Article

A treatment protocol to guide the delivery of dialogical engagement with auditory hallucinations: Experience from the Talking With Voices pilot trial

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Abstract

Purpose: To present a treatment protocol for delivering Talking With Voices, a novel intervention for people with psychosis that involves dialogical engagement with auditory hallucinations. Method: This paper presents a manualized approach to therapy employed in the Talking With Voices trial, a feasibility and acceptability randomized control trial of 50 adult participants. A rationale for following a treatment manual is provided, followed by the theoretical underpinnings of the intervention and its principles and values, including the main tenet that voices can often be understood as dissociated parts of the self which serve a protective function by indicating social-emotional vulnerabilities. The four therapy phases for improving the relationship between the voice-hearer and their voices are outlined: (1) engagement and psychoeducation, (2) creating a formulation, (3) dialoguing with voices, and (4) consolidating outcomes, including key milestones at each phase. Implementation issues are discussed, as well as recommendations for best practice and future research. Results: The Talking With Voices treatment protocol indicates that it is feasible to manualize a dissociation-based approach to support service users who are distressed by hearing voices. Conclusion: For some individuals, it is possible to engage in productive dialogue with even extremely hostile or distressing voices. Developing coping strategies, creating a formulation, and ultimately establishing a dialogue with voices has the potential to improve the relationship between voice(s) and voice-hearer. Further research is now required to evaluate feasibility, acceptability, and efficacy. Practitioner points: It is feasible to integrate a dissociation model of voice-hearing within a psychological intervention for people with psychosis. Combining psychosocial education, formulation and direct dialogue can be used to facilitate a more peaceful relationship between clients and their voices. Practitioners trained in other therapeutic modalities can draw on existing transferrable skills to dialogue with their clients' voices. The input of those with lived experience of mental health difficulties has an important role in guiding treatment design and delivery.

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... Moreover, because of the afore-mentioned heterogeneity of madness, clinicians ought to have a large toolbox of treatments and approaches at their disposal. There is some research on alternative approaches such as engaging in dialogue with the voices one hears (Longden et al., 2021), but we should continue to expand the toolbox and study the tools. This is an area where one size is unlikely to fit all. ...
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... Provision of a broader range of trauma therapies is also likely to improve therapy uptake, engagement, and outcomes, and it would be preferable for people to be offered a choice of therapeutic interventions. For example, dialogical approaches, such as Talking with Voices and AVATAR therapy, show promise in supporting people with trauma-related voice hearing, and warrant further investigation (63)(64)(65). ...
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... Similarly, relationally based therapies, such as relating therapy (Hayward et al., 2017;Paulik et al., 2013), the Talking With Voices approach (e.g. Longden et al., 2021), or AVATAR therapy (Craig et al., 2018;Ward et al., 2020) may be indicated where relationships with voices mirror past experiences of discrimination, victimization, or marginalization and this appears to fuel negative content. Large trials that assess negative voice content as an outcome and which use mediation analysis to assess mechanisms of change in therapy would provide increased knowledge in this area. ...
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Objective: People who experience distressing voices frequently report negative (e.g. abusive or threatening) voice content and this is a key driver of distress. There has also been recognition that positive (e.g. reassuring, or guiding) voice content contributes to better outcomes. Despite this, voice content has been neglected as a standalone outcome in evaluations of psychological therapies for distressing voices. We aimed to examine whether a modular cognitive-behavioural therapy (CBT) intervention for voices led to changes in negative and positive voice content. Design/methods: In a naturalistic, uncontrolled pre- and post- service evaluation study, 32 clients at an outpatient psychology service for distressing voices received eight sessions of CBT for distressing voices and completed self-report measures of negative and positive voice content at pre-, mid- and post- therapy. Results: There was no significant change in positive voice content. There was no significant change in negative voice content from pre- to post-therapy; however, there was a significant change in negative voice content between mid and post-treatment in which the cognitive therapy component was delivered. The CBT treatment was also associated with significant changes in routinely reported outcomes of voice-related distress and voice severity. Conclusions: The cognitive component of CBT for distressing voices may be associated with changes in negative, but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content.
... These findings bring additional support to the Making Sense of Voices-approach to therapy (Steel et al., 2020), which advocates engagement and understanding of the voices rather than dampening them with medication. Psychological interventions such as Talking with Voices therapy (Longden et al., 2021) could be useful for increasing resilience, and in helping people to navigate through the new, complex circumstances related to the global pandemic. ...
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... Accordingly, the aim of talking with voices is to comprehend the biography, meaning, and intentions of voices and resolve voice-hearer conflicts (Corstens, Longden, & May, 2012). Studies suggest that, for people experiencing psychosis, Voice Dialogue provides understanding and increased control over voices and reduces voice-related distress (Longden et al., 2021a;Longden et al., 2021b;Schnackenberg, Fleming, Walker, & Martin, 2018;Steel et al., 2020). However, research is yet to explore the applications of Voice Dialogue to voices experienced in other groups. ...
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A proportion of individuals given an eating disorder diagnosis describe the experience of an eating disorder ‘voice’ (EDV). However, methods for working with this experience are currently lacking. Voice Dialogue (Stone & Stone, 1989) involves direct communication between a facilitator and parts of the self to increase awareness, understanding, and separation from inner voices. Adapted forms of this method have shown promise in working with voices in psychosis. This study aimed to explore the experience and acceptability of Voice Dialogue amongst individuals with anorexia nervosa who experience an EDV. Nine women participated in a semi‐structured interview following a single Voice Dialogue session. Interview transcripts were analysed using interpretative phenomenological analysis (IPA). Three overarching themes were identified: (i) “separating from the EDV”; (ii) “better understanding of the EDV”; and (iii) “hopeful, motivated, and afraid of recovery”. The majority of participants found Voice Dialogue acceptable and helpful for exploring their EDV. Whilst preliminary, the results suggest that Voice Dialogue has potential in terms of helping individuals establish a more constructive relationship with their EDV and motivating change. Further research is needed to build upon these findings. Implications for addressing the EDV using voice‐focused interventions are explored.
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There is growing clinical interest in addressing relationship dynamics between service-users and their voices. The Talking With Voices (TwV) trial aimed to establish feasibility and acceptability of a novel dialogical intervention to reduce distress associated with voices amongst adults diagnosed with schizophrenia spectrum disorders. The single-site, single-blind (rater) randomised controlled trial recruited 50 participants who were allocated 1:1 to treatment as usual (TAU), or TAU plus up to 26 sessions of TwV therapy. Participants were assessed at baseline and again at end of treatment (six-months). The primary outcomes were quantitative and qualitative assessments of feasibility and acceptability. Secondary outcomes involved clinical measures, including targeted instruments for voice-hearing, dissociation, and emotional distress. The trial achieved 100 % of the target sample, 24 of whom were allocated to therapy and 26 to TAU. The trial had high retention (40/50 [80 %] participants at six-months) and high intervention adherence (21/24 [87.5 %] receiving ≥8 sessions). Signals of efficacy were shown in targeted measures of voice-hearing, dissociation, and perceptions of recovery. Analysis on the Positive and Negative Syndrome Scale indicated that there were no differences in means of general psychosis symptom scores in TwV compared to the control group. There were four serious adverse events in the therapy group and eight in TAU, none of which were related to study proceedings. The trial demonstrates the acceptability of the intervention and the feasibility of delivering it under controlled, randomised conditions. An adequately powered definitive trial is necessary to provide robust evidence regarding efficacy evaluation and cost-effectiveness. Trial registration: ISRCTN 45308981.
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Evidence suggests that dissociation is associated with psychotic experiences, particularly hallucinations, but also other symptoms. However, until now, symptom-specific relationships with dissociation have not been comprehensively synthesized. This is the first prospectively registered (CRD42017058214) meta-analysis to quantify the magnitude of association between dissociative experiences and all symptoms of psychosis. MEDLINE, PsycINFO, PubMed, and Scopus databases were searched using exhaustive terms denoting dissociation and psychotic symptoms. We included both nonclinical (58 studies; 16 557 participants) and clinical (46 studies; 3879 patient participants) samples and evaluated study quality. Ninety-three eligible articles considering 20 436 participants were retained for analysis. There was a robust association between dissociation and clinical and nonclinical positive psychotic symptoms (r = .437; 95%CI: .386 -.486), with the observed effect larger in nonclinical studies. Symptom-specific associations were also evident across clinical and nonclinical studies, and included significant summary effects for hallucinations (r = .461; 95%CI: .386 -.531), delusions (r = .418; 95%CI: .370 -.464), paranoia (r = .447; 95%CI: .393 -.499), and disorganization (r = .346; 95%CI: .249 -.436). Associations with negative symptoms were small and, in some cases, not significant. Overall, these findings confirm that dissociative phenomena are not only robustly related to hallucinations but also to multiple positive symptoms, and less robustly related to negative symptoms. Our findings are consistent with proposals that suggest certain psychotic symptoms might be better conceptualized as dissociative in nature and support the development of interventions targeting dissociation in formulating and treating psychotic experiences.
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Objective: Increasing evidence suggests experiences of childhood trauma may be causally related to the development of hallucinations. Cognitive theories of psychosis suggest post-traumatic intrusions to be a primary mechanism in this relationship. These theories predict that the content of hallucinations will be related to traumatic experiences; however, few studies have investigated this. This study examined the relationship between childhood trauma, the content of hallucinations, and the content of post-traumatic intrusions in a sample with first-episode psychosis. Methods: Sixty-six young people aged 15-25 experiencing a first episode of psychosis were recruited from an early intervention service. Participants completed assessments of traumatic experiences, hallucination content, and post-traumatic intrusion content using a systematic coding frame. The coding frame assessed for three types of relationships between traumatic experiences, the content of hallucinations, and the content of post-traumatic intrusions: direct relationships (hallucination content exactly matching the trauma/intrusion), thematic relationships (hallucinations with the same themes as the trauma/intrusion), and no relationship (hallucination and trauma/intrusion content unrelated). Results: Of those people who reported trauma and hallucinations (n = 36), 22 of these (61%) experienced post-traumatic intrusions, and of these, 16 (73%) experienced hallucinations that were directly or thematically related to their post-traumatic intrusions. Twelve people experienced hallucination content directly related to their trauma, six of whom (50%) also had intrusions relating to the same traumatic event as their hallucinations. Conclusions: The finding that some people experience hallucinations and post-traumatic intrusions relating to the same traumatic event supports theories proposing a continuum of memory intrusion fragmentation. These results indicate that early intervention services for young people with psychosis should provide assessment and intervention for trauma and PTSD and should consider the impact of past traumatic events on the content of current hallucinatory experience. Practitioner points: Trauma and post-traumatic stress disorder should be assessed in those experiencing a first episode of psychosis. Interventions for trauma should be offered in early intervention for psychosis services. In a notable proportion of people, hallucination content is related to traumatic experiences. Clinical assessment and formulation of hallucinations requires consideration of how past traumatic events may be contributing to hallucinatory experience. It is important for clinicians to have an understanding of the phenomenological differences between hallucinations and post-traumatic intrusions when conducting clinical assessments with people with comorbid psychosis and PTSD.
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Over the past three decades in Maastricht, the Netherlands, psychiatrist Marius Romme and researcher Sandra Escher have developed a new approach to hearing voices which emphasizes accepting and making sense of the experience. Since Romme and Escher's initial work, substantial empirical support has been provided for the Maastricht approach's key propositions. The alternative approach of the Maastricht model is based on helping people make sense of their voices and learning to cope and relate with them. A clinical strategy particularly associated with this endeavour is the Maastricht Hearing Voices Interview (MHVI). In the Voice Dialogue method, every person is viewed as consisting of many individual selves or sub‐personalities, each with its own personal history, physical characteristics, emotional and physical reactions, and ways of perceiving the world. The Maastricht approach rejects the conception of voice hearing as a meaningless pathological symptom and, instead, emphasizes the need to place the experience within an interpersonal context.
Article
NICE guidelines recommend use of treatment protocols that have trial-based evidence of efficacy to guide the delivery of CBT for psychosis. The rationale for using such an approach, and a manual that has been used to ensure fidelity and adherence within six clinical trials, is described. The protocol emphasises principles and values, such as collaborative teamwork, active participation involving between session tasks for service users and therapists and a normalising philosophy, as well as specific milestones such as early agreement of a shared goal, maintenance formulations and use of defined change strategies. Challenges to implementation and methods for promoting good practice are considered and implications for future research and practice are discussed.
Article
Despite the long association between auditory verbal hallucinations (AVH) or voice hearing and schizophrenia, recent research has demonstrated AVH's presence in other disorders and in persons without a diagnosis, particularly amongst those with a history of traumatization. But are there differences in the type of voices between these populations?
Article
Cognitive behavioural therapy for psychosis (CBTp) is, at times, perceived as a technical therapy that undervalues the importance of human relationships and the fundamental principles on which CBTp itself is based (such as collaboration, validation, optimism and recovery-orientated practice). As such, it can be dismissed by service users or practitioners as undesirable. It is also possible that delivering CBTp that does not adhere to these values can be unhelpful or harmful. We review the evidence regarding what service users want from mental health services and the ability of CBTp to meet these standards. Evidence from qualitative studies and randomised controlled trials suggests that CBTp should be delivered in a manner that is both acceptable to, and empowering of, service users. We suggest strategies that are likely to maximise the likelihood of successful implementation that is consistent with both values base and evidence base.
Article
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 centre in the UK. Patients (18+years) with persistent and distressing AH, irrespective of diagnosis were randomly allocated to receive either Relating Therapy and Treatment-as-usual (RT) or Treatment as-usual alone (TAU). Assessment of outcome was completed pre-randomisation (T0), 16weeks post-randomisation (T1) and 36weeks post-randomisation (T2). The primary outcome was the 5-item Distress scale of the Psychotic Symptoms Rating Scale - Auditory Hallucinations (PSYRATS-AHRS) at T1. We randomly assigned 29 patients to receive RT (n=14) or TAU (n=15). Twenty-five patients (86%) provided complete datasets. Compared with TAU, RT led to reductions in AH distress in the large effect size range across T1 and T2. Our findings suggest that Relating Therapy might be effective for reducing AH distress. A larger, suitably powered phase 3 study is needed to provide a precise estimate of the effects of Relating Therapy for AH distress.
Article
Background: There is a need for improved psychosocial interventions for distressed voice hearers. Aims: To evaluate a novel approach to hearing voices: Experience Focused Counselling (EFC) aka Making Sense of Voices. Study design and methods: Twelve voice hearers were randomly assigned to a 44-week EFC or Treatment As Usual intervention as part of a pilot study design. Results: At the end of intervention, EFC showed clinically large treatment effect improvements on the Brief Psychiatric Rating Scale – Expanded Version psychotic symptoms (Cohen’s d=1.6) and overall psychopathology domains (d=1.3), and the Psychotic Symptom Rating Scales voices (d=1) and delusions (aka non-shared reality) (d=1) scales. EFC voice hearers also felt more able to do first trauma disclosures (n=4) than TAU group voice hearer (n=1). Discussion: EFC improvements may have been related to the focus on reducing voices-related distress. EFC holds some promise as a safe and effective intervention for voice hearers, with possible improvements in general psychopathology, psychosis, voices and non-shared reality (aka delusions)-related distress. This will need replicating in more powerful studies.
Chapter
Auditory hallucinations are relatively common in those with chronic trauma disorders (12–98 %). They typically begin after a traumatic event and following the development of trauma-related disorders. They often contain themes related to trauma. Auditory hallucinations in chronic trauma disorders are commonly negative in content, heard inside the head or both inside and outside the head, occur relatively frequently, and cause distress. Those with PTSD who experience auditory hallucinations often have experienced more severe trauma and have a more severe symptom presentation than those who do not experience them. Dissociation, especially depersonalization, has been routinely linked to post-traumatic auditory hallucinations. As a phenomenon, depersonalization may transform mental activity into strange and foreign experiences that manifest as auditory hallucinations. Yet, depersonalization seems unable to account for many of the key features of auditory hallucinations. Structural dissociation at the level of personality, either in isolation or in combination with depersonalization, seems to offer a more complete account of auditory hallucinations in chronic trauma disorders.
Article
There are an increasing number of studies exploring the association between voice-hearing (auditory verbal hallucinations) and dissociative experiences. The current study provides a systematic literature review and meta-analytic synthesis of quantitative studies investigating the relationship between voice-hearing and dissociation. A systematic search identified and included 19 clinical studies, comprising 1620 participants, and 12 non-clinical studies, comprising 2137 participants, published between 1986 and 2014. Nineteen of these studies provided sufficient data to be included within the meta-analysis. The narrative review findings suggested that dissociative experiences may be implicated in voice-hearing, and may potentially be a mediating factor within the well-established trauma and voice-hearing relationship. Similarly, the meta-analytic findings suggested that the majority of the identified studies showed a significant positive relationship between dissociative experiences and voice-hearing. The magnitude of the summary effect was large and significant (r=.52), indicating a robust relationship between these two phenomena. However, considerable heterogeneity within the meta-analytic results and methodological limitations of the identified studies were evident, highlighting areas for future investigation. As the majority of the studies were cross-sectional by design, we recommended future research to include longitudinal designs with a view to exploring directional effects. Additionally, future studies should control for potential confounding factors. Clinical implications of the findings were also considered. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
A cognitive approach to the understanding of psychotic symptoms that focuses on the interpretation of intrusions into awareness is outlined. It is argued that many positive psychotic symptoms (such as hallucinations and delusions) can be conceptualized as intru-sions into awareness or culturally unacceptable interpretations of such intrusions, and that it is the interpretation of these intrusions that causes the associated distress and disability. It is also argued that the nature of these interpretations is affected by faulty self and social knowledge and that both the intrusions and their interpretations are maintained by mood, physiology, and cognitive and behavioural responses (including selective attention, safety behaviours and counterproductive control strategies). The literature is reviewed and found to be compatible with such a model and the clinical implications are discussed.
Article
A substantial proportion of Borderline Personality Disorder (BPD) patients respond by a marked decrease of psychopathology when treated with Dialectical Behavioral Therapy (DBT). To further enhance the rate of DBT-response, it is useful to identify characteristics related to unsatisfactory response. As DBT relies on emotional learning, we explored whether dissociation-which is known to interfere with learning- predicts poor response to DBT. Fifty-seven Borderline Personality Disorder (BPD) patients (DSM-IV) were prospectively observed during a three-month inpatient DBT program. Pre-post improvements in general psychopathology (SCL-90-R) were predicted from baseline scores of the Dissociative Experiences Scale (DES) by regression models accounting for baseline psychopathology. High DES-scores were related to poor pre-post improvement (β = -0.017 ± 0.006, p = 0.008). The data yielded no evidence that some facets of dissociation are more important in predicting DBT-response than others. The results suggest that dissociation in borderline-patients should be closely monitored and targeted during DBT. At this stage, research on treatment of dissociation (e.g., specific skills training) is warranted.
Article
Although an association between hallucinations and sexual abuse has been documented, the relation between specifically auditory verbal hallucinations (AVHs) and childhood sexual abuse (CSA) is less clear. This study reviewed quantitative studies of AVHs and CSA. 36% of psychiatric patients with AVHs, and 22% of non-psychiatric patients with AVHs, reported CSA. At least 16% of the general population with auditory hallucinations also reported CSA. The majority of studies reviewed found that those with AVHs were more likely to be survivors of CSA than individuals without AVHs. 56% of psychiatric patients with CSA reported AVHs, and at least 21% of the general population with CSA reported auditory hallucinations. A majority of studies found survivors of CSA were more likely to report AVHs than individuals without CSA. Ability to impute a causal role for CSA was impaired by such studies' failures to control for potentially confounding variables. Yet, studies of AVH content showed links between the content of voices and the content of CSA in some voice-hearers. It is concluded that although a clear association between CSA and AVHs exists, there is not yet reliable quantitative evidence of a causal relation. Implications for mental health professionals and for future research, are discussed.
Article
We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations.
Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology
  • D. Corstens
  • S. Escher
  • M. Romme
  • E. Longden
EMDR and dissociation. The progressive approach
  • A. Gonzalez
  • D. Mosquera
Psychosis as a personal crisis: An experience based approach
  • D. Corstens
  • R. May
  • E. Longden
Coping with trauma‐related dissociation: Skills training for patients and therapists
  • S. Boon
  • K. Steele
  • O. Hart
Attachment theory and psychosis: Current perspectives and future directions
  • E. Longden
  • D. Corstens
Embracing our selves: The Voice Dialogue training manual
  • H. Stone
  • S. Stone
Embracing your inner critic: Turning self‐criticism into a creative asset
  • H. Stone
  • S. Stone
Making sense of voices: A guide for mental health professionals working with voice‐hearers
  • M. Romme
  • S. Escher
Trauma model therapy: A treatment approach to trauma, dissociation, and complex comorbidity
  • C. A. Ross
  • N. Halpern