Psychosis

Psychological, Social and Integrative Approaches

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Relating Therapy for distressing voices: Who, or

what, is changing?

Mark Hayward, Leanne Bogen-Johnston & Felicity Deamer

To cite this article: Mark Hayward, Leanne Bogen-Johnston & Felicity Deamer (2018):
Relating Therapy for distressing voices: Who, or what, is changing?, Psychosis, DOI:
10.1080/17522439.2018.1469037

To link to this article: https://doi.org/10.1080/17522439.2018.1469037

Published online: 21 May 2018.

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Psychosis, 2018
https://doi.org/10.1080/17522439.2018.1469037

Relating Therapy for distressing voices: Who, or what, is

changing?
Mark Haywarda, Leanne Bogen-Johnstonb and Felicity Deamerc
a
School of Psychology, University of Sussex, Brighton, UK; bSussex Partnership NHS Foundation Trust, Hove, UK;
c
Department of Philosophy, Durham University, Durham, UK

ABSTRACT ARTICLE HISTORY

Background: The experience of hearing distressing voices has recently been Received 2 February 2018
conceptualised within relational terms, whereby the voice is perceived as Accepted 21 April 2018
a person-like stimulus with whom the hearer has a difficult relationship.
KEYWORDS
Therapeutic approaches are being developed that seek to modify the Relating Therapy;
relating of the hearer towards the voice, and a conversation has begun Interpersonal relationships;
about what or who may be changing within these therapies. We sought to Hearing voices; Auditory
empirically inform this discussion by exploring the experience of patients Hallucinations; Psychosis;
who had received Relating Therapy. Qualitative analysis
Methods: A semi-structured change interview was used to explore the
experience of nine participants. Interviews were transcribed verbatim and
were analysed using thematic analysis.
Results: The analysis of data generated three themes – two of which related
to aspects of change (in me and in voices), and one which related to a therapy
process (role plays).
Conclusions: The findings suggested that changes can be evident in
both the hearer and the voice, as a consequence of the hearer adopting
a different (more assertive) approach to communicating with the voice.
Such communication can enable the hearer to perceive themselves as less
vulnerable to the communicative intentions of others.

Introduction
Voice hearing (also known as “auditory hallucinations”) is a common and transdiagnostic experience
(Sommer et al., 2012; Thomas et al., 2007) that can have devastating effects on some peoples’ lives
due to high levels of distress (Birchwood & Chadwick, 1997), depression (Birchwood et al., 2004) and
an increased risk of suicide (Kjelby et al., 2015). Over the past 30 years, the development of psycholog-
ical therapies for distressing voices has been informed by the cognitive model of voices (Chadwick,
Birchwood, & Trower, 1996) with a moderate degree of success (van der Gaag, Valmaggia, & Smit, 2014).
However, within the psychological therapies literature there has been a recent shift from conceptualising
a voice as a sensory stimulus which the hearer holds beliefs about, to a voice as a person-like stimulus
which the hearer has a relationship with (Hayward, Berry, & Ashton, 2011). This seems appropriate given
that hearers typically personify their voices (McCarthy-Jones et al., 2014), assign names to them and
often develop close relationships with them as if they were real people (Chin, Hayward, & Drinnan, 2009).
The conceptualisation of the voice as a relational “other” has stimulated the development of a num-
ber of therapeutic approaches that seek to modify the relating of the hearer towards their voice(s). The
Voice Dialogue approach has been adapted by members of the Hearing Voices Movement and uses

CONTACT  Mark Hayward  mih21@sussex.ac.uk

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2    M. HAYWARD ET AL.

a dissociated “parts” explanation to facilitate constructive “live” dialogue between the hearer and the
voice (Corstens, Longden, & May, 2012). AVATAR therapy creates a visual depiction of the voice that is
displayed on a computer screen and the hearer is coached to respond assertively to the avatar (Craig et
al., 2017). And Relating Therapy uses experiential role plays to practice articulating assertive responses to
the typical utterances of the voice (or the social other with whom the hearer is in a difficult relationship)
(Hayward, Jones, Bogen-Johnston, Thomas, & Strauss, 2017). Each of these therapies is at a different stage
of development, yet discussions have already begun about how they may be exerting an influence – or
put more simply – “Who, or what is changing within relationally based therapies for distressing voices?”
(Alderson-Day & Jones, 2018; Hayward, 2018). Early candidates include the enhancement of self-esteem
(Leff, Williams, Huckvale, Arbuthnot, & Leff, 2014) and improved communicative dynamics, resulting in
a reduction in frequency and negative impact of voices (Deamer & Hayward, 2018), but, as yet, there
is limited empirical data to inform these discussions.
This study seeks to generate empirically derived insights about who or what may be changing by
exploring the experiences of patients who received Relating Therapy as participants within a pilot ran-
domised controlled trial (RCT; Hayward et al., 2017). The trial generated positive quantitative findings,
with a large between-groups effect on the primary outcome of voice-related distress (maintained at
follow-up) suggesting that Relating Therapy may be an effective intervention for distress reduction.
Consistent with the good practice for RCTs of psychological therapies recommended by Berry and
Hayward (2011), patients were offered the opportunity to participate in an exit interview at the conclu-
sion of therapy. The interviews sought to address the following research question: “How do participants
experience change (if any) within and after Relating Therapy for distressing voices?”

Method
Participants
Participants were eligible to participate within the RCT if they met the following inclusion criteria: aged
18 years or older; currently receiving specialist mental health care; hearing distressing voices for at least
one year (irrespective of diagnosis); scoring 3 or 4 (rated on a 0–4 scale) on either the intensity of distress
item or the amount of distress item on the Psychotic Symptoms Rating Scale – Auditory Hallucinations
Scale (PSYRATS-AHRS) (Haddock, McCarron, Tarrier, & Faragher, 1999) at the time of consent. Fourteen
patients were offered a maximum of 16 sessions of Relating Therapy over 3 phases: (1) socialisation
to Relating Therapy and its implications for the interrelating between the patient and the voice; (2)
exploration of themes within the relational history of the patient, with respect to voices and other
people; and (3) exploration and development of assertive approaches to relating, with extensive use
of experiential role plays (see Hayward, Strauss, & Bogen-Johnston, 2014; Hayward, Strauss, & Kingdon,
2018 for a description of the therapy). Therapy was provided by experienced therapists and was in
addition to the patient’s usual care. After the completion of their follow-up assessment at 36 weeks
post randomisation, the researcher offered all 14 patients the opportunity to be interviewed about
their experience of receiving therapy. Informed consent was taken from the patients who accepted
this invitation.
The Surrey Research Ethics Committee (number 12/LO/2045) provided NHS ethics approval for the
study.

Semi-structured interview
A semi-structured schedule was used to guide the interviews, based on the Change Interview of Elliott,
Slatick and Urman (2001). The interview schedule utilised a number of open-ended questions (with
suggested prompts), which were designed to explore participants’ experiences in six broad areas: (1) any
changes since the start of therapy, (2) the possible causes of these changes, (3) helpful aspects of the
therapy, (4) personal strengths that helped to make use of therapy, (5) personal limitations that made it
 PSYCHOSIS   3

hard to make use of therapy and (6) problematic aspects of the therapy. Interviews were conducted at
NHS mental health centres by a researcher who was independent of the therapy process. She remained
curious and flexible in an attempt to allow participants to fully explore their experience without feeling
constrained by the structure of the schedule. Interviews ranged between 15 and 55 min (mean = 39
min) in duration, were digitally recorded and transcribed verbatim (54,362 words were transcribed).

Analysis
Transcription (guided by McLellan, MacQueen, & Neidig, 2003), coding and identification of candidate
themes was conducted independently by LB-J, who was not involved in the delivery of therapy.
An Inductive Thematic Analysis (TA) was conducted and followed the phases of analysis described
by Braun and Clarke (2006): (1) transcription; (2) reading and familiarisation of transcript; (3) coding;
(4) searching for themes; (5) reviewing themes; and (6) defining and naming themes. TA is a flexible
approach that allowed for an in-depth understanding of interviewees’ experiences of therapy within an
exploratory, non-theoretical approach. However, flexibility can also hinder decisions as to which part
of the data should be focused on and, in the absence of a theoretical framework, TA has limited inter-
pretative power (Braun & Clarke, 2006). The aim of the analysis was to conduct an inductive, bottom-up
approach whereby themes emerged reflecting each participant’s experience of Relating Therapy.
Each interview was transcribed verbatim, read several times and coded systematically. The codes
were reviewed for patterns across the entire data-set and classified into potential candidate themes. The
candidate themes were further reviewed, refined and checked for internal homogeneity and external
heterogeneity to ensure that they produced a coherent and meaningful analysis. This process involved
two levels of reviewing and refinement. Initially, candidate themes were reviewed at the level of coded
data extracts, whereby all extracts for each theme were read to ensure they formed a coherent pattern. If
any data extracts were seen to not “fit” with candidate themes, new themes were developed or reworked
to accommodate extracts. Extracts that did not work within pre-existing or newly created themes were
discarded. Thematic refinement considered the candidate themes in relation to the entire data-set to
see if they “accurately” reflected the data-set as a whole. That is, comments from one participant could
not result in a theme. Once candidate themes had been refined, a description of the “essence” of the
themes was used to define each theme and sub-theme (Braun & Clarke, 2006). This final stage was
conducted by all of the authors.

Results
Nine patients accepted the invitation to an exit interview, gave written consent and were interviewed (six
women). Four had a diagnosis of Schizophrenia Spectrum Disorder, three had a diagnosis of Borderline
Personality Disorder, one had a diagnosis of OCD and one had a diagnosis of depression. Participants
were aged between 24 and 61 years (M = 45 years) and described their ethnicity as White British (seven),
Asian/British (one) or Mixed (one). Most participants were currently unemployed and either single or
separated/divorced.
The analysis of data generated three themes – two of which related to aspects of change (in me and in
voices), and one which related to a therapy process (role plays). Each theme (and associated subthemes
[in italics]) will be described below, with participant quotes used to exemplify the theme content.

Theme 1 – Changes in me
The first and most extensive theme related to changes that participants noticed in themselves. These
changes reflected issues of well-being, assertiveness and connectedness, each of which is represented
in a subtheme.
4    M. HAYWARD ET AL.

Feeling stronger
Most participants (6 of 9) reported a greater sense of well-being as a result of the therapy, with individ-
ual differences in how this was described. For P1, greater well-being reflected the noticing of hidden
strengths:
Well I realised that I’m strong. Stronger than what I thought I was. So that helped. So that came out quite, I just
didn’t realise just how strong I was {Laughs}. Strong!
P1

Whereas, for P16 there was a sense that therapy had helped to “ground” them in the world. This was
a feeling that continued after therapy. They no longer had to fight to take their place in life but now
believed this was a space that they were entitled to:
Participant (P): I’m earthed. Yeah! Erm, that’s, that’s where I’m firmly planted on the ground with my feet on the
ground and erm, that’s my place {I: Yeah!} in my life, this world, whatever (laughs) you know. Its
erm, it has to be.
Interviewer (I): And do you feel that place where you stand more strongly now than before the therapy?
P: Much stronger {I: Yeah!} Yeah, but it’s, it’s erm, before it would be aggressively. Sort of like stubbornly.
Now it’s “no, I have this space in my, in my life. This is my space”.
P16

For other participants, greater well-being was reflected by an improving mood: “Erm, erm, not so
down all the time. Try an’, still have my good days an’ my bad days, but try an’ just remember what did
in therapy to draw back on really” (P22). Some participants were able to make links between their mood
and the activity of voices, and suggested that positive changes in mood were helpful for managing
voices:
I’m trying not to get down ’cause that’s, that’s another time when they do come back is when I’m down an’ low in
myself. Erm, (.) that’s when I find they’re there the most {I: Yeah!} Well all the time really when I’m on a low but at
the moment I’m, since February, since we finished the course I’ve been on a bit of a, a good run really.
P18

Standing up for myself

Learning to stand up for themselves by being assertive with voices was a novel idea for some partici-
pants. P2 described how therapy had taught them about a different way of responding that helped to
break into a cycle of helplessness around voices and gain more control:
…sometimes I’ve felt that they were completely in control of my life and it was very difficult to get out of that cycle.
You know sort of thinking that there was nothing I could do. Err, it’s, it’s obviously still difficult but I’ve learnt a little
bit more about assertiveness with them and to be able to maybe erm, challenge them a lot more easier than I have
before. And I don’t mean challenging them err, sort of verbally but in my head trying to sort of be assertive about
things an’ getting on top of it. And erm, making it not too easy for them as it had been in the past.
P2

The use of the phrase “assertive” was used by most participants and may have reflected a process
of being socialised in its use during therapy. A more nuanced description of assertiveness was offered
by P5 in terms of being able to disagree with voices:
“I disagree with what you are saying. I dislike it when you talk to me that way. I’m going to continue sitting here.”
That’s what I usually go through every time - those three assertive statements; and sometimes I say it without
hearing the voices just as a, just so they don’t come you know? So, I just say it randomly throughout the day and
that seems to help as well.
P5

And P16 spoke of the value of giving the voice more of an identity, and how this aided the process
of being respectful when responding assertively:
P: …you give it a single entity when you converse but when [therapist] was doing it she gave it a face
as well. So it was much easier to you know “well hang on! I’ve got to be gentle here. I’ve gotta be
 PSYCHOSIS   5

realistic” {I: yeah} and erm, you answer the best I can {I: okay} without being con-confrontational {I:
Yeah!} Erm, but being certain of my place but not in a point where I’m aggressive.
I: 
Yeah! So in your place did you say?
P: Erm, yeah! Standing on, err, up, at my place you know. Saying “No, I don’t agree with that” {I: hold
your ground} Yes! Yes! Hold my ground {I: Yeah!} Erm, and having my own views.
P16

For P1, assertiveness with voices was achieved by learning to understand and control their own
tone of voice:
I: 
How were things for you? Like in terms of your voices and everything else going on before the therapy
started?
P: Oh quite bad.
I: 
Quite bad.
P: No, quite bad. They were quite loud and bossy, and wouldn’t get out of my head at all. And just
wouldn’t leave me alone. Whereas once the therapy started, and I started using the assertiveness
and the chair exercises [role plays] that we did which were really good, that helped. That helped
quite a lot actually. Yeah!
I: 
How was it doing the chair exercises?
P: Really good ’cause I realised when I first spoke up I was quite gentle voiced {I: Yeah!} an’ then by the
end of it I was quite assertive (laughs) so which was good which taught me how to be, the difference
in my tone of voice. It’s the tone of voice that’s important.
P1

Connecting with others

Some participants spoke of how therapy had a positive effect upon their ability and desire to connect
with other people. For P9, this confidence enabled them to try new ways of connecting socially with
others which they may not have previously considered:
I: 
Erm, is there anything that kind of other people around you have noticed has changed?
P: Yeah, they’ve all said I’m better an’ more confident you know an’ generally a lot, I’ve made a lot you
know I’ve actually gone on Facebook which is a bit of a nightmare (laughs) and that but I’ve actually
made progress with my life in general more so than I ever thought I would have done thanks to the
input from [Therapist].
P9

Whereas, for P22, the connection was with family members with whom struggles could be shared:
I: 
…is there anything else that you, you picked up on during the therapy?
P: Erm, (.) just talking it through with family an’ that really, just you know if you’re going through a really
bad time then just talking to family about how you’re feeling just helps.
I: 
Is that something that you did before?
P: No! No! Usually kept it to myself.
I: 
Oh, okay! How’s it been talking to your family about what’s going on?
P: Err, different ’cause I don’t think they really understand how, how I feel at times so it’s, it can be quite
difficult but just trying to explain how things are really, things like that.
I: 
Okay! So when you do talk to your family how does it make you feel?
P: Err, just makes me feel better. Generally it’s like a weight lifted.
P22
6    M. HAYWARD ET AL.

Theme 2 – Changes in voices

In addition to noticing changes in themselves, some of the participants (four of nine) also spoke of
the changes they had noticed in voices during the therapy. The specific changes were varied. For P1,
voices became quieter:
Yeah! But they’re a bit quieter once I answer back. Then they tend to shut up an’ leave me alone a bit more than
what they used to (giggles) {I: Okay!} ’cause I answer back assertively (laughs).
P1

The exact opposite was reported by P2 – at least during the therapy sessions as voices became more
vocal, possibly as a result of feeling threatened:
So it did make it quite, quite difficult because they were quite vocal during the therapy…, it did seem as if they were
really threatened by this and maybe it was because I was being taught to be more assertive with them where as
they preferred me to be erm, submissive. Err, and not, you know, an’ I think it’s the first time that probably they had
sort of err, witnessed me even remotely trying to be assertive with them and sort of you know, answering them
back in my own way err, in writing which I’d never done. An’ I think that did pose a threat.
P2

The content of voice comments was reported as changing by P16 and had become uncharacteris-
tically positive:
P: …gives me compliments when I’ve done something good or right. Erm, even being sympathetic if
I do something wrong “it’s okay! Don’t get upset.”
I: 
Was there any aspect of that before?
P: No, it was all negative {I: Right!} I never, ever got any compliments or you know, erm, I hate looking
in the mirror but when I do my voice says “that looks nice on you” or “your hair looks nice.” At the
moment it says “your hair looks like it needs doing.” (laughs) But you know erm, it’s all, it’s become
positive.
P16

And for P18, voices had stopped altogether:

I: 
So first things first: how you doing? How is stuff going?
P: Erm, quite well at the moment actually and erm, a good thing I haven’t heard the voices for quite
some time now. And erm, the way [therapist]…to interpret the voices in a different way and so I
have been doing that and gradually they’ve, they tailed off an’ I’ve not heard them at all.
P18

Theme 3 – …and those role plays!

Role plays are an integral part of Relating Therapy and offer patients the opportunity to have multiple
and practical experiences of responding assertively. At first, participants often found role playing con-
fusing and anxiety provoking:
The chair exercises were difficult to do actually. To begin with, I mean it, I go-I wasn’t used to speaking out loud an’
speaking assertively. An (Therapist) taught me to speak assertively. So yeah, it was difficult to begin with.
P1

However, despite these understandable reservations, there was a sense of the role plays being an
important part of the therapeutic process for the majority of the participants (six of nine), and one that
became less daunting with time:
Erm, the, I say helpful or, or difficult was having to do the role plays. At first I did find that quite difficult. And at first
I wasn’t going to, I was going to do it and obviously I wasn’t forced to do it. It was, you know obviously erm, and I
did find it a bit strange and a bit difficult to start with but actually, it was quite useful because I’ve never done that
before and at first I thought “how we going to do this?” You know? “Who’s going to be like you know my voices?
…” And I couldn’t, I couldn’t understand how that was going to work anyway but err, here again after I got over
that initial sort of anxiety err, at the thought of it erm, after a few times we did it, it was actually err, the experience
 PSYCHOSIS   7

actually improved and err, err, it did actually go quite, quite well. So, it was something that was difficult, but it was
quite useful at the same time. And here again, never, never had a chance to do that before. Erm, never!
P2

And, despite the challenges of role play, most participants suggested that this part of the therapy
process was essential:
I: 
…If you were designing the therapy would you take that bit out or do you think it should be there?
P: Erm, I suppose it should be there because it does help you see things in a different point of view but
it’s difficult at the time when you do it but after you’ve done it, it’s alright.
P22

However, one aspect of the role plays that seemed most difficult was the role playing of the voice(s).
Typically, a patient would be invited to role play their voice at some point in the therapy process, as
this offers an insight into what it’s like to be the recipient of assertive responding. Some participants
described how this was too difficult for them:
P: Erm, one thing I did find a bit hard erm, was when [therapist] said “shall I be you?” I felt I couldn’t
do that because I felt if I gave my voice a body I was crossing the line. I was, it wasn’t right for me. {I:
Okay!} I was frightened of erm, maybe letting it in so much {I: Okay!}.
I: 
Uniting the voice with your body somehow it might, might have united {P: Yes!} united it in a way that’s
not good for you.
P: Yes! It might take control of me.
P16

Discussion
The quantitative findings from the RCT suggest that Relating Therapy may be an effective intervention
for the reduction of voice-related distress, but until now, we have lacked a fine-grained understanding
of what may be changing as a result of the therapy, and how any changes might bring about these pos-
itive outcomes. This analysis, via first person accounts, offers some insights into how and why patients’
voice hearing experiences may be changing during and after therapy.
We have previously suggested (Deamer & Hayward, 2018) that initiating change in the way the
patient relates to their voice, might lead to positive changes in the patient, the relationship between
the patient and their voice(s) (as well as between the patient and others) and the frequency of voices.
Our previous analysis of a single exit interview provided preliminary evidence of just that, but this
in-depth analysis of nine patients’ exit interviews further supports this. Participants show signs of feel-
ing stronger and of improved mood, which has in turn enabled them to stand up for themselves and
be more assertive, not just with their voice but with family and friends. The voices have changed for
some participants through becoming quieter and more positive, and for one participant they stopped
altogether.
It is clear how the increased assertiveness gives the participants a feeling of strength, improves
their mood and their relationship with the voice. It is, however, less obvious why this should impact
on the nature, frequency or sometimes even the presence, of the voices. In order to understand these
changes, we suggest that in many cases, the negative and submissive relationship with the voice should
be understood as a necessary condition of the voice’s very presence. The voice is present is so far as it is
communicating negatively (Deamer & Hayward, 2018). The therapy assists the participant in becoming
less of an easy target for someone who “has it in for them”. Relating Therapy provides a platform from
which voice hearers can view their voices as coming from agents whose communicative behaviour
is (to a certain extent) dependent on the voice hearer’s self-perception (their strength or mood), and
how they relate to the voice (their assertiveness). This analysis illustrates that initiating change in this
way can lead to positive changes in the relationship between the patient and their voice(s), albeit after
a potential increase in distress that might occur through the process of change (as is the case for P2).
Such an initial increase in distress is perhaps unsurprising given that the relationship with the voice is
8    M. HAYWARD ET AL.

modelled on interpersonal relationships generally – standing up to a playground bully, for example,

might also cause initial distress. However, in being encouraged to display increasingly assertive behav-
iour, the participant perceives the voice to be less dominant (Birchwood et al., 2017).
Relating Therapy also seems able to trigger changes in the perception of the voice’s attitude. For
example, P16 reported a significant change in the content of their voice; shifting from being all neg-
ative to containing a certain amount of positivity, such as compliments and encouragement. This is
remarkable, but we suspect that this kind of qualitative change in the content of the voice might be
restricted to a minority of individuals (as is born out in this analysis). If, as we suggest, for many hearers
of distressing voices the negative relationship with the voice, and hence the negative content of what
the voice says, is a necessary condition of the voice being there at all, then the voice is unlikely to persist
if that relationship has been significantly improved by the therapy. As this analysis illustrates, Relating
Therapy is more likely to result in a reduction in the frequency of the voice(s) and/or the distress caused
than in any tangible change in “what the voices say”.
Auditory hallucinations vary a great deal, and it is worth reflecting on the conditions under which
Relating Therapy might not be so efficacious. Although we argue that the vast majority of voices do
have communicative content (an intended meaning), not all voices do (Deamer & Hayward, 2018), for
example, some voices might have robotic characteristics and/or not have any decipherable mean-
ing. The minority that don’t have communicative content are unlikely to have an identifiable “speaker
behind the voice”, which means they are unlikely to respond well to Relating Therapy; attempting to
enter into a dialogue of any sort with an absent agent could be futile. Having said this, P16 suggests
that Relating Therapy provides a platform for the voice to gain more of an identity and become more
personified (Chin et al., 2009). The act of entering into a conversation with the voice, emphasised the
communicative agency behind the voice, which enabled the participant to perceive the voice as they
would any other interlocutor, and to interact with them accordingly: in a non-confrontational, respect-
fully assertive manner.
The reflections on the role play aspect of the Relating Therapy are also informative, not least because
the role play aspect of Relating Therapy is what sets it apart from other relational therapies, such
as AVATAR Therapy. It is not surprising that patients often find role plays challenging. Most people
aren’t used to entering into a mode of pretence, especially not in someone else’s presence. Add to this
that the role plays require patients to interact directly with their voice(s) (who typically cause them a
great deal of distress), and/or to take on the persona of their voice, which must require them to really
embody the perspective of the voice, then it is not surprising that the role plays require a great deal of
effort and emotional resilience. Despite this, we can see that the majority of the patients recognised
the importance of this enacted dimension to the therapy. Human communication is underpinned by
the ability to interpret other people’s actions and utterances on the basis of understanding their per-
spective. The better we are at being able to take the perspective of our interlocutors (whether that be
our friends and family, or our enemies), the better we will be at (and the more confident we will be in)
negotiating interactions. The more we can understand what our own actions and behaviours might
be contributing to a negative relationship or interaction, the more likely we will be to be able to make
effective changes to our behaviour.
In summary, this paper sought to empirically inform the conversation about what may be changing
within relationally based therapies for distressing voices. With regard to Relating Therapy, the analysis
of post-therapy exit interviews suggests that changes can be evident in both the hearer and the voice,
as a consequence of the hearer adopting a different (more assertive) approach to communicating
with the voice. Such communication can enable the hearer to perceive themselves as less vulnerable
to the communicative intentions of others. These findings emphasise the importance of the hearer
having an opportunity to experience themselves communicating differently within therapy, and such
opportunities are provided by all relationally based therapies. An outstanding question concerns the
specific processes (e.g. role plays, avatars, live dialogue) that are necessary to provide this experience
within therapy (Hayward, 2018). Future research could also explore and learn from the experiences of
patients for whom relationally based therapies are not beneficial.
 PSYCHOSIS   9

Disclosure of interest
The authors report no conflict of interest. 

Acknowledgements
We are grateful to the British Academy and Sussex Partnership NHS Foundation Trust for providing funding to support
this study. Thanks are due to Cassie Hazell for conducting the interviews, and to the participants who were willing to share
their experiences.

Funding
This work was supported by the British Academy; Sussex Partnership NHS Foundation Trust. FD was supported by the
Wellcome Trust.

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