Voice hearers

Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 17, 363–373 (2010)
Published online 29 December 2009 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.672

Relating Therapy for People who
Hear Voices: Perspectives from
Clients, Family Members, Referrers
and Therapists
Mark Hayward* and Ella Fuller
Psychology, University of Surrey, UK
Sussex Partnership NHS Foundation Trust, UK

Current psychological models of voice hearing emphasise the per-
sonal meaning that individuals attribute to the voice hearing experi-
ence. Recent developments in theory and research have highlighted
the importance of the relationship between the hearer and the voice.
This study aims to contribute to this area of research, by exploring the
experience and usefulness of a new form of ‘Relating Therapy’ that
aims to modify distressing relationships with voices.
Semi-structured interviews were conducted with ten participants
and explored the experience and usefulness of a pilot of Relating
Therapy: three therapists, three voice hearers, two relatives and two
referrers. Interviews were transcribed and analysed using Interpreta-
tive Phenomenological Analysis. Three themes that emerged from the
analysis are presented for discussion: engaging with the therapeutic
model; developing a new relating style; and how change is described
and deﬁned by participants.
This study is consistent with the growing body of theory and research
that highlights the interpersonal nature of the voice hearing experi-
ence. It also offers tentative support for a therapeutic framework that
aims to modify distressing relationships with voices as a means of
bringing about positive change. Clinical implications and areas for
future research are outlined. Copyright © 2009 John Wiley & Sons,
Ltd.

Key Practitioner Message:
• Conceptualising the voice hearing experience within a relational
framework may be normalising, hopeful and helpful for some
clients.
• Similarities exist between social relationships and the relationship
with the voice.
• Therapy that aims to modify distressing relationships with voices
may be of beneﬁt for some voice hearers.

Keywords: Voice Hearing, Therapy, Perspectives, Relating, Interpreta-
tive Phenomenological Analysis

* Correspondence to: Mark Hayward, Psychology Department, University of Surrey, Guildford, Surrey GU2 7XH.
E-mail: m.hayward@surrey.ac.uk

Copyright © 2009 John Wiley & Sons, Ltd.

364 M. Hayward and E. Fuller

INTRODUCTION experience of hearing voices (Birchwood & Chad-
wick, 1997; Nayani & David, 1996). An interpersonal
Attempts to understand the psychological factors theory capable of considering issues of power and
that may mediate the emotional impact of voice proximity has been developed by Birtchnell (1996,
hearing have focused primarily upon cognitive 2002) who describes relating along the intersect-
variables: beliefs about the voice’s power and ing axes of power and proximity, represented at
intent (Chadwick & Birchwood, 1994; Birchwood their two poles by ‘upper–lower’ and ‘distant–
& Chadwick, 1997), and beliefs about the self in close’, respectively. Birtchnell’s Relating Theory dis-
terms of esteem and efficacy (Chadwick, 2006; tinguishes between positive and negative relating;
Close & Garety, 1998). A recent conceptual devel- the difference between these descriptions being a
opment has led to the consideration of the voice as matter of relating competence and versatility.
a representation of an interpersonal ‘other’. Ben- The application of Relating Theory to the experi-
jamin (1989) was first to offer empirical findings ence of hearing voices has suggested that hearers
suggesting that hearers had ‘integrated, personally perceive their voices to relate to them negatively in
coherent relationships with their voice’ (p. 308). a dominant (upper) and intrusive (close) manner,
Subsequently, the phenomenological literature both associated with distress. In response, the
highlighted that voices are frequently aligned with hearer may seek to attain distance (also associated
significant individuals in the hearer’s social world with distress) or accept the need to relate depend-
(Leuder, Thomas, McNally & Glinski, 1997; Nayani ently (a mixture of closeness and lowerness—
& David, 1996) and are engaged with in conver- associated with lessening distress) (Hayward,
sation (Garrett & Silva, 2003). This sense of rela- 2003; Hayward, Denney, Vaughan, & Fowler 2008;
tionship with voices was qualitatively explored by Vaughan & Fowler, 2004).
Chin, Hayward, and Drinnan (2009) who reported The understandings of voice hearing derived
the acceptance of relational frameworks and an from Birtchnell’s Relating Theory lead to the devel-
evolving sense of ‘we-ness’ by the majority of their opment of ‘Relating Therapy’ (Hayward, Overton,
participants. Dorey, & Denney, 2009). Relating Therapy pro-
The influence of relating variables upon hearers’ gresses through three broad and overlapping
responses to their voices has been clarified through stages: (1) socialization to Relating Theory and its
the application of Social Rank Theory (Gilbert & implications for the interrelating between hearer
Allan, 1998). Concerned primarily with issues of and voice, (2) exploration of themes within the
power, Social Rank Theory has suggested that relational history of the hearer (with regard to
the powerlessness of hearers relative to distressing social and voice relationships) and (3) exploration
voices is mirrored within the hearer’s social rela- and development of assertive approaches (e.g.,
tionships (Birchwood, Meaden, Trower, Gilbert, & Dryden & Constantinou, 2004) to relating (to the
Plaistow, 2000). Furthermore, this powerlessness voice and socially); and use of the ‘empty chair’
seems to be rooted within interpersonal schema, and ‘experiential role plays’ (Chadwick, 2006) to
both reflecting and shaping pervasive patterns of explore the motives of the voice and practice relat-
relating across an individual’s lifespan (Birchwood ing in an assertive manner (see Hayward et al.,
et al., 2004). The mirroring of social and voice 2009 for further details of the therapy protocol).
relationships creates therapeutic opportunities to Relating Therapy was piloted on an individual
affect change in one domain with an expectation of basis with five clients who heard distressing voices
change in the other. Indeed, Birchwood, Meaden, (Hayward et al., 2009). The experience of distress-
Trower, & Gilbert (2002) have demonstrated how ing voices and related ‘psychotic’ experiences can
interventions focussed upon social relationships significantly impact upon many people who are in
can impact on distressing relationships with voices, contact with the client, e.g., family members (Add-
and Byrne, Birchwood, Trower, and Meaden (2006) ington, Coldham, Jones, To, & Addington, 2003)
focused on changes in the relationship with the and therapists (Lloret, Hayward, & Brown, 2009).
voice that enabled changes in social relating. Additionally, the experience of hearing voices is
However, if relationships with voices are influ- embedded in a relational context, and may be
enced by interpersonal experience, they are likely to influenced by relationships and social interaction
be imbued with all the complexity and idiosyncrasy with family, friends and mental health workers.
of social relationships. In addition to power, this will Consequently, this study aimed to qualitatively
include issues of proximity and intimacy, themes explore and capture the experiences and views of
that have been reported as prevalent within the Relating Therapy across multiple perspectives by

Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010)
DOI: 10.1002/cpp

Relating Therapy for People who Hear Voices 365

interviewing clients, members of their families, the tate answering the research question), and is also
therapists and referrers. This approach is consistent flexible enough to enable the researcher to respond
with an important systemic notion that situates to the content of each individual’s interview, e.g.,
the therapy process within a system of relation- by following-up interesting avenues that emerge
ships that may both influence and be influenced (Smith, 1995).
by the intervention. Systemic approaches also The interview schedule aimed to explore the
advocate that exploring multiple key perspectives research question: What are the views of people
generates a more complete overview of the topic who hear voices, therapists, referrers and relatives
under investigation, enhancing understanding and about the experience and usefulness of a thera-
enabling the results to be cross-checked to explore peutic approach that uses a relational framework?
credibility (Dallos & Vetere, 2005). Three broad areas were covered: (1) general/
scene-setting, (2) experience and views of Relat-
ing Therapy and the relational approach and (3)
METHOD
perceived change. The interviews were conducted
Participants by the second author, audiotaped and transcribed
verbatim.
Participants in the current study were either:
• clients who had participated in Relating Analysis
Therapy as part of Hayward et al.’s (2009)
Interpretative Phenomenological Analysis was
therapy pilot (N = 3);
selected as its aims and the epistemological back-
• therapists who had offered Relating Therapy as
ground are consistent with this study. The analy-
part of the therapy pilot (N = 3);
sis of the transcripts followed guidelines outlined
• referrers of clients to the therapy pilot, who had
by Jonathon Smith (e.g., Smith, Jarman, & Osborn,
regular contact with the client (N = 2) or
1999). The first transcript was read a number of
• relatives of clients within the therapy pilot, who
times and notes were made in the left hand margin
had regular contact with the client (N = 2).
about anything that was perceived as important
Demographic information about the participants or significant. The right hand margin was then
is presented in Table 1. used to note emerging theme titles that ‘capture
the essential quality’ of what was found in the text
(Smith et al., 1999, p. 221). These included some
Development of the Interview Schedule
broader summaries of the text and more abstract
Semi-structured interviewing was selected as this interpretations. Tentative connections between
provides the opportunity for some degree of struc- themes were then made, looking for clusters of
ture to guide the researcher’s questioning (to facili- topics or concepts. These clusters were then allo-

Table 1. Demographic characteristics of participants

Gender Age Ethnicity Duration of voice hearing Treatment for voice hearing
Therapist
T1 Female 40–49 White British
T2 Male 40–49 White British
T3 Female 40–49 White British
Client
C4 Male 20–29 White British Less than 5 years Antipsychotic medication
C5 Female 20–29 White British More than 10 years Antipsychotic medication
C6 Female 40–49 White British More than 10 years Antipsychotic medication
Relative
F7 Female 50–59 White British
F8 Male Over 60 White British
Referrer
R9 Male 50–59 Chinese
R10 Male 50–59 White British

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Table 2. List of superordinate themes and subthemes

Superordinate theme Subtheme
1. Engaging with the • An intuitive model of voice hearing
relational framework • Assessment of relating styles
• Openness and honesty
2. Therapists’ approach • Therapeutic relationship
• Non-judgemental about psychotic experiences
3. Developing a new • Developing understanding
relating style • Drawing on positive relating styles
• Assertiveness training
• Bringing the dialogue into the room
4. Challenges to change • Perceived risks within therapy
• Entrenched relating styles
5. Impact of change • Voice-hearer relationship
• Acceptance of voices
• Mental health and perceptions of self
• Independence-seeking
• Social relationships
• Hopefulness and the possibility of change

cated superordinate theme titles, resulting in a list Evaluation and Validity
of preliminary superordinate themes for that par-
Independent audit was used to explore the coher-
ticipant. Throughout this process, it was important
ence of the analysis and the grounding of inter-
to check that these themes connected to the tran-
pretations in the data (Dallos & Vetere, 2005). This
script to ensure that interpretations were grounded
included a qualitative research group analysing
in the text.
extracts from two transcripts and also allocating
The remaining transcripts were analysed in
randomly selected quotations (from all 10 partici-
the same manner. Throughout this process, the
pants) to superordinate themes and subthemes. A
preliminary superordinate theme titles from the
transcript with left and right margin comments
first transcript were held in mind, while there
was also read by a psychologist with extensive
remained an openness to new and different ideas
methodological experience who cross-checked
and issues. New emergent theme titles were then
the comments with the transcript’s list of prelimi-
tested against earlier transcripts, and the superor-
nary superordinate themes. In relation to both the
dinate theme lists (for each transcript) were modi-
qualitative research group and the psychologist,
fied as appropriate in the ongoing analysis. This
where differences or elaboration arose, these were
process resulted in lists of preliminary superordi-
discussed and agreement was reached about the
nate themes for each of the 10 participants.
allocation or interpretation of a particular quota-
The lists of themes from all 10 transcripts were
tion or comment.
amalgamated and redefined into a master list1 of
superordinate themes and subthemes, again check-
ing that the themes were represented in the tran-
scripts (Smith et al., 1999). During this process,
RESULTS
some themes were dropped, based on relevance The results section will provide a narrative account
to the research question, the richness of the pas- of the experience and usefulness of Relating Therapy,
sages supporting the theme, and the frequency of from multiple perspectives (Smith & Osborn, 2003).
the theme within and across transcripts (Smith & Themes and subthemes developed from the inter-
Osborn, 2003). view transcripts are presented in Table 2.
Three superordinate themes are partially reported.
These themes and subthemes have been selected
1
The language used to describe the themes (‘master list’ of for presentation because they reflect the process
‘superordinate’ themes and ‘subthemes’) is consistent with of this novel form of therapy, rather than more
conventions outlined by Smith and colleagues (1999). contextual factors that may apply more generi-

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cally to therapy with people who hear voices, e.g., talked about the importance of developing a ‘lon-
therapeutic relationship. The majority of reported gitudinal formulation’ with clients (T1) to guide the
themes and subthemes were evident within the intervention around their voice-hearing experience:
data elicited from each of the four perspectives. ‘look beneath the surface and get a sense of . . . what this
Subthemes that represent a more restricted range experience connects to, relationally . . . and get a sense
of perspectives are identified below. of the underlying issues that need to be addressed’ (T2).
For example, with one client the underlying issues
Theme 1: Engaging with the Relational Model were around shame (T2).
The therapy was described as helping clients to
An Intuitive Model of Voice Hearing
‘see a connection between that which they experience
Encouraging clients to gain a sense of being in a
and that which is going on in their lives’ (R9). T3
relationship with the voice was described as ‘intu-
referred to a ‘powerful week’ where the genogram
itively . . . appealing’ (R9), because it offered a con-
was used to consider the links between a past
ceptualization of the experience in ‘a ballpark where
abusive relationship and the current voice rela-
the hearer has a real sense of knowing the terrain’ (T2).
tionship. C6 agreed that this connection ‘became
This was linked to the universal nature of expe-
clearer through the therapy’ and described the impact
riencing relationships (e.g., T3). Voices were gen-
on her relationship with the voice: ‘I’m much less
erally described as having a personified identity,
afraid than I was before. I have more understanding of
knowledge, intent (e.g., malevolence), and a history
what’s occurring and having that gives me more power
of interactions and dialogue with the client.
against him [the voice]’. F8 described this as discuss-
The intuitive nature of the relational framework
ing things that were ‘deep down’.
was reflected in the ease with which participants
Some participants valued the exploration of pat-
could compare experiences with the voice to those
terns of interaction, as a means of developing new
within social relationships. The concept of disem-
understandings about relationships. For example,
powerment within both social relationships and
C5 developed a new interpretation that hearing
the relationship with the voice was common in
the Devil (her predominant voice) was a test of
participants’ accounts (e.g., R10): C4 expressed that
faith rather than a punishment, by considering
teachers used to ‘talk about me, and make decisions’
‘why would he do this, what would he be achieving by
without involving him. He compared this with
doing this?’ The process of exploring clients’ inter-
the voices; ‘it’s the same sort of thing. They’ve had a
pretations of relationships was also described as
meeting without me, and come to decisions without me’.
facilitating changes in their views of themselves.
The process of comparing relationships facilitated
C6 explained that ‘she [the therapist] was working
clients in making sense of their voice-hearing expe-
with me on accepting the fact that I hear voices, and that
riences: ‘being able to see that kind of link as opposed
it didn’t mean that you were mad or bad’. These new
to . . . I don’t understand this but it’s happening, I think
understandings were seen as facilitating clients in
has been very illuminating for her’ (R9).
making small changes in their relating styles (T1).
Therapists also described the model as normaliz-
ing and empowering for clients. There was a ‘sense
Drawing on Positive Relating Styles
of relief’ (T1) as clients were encouraged to under-
This subtheme was evident primarily within the
stand their experiences within the ‘ordinary domain’
perspectives of the therapists. Therapists high-
of relationships rather than as ‘mad stuff’ (T2). The
lighted that one way of gaining ideas for introduc-
emphasis on reciprocity in relationships allowed
ing difference in the relationship with the voice was
clients to gain ‘a sense of . . . playing an active role
by drawing on clients’ own experiences of positive
in that relationship’ (T2), and recognize that they
relating within ‘more functional’ relationships (T1).
have ‘a choice about . . . how [to] respond’ (T1). In
Therapists would aim to ‘shine a spotlight on times
this way, clients realized that ‘like any relationship,
when maybe she’s not been the passive recipient of an
[the relationship with the voice] has the potential to
experience, but she’s . . . taken more active roles in those
change’ (T2).
relationships’ (T2). Therapists might ask how the
client would respond to criticism or threat within
Theme 3: Developing a New Relating Style
these relationships and explore the possibility of
Developing Understanding using these ideas within the relationship with the
Developing understanding about underlying voice (T1).
issues and connections between experiences was Birtchnell’s octagon (a diagrammatic representa-
consistently valued by participants. Therapists tion of relating styles; Birtchnell, 1994) was used

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to record both positive and negative relating, so whisper. If you’ve got something to say, you say it out
was important in stimulating discussion about past loud or I won’t pay any attention to you at all’. She also
experiences of positive relating (T3). The genogram talked about counteracting the voice with logic.
was also used to explore when and how clients For example; ‘If he’s saying you’re stupid, I’ll say I’m
had achieved more positive relating within other not stupid because I do group work, I do lecture work’
relationships (T3). Both these diagrams facilitated (C6). C4 described ‘trying to reason with it’ but felt
the process of identifying ideas for change, and the ‘it doesn’t work’.
possible impact of change, in the relationship with Therapists likened this process to cognitive
the voice (T3). behavioural therapy, in which clients challenge
the validity of their own negative thoughts (T2).
Assertiveness Training For example, T3 explained ‘when we were doing the
The purpose of assertiveness training was ‘to evidential review of the voice content and its accuracy,
think about the process of learning to relate differently’ that felt very CBT’. Yet therapists were clear that the
to the voice (T2). Clients were encouraged to be approach was always ‘underpinned by this interper-
‘less unquestioningly subservient’ to the voice, and sonal theory’ (T1).
in the context of Birtchnell’s Relating Theory, to
‘take a more upper position’ (T1). Therapists also Bringing the Dialogue with the Voice
highlighted that assertiveness training gave clients into the Room
more choice about possible responses to the voice This subtheme was evident primarily within the
(T3). This is consistent with an important aspect of transcripts of the therapists and clients who talked
Relating Theory that advocates increasing versatil- about the process of bringing the dialogue with the
ity in relating styles (T1). voice into the therapy room. Often this took the
Therapists and clients described the process of form of role play with the therapist saying some-
learning to relate more assertively to the voice. thing that the voice might say (T3), and asking
This involved identifying different relating styles, the client to respond (T1). One therapist used an
e.g., ‘relating passively, aggressively and assertively’ ‘empty chair’ to invite the voice into the room
(T2). C5 and C6 valued using an ‘assertive[ness] more explicitly (C4, C5): ‘I essentially would, with
book’ (C5) that explained these relating styles (T3). his permission, clear a space on the settee and invite
Clients were encouraged to explore the possible the voice into the room and ask him to converse as if
impact of each relating style on themselves and the the voice was there, and tell me how he believed that the
relationship with the voice (T1). It was also impor- voice might respond’ (T2).
tant to consider why it might be difficult for clients Bringing the dialogue into the room allowed
to be assertive in particular situations (T3). clients and therapists to gain further understanding
Once clients were familiar with the concepts, of clients’ relating styles and unhelpful ‘reciprocal
‘then we tried to figure out assertive answers to the roles’ within relationships (T2). C4 emphasized that
voices’ (C5). Frequently this involved challenging the aim for him was also to ‘get the voice to under-
the voice in terms of ‘the validity and accuracy of stand me a bit more’. This process enabled clients to
what he’s saying’ (T2) and whether the voice was experiment with ‘speaking in different ways’ to the
being ‘reasonable or unreasonable’ (R10). Assertive voice (T1). T2 explained that the purpose was to
responses were written down to facilitate clients’ demonstrate ‘if [the client] or [voice] threw in some-
recall of this new relating style, e.g., on cue cards thing different, how that could lead to all sorts of differ-
(T3) or keyrings: ent conversations spiralling off of it. So it was creating
the opportunity to have a different kind of conversation’.
C5 We looked at ways of trying to remember how to be
This often involved ‘practice and rehearsal’ of more
assertive and how to respond to the Devil [voice]
assertive responses (T3).
in a better way.
T1 suggested that this process can make the dia-
I And what were those ways? logue ‘more real’ and ‘more personified’. T2 suggested
that this was initially experienced as uncomfort-
C5 . . . We made little notes on keyrings, it says ‘soul-
able by C4, as it ‘brought the experience much closer’,
mates will never be kept apart’, ‘show me some
but after repeated practice, he ‘began to welcome
proof’, ‘show me someone who agrees with you’, ‘I
the opportunity’. C5 did not expect the ‘empty
know God’s real because He speaks to me’. (C5)
chair’ to work because ‘the voices . . . come from the
C6 expressed assertive responses to the whisper- air . . . from all around, they’re not going to come and
ing voices that she hears: ‘you’re extremely rude to want to sit in one chair’. The ‘empty chair’ seemed

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to be stressful for C5 as she talked about it trigger- therapy was novel in its goal to facilitate clients in
ing a migraine. living with voices (F8), rather than an approach
that ultimately seeks to eradicate voices. Partici-
pants highlighted the role of power and control
Theme 5: Impact of Change
(R10) in enabling clients to learn to live with the
Voice-Hearer Relationship voice (T3): ‘with the therapy I’ve come to the conclu-
Participants described a shift in clients’ relating sion that I might not be able to get rid of him. But I
styles from attempted distancing to more assertive can control him, and I don’t have to be depressed by
engagement: ‘I’ve been trying to run away from the him’ (C6).
voice all the time and I’ve learned to stand firm and This change through therapy seemed consistent
fight back’ (C6). C5 also referred to a more ‘assertive’ with the goals and views of participants. C5 com-
style, and less attempts to ‘escape’ the voice. This mented ‘there is definitely something good about accept-
assertive relating style was commonly described ing the voices’, ‘I don’t want to get rid of them, I don’t
as involving more engagement with the voice in feel like they should ever really die or anything’. F7
terms of challenging rather than passively accept- noted the importance of relatives ‘coming to terms’
ing its content (T3). For C5, this improved com- with voices too: ‘I’ve come to the conclusion that it’s
munication with the voice and ‘we’re not complete not just going to be a miracle cure now . . . think he’s
enemies anymore’ (C5). C6 explained that the voice got to live with it’.
‘runs out of steam’ when she responds assertively,
then she can disregard him. Mental Health and Perceptions of Self
Initially, clients were positioned as powerless Most participants identified changes in mental
victims in relation to critical, powerful voices (e.g., health as important outcomes from therapy.
R10). Many participants associated assertive relat- Clients were described as ‘no longer as distressed or
ing with an increase in clients’ power, e.g., feeling depressed’ (R9), ‘happier’ (C5) and showing a new
‘slightly more in control, slightly more power, as if the ‘brightness’ in mood (F8). C6 reported that since
relationship is becoming a slightly more balanced one’ therapy, she had experienced her longest period
(T2). This was linked to a parallel decrease in the of time ‘without illness’ (C6). C4’s mother identified
perception of the voices’ power. Voices became that ‘he’s definitely less paranoid’ (F7), which was
‘more nuisance than . . . powerful’ (R10), and ‘less evident through him going out more. C4 said there
important’ to the clients through therapy (T1). C6 had not been any changes in the way he feels.
summed up this parallel, reciprocal process of a Many participants talked about changes in clients’
shift in power within the relationship; ‘the more views of themselves. C6’s therapist explained that
power I get, the less he has’. For one client, this shift ‘her confidence seems to have grown’ as C6 feels better
in power was evident in the client feeling less about herself and her abilities (T3). Improved self-
compelled to comply with the voice’s commands esteem reinforced changes in the relationship with
(R9). the voice, as clients came to believe ‘I have a right
C4 did not express any changes in his relation- to set a boundary’ (R10) or ‘I don’t deserve that’
ship with the voice; ‘the voices are still very much (T1). Changes in the relationship with the voice
the same. So it hasn’t really touched upon it’. He served to strengthen self-esteem: ‘that gives me
continued to describe the voice as a ‘bully’ with more confidence, more self-esteem, because I think I
malevolent intent, great knowledge and power. don’t have to be . . . under the control of the Devil
When asked about his expectations about therapy, [voice] anymore. I can just try and be myself’ (C5).
C4 said: ‘I thought I would get told about the whole Self-respect was described as evident in clients’
conspiracy behind me. And then they would work with improved self-image (C6) and care about their
me on the real issues, you know’. He described this appearance (F8).
as ‘the only therapy that I could see that would work’. Participants also referred to improved self-effi-
This was linked to the content of his voices: ‘my cacy, e.g., the extent to which clients believed
voices always tell me that . . . one day you’re going to they could cope with problems. Through therapy,
know about it’. clients developed ‘tools to deal with the voice’ (R10)
that enabled them to feel ‘more able to deal with
Acceptance of Voices the voices when they’re bad’ (C5). T2 described an
Participants across all perspectives referred to increase in C4 feeling ‘he can change things, he can
the importance of clients coming to accept their control things’, although this was not supported by
voices. This was linked to a common idea that the C4’s account.

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Social Relationships future. Whereas now I can see that with practice . . . I
This subtheme emerged in participants’ descrip- can get . . . [the voice] under control’ (C6).
tions of how the therapy had affected clients’ social Therapists described the therapy as ‘intrinsically
relating and subsequently relationships with family, optimistic’ about the possibility of change (T1).
friends and partners. T2 described how facilitating Yet they recognized that, in the context of long-
assertive relating to the voice had a ‘ripple effect’ on standing negative relationships with voices, clients
social relationships by clients applying the ‘guiding might struggle to believe that things could be dif-
principles of our conversations’ to their life experi- ferent (T1). In this way, strengthening the belief in
ences. Some participants referred to clients taking the possibility of change was seen as a significant
more interest in social relationships, e.g., F7 talked outcome from therapy: ‘if we, over a space of a few
about her son increasing engagement with friends short weeks, can work to a point where maybe change
and family. can be um conceived of . . . maybe that’s actually some-
Many participants described clients becoming thing quite significant’ (T2).
more assertive in their relating to others, and the
impact of this on their positioning within social
relationships. A significant change for both C5 and DISCUSSION
C6 was being able to say no within relationships:
The aim of this study was to explore multiple per-
spectives on the experience, process and useful-
‘it gives me the power to say no without feeling
ness of a pilot of Relating Therapy for people who
guilty . . . I can choose what I want to do more,
hear voices. The results suggest that the therapy
rather than . . . let him control me, and just be
can be understood as a process of engaging with
submissive’. (C5)
the relational model, developing understanding,
introducing different relating possibilities and ulti-
Participants highlighted the importance of being
mately bringing about change. Most participants
able to say no and set boundaries in relationships
experienced and understood Relating Therapy as
(R10), while ‘feeling ok’ and ‘without losing the person’
a helpful and positive process.
(T3). C5 similarly described a shift with her partner
to more ‘equal terms’. For F8, the shift in social
relationships was about a return to C6’s former
Spread of Perspectives Across Themes
self: he affectionately described the re-emergence
of the ‘bossy-boots’ and was ‘happy with the fact that The spread of themes across perspectives is
we’re getting my daughter back’. noteworthy given the decision to take a pan-
Consistent with assertive relating, clients were perspective approach to analysis. The views of the
described as being more open and able to ask for therapists were evident across all of the reported
help from their family: ‘I’ve learned to be, with the subthemes, suggesting that they were engaged
therapy, to be more honest and ask for help when I need with the relational framework, its therapeutic use
it, rather than wait until its too late and I’m ill’ (C6). F8 and the resulting changes. The views of clients
talked about C6 being more open about her voices were similarly evident across subthemes, with
and paranoid worries. The impact of openness was the exception of drawing on positive relating styles.
that her family could ‘try and point out what the This exception may relate to the differing tempo-
solution is’ or help her challenge her worries and ral emphasis placed upon social relating by thera-
‘allay her fears’. pists and clients: therapists working subtly with
positive experiences of past social relationships
Hopefulness and the Possibility of Change in a theory and formulation driven manner; and
A further area of change identified by partici- clients focusing upon relationships (with voices
pants concerned clients’ views about the future. and socially) primarily within a forward-looking
C6 felt that therapy had allowed her to ‘face the recovery orientation.
future’ more positively by helping her to ‘face up’ The most notable differences across perspec-
to her traumatic past. C5 referred to the therapy tives concerned the referrers and relatives, whose
giving her a ‘more positive outlook on life’ by helping views were less consistently represented within
her use assertive responses to challenge the voice’s the superordinate theme that focused upon the
pessimism. Some participants associated hopeful- therapeutic process (developing a new relating style).
ness with increased independence seeking (T3) This raises questions about the extent to which
and self-efficacy (R10): ‘before I thought I had no referrers should be in dialogue with therapists

DOI: 10.1002/cpp


about psychological interventions; and the extent with this proposition, as therapy was described
to which therapy should be situated in a broader as enabling clients to consider new understand-
process of family work. Referrers and relatives may ings and interpretations of the voices’ negative
not feel sufficiently informed about specific interrelating.
ventions (which may or may not be appropriate
depending on individual contexts), yet they may
How is Change Defined?
have important views about clients’ experiences,
care and management that could impact upon the The participants within this study described
therapeutic process. perceived outcomes as meaningfully linked and
interconnected, rather than discrete ‘categories’.
Consistent with the focus of therapy and its theo-
The Interpersonal Nature of Voice Hearing retical underpinnings, the improved relationship
with the voice was described as contributing to
The results of this study are consistent with
many of the positive outcomes, e.g., facilitating a
literature that highlights the interpersonal nature
more efficacious view of the self (Close & Garety,
of the voice-hearing experience (Benjamin, 1989;
1998) and less negative relating within social rela-
Birchwood et al., 2000, 2004; Chin et al., 2009).
tionships (Birchwood et al., 2002; Hayward, 2003).
Participants’ accounts suggest that the idea of a
The outcomes related to acceptance and hope are
relationship with the voice is a meaningful, under-
consistent with the recent emphasis on recovery
standable and intuitive concept, and was reflected
oriented approaches that view enhancement of
in the way that participants talked about voices as
quality of life as possible despite continuing ‘psy-
personified entities, with knowledge, intent and a
chotic’ experiences (e.g., Hayward & Slade, 2008).
history of interaction and dialogue that commonly
It was interesting to note that C4 was the only
positioned the voice as powerful and intrusive,
participant who did not identify positive changes
and the hearer as powerless and seeking distance.
from therapy. As the results suggest, C4 expected
Furthermore, the ease with which participants
or hoped that therapy would validate the reality
identified similarities between social relationships
of his beliefs about a conspiracy against him, and
and the relationship with the voice corroborated
help him deal with the subsequent situation. His
the findings of Birchwood et al. (2000, 2004) and
therapist (T2) talked about being non-challenging
Hayward (2003).
of beliefs, but was clear that he understood the task
of therapy as facilitating C4 in relating differently
to the voice. Consequently, the absence of reported
Relating Therapy
change may be attributed to the lack of a shared
Accounts about the process of change seem con- goal between client and therapist (McGowan, Lav-
gruent with literature suggesting that increased ender, & Garety, 2005).
dialogical engagement with the voice can con-
tribute to positive outcomes (e.g., Chadwick, 2006;
Limitations
Davies, Thomas, & Leudar, 1999; Leudar, Thomas,
McNally, & Glinski, 1997). This process of learning The sampling and data collection process may
to relate differently promoted assertive engage- have created potential biases that limit the utility of
ment with the voice, rather than passive acceptance the results. The sample were selected on the basis
and subservience, or resistance through shouting, that they were involved in the Relating Therapy
avoiding and attempting to escape (Chadwick & pilot and therefore were relevant to answering the
Birchwood, 1994). research questions about experiences and views
Within Birtchnell’s model, Relating Therapy can of this therapy (Smith & Osborn, 2003). Yet the
be understood as encouraging clients to relate less sample was very broad in that participants varied
negatively from a position of dependence (within greatly in perspective, age and other contextual
the power domain), involving less distancing and factors. This seems appropriate in an exploratory
more involvement and engagement with the voice study that seeks to develop understanding about
(within the proximity domain). As well as modi- a novel form of therapy and generate further areas
fying relating styles, Birtchnell also proposed that for exploration (Dallos & Vetere, 2005). However,
therapy should help clients tolerate others’ negative this issue, combined with the small number of
relating styles. Participants’ accounts within the participants, does reduce the extent to which the
subtheme developing understanding were consistent results can be generalized beyond this sample.

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Future Research (Ed.), A casebook of cognitive therapy for psychosis (pp.
108–131). Hove: Brunner-Routledge.
This study suggests that conceptualizing the voice- Birchwood, M., Meaden, A., Trower, P., Gilbert, P., &
hearing experience as a relationship may be nor- Plaistow, J. (2000). The power and omnipotence of
malizing, hopeful and helpful for some clients. voices: Subordination and entrapment by voices and
Future studies should attempt to clarify the factors significant others. Psychological Medicine, 30, 337–344.
Birtchnell, J. (1996). How humans relate: A new interpersonal
that may contribute to making this framework
theory. Hove: Psychology Press.
more or less helpful for different voice hearers. For Birtchnell, J. (1994). The interpersonal octagon: An alter-
example, this may take the form of comparing how native to the Interpersonal cycle. Human Relations, 47,
meaningful and useful this framework is deemed 511–529.
to be by voice hearers with different characteris- Birtchnell, J. (2002). Relating in psychotherapy: The applica-
tics (such as different backgrounds, explanatory tion of a new theory. Hove: Brunner Routledge.
frameworks and voice characteristics). In addi- Byrne, S., Birchwood, M., Trower, P.E., & Meaden, A.
(2006). A casebook of cognitive behaviour therapy got
tion, multiple forms of data collection and mea- command hallucinations: A social rank theory approach.
sures of change would offer more information and Hove: Routledge.
understanding about this new form of therapy and Chadwick, P. (2006). Person-based cognitive therapy for dis-
boost the validity of the findings. This might take tressing psychosis. Chichester: Wiley.
the form of interviews and questionnaires before Chadwick, P.D.J., & Birchwood, M.J. (1994). Challeng-
therapy commences (about expectations, hopes ing the omnipotence of voices: A cognitive approach
to auditory hallucinations. British Journal of Psychiatry,
and fears), at different stages of therapy (possi- 164, 190–201.
bly utilizing observation of videotaped sessions) Chin, J., Hayward, M., & Drinnan, A. (2009). ‘Relating’
and after therapy is completed (to explore overall to voices: Exploring the relevance of this concept to
views and outcomes). Such research may helpfully people who hear voices. Psychology and Psychotherapy:
differentiate between the views and experiences Theory, Research and Practice, 82, 1–17.
of clients and therapists, enabling the distinctive- Close, H., & Garety, P. (1998). Cognitive assessment of
voices: Further developments in understanding the
ness and/or overlap of different perspectives to be
emotional impact of voices. British Journal of Clinical
further clarified. Psychology, 37, 173–188.
Dallos, R., & Vetere, A. (2005). Researching psychotherapy
and counselling. Berkshire: Open University Press.
Davies, P., Thomas, P., & Leudar, I. (1999). Dialogical
ACKNOWLEDGEMENTS engagement with voices: A single case study. British
Thanks are due to all the individuals who partici- Journal of Medical Psychology, 72, 179–187.
pated within the study, and to Arlene Vetere for Dryden, W., & Constantinou, D. (2004). Assertiveness:
Step by step. London: Sheldon Press.
her advice and guidance. Garrett, M., & Silva, R. (2003). Auditory hallucinations,
source monitoring, and the belief that ‘voices’ are real.
Schizophrenia Bulletin, 29, 445–457.
Gilbert, P., & Allan, S. (1998). The role of defeat and
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