New dialogues on voices

Cognitive behavioural therapy has long been accepted as a valid therapeutic intervention for people who hear voices. So what does the future hold for more radical approaches, such as voice dialogue, asks Adam James

Rewind to 1993. It was the year Accepting Voices by Professor Marius Romme and Sandra Escher was published.

The book argued that voices (aka aural hallucinations) experienced by people diagnosed with psychosis should be accepted as real. Don’t pathologise and seek to rid people of voices. Better, help people cope with them, they argued.

Some professionals were truly alarmed. In the British Medical Journal, Raymond Cochrane, a professor of psychology, slammed the book’s message as “potentially dangerous”. It meant colluding with delusions, he argued

In April last year the scientific community was similarly perturbed. This time after clinical psychologist Rufus May was shown on a television documentary using “voice dialogue” to help a voice-hearer. Directly communicating with the voices of a woman diagnosed with bipolar disorder was one of the psychological interventions Dr May used.

Dr May was also “dangerous” and should be reported to the British Psychological Society, NHS psychiatrists wrote on the bulletin board of One of Dr May’s colleagues at Bradford NHS Trust joined the fray, accusing May of “flagrant self promotion”. “Don’t let him [Dr May] near me if I become mentally ill,” weighed in Lisa Brownell, a psychiatrist at Queen Elizabeth Psychiatric Hospital in Birmingham.

But supporters of voice dialogue – involving conversing with a person’s voices to understand that person’s life experiences and the voices’ “motives” – point to some similarities it has not only with traditional cognitive behavioural therapy (CBT) but with a new wave of CBT techniques. These include Person-Based Cognitive Therapy (PBCT), Dialectical Behaviour Therapy, Acceptance and Commitment Therapy, and Relationship Theory. The solid “evidence-base” of CBT was recognised seven years ago when the National Institute for Health and Clinical Excellence (Nice) recommended it be available for all people diagnosed with schizophrenia.

PBCT is being largely developed by Paul Chadwick, professor of psychology at the University of Southampton, PBCT ushers in “substantial developments” on traditional CBT for psychosis, he says. Noticeably, it’s a further de-medicalisation of therapy because PBCT aims to alleviate “distress”, not disease “symptoms”. PBCT – while utilising core CBT tools – also employs a Buddhist form of meditation called mindfulness to help a hearer create distance between his/herself and the voice(s).

Relational therapy, being developed by researchers such as Mark Hayward, a clinical psychologist at the University of Surrey, is another CBT spin-off. When applied to voice-hearing, a therapist uses “Socratic dialogue”, “guided discovery” and again mindfulness in helping a person gain a more “balanced, interpersonal relationship” with their voice(s). Like voice dialogue – and indeed CBT and PBCT – relation therapists do “accept” a person’s voice(s) as real and meaningful. But, unlike voice dialogue, the therapist need have no direct conversation with a person’s voice(s), instead using role play.

“Relationship theory does not need the voice to be present,” says Dr Haywood. “But I will role-play the voice or hearer and may encourage the hearer to respond more assertively to a hostile voice. So, rather than step into a relationship with the voice, I encourage someone to step back from the voice.”

But voice dialogue supporters emphasise that voice hearers are in a perpetual relationship with their voices, often continually conversing with them. A third person relating directly to the voice can bring benefits. Dr May says: “For many people the most troubling thing is for the hearer to be alone with their voice. With someone else hearing what the voice says it means the voice is being witnessed [by someone else] – this can be validating and assuring. While some cognitive approaches might mindfully step back from the voices, voice dialogue can be seen as mindfully engaging with voices. But I’ll only talk to the voice if it actually helps the person, and voice dialogue is only one of many ways I might try and help someone.”

Dr Dirk Corstens, a psychiatrist and psychotherapist from Maastricht, Holland, who for 10 years has been running voice dialogue workshops for UK mental health professionals says: “Instead of using role play I talk to the voices. Often a person will talk all day to their voices. Voices can give important information about a person’s life.”

What of the evidence base for these approaches? Well only mall scale studies have been completed on the therapies evolved from CBT. But Dr Haywood is planning a bigger six-group randomised controlled study for relational therapy with people diagnosed with schizophrenia. “Growth in this area is slow,” he says. ““But I think these approaches are going to be more effective, and will have a bigger impact than CBT. All we can do is work with the momentum we have, and try to take people with us.”

As for voice dialogue, there have been no formal studies. Yet, Dr Corstens is putting together research with 30 people with a schizophrenia diagnosis. “I hope in four years time I’ll have something to show,” he says.

All this will be too late for the Nice guidelines on schizophrenia, due to be re-issued later this year. Again only traditional CBT is expected to be discussed.

And some CBT adherents, such as consultant psychiatrist Lynne Drummond, head of the cognitive behavioural psychotherapy unit at South West London and St George’s Mental Health NHS Trust remain mightily wary of new-wave CBT approaches and voice dialogue. “Sure, we need to push the boundaries of what does and does not work. But these theories need to cut the mustard. I could have a theory that voices are caused by caffeine and people need to detoxify from it. Family members of people with schizophrenia will cling to anything – so we need to stick with what is proven.”

Dr May, meanwhile, argues that Prof Romme and Sandra Escher’s small-scale studies published in Accepting Voices, justify voice dialogue. “Voice-hearers who are coping with their voices have some positive relationship with their voices. I’m basing it on that evidence,” he says.

As importantly, adds Dr May, who was himself diagnosed with schizophrenia when aged 18, voice dialogue is supported by many in the service user movement. Plus, it provides carers, relatives, friends and users with a jargon-free method to help people.

“A caring relative or friend can use voice dialogue with a couple of days training,” says Dr May. “Unlike CBT, it’s not stipulated that voice dialogue is only for professionals. You do not need a degree or diploma. It’s not a therapy, as such. It’s a way to help people deal with their voices. I’m interested in how knowledge in mental health can be redistributed, rather han being something only professionals have.”

While many service users and professionals rallied to support Dr May after the television documentary, the hostile responses served to again underline the deep divisions in mental health. As if to confirm this, Mind, Britain’s biggest mental health charity, shortlisted Dr May as its Mind champion of the year for “challenging discrimination” against people with mental health problems.


‘Proud to be a voice-hearer’

Eleanor Longden, 27, has for two years been a service user development worker for an early intervention in psychosis team in Bradford. A voice-hearer, she was diagnosed with paranoid schizophrenia when a teenager. She has helped develop a voice dialogue manual which is available at

I had a good understanding and control of my voices before I got my present job. I had achieved resolution with my voices. But before that I had struggled with aggressive voices for a long time. I was a troubled and fragile teenager, and getting diagnosed and seeing myself as a psychiatric patients compounded those feelings.

One thing that helped me with my voices was meeting a social psychiatrist called Pat Bracken. He was the first person who saw beyond the diagnosis of schizophrenia. He related to me as a person, and did not treat me as if I had a biological aberration. He introduced me to the Accepting Voices book by Marius Romme and Sondra Escher.

Whereas traditional psychiatry sees silencing voices as part of its “cure” response, voice dialogue technique requires an understanding and acceptance of voices – the recovery response. Having your voice-hearing experience being treated as meaningful and interpretable is so empowering.

To prepare the manual Rufus [May] practised voice dialogue with my voices. Having Rufus speak assertively to the most hostile of my voices was of immense help.

Looking back, I was too young to be told I had a lifelong condition and would be on medication for the rest of my life. Seeing voice-hearing as meaningful and being linked to your life history is a complete alternative. I had a lot of unresolved trauma and stress. And my voices were a metaphor for this. Even the most aggressive voice carried messages – and it makes no sense to shoot the messenger.

At the time the most negative and hostile voices represented how I felt about myself, my self esteem. I understand my voices as parts of myself. And if I am stressed and anxious the voices get worse. But this is nothing more sinister than my mum getting a headache when she is stressed. I am proud to be a voice hearer.

* This article first appeared in Mental Health Today magazine

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