“It allowed us to let our pain out”: perspectives from voice-hearers and their voices on the ‘talking with voices’ approach

ABSTRACT

Background

The “Talking with Voices” (TwV) approach is a novel, formulation-driven approach to helping people who hear distressing voices. It is based on an understanding of voice-hearing as a relational phenomenon, often linked to trauma. Therapy involves facilitation of dialogical engagement between hearers and their voices. There are as yet few empirical studies of the approach.

Method

The current study explored experiences of the TwV approach from the perspectives of voice-hearers and also of their voices. Ten qualitative interviews were subjected to Interpretative Phenomenological Analysis.

Results

Both hearers and their voices felt that the TwV approach can be a powerful enabler of positive change, and that it provides a valuable means of working through past trauma. Establishing a safe base – with time to build trust in the process – was considered key, as were the personal qualities of the facilitator, including openness, courage and a non-judgemental approach. Participants also saw flexibility as important, including the ability to try things out within the work. It was also important that the ideas behind the approach made sense to the participant. Perceived barriers included the medicalised nature of current services and the lack of availability of the TwV approach.

Conclusion

The findings provide support for the acceptability and value of dialogical approaches to helping people who hear voices. In particular, they suggest that participating in TwV can help people develop an understanding of, and a more peaceful relationship with, their voices. The study is novel in eliciting perspectives from the voices themselves, and this yielded valuable insights.

KEYWORDS:

• Talking with voices
• dialogical approaches
• voice dialogue
• voice-hearing

Introduction

Since the 17^th century, voice-hearing has typically been seen in the West as a symptom of mental illness (McCarthy-Jones, 2012). More recently, the idea that voices (and other “psychotic’ experiences) may be understandable psychological phenomena with which it may be useful to engage, has increasingly been accepted within mental health services (Cooke, 2020; Cupitt, 2018). The compatibility of this idea with the dominant medicalised approach is a matter of debate (Tate, 2019).

Romme and Escher’s seminal work in the late 1980s (Romme & Escher, 1989) and the subsequent work of the Hearing Voices Movement (e.g. see Corstens et al., 2014) have been fundamental in re-conceptualising voice-hearing in ways which centre the narratives of voice-hearers themselves and use ordinary rather than medicalised language (e.g. “voices’ rather than’ hallucinations’) (Corstens et al., 2014). Romme and Escher’s (2000) explanatory model suggests that voices often “arrive’ in people’s lives as part of a meaningful reaction to unresolved traumatic life events. Engagement with voices is therefore actively encouraged to explore content, develop meaning from the experience and understand voice motives. Drawing upon the knowledges and experiences of voice-hearers, voices are often viewed as people, beings, or parts of the self with whom the hearer has a relationship (McCarthy-Jones, 2012). This positioning has stimulated the development of a group of “dialogical’ therapeutic approaches both within and outside of services that focus on the interpersonal aspects of voice-hearing, with a therapist or other trained person facilitating dialogue between the voice-hearer and voice(s).

Dialogical approaches can be broadly clustered into two overlapping strands. One stems from traditional academic and clinical settings and includes: “Avatar Therapy’ (AT; Ward et al., 2020), “Virtual Reality assisted Therapy’ (VRT; Percie du Sert et al., 2018), and “Relating Therapy’ (RT; Hayward et al., 2017). The other stems from the Hearing Voices Movement (HVM). Referred to here as “HVM-led’, these approaches include “Making sense of Voices’ (MsV; Steel et al., 2020) also known as “Experience Focused Counselling’ (EFC; Schnackenberg et al., 2017) and “Talking with Voices’(TwV; Longden et al., 2021). Lastly, “Compassion Focused Therapy for Psychosis’ (“CFTp’; Heriot-Maitland et al., 2019), also termed “Compassion for Voices’, offers a fusion of these two strands.

Both Avatar Therapies and Relating Therapy focus on helping the voice-hearer develop assertive communication with a persecutory voice. In AT (e.g. Ward et al., 2020) and VRT (e.g. Percie du Sert et al., 2018) the voice is (re)created as an avatar, whereas in RT (e.g. Hayward et al., 2017) it is enacted by the voice-hearer or therapist through role-play exercises. Conversely, CFTp and HVM-led approaches focus on helping the voice-hearer to develop a more peaceful relationship with a persecutory voice (Heriot-Maitland et al., 2019; Longden et al., 2021). The various dialogical approaches are at different stages of theoretical and empirical development, with TwV, otherwise termed “Voice Dialogue’, being one of the newest to be manualised and systematically evaluated (Longden et al., 2021).

The Talking with Voices (TwV) approach is distinct in that it is predominantly derived from theory concerned with the psychology of self, including Jungian and Gestalt theory together with Transactional Analysis (Longden et al., 2021). Specifically, voices are construed as “disowned’ (or dissociated) selves or parts of the self, which relate to adversity in the voice-hearer’s life and can play an adaptive role by signposting unresolved emotional vulnerabilities (Longden et al., 2021). Further, the approach positions these “dissociated’ selves as dialogical (i.e. as parts of self that can be conversed with and relate to each other), suggesting that verbal engagement with voices might be a possible way to decrease conflict and promote better relationships between a person’s selves (Longden et al., 2021). Dialogical engagement with voices has become well established within the Hearing Voices Movement across the UK and worldwide (Longden et al., 2021). This includes use of the “Maastricht Interview’ (Escher et al., 2010), a tool created to help voice-hearers develop an understanding of voices within the contexts of their lives. By contrast, within mainstream clinical services, approaches which promote dialogical engagement with voices are still relatively uncommon (Longden et al., 2021).

To date, empirical investigations of HVM-led dialogical approaches are limited to a case series (Steel et al., 2019); a small randomised controlled trial (Schnackenberg et al., 2017) and three qualitative studies (Schnackenberg et al., 2018, 2018; Steel et al., 2020) examining clinical applications of the Maastricht Interview; and a pilot trial of the TwV approach (Longden et al., 2021). These studies’ findings provide preliminary evidence for the acceptability and feasibility of psychotherapeutic approaches which include dialogue with voices.

There remains a need to further understand the processes by which dialoguing might lead a person to become less (or more) distressed by voices, as well as other possible benefits such as promotion of broader aspects of recovery (Longden et al., 2021). Research to date has largely privileged the perspective of the therapist or facilitator, with less focus on the experiences of voice-hearers and little if any on the perspectives of the voices themselves. Seeking the latter is consistent with the suggestion within TwV that voices may represent different parts of the self, whose experiences are likely to diverge and whose perspectives may therefore yield important insights. However, no study has yet attempted this.

Aims

The current study explored experiences of the TwV approach from the perspectives of both voice-hearers and their voices. Specifically, it attempted to answer the following questions:

1. How do voice-hearers and their voices experience the TwV approach?

2. What do voice-hearers and their voices perceive has changed in their relationship, as a result of the TwV approach?

3. What do voice-hearers and their voices perceive has changed elsewhere in the hearer’s life?

4. What factors do voice-hearers and their voices think might have helped or hindered the described changes?

Method

Design

A qualitative approach, Interpretative Phenomenological Analysis (IPA, Smith & Shinebourne, 2012) was employed to gain an in-depth understanding of voice-hearers’ and voices’ subjective experiences within a critical realist framework (Collier, 1994).

Participants

Ten participants were interviewed: see Table 2 for demographics. The sample size is typical for qualitative studies of this kind (see e.g. Harper & Thompson, 2011).

Table 1. Participant inclusion criteria.

Aged 18 - 65
Not suffering from a neurological condition with which voice-hearing may be associated e.g. dementia
No significant history/current use of illicit drugs or alcohol which might affect ability to participate fully in the interview
Had heard/been hearing distressing voices for at least 12 months
Had experience of Voice Dialogue, currently or within the past 5 years
Able to give informed consent to participate
Not currently acutely distressed or in crisis

Table 2. Participant demographics.

Participant pseudonym	Gender	Age	Ethnicity
Angela	Female	55+	WB
Paul	Male	25- 34	WO
Erin	Non-binary	35-44	WO
Dan	Male	35-44	WB
Jackie	Female	55+	WB
Natalie	Female	25-34	WB
Steph	Female	18-24	WB
Mike	Male	35-44	WB
Steve	Male	45-54	WB
Chris	Male	35-44	WB

Inclusion criteria are listed in Table 1. Participants were recruited via a website developed by the first author, shared initially at an online Hearing Voices Network group facilitated by the third author. Prospective participants were invited to ask questions about the study in the HVN group, via the website or by email before consenting to take part. Voices were also invited to participate and ask questions. It was highlighted that voice participation was optional, and that adjustments could be made if necessary to facilitate their participation. Those interested were sent a study information sheet and consent form, before arranging an interview.

Interviews

A semi-structured interview was used to elicit participants’ experiences of the TwV approach. Interviews were facilitated by the first author and took place via a secure online video platform. Voice contributions were spoken via the voice-hearer.

Analysis

Interviews were audio-recorded, transcribed and analysed using Interpretative Phenomenological Analysis (Smith & Shinebourne, 2012). All comments which highlighted participants’ experiential and phenomenological understanding of the TwV approach were marked on the transcripts. These were then analysed closely in order to develop themes, illustrated below by participant quotes (pseudonyms have been used). Superordinate themes were developed by merging themes. Further details of methodology, analysis and quality assurance can be found in Middleton (2021).

Ethics

Ethical approval was obtained from the Canterbury Christ Church University Salomons Institute Ethics Panel.

Reflexivity

The authors believe that medical approaches are overused in mental health services and advocate for more holistic understanding and interventions including the exploration of dialogical approaches to helping people who hear distressing voices. The reader is invited to take this into account when judging the analysis and conclusions.

Results

Ten voice-hearers were interviewed (see Table 2 for demographics). Interviews lasted an average of 84 minutes. Four participants were recruited directly via a peer-led, UK-based Hearing Voices Group facilitated by the third author, and six via connections of this group. Seven had participated in voice dialogue sessions with the third author and three with an NHS nurse practitioner trained in the approach. At interview, half of participants confirmed that they had voices who wished to contribute, with a total of 10 voices participating (One voice N = 2, Two voices, N = 2, Four voices, N = 1).

Six people were accessing a Hearing Voices Group (HVG) at the time of study. Experience of voice dialoguing ranged from two to 31 sessions, with sessions still ongoing for four people. Participants had either been referred to a clinician trained in the approach or chosen to undertake sessions with a facilitator of a HVG.

Themes

Four themes were identified within participants’ experiences of the TwV approach: Voice Dialogue is a powerful enabler of positive change; A safe base is key; Medicalised services and lack of availability of the approach can be barriers to change, and finally Good relationships, flexibility and “fit’ of the ideas are facilitators of change. Together with the 14 subordinate themes, these are summarised below.

Voice dialogue is a powerful enabler of positive change

Most participants (whether hearers or voices) reported that engaging in facilitated dialogue had led to significant positive changes. These included enabling a conversation between them; helping to discover the meaning and purpose of the voices; helping to heal past trauma; enabling hearer and voices to get along better and helping relationships elsewhere in life.

1. Voice Dialogue started a conversation between us

Four people suggested that TwV had enabled two-way communication with voices for the first time:

Angela:

“I ignored the voices before. I was frightened [and] I didn’t know what else to do. I find that I can communicate with them and have a conversation with them now”.

Natalie:

“It’s always been a one-way conversation. When voices told me to do something, there wasn’t this second thought like “Should I really go through with this?” … It was always … “How can I …do it to make them shut up?”

People had also been able to continue the dialogue with their voices outside of sessions.

• (2) Voice Dialogue helps discover the meaning and purpose of the voices

Four people commented that the approach had enabled them to discover the meaning and purpose of the voices. For some this felt revolutionary:

Dan:

“It was really astonishing … that there were parts of me … which I came to call dissociative parts of me, that relate to things in my life that I had little or no awareness of until I started doing the dialoguing”.

Jackie:

“I knew I had voices but I didn’t know why … . voice dialoguing … was like putting a light switch on. It was like ‘Ah, this explains that and that explains that”.

Two voices described what this process had been like for them:

Jackie’s angry voices:

“It felt like at long last someone wanted to listen to our pain, because we were hurting. Even Jackie didn’t know about this [before the dialoguing]. It was like a manuscript that’s been in a dark cupboard and someone flashes a torch onto it”.

Steve’s voice Victor: “[Steve and I] were always getting into angry fall-outs. I used to tell him to smash people’s faces in because I wanted Steve to stick up for himself more. He knows this now”.

• (3) Voice Dialogue gave us a tool for healing past trauma

Five people, and one person’s voices, shared how valuable they had found Voice Dialogue for working through past trauma. They all highlighted how this had been both a difficult and liberating process, with timing and a focus on safety being paramount:

• (4) Voice Dialogue enabled us to get along better

Jackie:

“[Some voices] are stuck in a time-warp … they’ve had to hold a lot of pain for me … I remembered snapshots of the conversations [between the facilitator and voices] … but some of it was closed to me until [facilitator] went through what they had said. So, I learnt about why they were so angry. Because they took a lot of the abuse”.

Jackie’s voices:

“Voice dialoguing allowed us to let our pain out”.

Mike:

“I dialogued with the voice who [had] told me that there were cameras everywhere, [and] the voice came out as a child who was frightened of this man [who threatened me]. It was a beautiful experience”.

Dan:

“[The persecutory voice] turned out to be … defending a younger part inside by imitating somebody who had hurt me in childhood … the more this part dropped its mask of the perpetrator, the more the child emerged, kind of emboldened”.

Having two-way conversations and discovering the meaning and purpose of the voices had enabled people and voices to develop more empathic and peaceful ways of relating to each other. Voice-hearers commented that witnessing voices mature and evolve after they started relating to them differently, had been both striking and heartening:

Dan:

“[I developed] a relationship with the child part that emerged … It was like looking after a real child. This child part asked to do child-like things like be read a story, or go to a park … The more I established [this] relationship, basically by ministering to its childlike needs, the more this part grew up”.

Steve:

“I started treating them as individual people rather than something that I just didn’t want … I no longer see them as enemies and there are two or three … that are quite helpful in my life”.

Two voices described how it had felt when the hearer started relating to them differently:

Steph’s voices:

“It is better now that Steph talks to us. We don’t want people to think that we’re bad. We have important roles”.

Angela’s voice Father Jones: “It was so frustrating when Angela was ignoring us … when Angela asked me about being called Father Jones, I told her I loved it and it’s stuck”.

• (5) Voice Dialogue helped relationships elsewhere in life

Four people provided examples of how engagement with the approach had positively impacted other relationships.

Angela:

“Doing the dialoguing has helped bring [me and my daughter] closer together. She tells me she’s got her mum back”.

Mike:

“I just sat down and I told [my wife] … She didn’t know what to say, but she was just so loving to me, and just so generous in her kind of humility in not knowing what to do but being overwhelmed by it. We just talked for an hour. It just felt like this really heavy thing was just taken off me. I didn’t have to carry it around with me anymore”.

A safe base is key

Both hearers and voices highlighted that developing a “safe base’ from which to approach dialogue work was paramount. This was because the prospect of dialoguing had been anxiety-provoking, because time was needed to build trust in the process, and because the timing needed to be right.

1. Feeling apprehensive about dialoguing

Five hearers and two voices had initially felt very uneasy about the prospect of facilitated dialoguing. The hearers’ decision to give permission for someone else to engage with their voices had been a very difficult one. Two had worried that it might not be safe, leading them to delay using this approach.

Voices often hold energy or characteristics that we judge quite harshly in our society, so it’s really difficult to talk about … I was worried that [the voices] would say things I didn’t want to feel responsible for because I knew how counter-cultural and how harshly judged it would be.

Erin:

“Even though I worked on talking with the voices myself, I had a lot of anxiety about letting somebody else talk to them”.

Angela:

“I felt quite uncomfortable about even naming my voices at first”.

Voices themselves had mixed opinions about using the approach. Sometimes fear had led them to discourage hearers from engaging with it:

Erin’s voice, Sylvester:

“It was a very fragile time, and I remember how involved and excited Erin was and I was glad that she became more cautious … Erin was lucky that [the facilitators] were trustworthy people and that it was kept safe, and she had some skills already to keep herself safe. [If that wasn’t so], she could have been taken advantage of”.

Steph’s voices:

“We told Steph not to tell anyone because it wasn’t safe, [plus we thought] it’s not going to work anyway so there’s no point in trying”.

Two voices had feared that dialoguing would mean the end of them:

Steph’s voices:

“We thought that voice dialoguing might get rid of us, but [the facilitator] told Steph that they’re not trying to do that, they’re just trying to understand us”.

Jackie’s angry voices:

“We were concerned that if [the approach] stopped us from being angry, we would die”

One person’s voice had welcomed the prospect of facilitated dialoguing:

Erin’s voice, Monica:

“I [remember thinking] it might be a really exciting experience and I was sort of frustrated with some of the other voices who put a block on it at the time.

Another person reflected that conflicting messages from voices about entering into dialogue work are common.

• (2) It can take time to build trust in the process

Six people shared difficult past experiences with services, including not feeling heard and staff being dismissive or fearful when they had shared experiences of voice-hearing. People described how these experiences had initially led them to be mistrustful or sceptical of voice dialoguing:

Paul:

“I never wanted to tell anyone what was happening to me. I didn’t want to engage in any types of services”.

Erin:

“I thought, is this just another way to try and get me to accept and be compliant? I thought that I might get tricked or something”.

• (3) The timing must be right

Five people spoke about the importance of being in a relatively stable place before pursuing dialoguing work, recognising that this type of work requires a significant amount of personal and emotional investment, and therefore could not be undertaken during a time of stress or crisis:

Dan:

“I was in a state after having a breakdown and I just needed to become stable in a very basic sense. First by getting [an] income … and finding a place to live. I spent a couple of years just doing that [before starting dialoguing]”.

Chris:

“There’s no way I could’ve done [voice dialoguing] in crisis … There are more immediate things you need to do … ” [Later]: “I felt safer. If you don’t feel safe you can’t open up, and it feels like your voices won’t let you because they don’t feel safe”.

Medicalised services and availability of the approach can be barriers to change

Participants drew attention to factors which they viewed as possible barriers to achieving change through dialogue work. These were that the ideas behind the approach are often not accepted or understood in services, and that the approach is often not available.

1. These ideas are often not accepted or understood in services

By and large, both people and voices felt that services had failed to listen to them, and (with some notable exceptions) had imposed a medicalised view and interventions.

Erin:

“There was a lot of tension between me and services about what I thought was going on and what they thought was going on, and we clashed around it”.

Similarly, two people contrasted experiences of drawing on TwV ideas within services, with experiences outside, noting that within services they feared negative consequences for being honest:

Natalie:

“The [HVGs] have been vastly different. The first one [at] the hospital … was very [orderly] … and scheduled. [Outside of services] you didn’t have to be so careful with what you said”.

Chris:

In services: “You don’t know how [staff] will react and so people have to censor what they say … I was hospitalised the moment I said about people being able to … read my thoughts”. Outside of services: “I could just say whatever I felt, and it wasn’t ever a problem and everyone else could do the same”.

Three people felt that it was important for others to understand that voices were also people with needs and feelings, and to acknowledge their reality.

• (2) The approach is often not available

Most people, and most voices, highlighted the general lack of availability of TwV and wished that it was more widely available:

Jackie:

“I’ve asked to do voice dialoguing again because I found it so useful. But no one does it in [place]. Which is a pity because it helped me such a lot”.

Dan:

“It’s quite a rare thing to find somebody who knows what to say and how to say it, [who has read] professional literature on trauma, dissociation, voice-hearing and on voice dialoguing”.

Good relationships, flexibility and ‘fit’ of the ideas are facilitators of change

There were several factors which both hearers and voices felt facilitated change within the dialoguing process. Qualities of the facilitator were considered key, together with having a support network and flexibility to fit the approach to their needs. It was also important that the ideas behind the approach made sense to them.

1. Qualities of the facilitator are key

Five people and one voice referred to personal qualities of the facilitator which they considered essential. These included being open, non-judgmental, trustworthy, and courageous.

Paul:

“Having someone you can trust is a big part of it. [My facilitator] takes the time to understand and see what you want to talk about. When someone tries to understand, it’s easier to open up”.

Erin:

“There was a real emphasis on safety and choice … [Facilitator] acknowledged the reality of [the voices] … Even towards things that are very strange and unfamiliar, [facilitator] was just persistently non-judgmental and open minded … He didn’t take sides, he wasn’t about me against the voices, or helping me tell off the voices for being evil or nasty or critical or ruining my life … he was curious and compassionate. It just helped me reconnect with feeling curious about what was going on, and not just dismiss it and ignore it and be angry about it”.

Erin’s voice Monica:

“I think it’s also about [facilitators] possessing courage. I would really love people to have the courage to engage with me”.

Participants said that voices would resist a facilitator who did not embody those qualities, because they would feel unsafe.

• (2) You need support around you

Seven people referred to having a good level of social support around them, which was both needed and enabled by dialoguing work. This included access to peer support, often through a HVG.

• (3) Flexibility is key

Angela:

“It affected me in a great way. I started socialising and going out. My confidence grew … that gave me my life back”.

Steve:

“I think the peer support that you get helps you make friends”.

Five people described adaptations that had helped them both to engage and to persist with dialoguing. These included building in ideas from other therapeutic approaches, using a Hearing Voices Group as graded introduction and dialoguing with voices in a group setting.

Steph: “We’ve been doing some compassion-based therapy [then] moved to the dialogue work. It’s been really good”.

• (4) The ideas needed to make sense to me

Steve:

“Talking about the method of voice dialoguing in the [HVG] first was a nice opening”.

Erin:

“I found it a lot easier demonstrating Voice Dialogue to an audience (HVG) than doing it one-to-one with the therapist, so for me there’s something about the communal approach”.

Two people commented that it was important for the ideas behind the TwV approach to make sense to them:

Steve:

“I got on board with the [idea that voices] are parts of me from the past who dealt with difficult situations. [As a result] my experience was easier probably”.

Erin:

“I was very influenced by the original Voice Dialogue from Hal and Sidra Stone, using it to get to know parts of self, and … become more compassionate and understanding to what’s going on … I keep coming back to [these] ideas. I find them supportive … in my relationship with myself and approaching things with an attempt to relate and dialogue with it; not just to talk at it”.

One person expressed feeling uncomfortable with the idea of seeing himself as “parts’. He stressed the importance of acknowledging and working with other lenses:

I think dialoguing in the UK is looking through a white lens. We have to be more creative.

Mike:

“I do think the voices are meaningful messages and messengers … . but I suppose there’s a bit of me … that doesn’t feel comfortable to say, ‘this part of you is split off and is being represented out here’. It’s just not been my experience … ”

Discussion

The Talking with Voices approach appeared to be broadly acceptable to both voice-hearers and their voices, and enabled helpful dialogue between them. Most participants felt that it had helped to uncover the voices’ meaning and purpose, and to heal past trauma. This had often resulted in hearer-voice relationships which were more peaceful and empathic, and which for some people had helped them to develop good relationships elsewhere in life.

These positive experiences are consistent with the one extant feasibility study of this approach (Longden et al., 2021), as well as with the literature on other HVM-led approaches which support recovery by facilitating exploration and understanding of voices (e.g. Schnackenberg et al., 2017; Steel et al., 2019). They also contrast with the frequent dissatisfaction reported with many mainstream services (O’Hagan, 2016).

Turning to theory, the current findings provide evidence for previous suggestions that voices often reflect threatening or overwhelming events in a hearer’s life, and that it is possible both to understand them and to engage them in dialogue (Longden et al., 2021). This suggestion is consistent with wider understandings of dissociative responses to trauma (e.g. Dillon et al., 2014). It is also consistent with the evidence that therapeutic interventions targeting dissociation can help some voice-hearers with a history of interpersonal trauma (e.g. Varese et al., 2021).

In terms of delivery, participants emphasised the need for facilitators to be flexible, and – as with other trauma-focused or emotionally intense therapy (Lee & James, 2012) – for people to have access to practical and emotional support during the process.

As with other approaches which focus on the hearer-voice relationship such as Relating Therapy (Hayward et al., 2017) or Avatar Therapy (Ward et al., 2020), participants described changed relationships with voices. However, the nature of the changes was different. Whilst participants in the latter described increased power over voices, participants in the current study described increased understanding and acceptance of the voices, and a more peaceful relationship with them. This appears to be a significant finding and is worthy of further exploration (see below).

Limitations

For feasibility reasons, participants were recruited directly or indirectly via a HVG facilitated by the third author. Some participants had taken part in dialogue sessions facilitated by the third author. This could have resulted in an overrepresentation of people and voices who found the TwV approach helpful. Although participants did describe circumstances where they felt the approach might be less helpful, future studies could use theoretical sampling to include people who had not found the approach particularly helpful.

As a qualitative study, the aim was not generalisability but rather to develop a detailed understanding of these experiences and processes. The findings cannot therefore necessarily be generalised to all voice-hearers. Further, most participants were white British. This will have affected the findings, especially given that western cultures tend to be less open to the idea of voice-hearing as a spiritual or religious phenomenon.

Future research

Future research could usefully explore experiences of, and views on the approach among people from a range of different cultural backgrounds. Although the TwV approach is underpinned by the Hearing Voices Movement principle of accepting all explanations of voices, its wider implementation among people who hold different conceptualisations, for example seeing voices as a spiritual or religious phenomenon, is yet to be systematically tested.

Future research could usefully explore similarities and differences with other dialogical approaches and what the distinct “active ingredients’ might be of the TwV approach – for example, the extent to which increased understanding and acceptance of voices, rather than power over them, is key. This will further understanding of which therapeutic approach(es) might benefit any given individual, and of circumstances where the approach may be more or less helpful.

The current study also speaks to the value of centering the experiences of voice-hearers in research, as to the possibility and value of gathering perspectives from voices. Researchers should therefore seek to forge and prioritise collaborative relationships with voice-hearers, and with permission, voices; to facilitate their active involvement in the design and conduct of future research.

Clinical implications

The findings provide preliminary evidence that the TwV approach can create positive change for people, reducing distress and helping to work through past trauma, and could usefully be further investigated for use within services. It also appears to offer a method of developing compassion for and understanding of voices in contrast to other dialogical approaches which promote developing assertiveness over voices. If (at least some) voices are conceptualised as traumatised parts of the self, then compassion, engagement and understanding would appear key in helping to work through past trauma and reducing distress.

Correspondingly, the study highlights the challenges of implementing such an approach within our current medicalised culture where different conceptualisations of voice-hearing might not always be understood or accepted. Careful thought is needed as to how this and related approaches can be implemented in such a way that their ethos and underlying principles are maintained. This requires workers to adopt an attitude of epistemological and aetiological humility by holding all frameworks of understanding lightly and not imposing ideas about what the voice-hearing experience might mean for any particular person.

Conclusion

The current study aimed to provide qualitative insight into the Talking with Voices approach, a novel approach which promotes dialogical engagement with voices, from the perspectives of both voice-hearers and their voices. The study findings suggest that the TwV approach can be a powerful enabler of change with respect to improving hearer-voice and self-other relationships, finding meaning and purpose in the voice-hearing experience, and helping to heal past trauma. Future research is needed to develop theoretical understanding of the approach together with how it can best be applied within services.

Acknowledgements

We thank all of the people and voices who participated in this study, as well as our anonymous reviewers for their helpful contributions.

Disclosure statement

The third author’s involvement in facilitation of dialogue sessions and a UK-based HVG, from which some participants were recruited, has been acknowledged in this paper.