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Psychology and Psychotherapy: Theory, Research and Practice (2021), 94, 558–572
© 2021 The British Psychological Society
www.wileyonlinelibrary.com
A treatment protocol to guide the delivery of
dialogical engagement with auditory
hallucinations: Experience from the Talking With
Voices pilot trial
Eleanor Longden*1,2,3
, Dirk Corstens4
, Anthony P. Morrison1,2
,
Amanda Larkin1
, Elizabeth Murphy1
, Natasha Holden1
, Ann Steele1
,
Alison Branitsky1,2,3
and Samantha Bowe1
1
Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust,
UK
2
Division of Psychology and Mental Health, School of Health Sciences, Faculty of
Biology, Medicine and Health, Manchester Academic Health Science Centre, The
University of Manchester, UK
3
Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health
NHS Foundation Trust, UK
4
GGZ Noord-Holland Noord, Texel/den Helder, The Netherlands
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
*Correspondence should be addressed to Eleanor Longden, Psychosis Research Unit, Greater Manchester Mental Health NHS
Foundation Trust, Harrop House, Bury New Road, Prestwich M25 3BL, UK (email: Eleanor.Longden@gmmh.nhs.uk).
Trial Registration: ISRCTN 45308981
DOI:10.1111/papt.12331
558
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.
Despite longstanding associations with psychiatric illness, there is growing recognition
that voice-hearing (‘auditory hallucinations’) is a psychosocially meaningful event with
manifest associations between adverse life events and the content of, and responses to,
the voices people hear (Corstens  Longden, 2013; McCarthy-Jones, 2011; Peach et al.,
2020). In turn, a proportion of individuals may also experience dynamic relationships
with their voices, perceiving them as distinct and separate from their sense of self (Dorahy
 Palmer, 2016; McCarthy-Jones et al., 2014; Romme, Escher, Dillon, Corstens,  Morris,
2009). Correspondingly, an emergent wave of treatment strategies is placing greater
emphasis on the interpersonal aspects of voice-hearing. These include compassion-
focused techniques (Heriot-Maitland, McCarthy-Jones, Longden,  Gilbert, 2019);
Progressive Approach psychotherapy, which facilitates an attitude of acceptance and
empathy from the reflective ‘Adult Self’ to the distressed ‘experiencing self’ (Gonzalez 
Mosquera, 2012; Mosquera  Ross, 2017); Avatar therapy, a dialogical approach that
incorporates digital representations of hostile voices (Leff, Williams, Huckvale, Arbuth-
not,  Leff, 2014); Relating Therapy, which addresses ‘power’ and ‘proximity’ dynamics
between hearer and voice (Hayward, Jones, Bogen-Johnston, Thomas,  Strauss, 2017)
and Cognitive Behavioral Therapy for psychosis (CBTp), which examines how
psychosocial dynamics can influence voice phenomenology (Tai  Turkington, 2009).
Taken together, these approaches expand traditional views of voices as merely perceptual
anomalies by explicitly acknowledging the impact of the hearer–voice relationship both
in maintaining distress and promoting recovery.
Talking With Voices (TwV) is one such intervention which incorporates recent
advances for understanding voices in more relational terms. Specifically, it draws from a
growing clinical/conceptual position that voices, at least for some individuals, may be
understood as dissociated parts of the self which serve a protective function by indicating
social and emotional vulnerabilities (see Longden, Moskowitz, Dorahy,  Perona-
Garcel
an, 2019; Moskowitz, Mosquera,  Longden, 2017). Within this framework, voices
can be considered a dialogical experience: ‘self-positions imbued with intentionality and
shaped by one’s unique interpersonal circumstances [in a way which] highlights the
interaction between subjective mental experience and external social influence’
(Longden et al., 2019; p. 216). This premise is expanded upon elsewhere (Longden
et al., 2019; Perona-Garcel
an, P
erez-
Alvarez, Garc
ıa-Montes,  Cangas, 2015) but
essentially presents a rationale for moving beyond models of hallucinations primarily
based in cognitive/perceptual dysfunction; instead considering voices as a dynamic
embodiment of social, emotional and interpersonal influences which are often
Talking with voices therapy protocol 559
experienced as subjectively real states of consciousness. Correspondingly, positioning
voices as dialogical provides a framework for verbally engaging with them as a possible
way to decrease conflict and promote a process of understanding and reconciliation.
Although dialogical engagement with voices is employed and promoted within the
survivor-led Hearing Voices Movement (HVM: Corstens, Longden, McCarthy-Jones,
Waddingham,  Thomas, 2014), evidence from clinical services remains in development.
In addition to the TwV study, empirical investigations are limited to a case series (n = 15;
Steel et al., 2019), and a small randomized control trial ([RCT] n = 12; Schnackenberg,
Fleming,  Martin, 2017); yet while not all participants report a positive experience of
communicating with voices (Steel et al., 2020), this emerging evidence-base suggests
provisional signals of efficacy and no indications for adverse events. It is hoped these
results can be further refined through definitive, clinical and cost-effectiveness trials. As
such, TwV is currently being evaluated in a single-blind feasibility and acceptability RCT in
which 50 participants with a diagnosis of psychosis are allocated to receive either
treatment as usual (TAU), or TAU plus up to 26 sessions of TwV over six months.
Experience from the therapy team, qualitative participant feedback and empirical
measures of recruitment and retention so far suggest that it is an acceptable treatment
option to offer patients, and below we offer our impressions of engaging in psychother-
apeutic dialogues with the voices people hear.
Overview of the protocol
Talking With Voices follows four phases for working with clients: engagement and
psychoeducation, formulation, dialogical work, and consolidating outcomes. While
dialogue is the focus, it is important to acknowledge that voice engagement is something
many individuals naturally undertake without any kind of formal therapeutic input.
However, the conceptual/theoretical background for TwV is inspired by Voice Dialogue,
a therapeutic approach developed by Stone and Stone (1989, 1993). Within this model, all
individuals are considered to contain different subpersonalities, or Selves, each of which
possess their own physical, emotional, and cognitive characteristics and ways of relating
to the environment. These Selves are believed to develop in response to formative social
and emotional circumstances and are arranged in opposites: ‘primary’ Selves, which
emerge as dominant; and ‘disowned’ Selves, which become suppressed. Their expansion
and compartmentalization are deemed a protective process to promote attachment and
avoid social rejection, and Voice Dialogue aims to facilitate healthy functioning by
experiencing and acknowledging the different Selves and understanding their develop-
mental perspective.
In contrast, voices are often experienced as autonomous entities who impose on the
hearer rather than as personality parts (although the overlap between voices and
dissociated structures observed in dissociative identity disorder is also noted: Moskowitz
et al., 2017). Nevertheless, TwV is derived from the same premise as Voice Dialogue, in
that contact is established with voice(s) in order to understand more about what they are
trying to achieve through their interactions with the voice-hearer. Consistent with the
growing emphasis on voices as a dissociative experience (Longdenet al., 2020; Moskowitz
 Corstens, 2007; Pilton, Varese, Berry,  Bucci, 2015), the model offers a comparative
view of ego-dystonic voices as disowned (or dissociated) selves which relate to adversity
in the voice-hearer’s life and offer an adaptive function by signposting unresolved
emotional vulnerabilities (sometimes in a metaphorical way). Gaining a different
560 Eleanor Longden et al.
perspective on what the voices are expressing can, therefore, help develop a more
peaceful, empathic way of relating to the Self that decreases internal conflict (Ross 
Halpern, 2009). As such, the intervention aims to develop a more constructive
relationship by (1) reducing hostility, (2) promoting cooperation and communication,
and (3) providing an increased awareness of the voices’ protective role. In turn, and
consistent with existing cognitive models (Birchwood et al., 2004; Chadwick 
Birchwood, 1994; Morrison, 2001), it is expected that reducing negative beliefs and
attributions for the voice(s) are central for a corresponding reduction in distress.
Therapeutic principles and values
Talking With Voices adheres to general best-practice principles for psychological therapy
with psychosis patients, including building collaborative relationships, developing shared
goals, using inclusive language, validating individual experiences, and providing hope
that recovery is possible (Brabban et al., 2017). In turn, these principles underpin many of
the specific values of TwV, which are outlined below.
As discussed previously, dialogical approaches are already established within the
HVM, an influential initiative derived from the work of Romme and Escher (1993, 2000)
that promotes a psychosocial, person-centred approach to the voice-hearing experience
(see Corstens et al., 2014). TwV is, therefore, guided by many of these same core values.
Firstly, it incorporates a normalising approach by acknowledging voices as a common
human experience that may cause distress but from which many people recover.
However, it is important to note that the concept of ‘recovery’ within the HVM is not
defined by cessation of clinical symptoms; instead, an emphasis is placed on reducing
distress and promoting positive goals, with full recognition that individuals can live
fulfilling lives as voice-hearers (Romme et al., 2009). It is also a user-led intervention,
where clients have a central role for determining the pace and goals of therapy and
identifying the most useful strategies to cope with their experiences. In this regard, a
subjective interpretative framework for understanding voices (e.g., trauma-based,
spiritual, cultural) is also respected, and the therapist works within that mindset without
insisting their clinical perspective is the correct one (Corstens, Escher, Romme, 
Longden, 2019; Longden  Corstens, 2020).
There are also additional values rooted in the theoretical framework within which
TwV is based. Primarily, it understands voices, including hostile or derogatory ones, as
representing parts of the self that ultimately serve a protective purpose. These parts
(which may or may not occur with the level of structural dissociation linked with
dissociative identity disorder: van der Hart, Nijenhuis,  Steele, 2011) may often originate
in traumatic events and/or reflect overwhelming emotion along with negative beliefs
about oneself, other people, and the world. The core of the intervention is to use emerging
information about the voices’ ‘purpose’ in a way that facilitates a more peaceful
relationship. Voices’ comments are therefore seen as meaningful in the sense of drawing
attention to unresolved distress, and it is considered valuable to explore the protective
role they have played in the person’s life and understand how features such as persecution
or aggression are often masks for unresolved pain. In this respect voices often originate in
overwhelming situations (and are frequently rejected by the voice-hearer), so are forced to
communicate in ways that are hostile, critical, or otherwise extreme in order to be noticed
(Romme  Escher, 2000). Because attempts to suppress the voice may also suppress the
emotions/beliefs which they embody, a complementary goal is therefore to help the voice
Talking with voices therapy protocol 561
communicate its purpose and needs in ways that are more constructive and respectful of
the voice-hearer. Indeed, as noted by Mosquera and Ross (2017), ‘any approach that
implies getting rid of the voices or ignoring them, only creates more internal conflict. The
greater the [. . .] conflict, the greater the dissociative barriers need to be and the less
integrative capacities the patients develop’ (p. 168).
Protocol phases
Adherence to a therapy manual may be associated with several positive outcomes,
including service-user satisfaction and improved treatment effects (Morrison, 2017). It is
additionally important in a research context for reliability/validity and assists the
dissemination and replication of therapies in clinical settings, as well as being
advantageous for therapist training/supervision, promoting consistency, examining
therapy acceptability, and determining whether milestones are achievable. However,
despite these benefits, adhering to a manual should not mean sessions are delivered in
didactic fashion or inhibit creativity on the part of the therapist. The therapeutic
relationship remains paramount and a competent, well-trained practitioner can be skilled
at adhering to a manual while remaining responsive to client needs and delivering
individualized therapy with empathy and respect.
The phases and associated milestones of TwV were offered in 26 hourly sessions over
6 months (see Table 1). As discussed, it is important to apply these in a flexible,
customised manner and variations should be expected in session attendance, as well as
their length/frequency and the pace (and potentially order) in which milestones are
attained. The five therapists delivering the intervention were clinical psychologists
specializing in CBTp, all of whom had previously worked on RCTs and whose practice
experience post-qualification ranged from 3 to 18 years (mean length = 7.4 years). They
received eight-day training and fortnightly supervision from the trial’s chief investigator
(EL), a lived experience researcher (AB), and a psychiatrist with experience of the
technique (DC). To maximize fidelity, adherence checklists and electronic session
records were utilized, with any protocol divergences monitored during supervision.
Unless requested otherwise, therapy was conducted in client homes in a manner
consistent with assertive outreach practice.
Phase 1: Engagement and psychosocial education
The start of therapy focuses on engagement and psychosocial education, with an
emphasis on normalizing voice-hearing and providing literature on coping and recovery.
It also covers an explanation/negotiation of the protocol, including confidentiality,
logistics, and the basic premise of the intervention, as well as a discussion of the client’s
presenting difficulties, treatment history, and beliefs about their voices. Further time is
spent establishing a sense of safety and refining self-soothing/coping techniques in
preparation for more in-depth emotional exploration. Following initial discussions, this
latter area should then be regularly revisited throughout subsequent sessions.
Because many people feel a degree of shame about their experiences, it is important
for therapists to model from the outset that it is normal to have conversations about voice-
hearing. In turn, a key component of this early stage is establishing an alliance with the
voices by emphasizing that the therapist does not intend to act in a hostile way or attempt
to banish them; rather, the aim is to facilitate a more constructive relationship through an
562 Eleanor Longden et al.
Table 1. Therapy phases and associated milestones for Talking With Voices
Phase
Approximate
session number Therapy milestones
Engagement and
psychosocial
education
1–2 Establishing client contact and explaining intervention
Discussing experiences of, and beliefs about, hearing voices
Normalizing and destigmatizing voice-hearing
Psychosocial education focusing on the relationship
between voice-hearing, life circumstances and negative
emotions
Establishing an alliance with the voices
Commencing development of self-care and
coping/grounding skills
Assessment and
formulation
3–5 Developing a construct that encompasses all the voices a
person hears
Where applicable, explore renaming voices with less
negative/derogatory names
Based on the construct, have a shared understanding of (1)
who or what the voices represent, and (2) what difficulties
the voices represent
6 Make a report of the construct and have a conversation
about the report
7 Reiterating therapy aims
Planning which voices to speak with and the issues to
explore
Gaining voices’ permission to dialogue
Developing acceptable shared goals for dialogue
Establishing the client’s capacity to regain control and pre-
agreeing a signal for ending the dialogue
Identifying an ally within the client’s social network and/or
health care team to attend the final sessions
Dialogical work 8–23 Collaboratively setting between-session tasks
Establishing boundaries for the voice via ‘time-sharing’
Encouraging voices to use therapy sessions as a space to
express their own frustrations, rather than harassing the
client during the week
Achieving a direct dialogue with the voices
Developing short replies/mantras that the client can use
between sessions in response to the voices’ concerns
Evaluation and
consolidation
24–26 If desired/available, assist the client to access a local HVN
peer-support group and provide signposting to relevant
local services
Handover session with identified family member and/or
health care worker for support to take the work forward
Create a collaborative summary of what was achieved
during therapy and identify strategies/goals for the future
(e.g., continue time-sharing, using respectful langue, not
obeying commands, self-soothing)
Talking with voices therapy protocol 563
increased understanding of their concerns and their role in the client’s life. This requires
sensitive negotiation, as many voice-hearers understandably wish to eradicate their
voices. However, we have found that this is not necessarily a realistic aim, at least in the
short-term, and can ultimately create further conflict between hearer and voice.
Phase 2: Assessment and formulation
The second phase applies a standardized method known as ‘the construct’ as a means of
psychological formulation (Romme  Escher, 2000). This involves the therapist and client
co-constructing a shared understanding of the psychosocial conflicts represented by the
voices, as well as developmental events that may havepredisposed a vulnerability to voice-
hearing and/or created difficulties in tolerating and regulating strong emotions. An
emphasis is placed on experiences of abuse and adversity, and therapists should help
clients prepare for the emotional challenges of these conversations. Likewise, the client
should not be pressured into disclosing information before they are ready (for highly
dissociative clients, it may also be the case that such events are initially inaccessible and
are subsequently disclosed by the voices).
Detailed descriptions of the construct method are available elsewhere (Corstens et al.,
2019; Longden et al., 2012). In summary, it focuses on the voices’ (1) identity and
characteristics, including gender, age, emotional valence, frequency, and content; (2)
their emotional and social triggers; (3) their history, including the circumstances in which
they first arose and whether they have changed over time; and (4) the life history of the
voice-hearer. The final construct should encompass all the voices a person hears, but in
case of time constraints should prioritize the most problematic ones. The method’s final
goal is twofold: to have a shared understanding of who or what the voices represent and to
elucidate what problems or challenges they might embody.
Phase 3: Dialogical work
Dialogue is the intervention’s main focus and is guided by frameworks developed in the
previous phases: specifically, that voice-hearing often relates to adversity and that voices,
including threatening or critical ones, have a protective function in terms of indicating
underlying vulnerabilities. The overarching aim of this work is toimprove the hearer-voice
relationship through developing more positive communication styles, increasing the
client’s sense of empowerment, increasing understanding towards the voices, and
identifying the voice’s goals (i.e., their protective functions) while exploring how they can
be supported to achieve these in ways that are more constructive and less distressing for
the voice-hearer. Three main methods are employed for achieving this: (1) between-
session tasks; (2) role-play, which entails practicing communicating with the voices in the
session; and (3) the therapist communicating with the voices by requesting the voice-
hearer repeat their responses, either directly or by paraphrasing.
Although many people resist distressing voices, a common result of such avoidance is
that the voices intensify their attempts to gain the person’s notice, often through
increasingly disruptive behaviours. A main goal of between-session tasks is therefore to
establish a sense of control for the client while reinforcing feelings of safety, practicing
self-soothing techniques, and facilitating change strategies. One such task is ‘time-
sharing’, where clients set specific daily slots to listen to their voices on the condition that
the voices cannot expect their attention outside the allotted ‘meeting’. A further
technique focused on boundary-setting and assertiveness is developing short replies,
564 Eleanor Longden et al.
which the client can use to acknowledge the voices’ presence without being drawn into a
distressing exchange (e.g., ‘I know you’re trying to tell me something you feel is
important, but I can’t discuss that right now’). The voices’ concerns can then be explored
later with the support of the therapist. Other between-session techniques include diary-
keeping, the use of visual imagery, and practicing grounding and self-soothing techniques.
The client may also set tasks for the therapist, such as collecting specific information (e.g.,
self-help leaflets, contact details for local services), researching a relevant topic (e.g., a
certain cultural practice/belief), or arranging requested meetings (e.g., with a religious
leader or police officer). Any tasks should be collaboratively agreed upon and regularly
reviewed in-session.
Prior to beginning dialogue, shared goals should be developed that are meaningful,
achievable, and mutually acceptable for both voices and voice-hearer (e.g., a goal ‘to get
rid of the voices’ is one that the voices themselves are unlikely to cooperate with). These
will typically be related to a greater understanding of why a voice behaves the way it does,
which in turn is often linked to developing longer-term goals for reducing distress and
enhancing quality of life. Role-play may be used in advance to increase the client’s
confidence and familiarity with the concept of engaging with voices, which might include
improvising a voice’s comments, practicing how to respond to the voice in a constructive
way, or engaging with one of the Selves in the manner of Voice Dialogue.
In advance of the allotted session, therapist and client will decide which voices to
speak with and the specific issues to explore. However, it is generally better to not begin
with the most vulnerable voices, as the dominant voice (whose role is to protect the
person’s vulnerabilities) may grow threatened and aggressive. The client’s ability to regain
control is likewise ascertained in advance, and a pre-agreed signal to end the dialogue
(including the use of a ‘panic button’ metaphor) can also be explored. Before dialogue
commences, it is also important to re-emphasize that the aim is simply to explore the
voices’ perspective, not to try to change or eradicate them. The therapy session is a space
focused not just on the reactions and needs of the client, but also of the voices; therapists
should therefore acknowledge the role the voices have played in the client’s life, ask the
voices questions about how they feel about what is going on, and use a respectful language
and tone. Permission to dialogue should likewise be sought from the voices in addition to
the voice-hearer, and consent should be re-established during every session.
Dialogue itself can be applied either directly or indirectly. In the indirect method, the
therapist begins a conversation by asking the client to paraphrase the voice’s responses
whereas direct dialogue involves the client repeating its words verbatim. It may be easier
to start with indirect dialogue; however, with the client and voice’s permission, it is
recommended to use the direct method so the voice can express itself more fully. When
the dialogue is ready to begin, the therapist invites the client to move their chair to a
desired place in the room and then welcomes the voice (if the client does not wish to
move, then the therapist can change positions instead). The conversation is conducted in
an open, committed way and after the questions have been answered the therapist thanks
the voice for its explanations. Initial queries can focus on the identity and purpose of the
voice, the relationship it has with the client and, where appropriate, the relationship
between the voices and the therapist. Some potential questions are outlined in Table 2.
Once dialogue is underway, specific questions will vary based on the identity and purpose
of the voice, as well as the mutual goals established by the voice and voice-hearer.
Examples of such dialogues are provided in more detail by Corstens, Longden, and May
(2012), Corstens, May, and Longden (2012) and Longden and Corstens (2020).
Talking with voices therapy protocol 565
At the close of the conversation, the client and therapist reflect on what occurred and
discuss any new insights or questions. The therapist may summarize what s/he
experienced and check this interpretation with the client. Based on what content arose,
future conversations can be planned and more specific between-session tasks can be set.
For highly dissociative clients, we have found that audio-recording can be a useful way to
assist processing the events of the session.
Phase 4: Evaluation and consolidation
The final sessions provide time for the client, therapist, and voices to collaboratively
review their progress, discuss ways of consolidating new knowledge, and develop
monitoring and action plans for future difficulties, including planning tasks with the voice
(s). A written summary of this discussion is then provided by the therapist. The
penultimate session is delivered in collaboration with a supporter(s) of the client’s
choosing (e.g., a friend, family member and/or health care worker) to help facilitate
continuity of the approach and establish shared goals and strategies. However, the final
session is reserved for the client, voices, and therapist to privately review and reflect on
their experiences and to say goodbye to one another. At this stage, clients will also be
supported to access local HVM peer-support groups, if available and/or desired.
Implementation issues
Current indications from the feasibility trial suggest that TwV can be delivered within
clinical services as a complement to routine care. The main challenges include those
Table 2. Potential questions to ask a voice when beginning a dialogue
Area of enquiry Example questions
Voice identity and function [Client] told me your name was X; do you agree?
How do you feel at the moment?
When did you first come into [client’s] life? Why?
What is your task/role?
What would happen in [client’s] life if you weren’t present?
Relationship between voice and voice-
hearer
What’s it like being a part of [client’s] life?
How does [client] relate to you and how do you relate to
them?
How would [client] behave/feel if you weren’t there?
Do you have any advice for [client]?
Do you need anything from [client]?
Is there anything you would like to change in your
relationship
with [client]?
Do you want to change anything more generally?
Relationship between voices Do you know the other voices?
How do you relate to them? How do they relate to you?
Relationship between voice and therapist Do you have any questions for me?
Is there anything you think I could help you with?
Would you like me to give a message to [client]?
Would you like to speak with me again?
566 Eleanor Longden et al.
applicable to psychological therapies for psychosis more generally, such as training and
supervision of therapists, client motivation, establishing a therapeutic relationship, and
difficulties with attention and memory. There are also issues more specific to the protocol,
which are discussed further below.
Trauma and dissociation
Dissociation is known to affect therapy outcomes across different modalities and
presenting difficulties (Jepsen, Langeland,  Heir, 2013; Kleindienst et al., 2011; Resick,
Suvak, Johnides, Mitchell,  Iverson, 2012). In turn, it is our experience that core beliefs
resulting from trauma exposure (e.g., ‘The world is dangerous’, ‘I’m a bad person’,
‘Other people cannot be trusted’) are often embodied in voice content. Precautions
should therefore be taken to help clients facilitate an ongoing sense of safety before and
during the dialogue. This includes awareness from the therapist of interactions between
different parts of the person’s internal system (e.g., perpetrator-identified voices in
relation to child voices), an understanding of the impact of dissociated memories and
beliefs, knowledge of appropriate soothing/grounding strategies, and the ability to
monitor emotional responses during the session (see Boon, Steele,  van der Hart, 2011).
In many cases, psychoeducation and normalization of the impact of trauma may also be
required. In this regard, it is important to remember that a sense of safety is a fundamental
principle from which all subsequent work is conducted.
Voices refuse to dialogue
Voices are often wary of engaging with a therapist, so time must be spent acknowledging
their presence and building an alliance with them in tandem to that developed with the
voice-hearer. Where necessary, this should also include proactively addressing voices’
beliefs that therapists want to get rid of them. However, if the voice continuously refuses
to dialogue no pressure should be exerted. Instead, both voice and voice-hearer should be
reassured that it is not their fault if this method is not right for them and that other therapy
approaches are available which may suit them better. Flexibility should be employed
wherever possible, and we have used several strategies for maintaining communication
which include role-play, indirect dialogue, therapists acknowledging the voices’ presence
during each session, drawing/writing messages to give to the therapist, and asking the
voice-hearer to provide translation for a voice that did not speak English. If clients
themselves choose not to dialogue, then role-play techniques can likewise be employed.
However, if this proves unacceptable, the decision must be respected and the therapist
can place a greater focus on the protocol’s formulation and psychosocial education
aspects as a substitute, or instead refer to alternative therapeutic approaches.
Perpetrator voices
Therapists may feel apprehensive about engaging with voices that are strongly identified
with a real-life perpetrator. However, it is our experience that these voices still perform a
protective function (e.g., by taking on the role of aggressor in preference to feeling
victimized, pre-emptively criticizing to avoid external disapproval, drawing attention to
unprocessed emotions, and/or being primed to detect potential sources of threat: see
Moskowitz et al., 2017; Mosquera  Ross, 2017; Ross  Halpern, 2009). In turn, it may
often be the case that very hostile, dominant voices represent the most wounded parts of
Talking with voices therapy protocol 567
the person’s internal system and are ultimately in need of the most compassion and
reassurance (Heriot-Maitland et al. 2019). It is our experience that voices do not inevitably
claim to be a real-life perpetrator when asked directly about their identity. However, they
can often replicate messages that were learnt from real-life aggressors, and it can be
helpful to explore ways of framing them as ‘copies’ or ‘screenshots’ to introduce a sense of
distance: that is, that despite surface similarities, the voices’ role is to embody feelings and
beliefs about what happened as opposed to being the ‘actual’ perpetrator. As noted by
Romme and Escher (1993, 2000), voices are both ‘the problem and the solution’ in that
while their function is to protect the person, this paradoxically occurs in a way that causes
significant distress. As such, a voice that is identified with a real-life aggressor is likely to
have internalized these external messages and thus have a limited repertoire of emotional
responses/strategies with which to achieve its goals. However, as described by Mosquera
and Ross (2017), even very aggressive voices will often prove responsive to attempts to
increase safety and learn more positive ways to protect the voice-hearer.
An important exception to this are voices which cannot dialogue and communicate
solely with repetitive statements. A conversant voice implies a degree of co-conscious-
ness; thus, it can be understood as being internally generated as part of the Self to fulfil a
protective function. In contrast, more explicitly memory-based voices have been
externally imposed on the person and, with the exception of drawing attention to
unresolved conflict, have a narrower psychological role. These voices are less complex
and therefore more suitably addressed with broader trauma-informed techniques than
direct attempts at engagement. They are also not conceptualized as protective in the way
described above. However, if the client is amenable, then time can still be spent with
reassurancethat such voices are a commonresponse toadversity and represent the mind’s
tenacity in attempting to process an overwhelming event.
Distressed voices
Distressed voices are those which ostensibly express high levels of fear, shame and/or
guilt. They may also be experienced in a child-like way, and therapists are advised to match
the ‘energy’ of different voices with a suitable tone and demeanour: assertive yet
respectful with a hostile voice, and soothing and age-appropriate with a more vulnerable
one. For the latter, we also advise caution with language that may be triggering for child
grooming (e.g., ‘You should trust me’ or ‘You’re a good girl’). In this respect, if a voice
wishes to reveal abuse, consideration should be given to the effect on the whole system.
For example, a voice identified with a perpetrator may feel threatened by such a
disclosure, as might voices which have internalized real-life threats of retaliation for
speaking out. It is important to cultivate a sense of safety for distressed voices and various
methods can be employed to assist this, including the use of imagery, flash cards, reading
aloud, colouring books, transitional objects like blankets or soft toys, or grounding items
such as a reassuring photograph. In time, we have found it may often be possible to
facilitate an alliance between different voices, wherein the dominant ones learn to adopt a
comforting or supportive role on behalf of the voice-hearer and/or more distressed voices.
Systemic issues
In may sometimes be the case that clients are exposed to external situations which can
hinder therapeutic progress. For example, they may receive contradictory explanatory
messages about their experiences from health care staff (e.g., as a symptom of disease) or
568 Eleanor Longden et al.
their community (e.g., as a sign of demonic possession). They may also live in unsafe
housing or in proximity to abusive individuals. In such instances potential for progress can
be limited, although time should still be spent developing coping strategies, providing
psychoeducation, and signposting towards alternative sources of support. Offering a
choice for therapy venue is often advantageous, as is confirming prior access to health and
social services (including safeguarding) to ensure client well-being and avoid the session
being overtaken with care coordination duties.
Beliefs about voices
People with strong convictions about their voices (e.g., that they are electronic
communications) may be especially wary or sceptical of the rationale for dialoguing. It is
important to work within a client’s belief system at all times and to not impose a
psychological framework that is inconsistent with their preference. However, it is our
experience that changing causal beliefs is unnecessary for successful dialogue. Instead, it
can be beneficial to frame the voices (whatever their perceived origin) as being in a
relationship with the voice-hearer, in which the goal is simply to improve the relationship.
Conclusions
Talking With Voices is a user-informed intervention guided by the ethos of the HVM and
the work of Romme and Escher (1993, 2000) which draws upon dissociation theory and
the Voice Dialogue model (Stone  Stone, 1989) to propose that the concept of disowned
and primary Selves can be applied to understanding auditory hallucinations, specifically as
a form of mental compartmentalization that arises in response to adversity. The protocol
has specific phases and milestones and aims to improve the hearer–voice relationship via
normalization; increasing a person’s understanding of their voices, including the life
events and conflicts they might represent; and dialoguing with voices to achieve shared
goals. A strong emphasis is also placed on developing adequate coping strategies, along
with creating a collaborative formulation, before embarking upon dialogue work. Taken
together, it is intended that these components can increase patient benefit while
minimizing the likelihood of adverse effects.
Talking With Voices is part of a growing range of therapeutic models which emphasize
the value of interpersonal, relational, and dialogical principles for supporting voice-
hearers (including those with a diagnosis of psychosis/schizophrenia). However, it is
important to note that the current trial is only the first step in establishing an evidence-
base for this novel approach. Further research is required to demonstrate cost-
effectiveness and treatment efficacy, as well as refining ways that the method could be
used in routine practice to complement established interventions, such as CBTp.
However, our protocol suggests that it is possible to manualize a dissociation-based model
to support psychosis patients with distressing auditory hallucinations and that this is a
feasible and acceptable treatment option to implement within formal health care settings.
Overall, it is hoped that future work can contribute to continued understanding of the role
of relational dynamics in facilitating recovery from distressing voices.
Talking with voices therapy protocol 569
Acknowledgements
Eleanor Longden is funded by a National Institute for Health Research (NIHR) Postdoctoral
Fellowship Scheme for this research project (PDF-2017-10-050). This paper presents
independent research funded by the NIHR: the views expressed are those of the authors
and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.
The study was facilitated by the Greater Manchester Local Clinical Research Network. The
authors would like to thank Dr. Jacqui Dillon of the English Hearing Voices Network and the
members of the Psychosis Research Unit’s Service User Reference Group for their valuable
feedback on the trial’s therapy manual.
Conflicts of interest
Three authors (EL, DC, and AB) have received financial payments for delivering teaching
and/or supervision on the Talking With Voices approach. There are no other reported
conflicts of interest.
Data availability statement
Data sharing is not applicable to this article as no new data were created or analysed in this
study.
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A treatment protocol to guide the delivery of

  • 1. Psychology and Psychotherapy: Theory, Research and Practice (2021), 94, 558–572 © 2021 The British Psychological Society www.wileyonlinelibrary.com A treatment protocol to guide the delivery of dialogical engagement with auditory hallucinations: Experience from the Talking With Voices pilot trial Eleanor Longden*1,2,3 , Dirk Corstens4 , Anthony P. Morrison1,2 , Amanda Larkin1 , Elizabeth Murphy1 , Natasha Holden1 , Ann Steele1 , Alison Branitsky1,2,3 and Samantha Bowe1 1 Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, UK 2 Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, UK 3 Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, UK 4 GGZ Noord-Holland Noord, Texel/den Helder, The Netherlands 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 *Correspondence should be addressed to Eleanor Longden, Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Harrop House, Bury New Road, Prestwich M25 3BL, UK (email: Eleanor.Longden@gmmh.nhs.uk). Trial Registration: ISRCTN 45308981 DOI:10.1111/papt.12331 558
  • 2. 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. Despite longstanding associations with psychiatric illness, there is growing recognition that voice-hearing (‘auditory hallucinations’) is a psychosocially meaningful event with manifest associations between adverse life events and the content of, and responses to, the voices people hear (Corstens Longden, 2013; McCarthy-Jones, 2011; Peach et al., 2020). In turn, a proportion of individuals may also experience dynamic relationships with their voices, perceiving them as distinct and separate from their sense of self (Dorahy Palmer, 2016; McCarthy-Jones et al., 2014; Romme, Escher, Dillon, Corstens, Morris, 2009). Correspondingly, an emergent wave of treatment strategies is placing greater emphasis on the interpersonal aspects of voice-hearing. These include compassion- focused techniques (Heriot-Maitland, McCarthy-Jones, Longden, Gilbert, 2019); Progressive Approach psychotherapy, which facilitates an attitude of acceptance and empathy from the reflective ‘Adult Self’ to the distressed ‘experiencing self’ (Gonzalez Mosquera, 2012; Mosquera Ross, 2017); Avatar therapy, a dialogical approach that incorporates digital representations of hostile voices (Leff, Williams, Huckvale, Arbuth- not, Leff, 2014); Relating Therapy, which addresses ‘power’ and ‘proximity’ dynamics between hearer and voice (Hayward, Jones, Bogen-Johnston, Thomas, Strauss, 2017) and Cognitive Behavioral Therapy for psychosis (CBTp), which examines how psychosocial dynamics can influence voice phenomenology (Tai Turkington, 2009). Taken together, these approaches expand traditional views of voices as merely perceptual anomalies by explicitly acknowledging the impact of the hearer–voice relationship both in maintaining distress and promoting recovery. Talking With Voices (TwV) is one such intervention which incorporates recent advances for understanding voices in more relational terms. Specifically, it draws from a growing clinical/conceptual position that voices, at least for some individuals, may be understood as dissociated parts of the self which serve a protective function by indicating social and emotional vulnerabilities (see Longden, Moskowitz, Dorahy, Perona- Garcel an, 2019; Moskowitz, Mosquera, Longden, 2017). Within this framework, voices can be considered a dialogical experience: ‘self-positions imbued with intentionality and shaped by one’s unique interpersonal circumstances [in a way which] highlights the interaction between subjective mental experience and external social influence’ (Longden et al., 2019; p. 216). This premise is expanded upon elsewhere (Longden et al., 2019; Perona-Garcel an, P erez- Alvarez, Garc ıa-Montes, Cangas, 2015) but essentially presents a rationale for moving beyond models of hallucinations primarily based in cognitive/perceptual dysfunction; instead considering voices as a dynamic embodiment of social, emotional and interpersonal influences which are often Talking with voices therapy protocol 559
  • 3. experienced as subjectively real states of consciousness. Correspondingly, positioning voices as dialogical provides a framework for verbally engaging with them as a possible way to decrease conflict and promote a process of understanding and reconciliation. Although dialogical engagement with voices is employed and promoted within the survivor-led Hearing Voices Movement (HVM: Corstens, Longden, McCarthy-Jones, Waddingham, Thomas, 2014), evidence from clinical services remains in development. In addition to the TwV study, empirical investigations are limited to a case series (n = 15; Steel et al., 2019), and a small randomized control trial ([RCT] n = 12; Schnackenberg, Fleming, Martin, 2017); yet while not all participants report a positive experience of communicating with voices (Steel et al., 2020), this emerging evidence-base suggests provisional signals of efficacy and no indications for adverse events. It is hoped these results can be further refined through definitive, clinical and cost-effectiveness trials. As such, TwV is currently being evaluated in a single-blind feasibility and acceptability RCT in which 50 participants with a diagnosis of psychosis are allocated to receive either treatment as usual (TAU), or TAU plus up to 26 sessions of TwV over six months. Experience from the therapy team, qualitative participant feedback and empirical measures of recruitment and retention so far suggest that it is an acceptable treatment option to offer patients, and below we offer our impressions of engaging in psychother- apeutic dialogues with the voices people hear. Overview of the protocol Talking With Voices follows four phases for working with clients: engagement and psychoeducation, formulation, dialogical work, and consolidating outcomes. While dialogue is the focus, it is important to acknowledge that voice engagement is something many individuals naturally undertake without any kind of formal therapeutic input. However, the conceptual/theoretical background for TwV is inspired by Voice Dialogue, a therapeutic approach developed by Stone and Stone (1989, 1993). Within this model, all individuals are considered to contain different subpersonalities, or Selves, each of which possess their own physical, emotional, and cognitive characteristics and ways of relating to the environment. These Selves are believed to develop in response to formative social and emotional circumstances and are arranged in opposites: ‘primary’ Selves, which emerge as dominant; and ‘disowned’ Selves, which become suppressed. Their expansion and compartmentalization are deemed a protective process to promote attachment and avoid social rejection, and Voice Dialogue aims to facilitate healthy functioning by experiencing and acknowledging the different Selves and understanding their develop- mental perspective. In contrast, voices are often experienced as autonomous entities who impose on the hearer rather than as personality parts (although the overlap between voices and dissociated structures observed in dissociative identity disorder is also noted: Moskowitz et al., 2017). Nevertheless, TwV is derived from the same premise as Voice Dialogue, in that contact is established with voice(s) in order to understand more about what they are trying to achieve through their interactions with the voice-hearer. Consistent with the growing emphasis on voices as a dissociative experience (Longdenet al., 2020; Moskowitz Corstens, 2007; Pilton, Varese, Berry, Bucci, 2015), the model offers a comparative view of ego-dystonic voices as disowned (or dissociated) selves which relate to adversity in the voice-hearer’s life and offer an adaptive function by signposting unresolved emotional vulnerabilities (sometimes in a metaphorical way). Gaining a different 560 Eleanor Longden et al.
  • 4. perspective on what the voices are expressing can, therefore, help develop a more peaceful, empathic way of relating to the Self that decreases internal conflict (Ross Halpern, 2009). As such, the intervention aims to develop a more constructive relationship by (1) reducing hostility, (2) promoting cooperation and communication, and (3) providing an increased awareness of the voices’ protective role. In turn, and consistent with existing cognitive models (Birchwood et al., 2004; Chadwick Birchwood, 1994; Morrison, 2001), it is expected that reducing negative beliefs and attributions for the voice(s) are central for a corresponding reduction in distress. Therapeutic principles and values Talking With Voices adheres to general best-practice principles for psychological therapy with psychosis patients, including building collaborative relationships, developing shared goals, using inclusive language, validating individual experiences, and providing hope that recovery is possible (Brabban et al., 2017). In turn, these principles underpin many of the specific values of TwV, which are outlined below. As discussed previously, dialogical approaches are already established within the HVM, an influential initiative derived from the work of Romme and Escher (1993, 2000) that promotes a psychosocial, person-centred approach to the voice-hearing experience (see Corstens et al., 2014). TwV is, therefore, guided by many of these same core values. Firstly, it incorporates a normalising approach by acknowledging voices as a common human experience that may cause distress but from which many people recover. However, it is important to note that the concept of ‘recovery’ within the HVM is not defined by cessation of clinical symptoms; instead, an emphasis is placed on reducing distress and promoting positive goals, with full recognition that individuals can live fulfilling lives as voice-hearers (Romme et al., 2009). It is also a user-led intervention, where clients have a central role for determining the pace and goals of therapy and identifying the most useful strategies to cope with their experiences. In this regard, a subjective interpretative framework for understanding voices (e.g., trauma-based, spiritual, cultural) is also respected, and the therapist works within that mindset without insisting their clinical perspective is the correct one (Corstens, Escher, Romme, Longden, 2019; Longden Corstens, 2020). There are also additional values rooted in the theoretical framework within which TwV is based. Primarily, it understands voices, including hostile or derogatory ones, as representing parts of the self that ultimately serve a protective purpose. These parts (which may or may not occur with the level of structural dissociation linked with dissociative identity disorder: van der Hart, Nijenhuis, Steele, 2011) may often originate in traumatic events and/or reflect overwhelming emotion along with negative beliefs about oneself, other people, and the world. The core of the intervention is to use emerging information about the voices’ ‘purpose’ in a way that facilitates a more peaceful relationship. Voices’ comments are therefore seen as meaningful in the sense of drawing attention to unresolved distress, and it is considered valuable to explore the protective role they have played in the person’s life and understand how features such as persecution or aggression are often masks for unresolved pain. In this respect voices often originate in overwhelming situations (and are frequently rejected by the voice-hearer), so are forced to communicate in ways that are hostile, critical, or otherwise extreme in order to be noticed (Romme Escher, 2000). Because attempts to suppress the voice may also suppress the emotions/beliefs which they embody, a complementary goal is therefore to help the voice Talking with voices therapy protocol 561
  • 5. communicate its purpose and needs in ways that are more constructive and respectful of the voice-hearer. Indeed, as noted by Mosquera and Ross (2017), ‘any approach that implies getting rid of the voices or ignoring them, only creates more internal conflict. The greater the [. . .] conflict, the greater the dissociative barriers need to be and the less integrative capacities the patients develop’ (p. 168). Protocol phases Adherence to a therapy manual may be associated with several positive outcomes, including service-user satisfaction and improved treatment effects (Morrison, 2017). It is additionally important in a research context for reliability/validity and assists the dissemination and replication of therapies in clinical settings, as well as being advantageous for therapist training/supervision, promoting consistency, examining therapy acceptability, and determining whether milestones are achievable. However, despite these benefits, adhering to a manual should not mean sessions are delivered in didactic fashion or inhibit creativity on the part of the therapist. The therapeutic relationship remains paramount and a competent, well-trained practitioner can be skilled at adhering to a manual while remaining responsive to client needs and delivering individualized therapy with empathy and respect. The phases and associated milestones of TwV were offered in 26 hourly sessions over 6 months (see Table 1). As discussed, it is important to apply these in a flexible, customised manner and variations should be expected in session attendance, as well as their length/frequency and the pace (and potentially order) in which milestones are attained. The five therapists delivering the intervention were clinical psychologists specializing in CBTp, all of whom had previously worked on RCTs and whose practice experience post-qualification ranged from 3 to 18 years (mean length = 7.4 years). They received eight-day training and fortnightly supervision from the trial’s chief investigator (EL), a lived experience researcher (AB), and a psychiatrist with experience of the technique (DC). To maximize fidelity, adherence checklists and electronic session records were utilized, with any protocol divergences monitored during supervision. Unless requested otherwise, therapy was conducted in client homes in a manner consistent with assertive outreach practice. Phase 1: Engagement and psychosocial education The start of therapy focuses on engagement and psychosocial education, with an emphasis on normalizing voice-hearing and providing literature on coping and recovery. It also covers an explanation/negotiation of the protocol, including confidentiality, logistics, and the basic premise of the intervention, as well as a discussion of the client’s presenting difficulties, treatment history, and beliefs about their voices. Further time is spent establishing a sense of safety and refining self-soothing/coping techniques in preparation for more in-depth emotional exploration. Following initial discussions, this latter area should then be regularly revisited throughout subsequent sessions. Because many people feel a degree of shame about their experiences, it is important for therapists to model from the outset that it is normal to have conversations about voice- hearing. In turn, a key component of this early stage is establishing an alliance with the voices by emphasizing that the therapist does not intend to act in a hostile way or attempt to banish them; rather, the aim is to facilitate a more constructive relationship through an 562 Eleanor Longden et al.
  • 6. Table 1. Therapy phases and associated milestones for Talking With Voices Phase Approximate session number Therapy milestones Engagement and psychosocial education 1–2 Establishing client contact and explaining intervention Discussing experiences of, and beliefs about, hearing voices Normalizing and destigmatizing voice-hearing Psychosocial education focusing on the relationship between voice-hearing, life circumstances and negative emotions Establishing an alliance with the voices Commencing development of self-care and coping/grounding skills Assessment and formulation 3–5 Developing a construct that encompasses all the voices a person hears Where applicable, explore renaming voices with less negative/derogatory names Based on the construct, have a shared understanding of (1) who or what the voices represent, and (2) what difficulties the voices represent 6 Make a report of the construct and have a conversation about the report 7 Reiterating therapy aims Planning which voices to speak with and the issues to explore Gaining voices’ permission to dialogue Developing acceptable shared goals for dialogue Establishing the client’s capacity to regain control and pre- agreeing a signal for ending the dialogue Identifying an ally within the client’s social network and/or health care team to attend the final sessions Dialogical work 8–23 Collaboratively setting between-session tasks Establishing boundaries for the voice via ‘time-sharing’ Encouraging voices to use therapy sessions as a space to express their own frustrations, rather than harassing the client during the week Achieving a direct dialogue with the voices Developing short replies/mantras that the client can use between sessions in response to the voices’ concerns Evaluation and consolidation 24–26 If desired/available, assist the client to access a local HVN peer-support group and provide signposting to relevant local services Handover session with identified family member and/or health care worker for support to take the work forward Create a collaborative summary of what was achieved during therapy and identify strategies/goals for the future (e.g., continue time-sharing, using respectful langue, not obeying commands, self-soothing) Talking with voices therapy protocol 563
  • 7. increased understanding of their concerns and their role in the client’s life. This requires sensitive negotiation, as many voice-hearers understandably wish to eradicate their voices. However, we have found that this is not necessarily a realistic aim, at least in the short-term, and can ultimately create further conflict between hearer and voice. Phase 2: Assessment and formulation The second phase applies a standardized method known as ‘the construct’ as a means of psychological formulation (Romme Escher, 2000). This involves the therapist and client co-constructing a shared understanding of the psychosocial conflicts represented by the voices, as well as developmental events that may havepredisposed a vulnerability to voice- hearing and/or created difficulties in tolerating and regulating strong emotions. An emphasis is placed on experiences of abuse and adversity, and therapists should help clients prepare for the emotional challenges of these conversations. Likewise, the client should not be pressured into disclosing information before they are ready (for highly dissociative clients, it may also be the case that such events are initially inaccessible and are subsequently disclosed by the voices). Detailed descriptions of the construct method are available elsewhere (Corstens et al., 2019; Longden et al., 2012). In summary, it focuses on the voices’ (1) identity and characteristics, including gender, age, emotional valence, frequency, and content; (2) their emotional and social triggers; (3) their history, including the circumstances in which they first arose and whether they have changed over time; and (4) the life history of the voice-hearer. The final construct should encompass all the voices a person hears, but in case of time constraints should prioritize the most problematic ones. The method’s final goal is twofold: to have a shared understanding of who or what the voices represent and to elucidate what problems or challenges they might embody. Phase 3: Dialogical work Dialogue is the intervention’s main focus and is guided by frameworks developed in the previous phases: specifically, that voice-hearing often relates to adversity and that voices, including threatening or critical ones, have a protective function in terms of indicating underlying vulnerabilities. The overarching aim of this work is toimprove the hearer-voice relationship through developing more positive communication styles, increasing the client’s sense of empowerment, increasing understanding towards the voices, and identifying the voice’s goals (i.e., their protective functions) while exploring how they can be supported to achieve these in ways that are more constructive and less distressing for the voice-hearer. Three main methods are employed for achieving this: (1) between- session tasks; (2) role-play, which entails practicing communicating with the voices in the session; and (3) the therapist communicating with the voices by requesting the voice- hearer repeat their responses, either directly or by paraphrasing. Although many people resist distressing voices, a common result of such avoidance is that the voices intensify their attempts to gain the person’s notice, often through increasingly disruptive behaviours. A main goal of between-session tasks is therefore to establish a sense of control for the client while reinforcing feelings of safety, practicing self-soothing techniques, and facilitating change strategies. One such task is ‘time- sharing’, where clients set specific daily slots to listen to their voices on the condition that the voices cannot expect their attention outside the allotted ‘meeting’. A further technique focused on boundary-setting and assertiveness is developing short replies, 564 Eleanor Longden et al.
  • 8. which the client can use to acknowledge the voices’ presence without being drawn into a distressing exchange (e.g., ‘I know you’re trying to tell me something you feel is important, but I can’t discuss that right now’). The voices’ concerns can then be explored later with the support of the therapist. Other between-session techniques include diary- keeping, the use of visual imagery, and practicing grounding and self-soothing techniques. The client may also set tasks for the therapist, such as collecting specific information (e.g., self-help leaflets, contact details for local services), researching a relevant topic (e.g., a certain cultural practice/belief), or arranging requested meetings (e.g., with a religious leader or police officer). Any tasks should be collaboratively agreed upon and regularly reviewed in-session. Prior to beginning dialogue, shared goals should be developed that are meaningful, achievable, and mutually acceptable for both voices and voice-hearer (e.g., a goal ‘to get rid of the voices’ is one that the voices themselves are unlikely to cooperate with). These will typically be related to a greater understanding of why a voice behaves the way it does, which in turn is often linked to developing longer-term goals for reducing distress and enhancing quality of life. Role-play may be used in advance to increase the client’s confidence and familiarity with the concept of engaging with voices, which might include improvising a voice’s comments, practicing how to respond to the voice in a constructive way, or engaging with one of the Selves in the manner of Voice Dialogue. In advance of the allotted session, therapist and client will decide which voices to speak with and the specific issues to explore. However, it is generally better to not begin with the most vulnerable voices, as the dominant voice (whose role is to protect the person’s vulnerabilities) may grow threatened and aggressive. The client’s ability to regain control is likewise ascertained in advance, and a pre-agreed signal to end the dialogue (including the use of a ‘panic button’ metaphor) can also be explored. Before dialogue commences, it is also important to re-emphasize that the aim is simply to explore the voices’ perspective, not to try to change or eradicate them. The therapy session is a space focused not just on the reactions and needs of the client, but also of the voices; therapists should therefore acknowledge the role the voices have played in the client’s life, ask the voices questions about how they feel about what is going on, and use a respectful language and tone. Permission to dialogue should likewise be sought from the voices in addition to the voice-hearer, and consent should be re-established during every session. Dialogue itself can be applied either directly or indirectly. In the indirect method, the therapist begins a conversation by asking the client to paraphrase the voice’s responses whereas direct dialogue involves the client repeating its words verbatim. It may be easier to start with indirect dialogue; however, with the client and voice’s permission, it is recommended to use the direct method so the voice can express itself more fully. When the dialogue is ready to begin, the therapist invites the client to move their chair to a desired place in the room and then welcomes the voice (if the client does not wish to move, then the therapist can change positions instead). The conversation is conducted in an open, committed way and after the questions have been answered the therapist thanks the voice for its explanations. Initial queries can focus on the identity and purpose of the voice, the relationship it has with the client and, where appropriate, the relationship between the voices and the therapist. Some potential questions are outlined in Table 2. Once dialogue is underway, specific questions will vary based on the identity and purpose of the voice, as well as the mutual goals established by the voice and voice-hearer. Examples of such dialogues are provided in more detail by Corstens, Longden, and May (2012), Corstens, May, and Longden (2012) and Longden and Corstens (2020). Talking with voices therapy protocol 565
  • 9. At the close of the conversation, the client and therapist reflect on what occurred and discuss any new insights or questions. The therapist may summarize what s/he experienced and check this interpretation with the client. Based on what content arose, future conversations can be planned and more specific between-session tasks can be set. For highly dissociative clients, we have found that audio-recording can be a useful way to assist processing the events of the session. Phase 4: Evaluation and consolidation The final sessions provide time for the client, therapist, and voices to collaboratively review their progress, discuss ways of consolidating new knowledge, and develop monitoring and action plans for future difficulties, including planning tasks with the voice (s). A written summary of this discussion is then provided by the therapist. The penultimate session is delivered in collaboration with a supporter(s) of the client’s choosing (e.g., a friend, family member and/or health care worker) to help facilitate continuity of the approach and establish shared goals and strategies. However, the final session is reserved for the client, voices, and therapist to privately review and reflect on their experiences and to say goodbye to one another. At this stage, clients will also be supported to access local HVM peer-support groups, if available and/or desired. Implementation issues Current indications from the feasibility trial suggest that TwV can be delivered within clinical services as a complement to routine care. The main challenges include those Table 2. Potential questions to ask a voice when beginning a dialogue Area of enquiry Example questions Voice identity and function [Client] told me your name was X; do you agree? How do you feel at the moment? When did you first come into [client’s] life? Why? What is your task/role? What would happen in [client’s] life if you weren’t present? Relationship between voice and voice- hearer What’s it like being a part of [client’s] life? How does [client] relate to you and how do you relate to them? How would [client] behave/feel if you weren’t there? Do you have any advice for [client]? Do you need anything from [client]? Is there anything you would like to change in your relationship with [client]? Do you want to change anything more generally? Relationship between voices Do you know the other voices? How do you relate to them? How do they relate to you? Relationship between voice and therapist Do you have any questions for me? Is there anything you think I could help you with? Would you like me to give a message to [client]? Would you like to speak with me again? 566 Eleanor Longden et al.
  • 10. applicable to psychological therapies for psychosis more generally, such as training and supervision of therapists, client motivation, establishing a therapeutic relationship, and difficulties with attention and memory. There are also issues more specific to the protocol, which are discussed further below. Trauma and dissociation Dissociation is known to affect therapy outcomes across different modalities and presenting difficulties (Jepsen, Langeland, Heir, 2013; Kleindienst et al., 2011; Resick, Suvak, Johnides, Mitchell, Iverson, 2012). In turn, it is our experience that core beliefs resulting from trauma exposure (e.g., ‘The world is dangerous’, ‘I’m a bad person’, ‘Other people cannot be trusted’) are often embodied in voice content. Precautions should therefore be taken to help clients facilitate an ongoing sense of safety before and during the dialogue. This includes awareness from the therapist of interactions between different parts of the person’s internal system (e.g., perpetrator-identified voices in relation to child voices), an understanding of the impact of dissociated memories and beliefs, knowledge of appropriate soothing/grounding strategies, and the ability to monitor emotional responses during the session (see Boon, Steele, van der Hart, 2011). In many cases, psychoeducation and normalization of the impact of trauma may also be required. In this regard, it is important to remember that a sense of safety is a fundamental principle from which all subsequent work is conducted. Voices refuse to dialogue Voices are often wary of engaging with a therapist, so time must be spent acknowledging their presence and building an alliance with them in tandem to that developed with the voice-hearer. Where necessary, this should also include proactively addressing voices’ beliefs that therapists want to get rid of them. However, if the voice continuously refuses to dialogue no pressure should be exerted. Instead, both voice and voice-hearer should be reassured that it is not their fault if this method is not right for them and that other therapy approaches are available which may suit them better. Flexibility should be employed wherever possible, and we have used several strategies for maintaining communication which include role-play, indirect dialogue, therapists acknowledging the voices’ presence during each session, drawing/writing messages to give to the therapist, and asking the voice-hearer to provide translation for a voice that did not speak English. If clients themselves choose not to dialogue, then role-play techniques can likewise be employed. However, if this proves unacceptable, the decision must be respected and the therapist can place a greater focus on the protocol’s formulation and psychosocial education aspects as a substitute, or instead refer to alternative therapeutic approaches. Perpetrator voices Therapists may feel apprehensive about engaging with voices that are strongly identified with a real-life perpetrator. However, it is our experience that these voices still perform a protective function (e.g., by taking on the role of aggressor in preference to feeling victimized, pre-emptively criticizing to avoid external disapproval, drawing attention to unprocessed emotions, and/or being primed to detect potential sources of threat: see Moskowitz et al., 2017; Mosquera Ross, 2017; Ross Halpern, 2009). In turn, it may often be the case that very hostile, dominant voices represent the most wounded parts of Talking with voices therapy protocol 567
  • 11. the person’s internal system and are ultimately in need of the most compassion and reassurance (Heriot-Maitland et al. 2019). It is our experience that voices do not inevitably claim to be a real-life perpetrator when asked directly about their identity. However, they can often replicate messages that were learnt from real-life aggressors, and it can be helpful to explore ways of framing them as ‘copies’ or ‘screenshots’ to introduce a sense of distance: that is, that despite surface similarities, the voices’ role is to embody feelings and beliefs about what happened as opposed to being the ‘actual’ perpetrator. As noted by Romme and Escher (1993, 2000), voices are both ‘the problem and the solution’ in that while their function is to protect the person, this paradoxically occurs in a way that causes significant distress. As such, a voice that is identified with a real-life aggressor is likely to have internalized these external messages and thus have a limited repertoire of emotional responses/strategies with which to achieve its goals. However, as described by Mosquera and Ross (2017), even very aggressive voices will often prove responsive to attempts to increase safety and learn more positive ways to protect the voice-hearer. An important exception to this are voices which cannot dialogue and communicate solely with repetitive statements. A conversant voice implies a degree of co-conscious- ness; thus, it can be understood as being internally generated as part of the Self to fulfil a protective function. In contrast, more explicitly memory-based voices have been externally imposed on the person and, with the exception of drawing attention to unresolved conflict, have a narrower psychological role. These voices are less complex and therefore more suitably addressed with broader trauma-informed techniques than direct attempts at engagement. They are also not conceptualized as protective in the way described above. However, if the client is amenable, then time can still be spent with reassurancethat such voices are a commonresponse toadversity and represent the mind’s tenacity in attempting to process an overwhelming event. Distressed voices Distressed voices are those which ostensibly express high levels of fear, shame and/or guilt. They may also be experienced in a child-like way, and therapists are advised to match the ‘energy’ of different voices with a suitable tone and demeanour: assertive yet respectful with a hostile voice, and soothing and age-appropriate with a more vulnerable one. For the latter, we also advise caution with language that may be triggering for child grooming (e.g., ‘You should trust me’ or ‘You’re a good girl’). In this respect, if a voice wishes to reveal abuse, consideration should be given to the effect on the whole system. For example, a voice identified with a perpetrator may feel threatened by such a disclosure, as might voices which have internalized real-life threats of retaliation for speaking out. It is important to cultivate a sense of safety for distressed voices and various methods can be employed to assist this, including the use of imagery, flash cards, reading aloud, colouring books, transitional objects like blankets or soft toys, or grounding items such as a reassuring photograph. In time, we have found it may often be possible to facilitate an alliance between different voices, wherein the dominant ones learn to adopt a comforting or supportive role on behalf of the voice-hearer and/or more distressed voices. Systemic issues In may sometimes be the case that clients are exposed to external situations which can hinder therapeutic progress. For example, they may receive contradictory explanatory messages about their experiences from health care staff (e.g., as a symptom of disease) or 568 Eleanor Longden et al.
  • 12. their community (e.g., as a sign of demonic possession). They may also live in unsafe housing or in proximity to abusive individuals. In such instances potential for progress can be limited, although time should still be spent developing coping strategies, providing psychoeducation, and signposting towards alternative sources of support. Offering a choice for therapy venue is often advantageous, as is confirming prior access to health and social services (including safeguarding) to ensure client well-being and avoid the session being overtaken with care coordination duties. Beliefs about voices People with strong convictions about their voices (e.g., that they are electronic communications) may be especially wary or sceptical of the rationale for dialoguing. It is important to work within a client’s belief system at all times and to not impose a psychological framework that is inconsistent with their preference. However, it is our experience that changing causal beliefs is unnecessary for successful dialogue. Instead, it can be beneficial to frame the voices (whatever their perceived origin) as being in a relationship with the voice-hearer, in which the goal is simply to improve the relationship. Conclusions Talking With Voices is a user-informed intervention guided by the ethos of the HVM and the work of Romme and Escher (1993, 2000) which draws upon dissociation theory and the Voice Dialogue model (Stone Stone, 1989) to propose that the concept of disowned and primary Selves can be applied to understanding auditory hallucinations, specifically as a form of mental compartmentalization that arises in response to adversity. The protocol has specific phases and milestones and aims to improve the hearer–voice relationship via normalization; increasing a person’s understanding of their voices, including the life events and conflicts they might represent; and dialoguing with voices to achieve shared goals. A strong emphasis is also placed on developing adequate coping strategies, along with creating a collaborative formulation, before embarking upon dialogue work. Taken together, it is intended that these components can increase patient benefit while minimizing the likelihood of adverse effects. Talking With Voices is part of a growing range of therapeutic models which emphasize the value of interpersonal, relational, and dialogical principles for supporting voice- hearers (including those with a diagnosis of psychosis/schizophrenia). However, it is important to note that the current trial is only the first step in establishing an evidence- base for this novel approach. Further research is required to demonstrate cost- effectiveness and treatment efficacy, as well as refining ways that the method could be used in routine practice to complement established interventions, such as CBTp. However, our protocol suggests that it is possible to manualize a dissociation-based model to support psychosis patients with distressing auditory hallucinations and that this is a feasible and acceptable treatment option to implement within formal health care settings. Overall, it is hoped that future work can contribute to continued understanding of the role of relational dynamics in facilitating recovery from distressing voices. Talking with voices therapy protocol 569
  • 13. Acknowledgements Eleanor Longden is funded by a National Institute for Health Research (NIHR) Postdoctoral Fellowship Scheme for this research project (PDF-2017-10-050). This paper presents independent research funded by the NIHR: the views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. The study was facilitated by the Greater Manchester Local Clinical Research Network. The authors would like to thank Dr. Jacqui Dillon of the English Hearing Voices Network and the members of the Psychosis Research Unit’s Service User Reference Group for their valuable feedback on the trial’s therapy manual. Conflicts of interest Three authors (EL, DC, and AB) have received financial payments for delivering teaching and/or supervision on the Talking With Voices approach. There are no other reported conflicts of interest. Data availability statement Data sharing is not applicable to this article as no new data were created or analysed in this study. References Birchwood, M., Gilbert, P., Gilbert, J., Trower, P., Meaden, A., Hay, J., . . . Miles, J. N. (2004). Interpersonal and role-related schema influence the relationship with the dominant ‘voice’ in schizophrenia: A comparison of three models. Psychological Medicine, 34, 1571–1580. https:// doi.org/10.1017/s0033291704002636 Boon, S., Steele, K., van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. New York, NY: Norton. Brabban, A., Byrne, R., Longden, E., Morrison, A. P. (2017). The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis. Psychosis: Psychological, Social and Integrative Approaches, 9(2), 157–166. https://doi.org/10.1080/17522439.2016.1259648 Chadwick, P., Birchwood, M. (1994). The omnipotence of voices: A cognitive approach to auditory hallucinations. British Journal of Psychiatry, 164(2), 190–201. https://doi.org/10. 1192/bjp.164.2.190 Corstens, D., Escher, S., Romme, M., Longden, E. (2019). Accepting and working with voices: The Maastricht Approach. In A. Moskowitz, M. J. Dorahy, I. Sch€ afer (Eds.), Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology (2nd ed., pp. 381–396). Chichester, UK: Wiley-Blackwell. Corstens, D., Longden, E. (2013). The origins of voices: Links between voice hearing and life history in a survey of 100 cases. Psychosis: Psychological, Social and Integrative Approaches, 5 (3), 270–285. https://doi.org/10.1080/17522439.2013.816337 Corstens, D., Longden, E., May, R. (2012). Talking with voices: Exploring what is expressed by the voices people hear. Psychosis: Psychological, Social and Integrative Approaches, 4(2), 95–104. https://doi.org/10.1080/17522439.2011.571705 Corstens, D., Longden, E., McCarthy-Jones, S., Waddingham, R., Thomas, N. (2014). Emerging perspectives from the Hearing Voices Movement: Implications for research and practice. Schizophrenia Bulletin, 40(S4), S285–S294. https://doi.org/10.1093/schbul/sbu007 570 Eleanor Longden et al.
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