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

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.

Interviewing anorexia: How do individuals given a diagnosis of anorexia nervosa experience Voice Dialogue with their eating disorder voice? A qualitative analysis

“…Much like other clinical groups who describe voice‐like experiences (e.g., individuals diagnosed with psychosis; Longden, Corstens, Morrison, et al, 2021; Schnackenberg, Fleming, Walker, & Martin, 2018), satisfaction with Voice Dialogue was generally high amongst individuals in this study. Participants felt that the dialogical process provided insights into the functions, intentions, consequences, and vulnerabilities underlying their EDV.…”

“…Accordingly, the aim of talking with voices is to comprehend the biography, meaning, and intentions of voices and resolve voice‐hearer conflicts (Corstens et al, 2012). Studies suggest that, for people experiencing psychosis, Voice Dialogue provides understanding and increased control over voices and reduces voice‐related distress (Longden, Corstens, Morrison, et al, 2021; Longden, Corstens, Pyle, et al, 2021; 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.…”

The memory and identity theory of ICD-11 complex posttraumatic stress disorder.

“…Therapy for individuals diagnosed with psychosis who experience auditory hallucinations can similarly use dialogical methods that attempt to correct fear or passivity when hearing voices and create a more constructive relationship with them. The aim is to understand the role of the voices and relate to them as useful rather than problematic parts of the self that are the products of the individual’s life history (Longden et al, 2021). The creation of a comprehensive mental model of the self is part of mentalization treatment for BPD, which recognizes that an inability to mentalize leads to major problems in affect regulation (Bateman & Fonagy, 2010).…”

Changes in positive and negative voice content in cognitive‐behavioural therapy for distressing voices

“…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.…”