behavioural therapy has long been accepted as a valid therapeutic
intervention for people who hear voices. So what does the future
hold for more radical approaches, such as voice dialogue, asks Adam
to 1993. It was the year Accepting
Voices by Professor Marius Romme and Sandra Escher was published.
The book argued that voices (aka aural hallucinations) experienced
by people diagnosed with psychosis should be accepted as real. Don’t
pathologise and seek to rid people of voices. Better, help people
cope with them, they argued.
professionals were truly alarmed. In the British Medical Journal,
Raymond Cochrane, a professor of psychology, slammed the book’s
message as “potentially dangerous”. It meant colluding
with delusions, he argued
April last year the scientific community was similarly perturbed.
This time after clinical psychologist Rufus May was shown on a television
documentary using “voice dialogue” to help a voice-hearer.
Directly communicating with the voices of a woman diagnosed with
bipolar disorder was one of the psychological interventions Dr May
May was also “dangerous” and should be reported to the
British Psychological Society, NHS psychiatrists wrote
on the bulletin board of doctors.net.uk. One of Dr May’s colleagues
at Bradford NHS Trust joined the fray, accusing May of “flagrant
self promotion”. “Don't let him [Dr May] near me if
I become mentally ill,” weighed in Lisa Brownell, a psychiatrist
at Queen Elizabeth Psychiatric Hospital in Birmingham.
supporters of voice dialogue – involving conversing with a
person’s voices to understand that person’s life experiences
and the voices’ “motives” – point to some
similarities it has not only with traditional cognitive behavioural
therapy (CBT) but with a new wave of CBT techniques. These include
Person-Based Cognitive Therapy (PBCT), Dialectical Behaviour Therapy,
Acceptance and Commitment Therapy, and Relationship Theory. The
solid “evidence-base” of CBT was recognised seven years
ago when the National Institute for Health and Clinical Excellence
(Nice) recommended it be available for all people diagnosed with
is being largely developed by Paul Chadwick, professor of psychology
at the University of Southampton, PBCT ushers in “substantial
developments” on traditional CBT for psychosis, he says. Noticeably,
it’s a further de-medicalisation of therapy because PBCT aims
to alleviate “distress”, not disease “symptoms”.
PBCT – while utilising core CBT tools – also employs
a Buddhist form of meditation called mindfulness to help a hearer
create distance between his/herself and the voice(s).
therapy, being developed by researchers such as Mark Hayward, a
clinical psychologist at the University of Surrey, is another CBT
spin-off. When applied to voice-hearing, a therapist uses “Socratic
dialogue”, “guided discovery” and again mindfulness
in helping a person gain a more “balanced, interpersonal relationship”
with their voice(s). Like voice dialogue – and indeed CBT
and PBCT - relation therapists
do “accept” a person’s voice(s) as real and meaningful.
But, unlike voice dialogue, the therapist need have no direct conversation
with a person’s voice(s), instead using role play.
theory does not need the voice to be present,” says Dr Haywood.
“But I will role-play the voice or hearer and may encourage
the hearer to respond more assertively to a hostile voice. So, rather
than step into a relationship with the voice, I encourage someone
to step back from the voice.”
voice dialogue supporters emphasise that voice hearers are in a
perpetual relationship with their voices, often continually conversing
with them. A third person relating directly to the voice can bring
benefits. Dr May says: “For many people the most troubling
thing is for the hearer to be alone with their voice. With someone
else hearing what the voice says it means the voice is being witnessed
[by someone else] – this can be validating and assuring. While
some cognitive approaches might mindfully step back from the voices,
voice dialogue can be seen as mindfully engaging with voices. But
I’ll only talk to the voice if it actually helps the person,
and voice dialogue is only one of many ways I might try and help
Dirk Corstens, a psychiatrist and psychotherapist from Maastricht,
Holland, who for 10 years has been running voice dialogue workshops
for UK mental health professionals says: “Instead of using
role play I talk to the voices. Often a person will talk all day
to their voices. Voices can give important information about a person’s
of the evidence base for these approaches? Well only mall scale
studies have been completed on the therapies evolved from CBT. But
Dr Haywood is planning a bigger six-group randomised controlled
study for relational therapy with people diagnosed with schizophrenia.
“Growth in this area is slow,” he says. ““But
I think these approaches are going to be more effective, and will
have a bigger impact than CBT. All we can do is work with the momentum
we have, and try to take people with us.”
for voice dialogue, there have been no formal studies. Yet, Dr Corstens
is putting together research with 30 people with a schizophrenia
diagnosis. “I hope in four years time I’ll have something
to show,” he says.
this will be too late for the Nice guidelines on schizophrenia,
due to be re-issued later this year. Again only traditional CBT
is expected to be discussed.
some CBT adherents, such as consultant psychiatrist Lynne Drummond,
head of the cognitive behavioural psychotherapy unit at South West
London and St George's Mental Health NHS Trust remain mightily wary
of new-wave CBT approaches and voice dialogue. "Sure, we need
to push the boundaries of what does and does not work. But these
theories need to cut the mustard. I could have a theory that voices
are caused by caffeine and people need to detoxify from it. Family
members of people with schizophrenia will cling to anything –
so we need to stick with what is proven.”
May, meanwhile, argues that Prof Romme and Sandra Escher’s
small-scale studies published in Accepting Voices, justify voice
dialogue. “Voice-hearers who are coping with their voices
have some positive relationship with their voices. I’m basing
it on that evidence,” he says.
importantly, adds Dr May, who was himself diagnosed with schizophrenia
when aged 18, voice dialogue is supported by many in the service
user movement. Plus, it provides carers, relatives, friends and
users with a jargon-free method to help people.
caring relative or friend can use voice dialogue with a couple of
days training,” says Dr May. “Unlike CBT, it’s
not stipulated that voice dialogue is only for professionals. You
do not need a degree or diploma. It’s not a therapy, as such.
It’s a way to help people deal with their voices. I’m
interested in how knowledge in mental health can be redistributed,
rather han being something only professionals have.”
many service users and professionals rallied to support Dr May after
the television documentary, the hostile responses served to again
underline the deep divisions in mental health. As if to confirm
this, Mind, Britain’s biggest mental health charity, shortlisted
Dr May as its Mind champion of the year for “challenging discrimination”
against people with mental health problems.
be a voice-hearer'
Longden, 27, has for two years been a service user development worker
for an early intervention in psychosis team in Bradford. A voice-hearer,
she was diagnosed with paranoid schizophrenia when a teenager. She
has helped develop a voice dialogue manual which is available at
had a good understanding and control of my voices before I got my
present job. I had achieved resolution with my voices. But before
that I had struggled with aggressive voices for a long time. I was
a troubled and fragile teenager, and getting diagnosed and seeing
myself as a psychiatric patients compounded those feelings.
thing that helped me with my voices was meeting a social psychiatrist
called Pat Bracken. He was the first person who saw beyond the diagnosis
of schizophrenia. He related to me as a person, and did not treat
me as if I had a biological aberration. He introduced me to the
Accepting Voices book by Marius Romme and Sondra Escher.
traditional psychiatry sees silencing voices as part of its “cure”
response, voice dialogue technique requires an understanding and
acceptance of voices – the recovery response. Having your
voice-hearing experience being treated as meaningful and interpretable
is so empowering.
prepare the manual Rufus [May] practised voice dialogue with my
voices. Having Rufus speak assertively to the most hostile of my
voices was of immense help.
back, I was too young to be told I had a lifelong condition and
would be on medication for the rest of my life. Seeing voice-hearing
as meaningful and being linked to your life history is a complete
alternative. I had a lot of unresolved trauma and stress. And my
voices were a metaphor for this. Even the most aggressive voice
carried messages – and it makes no sense to shoot the messenger.
the time the most negative and hostile voices represented how I
felt about myself, my self esteem. I understand my voices as parts
of myself. And if I am stressed and anxious the voices get worse.
But this is nothing more sinister than my mum getting a headache
when she is stressed. I am proud to be a voice hearer.
* This article
first appeared in Mental
Health Today magazine
to think 'anyone' can do voice dialogue
Louise Pembroke, voice hearer, London
February 19, 2009
Voice dialogue is another useful tool in assisting voice hearers
and I agree that anyone with the right outlook and approach could
use it, it doesn't have to be the excusive preserve of professionals.
I do think it's dangerous to suggest that absolutely anyone can
do it after attending a course for a day or two. Voice dialogue
takes considerable skill and sensitivity and even a good 'intervention'
can be practised badly whether the person is a mental health professional
Phil Barker, honorary professor of medicine, nursing and dentistry,
University of Dundee, Scotland
February 25, 2009
Might I dare to suggest that those who can 'do' and those who can't
run around collecting qualifications which deceive them into thinking
that they 'might'.
is about being human. Quite why it needs to be converted into CBT,
DBT and now PBCBT is beyond me. Who would you choose? Someone who
said, 'lets' talk' or someone who said 'let me offer you PBCBT?
do you think? Email your comments on the above
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