Relational Therapies for People Who Hear Voices: Operationalisation and Current Status of an Emergent Group of Psychological Therapies.

Summary

A new group of psychological interventions for hearing voices, called relational therapies, focuses on changing how a person relates to their voices. These therapies include Relating Therapy, Talking with Voices, and AVATAR Therapy. They use experiential dialogue with voices, such as role-play, direct conversation, or computer avatars, to improve the hearer-voice relationship. AVATAR Therapy has shown effectiveness in multiple randomized trials, Relating Therapy in two trials, and a trial for Talking with Voices is ongoing. Key mechanisms involve changing how the hearer relates to the voice, reducing threat, and integrating the voice experience into the person's life story. Future research should explore which therapy works for whom and how these therapies affect voice hearing itself.

Study at a glance

Abstract

A recent theme in the development of psychological interventions for hearing voices (auditory verbal hallucinations) has been the emergence of a group of overlapping approaches increasingly referred to as relational therapies: Relating Therapy (RT), Talking with Voices (TwV), and AVATAR Therapy (AT). Collaborative discussion among a group of researchers involved in developing these interventions combined with a systematic literature search were used to review this new genre, aiming to develop an agreed operationalisation; and identify common and distinctive aspects; potential mechanisms; and collective research directions. Relational therapies for voices can be operationalised as those that "consider patterns of interaction, and/or the relational dynamics between hearer and voice, as targets for therapeutic change, and use an experiential process of dialogue with identities associated with voices as a primary therapeutic method." Key differences involve the type of experiential hearer-voice dialogue used (ie, role-play chair work, direct dialogue with voices, and recreations of voice hearing using a computerised avatar), plus varying emphasis on models of interpersonal relating, broader relationships, and meaning encapsulated within voice-hearing experiences. AT has been found efficacious in several randomised controlled trials, with RT supported by evidence from two trials, and a multicentre trial for TwV underway. Mechanism domains include hearer-voice relating; habituation; threat and safety appraisals; and reformulation and integration of experiences. Common features and mechanisms can be identified across the relational therapies. Key future directions include considering what works for whom; how therapy influences voice phenomenology; the role of relational models; and implementation.