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

BACKGROUND: 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).

STUDY DESIGN: 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.

STUDY RESULTS: 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.

CONCLUSIONS: 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.