulance staff) have increasingly become part of the mental health care system, often being the first port of call for those experiencing a crisis. Despite their frequent involvement in supporting those with mental health problems, there is evidence that mental health stigma is high amongst first resp...

Background Hearing voices is a common experience in young people, irrespective of diagnosis. This experience can be associated with distress, self-harm and an increased risk of attempting suicide. However, there are currently no evidence-based interventions which specifically target distressing voice hearing experiences in young people. Method Thi...

Background Cognitive Behavioural Therapy for voice hearing (CBTv) has been shown to be effective at reducing distress. However, it is unclear why voice hearers might deteriorate or continue to benefit post-intervention. This study aimed to explore therapeutic change processes following CBTv. Methods A critical realist, grounded theory methodology...

Background: Auditory verbal hallucinations (AVH) commonly occur in the context of borderline personality disorder (BPD) yet remain poorly understood. AVH are often perceived by patients with BPD as originating from inside the head and hence viewed clinically as 'pseudohallucinations', but they nevertheless have a detrimental impact on wellbeing....

Background Cognitive–behavioural therapy (CBT) is recommended for all patients with psychosis, but is offered to only a minority. This is attributable, in part, to the resource-intensive nature of CBT for psychosis. Responses have included the development of CBT for psychosis in brief and targeted formats, and its delivery by briefly trained therap...

Background Research on gender differences has found that women relate to negative voice hearing experiences with more negative emotions and report more distress due to voices, which may be rooted in differences in relating to voices. This study used a robust methodology and a large sample to explore gender differences in relating to voices and voi...

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 hea...

Background The presence of auditory verbal hallucinations (AVH) does not currently feature in the main diagnostic criteria for Borderline Personality Disorder (BPD). However, there is accumulating evidence that a high proportion of BPD patients report longstanding and frequent AVH which constitute a significant risk factor for suicide plans and att...

Auditory verbal hallucinations (AVHs) are associated with distress and reduced functioning. Research suggests that distress is associated with the voice hearer’s responding to AVH in a passive and subordinate manner. A novel approach focuses on relating to AVH and teaches assertive responses to AVH using experiential role-plays. A small pilot study...

Background The number of mental health-related 999 calls to emergency services has increased in recent years. However, emergency services staff have an unfavourable reputation when it comes to supporting people experiencing mental health problems. Aims To assess the levels of explicit and implicit mental health stigma among accident and emergency,...

This paper describes effects on wellbeing as well as logistical difficulties of implementing regular Quiet Time (QT) via Transcendental Meditation (TM) among mainstream secondary school pupils with special educational needs, age 12–16 measured via a pilot Randomised Control Trial (RCT). Participants were recruited from three mainstreams and one spe...

Background Voice-hearing is a transdiagnostic experience with evident negative effects on patients. Good quality measurement is needed to further elucidate the nature, impact and treatment of voice-hearing experiences across patient groups. The Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) is a brief self-report measure which requ...

Psychological treatments for hallucinations typically target auditory verbal hallucinations (AVH) but neglect the influence of hallucinations in other sensory modalities. This study compared the baseline clinical characteristics and therapeutic outcomes (following brief Coping Strategy Enhancement) of adult clients (N = 100) with multimodal or unim...

Hearing voices is a distressing and trans-diagnostic experience. Cognitive behavioural therapy (CBT) is an effective psychological treatment for distressing voices, but is offered to only a minority of patients. Limited resources are a barrier to accessing CBT. Evaluations of brief forms of CBT for voices have offered encouraging findings, but the...

The original CHoice of Outcome In Cbt for psychosEs (CHOICE) measure was designed in collaboration with experts by experience as a patient-reported “Psychological Recovery” outcome measure for cognitive-behavioral therapy for psychosis (CBTp). A short version (CHOICE-SF) was developed to use as a brief outcome measure, with a focus on sensitivity t...

Advancements in CBT for distressing voices have led to the development of understandings and the treatment of voice hearing within relational frameworks. In this study, we aim to validate and revise the Voice And You (VAY), one of the first measures that was developed to assess distressing relationships with voices. Data was pooled from 5 sources...

Access to cognitive behaviour therapy for those with psychosis (CBTp) remains poor. The most frequently endorsed barrier to implementation is a lack of resources. To improve access to CBTp, we developed a brief form of CBTp that specifically targets voice-related distress. The results of our pilot trial of guided self-help CBT for voices (GiVE) sug...

Background: Person-based cognitive therapy (PBCT) was developed as a treatment for psychosis. The effectiveness of group PBCT was examined in the Mindfulness for Voices (M4V) randomized controlled trial and generated promising results. Group PBCT was implemented as a trans-diagnostic treatment for distressing voices within the Sussex Voices Clinic...

Background Cognitive models propose that behavioural responses to voices maintain distress by preventing disconfirmation of negative beliefs about voices. We used Experience Sampling Methodology (ESM) to examine the hypothesized maintenance role of behavioural responses during daily life. Method Thirty-one outpatients with frequent voices complete...

Background: Carers of people with psychosis are at a greater risk of physical and mental health problems compared to the general population. Yet, not all carers will experience a decline in health. This predicament has provided the rationale for research studies exploring what factors predict poor wellbeing in carers of people with psychosis. Our...

Background: The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behaviour Therapy for psychosis (CBTp) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBTp. This is attributable, in part, to the resource-intensive nature of CBT...

Background The effectiveness of psychological treatments for auditory hallucinations (‘voices’) needs to be enhanced. Some forms of novel treatment are working within relational frameworks to support patients to relate assertively to distressing voices. Yet, no measure of assertive relating to voices is available to assess the extent to which this...

Background The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behaviour Therapy for psychosis (CBTp) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBTp. This is attributable, in part, to the resource-intensive nature of CBTp....

Introduction: Hearing voices is a common and distressing symptom of First-Episode Psychosis. Formal and informal conversations about voices are helpful, but service users within Early Intervention in Psychosis (EIP) Services can be reluctant to discuss their voice hearing experiences. There is currently no literature that explores the experiences...

Existing models of Borderline Personality Disorder (BPD) suggest that a combination of genetic vulnerability, childhood trauma, and disrupted attachment can lead to the marked emotional lability, impulsivity and interpersonal difficulties observed clinically. Brain structural differences in frontal, limbic and hippocampal regions have been reported...

Background The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behaviour Therapy for psychosis (CBTp) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBTp. This is attributable, in part, to the resource-intensive nature of CBTp....

Background Existing models of the phases of hearing distressing voices have relied upon data from cross-sectional designs and the retrospective accounts of hearers. There is a need for a longitudinal study to examine the phases of voice hearing over time. Methods A longitudinal, mixed-methods design was used. Stage 1 - semi-structured interviews we...

Background: Voice-hearing experiences can be distressing and impairing, and existing psychological treatments show modest effectiveness. Ecological momentary assessment and intervention (EMA/I) are two promising approaches which may be used as digital tools to support and enhance existing psychological therapies. The aim of this study was to inves...

Research informing our clinical practice, and our clinical practice informing our research, is at the heart of the scientist-practitioner model. This chapter will demonstrate how psychologists can work within the scientist-practitioner model in the field of psychosis, using specialist “voices” clinics as the example. Voices clinics offer a symptom-...

Brief and single‐symptom forms of cognitive behaviour therapy (CBT) for distressing voices may increase access to evidence‐based psychological therapy and transcend diagnostic barriers. The current study evaluated the “C” and “B” in CBT for distressing voices in a transdiagnostic voices clinic. The B module (component of therapy) sought to enhance...

Hallucinations in children and adolescents are now known to occur on a continuum from healthy to psychopathology-related phenomena. Although hallucinations in young populations are mostly transient, they can cause substantial distress. Despite hallucinations being widely investigated, research so far has had limited implications for clinical practi...

Mindfulness-based group therapy shows promise as a treatment for distressing voice hearing. However, fostering engagement in groups can be challenging, and no theory of engagement in group therapy for distressing voices exists to guide practice or research. This study employed Grounded Theory Method to build a theory of engagement in mindfulness-ba...

Common approaches to the psychological treatment of distressing voice hearing experiences, such as cognitive behavioural therapy, aim to promote more adaptive cognitive, emotional and behavioural responses to these experiences. Digital technologies such as smartphones show promise for supporting and enhancing these treatments by linking immediate t...

Cognitive behaviour therapy is recommended internationally as a treatment for psychosis (targeting symptoms such as auditory hallucinations, or "voices"). Yet mental health services are commonly unable to offer such resource-intensive psychological interventions. Brief, symptom-specific and less resource-intensive therapies are being developed as o...

Background: The experience of hearing distressing voices has recently been conceptualised within relational terms, whereby the voice is perceived as a person-like stimulus with whom the hearer has a difficult relationship. Therapeutic approaches are being developed that seek to modify the relating of the hearer towards the voice, and a conversation...

The experience of hearing voices (‘auditory hallucinations’) can cause significant distress and disruption to quality of life for people with a psychosis diagnosis. Psychological therapy in the form of cognitive behavior therapy (CBT) for psychosis is recommended for the treatment of positive symptoms, including distressing voices, but is rarely av...

Background Smartphone-based ecological momentary assessment and intervention (EMA/I) show promise for enhancing psychological treatments for psychosis. EMA has the potential to improve assessment and formulation of experiences which fluctuate day-to-day, and EMI may be used to prompt use of therapeutic strategies in daily life. The current study is...

In a previous article in this journal, Turkington et al suggested a number of psychological approaches that an individual can use to reduce the distress caused by hearing voices. Despite having popular appeal, only some of these approaches have evidence for their effectiveness. Within a clinical context where few patients with psychosis have access...

Background: Only about half of people with obsessive compulsive disorder (OCD) show clinically significant improvement following the recommended therapy, exposure and response prevention (ERP), partly due to poor therapy acceptability. A mindfulness-based approach to ERP (MB-ERP) has the potential to improve acceptability and outcomes. Methods:...

Hearing voices can be highly distressing and impact our health, well-being and day-to-day lives. This self-help guide explains what voices are, what causes them and how to cope with this distressing experience.. Using clinically proven cognitive behavioural therapy (CBT) techniques, this book will help you to recognise the link between your though...

Paranoia is common and distressing in the general population and can impact on health, emotional well-being and social functioning, such that effective interventions are needed. Brief online mindfulness-based interventions (MBIs) have been shown to reduce symptoms of anxiety and depression in non-clinical samples; however, at present, there is no r...

We introduce therapeutic techniques that encourage voice hearers to view their voices as coming from intentional agents whose behavior may be dependent on how the voice hearer relates to and interacts with them. We suggest that this approach is effective because the communicative aspect of voice hearing might fruitfully be seen as explanatorily pri...

Hearing distressing voices is a key feature of psychosis. The time between voice onset and disclosure may be crucial as voices can grow in complexity. This study aimed to investigate barriers and enablers to early voice disclosure. In total, 20 voice hearers were interviewed, and Thematic Analysis was used to identify themes. Beliefs about the effe...

Background The caregivers of people who experience psychosis are themselves at risk of developing physical and mental health problems. This risk is increased for older adult caregivers who also have to manage the lifestyle and health changes associated with ageing. As a consequence, older adult caregivers are in particular need of support; we propo...

Hallucinated voices are common across psychiatric and non-clinical groups. The predominant cognitive theory about the impact of voices posits that beliefs about voice power (‘Omnipotence’) and voice intent (‘Malevolence’/‘Benevolence’) play a key role in determining emotional and behavioral reactions. The revised Beliefs about Voices Questionnaire...

Background: Few patients have access to cognitive behaviour therapy for psychosis (CBTp) even though at least 16 sessions of CBTp is recommended in treatment guidelines. Briefer CBTp could improve access as the same number of therapists could see more patients. In addition, focusing on single psychotic symptoms, such as auditory hallucinations ('v...

Background The Normalisation Process Theory (NPT) has been used to understand the implementation of physical health care interventions. The current study aims to apply the NPT model to a secondary mental health context, and test the model using exploratory factor analysis. This study will consider the implementation of a brief cognitive behaviour t...

Access to psychological therapies continues to be poor for people experiencing psychosis. To address this problem, researchers are developing brief interventions that address the specific symptoms associated with psychosis, i.e., hearing voices. As part of the development work for a brief Cognitive Behaviour Therapy (CBT) intervention for voices we...

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Complete analysis. (DOCX)

Background – hearing voices can be a common and distressing experience. Psychological treatment in the form of Cognitive Behaviour Therapy for Psychosis (CBTp) is effective, but is rarely available to patients. The barriers to increasing access include a lack of time for clinicians to deliver therapy. Emerging evidence is suggesting that CBTp deliv...

Recent studies have established associations between relating to voices and distress. However, the potential influence of mindfulness on this relationship has received little attention. This study was designed to explore the extent to which associations between relating to voices and distress are mediated by mindfulness. A cross-sectional study was...

Auditory hallucinations (AH) are a common and distressing experience and patients report distress reduction to be a priority. Relating Therapy adopts a symptom-specific and mechanism focused approach to the reduction of AH distress. We conducted this single-blind, pragmatic, parallel groups, superiority pilot RCT within a single mental health centr...

This study extends existing research and theoretical developments by exploring the potential mediating role of insecure attachment within the relationship between trauma and voice-hearing. Fifty-five voice hearers with a psychosis-related diagnosis completed comprehensive assessments of childhood trauma, adult attachment, voice-related severity and...

Hallucinations can occur across the five sensory modalities (auditory, visual, olfactory, tactile, and gustatory). Whilst they have the potential to be benign or even highly valued (Romme et al., 2009; Sommer et al., 2010), they can often be devastating experiences associated with distress, impaired social, and occupational functioning, self-harm a...

Although there is evidence of both clinical and personal recovery from distressing voices, the process of recovery over time is unclear. Narrative inquiry was used to investigate 11 voice-hearers’ lived experience of recovery. After a period of despair/exhaustion, two recovery typologies emerged: (a) turning toward/empowerment, which involved devel...

Background Cognitive behavior therapy for psychosis (CBTp) is an effective intervention for people who hear distressing voices (auditory hallucinations). However, there continues to be a problem of poor access to CBTp. Constraints on health care funding require this problem to be addressed without a substantial increase in funding. One solution is...

Group Person-Based Cognitive Therapy (PBCT) integrates cognitive therapy and mindfulness to target distinct sources of distress in psychosis. The present study presents data fromthe first randomised controlled trial investigating group PBCT in people distressed by hearing voices. One-hundred and eight participants were randomised to receive either...

The experience of hearing distressing voices has recently attracted much attention in the literature on psychological therapies. A new “wave” of therapies is considering voice hearing experiences within a relational framework. However, such therapies may have limited impact if they do not precisely target key psychological variables within the voic...

Sixteen sessions of individual cognitive behavior therapy for people with psychosis (CBTp) is recommended. However, access to CBTp is poor, so the potential of low intensity CBTp (fewer than 16 sessions of face-to-face contact) is being explored. A systematic review and meta-analysis was conducted of 10 controlled trials evaluating low intensity CB...

Adapted mindfulness-based interventions (MBIs) could be of benefit for people distressed by hearing voices. This paper presents a systematic review of studies exploring this possibility and we ask five questions: (1) Is trait mindfulness associated with reduced distress and disturbance in relation to hearing voices? (2) Are MBIs feasible for people...

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore...

Caregivers are at increased risk of poor health but often cannot engage with health care because of practical constraints. Writing therapies such as written emotional disclosure (WED) might represent an accessible therapy for this population. This study aimed to determine whether WED is a suitable therapy for caregivers of people with psychosis. Da...

The purpose of this study was to adapt the 'Voice and You' Scale (VAY) (Hayward, Denney, Vaughan, & Fowler, 2008) to Spanish and explore its psychometric properties for measuring the perceived relationship with voices. A sample of 50 psychiatric patients with verbal auditory hallucinations (48 had a psychotic disorder and two a borderline personali...

Background Obsessive Compulsive Disorder (OCD) is a distressing and debilitating condition affecting 1-2% of the population. Exposure and response prevention (ERP) is a behaviour therapy for OCD with the strongest evidence for effectiveness of any psychological therapy for the condition. Even so, only about half of people offered ERP show recovery...