Schizophrenia Research 250 (2022) 172–179

Contents lists available at ScienceDirect

Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

A psychological intervention for engaging dialogically with auditory

hallucinations (Talking With Voices): A single-site, randomised controlled
feasibility trial
Eleanor Longden a, b, c, *, Dirk Corstens d, Samantha Bowe a, Melissa Pyle a, Richard Emsley e,
Sarah Peters b, Alison Branitsky a, b, c, Nisha Chauhan a, Nikki Dehmahdi a, Wendy Jones a, b,
Natasha Holden a, Amanda Larkin a, Alissa Miners a, Elizabeth Murphy a, Ann Steele a,
Anthony P. Morrison a, b
a
Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
b
Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The
University of Manchester, Manchester, UK
c
Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
d
GGZ Noord-Holland Noord, Texel/den Helder, the Netherlands
e
Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK

A R T I C L E I N F O A B S T R A C T

Keywords: There is growing clinical interest in addressing relationship dynamics between service-users and their voices. The
Psychotherapy Talking With Voices (TwV) trial aimed to establish feasibility and acceptability of a novel dialogical intervention
Schizophrenia to reduce distress associated with voices amongst adults diagnosed with schizophrenia spectrum disorders. The
Dissociation
single-site, single-blind (rater) randomised controlled trial recruited 50 participants who were allocated 1:1 to
Treatment outcome research
Hearing Voices Movement
treatment as usual (TAU), or TAU plus up to 26 sessions of TwV therapy. Participants were assessed at baseline
and again at end of treatment (six-months). The primary outcomes were quantitative and qualitative assessments
of feasibility and acceptability. Secondary outcomes involved clinical measures, including targeted instruments
for voice-hearing, dissociation, and emotional distress. The trial achieved 100 % of the target sample, 24 of
whom were allocated to therapy and 26 to TAU. The trial had high retention (40/50 [80 %] participants at six-
months) and high intervention adherence (21/24 [87.5 %] receiving ≥8 sessions). Signals of efficacy were shown
in targeted measures of voice-hearing, dissociation, and perceptions of recovery. Analysis on the Positive and
Negative Syndrome Scale indicated that there were no differences in means of general psychosis symptom scores
in TwV compared to the control group. There were four serious adverse events in the therapy group and eight in
TAU, none of which were related to study proceedings. The trial demonstrates the acceptability of the inter­
vention and the feasibility of delivering it under controlled, randomised conditions. An adequately powered
definitive trial is necessary to provide robust evidence regarding efficacy evaluation and cost-effectiveness.
Trial registration: ISRCTN 45308981.

1. Introduction Bortolon et al., 2017; McCarthy-Jones, 2018; Varese et al., 2012),

Hearing voices (the perception of human speech with no objective
source) is considered a central feature of psychotic disorders and can
lead to significant distress. However, despite robust evidence for the link
between hallucinations and adversity exposure (Bailey et al., 2018;
adequate access to psychological therapies is a longstanding problem
within healthcare services (Colling et al., 2017; Johns et al., 2019).
Given that a subset of service-users find no relief from antipsychotic
medication (Harrow et al., 2014; Hassan and De Luca, 2015; Sommer
et al., 2012), combined with the considerable societal and economic

* Corresponding author at: Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Harrop House, Bury New Road, Prestwich M25 3BL,
UK.
E-mail address: Eleanor.Longden@gmmh.nhs.uk (E. Longden).

https://doi.org/10.1016/j.schres.2022.11.007
Received 24 August 2021; Received in revised form 3 October 2022; Accepted 6 November 2022
Available online 21 November 2022
0920-9964/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
E. Longden et al.
costs of unremittent schizophrenia (Chong et al., 2016; Jin and Mosweu,
2017), there is a clear need to refine clinical research efforts in order to
expand evidence-based interventions and promote service-user choice.
In this regard, a burgeoning field of interest are therapeutic strategies
which actively address the dynamics of the voice/hearer relationship.
Traditionally, hallucinations were primarily viewed as a perceptual
anomaly with which only limited psychological engagement was war­
ranted. However, an emergent wave of treatments is paying greater
attention to the interpersonal aspects of voice-hearing as a mechanism to
promote recovery, including Relating Therapy (Hayward et al., 2017),
which explores perceptions of proximity and power between hearer and
voice; compassion-focused techniques (Heriot-Maitland et al., 2019),
which aim to develop more empathic, accepting stances towards one's
voices and oneself; Avatar (Leff et al., 2014), a dialogical strategy that
employs digital representations of hostile voices, and Progressive
Approach psychotherapy, which supports an attitude of empathy and
acceptance from the reflective ‘Adult’ self to the distressed ‘experi­
encing’ self (Mosquera and Ross, 2017). The current intervention,
Talking With Voices (TwV), is a form of psychotherapy which integrates
such relational concepts in combination with the increasingly recog­
nised stance that dissociative frameworks can be applied to under­
standing voices (including those which occur in the context of psychosis:
Longden et al., 2020; Moskowitz and Corstens, 2007; Moskowitz et al.,
2017). More precisely, TwV conceptualises voices as a dialogical expe­
rience which embodies different social, cultural and interpersonal fac­
tors, and is often perceived as a subjectively real event which manifests
as autonomous to, and disconnected from, one's sense of self (Dorahy
and Palmer, 2016; Longden et al., 2019). From this basis, it provides a
format in which a therapist verbally engages with the voice(s) with the
aim of facilitating a more peaceful, equitable relationship with the
hearer. A full description of the therapy is provided by Longden et al.
(2021), but in brief involves psychosocial education on voice-hearing,
including coping strategies and recovery literature, followed by a pro­
cess of psychological formulation wherein therapist and client collabo­
rate to derive an understanding of how voices may relate to particular
social/emotional conflicts and develop shared goals for the desired
change in the relationship. The result of this work forms the basis for
subsequent dialogue, in which the therapist poses direct queries to the
voice and receives verbatim responses repeated by the client. In the
long-term, the approach aims to cultivate a more constructive rela­
tionship by increasing communication and cooperation, reducing hos­
tility, redressing unequal power dynamics, and promoting insight into
voice characteristics by contextualising their associations with adverse
emotions and life events. Consistent with cognitive models of psychosis
(Birchwood et al., 2004; Chadwick and Birchwood, 1994; Morrison,
2001) it is also anticipated that reducing negative voice-related attri­
butions will lead to a consequent reduction in distress.
Talking With Voices is a survivor-informed intervention (Corstens
et al., 2019) and dialogical engagement with voices is an approach
already utilised within the survivor-led Hearing Voices Movement
(Corstens et al., 2014). However, existing clinical evidence is limited to
descriptive case examples (e.g., Corstens et al., 2012; Longden and
Corstens, 2020; Moskowitz and Corstens, 2007), a case series with a
concurrent multiple baseline design (n = 15: Steel et al., 2019) and a
small randomised controlled trial (n = 12: Schnackenberg et al., 2017).
Although not all participants respond favourably to dialoguing with
their voices (Steel et al., 2020), this provisional evidence indicates sig­
nals of efficacy with no emergent safety concerns. However, there is a
clear need to refine such results before TwV could be considered a viable
treatment option. As such, the aim of the current study was to inform the
design of a definitive clinical and cost-effectiveness trial by evaluating
the feasibility and acceptability of TwV therapy compared to treatment
as usual (TAU) amongst adult voice-hearers with a diagnosis of a
schizophrenia spectrum disorder.
173
Schizophrenia Research 250 (2022) 172–179
2. Material and methods
2.1. Design
Talking With Voices was a single-site feasibility trial conducted ac­
cording to a single-blind (rater), two-arm, randomised controlled
design. Participants were recruited from Greater Manchester Mental
Health (GMMH) National Health Service (NHS) Foundation Trust in
northwest England, who also acted as the trial's sponsor. An additional
participant was also recruited from the neighbouring Pennine Care NHS
Trust. The study was funded by the National Institute of Health Research
(PDF-2017-10-05) and prospectively registered with the ISRCTN
(45308981). Ethical approvals were received from the North West­
–Preston Research Ethics Committee (17/NW/0633).
2.2. Participants
Eligible participants were aged ≥18 years; had heard voices for at
least one year and scored ≥4 on the auditory hallucination subscale of
the Positive and Negative Syndrome Scale (PANSS: Kay et al., 1987); had
no medication changes within the past month; met criteria for ICD
schizophrenia spectrum disorder; were able to provide written,
informed consent; were not currently receiving structured psychological
therapy for psychosis; were in contact with secondary care mental
health services and had a care coordinator; were willing and able to
communicate with their voices and relay voice utterances to a therapist;
and heard voices which were sufficiently personified to engage in dia­
logical work.
Individuals meeting any of the following criteria were subsequently
excluded: at immediate risk of harm to self or others, non-English
speaking, in receipt of a primary diagnosis of alcohol/substance
dependence or autism spectrum disorder, demonstrating a moderate/
severe learning disability, having an organic brain injury or illness
implicated in psychotic symptoms, scoring >5 on the conceptual
disorganization subscale of the PANSS, or being homeless and/or of no
fixed abode.
Participants were primarily referred to the trial by staff within
community mental health teams (CMHTs) or early intervention (EI)
services across the host site. Eligibility data were derived from admin­
istering standardised measures and through liaison with participants
and relevant healthcare workers.
2.3. Randomisation
Participants were randomly allocated in a 1:1 ratio to receive either
TAU alone, or TAU plus therapy. Randomisation to conditions was
conducted by the trial administrator via the secure online service
SealedEnvelope.com and was independent and concealed with outcome
assessors blinded to treatment group. It was not stratified for any vari­
ables and employed randomised-permuted blocks of 4, 6 and 8. Allo­
cation was made known to the chief investigator (EL) to monitor
adherence to the randomisation algorithm, the trial therapists, the trial
administrator, and communicated to participants and their healthcare
teams via phone call and letter. A standard operating procedure for
allocation concealment, including an adherence declaration, was read
and signed by trial staff and the importance of blinding was impressed
upon participants, their family members, and healthcare workers. Any
breaks were reported to the chief investigator, with learning points/
remedial action disseminated within the research team, then submitted
to the combined independent Trial Steering and Data Monitoring and
Ethics Committee (TSC-DMEC) for oversight purposes.
2.4. Procedure
Participants were allocated to receive either treatment as usual
(TAU), or up to 26 one-hour sessions of TwV therapy plus TAU over six
E. Longden et al. Schizophrenia Research 250 (2022) 172–179

months. The intervention was delivered by trained clinical psycholo­ 2.6. Statistical analysis
gists, with sessions typically offered once a week according to a struc­
tured protocol (Longden et al., 2021). The initial phase focused on A target sample of 50 participants was deemed sufficient to both
engagement, psychosocial education, and development of coping/self- demonstrate feasibility and to obtain reliable parameter estimates for
soothing strategies, followed by assessment and formulation of voices, sample size in a definitive trial (Browne, 1995). Given that the focus of
dialogical work, and a final period of evaluation and outcome consoli­ analysis was not hypothesis testing, a formal power calculation for
dation. Electronic session records and adherence checklists were utilised detecting treatment differences was not conducted. Instead, a focus was
to maximize fidelity, with any protocol divergences monitored during placed on descriptive statistics, point estimates, and associated 95 %
therapist supervision. These sessions occurred fortnightly using a group confidence intervals rather than tests of statistical significance.
peer-supervision format and were facilitated by a psychiatrist with Descriptive baseline and follow-up data were summarised as mean (SD)
clinical experience of TwV (DC) and two researchers with lived expe­ for continuous variables and frequencies/percentages for categorical
rience of voice-hearing (EL & AB). Unless requested otherwise, therapy variables. Analyses followed a pre-specified plan approved by the chief
was conducted in participants' homes in a manner consistent with investigator, the trial statistician, and the TSC-DMEC (available to view
assertive outreach practice, with participants seen by the same therapist online at www.isrctn.com/ISRCTN45308981) and was based on
whenever possible to maintain consistency and engagement. In the UK, intention-to-treat principles at the participant level. Linear regression
TAU for service-users with psychosis is based on the Care Programme was used to estimate the between-group adjusted mean difference con­
Approach and can comprise a range of interventions, including psychi­ trolling for baseline scores. All available data was used from each
atric medication, care coordination, rehabilitative and family interven­ timepoint, with missing data imputed with pro-rating. The main ana­
tion services, outpatient follow-up care, and access to cognitive lyses were all conducted in Stata (v.16: StataCorp, 2019).
behavioural therapy for psychosis (CBTp).
3. Results
2.5. Outcomes
A total of 127 individuals were referred to the trial between 08
The primary outcomes were evidence for the feasibility and accept­ February 2018 and 16 December 2019; 50 of whom were recruited for
ability of delivering the intervention under randomised conditions, the study, with 24 allocated to TwV and 26 to TAU. Follow-up assess­
including quality of data collection, retention and recruitment rates, ments were conducted between 12 September 2018 and 05 August
adherence to allocation, and treatment acceptability (assessed through 2020. Baseline characteristics are summarised in Table 1 and a
discontinuation rates and a nested qualitative study). A three-stage
model for progression criteria was utilised to establish the viability of
progressing to a definitive trial, which was approved in advance by the Table 1
TSC-DMEC and related to baseline recruitment, retention at six-month Baseline characteristics.
follow-up, and adherence to therapy. Specific criteria for progression Total sample (N Therapy (N = TAU (N = 26)
were at least 80 % of the target population (green zone), 60–79 % = 50) 24)
(amber zone) or <59 % (red zone), and were operationalised using Mean (SD) or N Mean (SD) or N Mean (SD) or
randomisation rates, completion of the PANSS at six-month follow-up, (%) (%) N (%)
and attendance of at least eight therapy sessions. Age 39.56 (11.55) 38.1 (10.1) 40.9 (12.8)
A number of secondary outcomes were also chosen to help identify Sex
relevant clinical variables and potential mechanisms of action for the Female 23 (46) 14 (58) 9 (35)
Male 27 (54) 10 (42) 17 (65)
intervention, as well as to assess the applicability and acceptability of
Ethnicity
collecting these in the event of a definitive trial. These included specific White background 33 (66) 12 (50) 21 (81)
measures of voice-hearing (the Voice and You scale [VAY: Hayward Asian 7 (14) 6 (25) 1 (4)
et al., 2008], the Subtypes of Voice Hearing Questionnaire [Cox et al., Black 3 (6) 2 (8) 1 (4)
Mixed background 4 (8) 2 (8) 2 (8)
2017], the Revised Beliefs about Voices Questionnaire [BAVQ-R:
Other ethnic group 3 (6) 2 (8) 1 (4)
Chadwick et al., 2000], and the PANSS hallucinations subscale) and Employment status
general clinical presentation (the Questionnaire About the Process of Unemployed 39 (78) 18 (75) 21 (81)
Recovery [QPR: Neil et al., 2009], the revised Dissociative Experiences Employed full-time 2 (4) 1 (4) 1 (4)
Scale [DES-II: Carlson and Putnam, 1993], and PANSS subscales). Employed part-time 4 (8) 3 (13) 1 (4)
Retired 2 (4) 0 (0) 2 (8)
Additional assessments included adversity exposure (the Revised Life
Student 2 (4) 1 (4) 1 (4)
Stressor Checklist [LSC-R: Wolfe et al., 1996]) and health economics Voluntary 1 (2) 1 (4) 0
data (the EQ-5D: van Reenen and Janssen, 2015). Measures were Highest educational level
administered at baseline and six-month follow-up by trained researchers Primary 3 (6) 2 (8) 1 (4)
who were blind and independent to treatment group. Participants in the Secondary 20 (40) 8 (33) 12 (46)
Further/college 12 (24) 6 (25) 6 (23)
intervention arm additionally completed a measure of therapeutic alli­ Higher/university 13 (26) 8 (33) 5 (19)
ance, the Working Alliance Inventory (Tracey and Kokotovic, 1989), and Did not respond 2 (4) 0 2 (8)
a customised therapy evaluation, both dispensed by trial therapists. A Diagnosis
nested qualitative evaluation was also conducted amongst trial thera­ Schizophrenia 33 (66) 16 (67) 17 (65)
Schizoaffective 2 (4) 1 (4) 1 (4)
pists (Longden et al., 2022) and participants (Longden et al., in
Psychosis (other) 15 (30) 7 (29) 8 (31)
preparation). Current antipsychotic
Serious adverse events (SAEs) and adverse events (AEs) were medication
recorded via participant self-report to therapists and/or research assis­ Yes 48 (96) 24 (100) 24 (92)
tants during the trial. Screening of electronic medical records was also No 2 (4) 0 2 (8)
Previous therapy for voices
conducted at follow-up by a researcher who was not masked to alloca­ Yes 20 (40) 7 (29) 13 (50)
tion. All SAEs were reported to the TSC-DMEC for independent No 27 (54) 14 (58) 13 (50)
monitoring. Did not respond 3 (6) 3 (13) 0
Voice-hearing duration 11.90 (11.04) 10.8 (8.4) 13.0 (13.2)
(years)

174
E. Longden et al.
CONSORT diagram depicting participant flow is presented in Fig. 1.
In terms of feasibility criteria, recruitments rates were 100 % of the
target sample (green progression zone). The conversion rate was around
2:1, with 35 (27.6 %) of the 127 referred individuals declining to
participate and an additional 29 (22.8 %) being ineligible. The most
frequently referring services were CMHTs, responsible for the referrals
of 36 (72 %) participants.
Forty participants were retained in the trial at the six-month (end of
treatment) assessment (80 %; green). Attrition was low, with seven
participants being uncontactable and three formally withdrawing from
the trial. Of the latter, one was from the therapy group owing to a
reluctance to engage with the intervention and two were from TAU, one
of whom cited disappointment with his allocation and the second who
Referrals (n=127)
Screened prior to eligibility
assessment
Assessed for eligibility
Randomised (n=50)
Talking With Voices (n=24)
Received allocated intervention (n=21)
Did not receive allocated intervention (n=3)
6-month assessment (n=21)
Withdrawn (n=1)
Uncontactable (n=1)
Deceased (n=1)
Fig. 1. CONSORT diagram for flow of participants.
Schizophrenia Research 250 (2022) 172–179
did not provide a reason. The number of full blind breaks was four, three
of which occurred in the therapy group, and all of which resulted from
participants disclosing their allocation to research workers. Two of these
breaks took place prior to the six-month assessment and were trans­
ferred to a new and independent assessor. The remaining two occurred
during the assessment process, in which case audio recorded PANSS
interviews were independently rated by a separate assessor.
Of the 24 participants in the treatment group, 21 (87.5 %) received at
least eight therapy sessions (green), the pre-defined feasibility criteria
for adherent delivery of TwV. The mean number of attended sessions
was 17.42 (SD = 8.3; range 2–39). Three individuals did not receive
their allocated intervention, owing to the death of the participant by
suicide after two sessions, withdrawal from the study after two sessions,
Excluded (n=75)
Ineligible (n=28)
o Risk issues (n=4)
o No care coordinator (n=4)
o No primary diagnosis of psychosis (n=4)
o No longer hearing voices (n=4)
o Voices unable/unwilling to dialogue (n=3)
o Under different NHS Trust (n=2)
o Non-English speaking (n=2)
o Currently receiving therapy (n=1)
o Learning difficulty (n=1)
o No fixed abode (n=1)
o Heard voices for less than a year (n=1)
o Referred after recruitment deadline (n=1)
Declined to participate (n=34)
o Disinterested in research/therapy (n=9)
o Lack of readiness for therapy (n=4)
o Not right time/too busy to participate (n=5)
o Participant unable/unwilling to dialogue with voices (n=4)
o Not distressed by voices/not help-seeking (n=3)
o Personal circumstances (n=1)
o No reason given (n=8)
Uncontactable (n=13)
Excluded (n=2)
Ineligible (n=1)
o Risk issues
Declined to participate (n=1)
o Lack of readiness for therapy
Treatment as Usual (n=26)
6-month assessment (n=19)
Withdrawn (n=2)
Uncontactable (n=4)
Deceased (n=1)
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E. Longden et al. Schizophrenia Research 250 (2022) 172–179

and disengagement from therapy after six sessions. Adherence to the Table 2
trial's therapy manual was high with key milestones met by a majority of Baseline and follow-up scores for both groups on the secondary assessment
participants. Specifically, of participants receiving at least eight ses­ measures.
sions, 21 (100 %) had a psychological formulation developed; 18 (85.7 TwV(N = TAU (N Adjusted mean 95 % CI
%) undertook at least one voice session of dialogue work; and targeted 24) = 26) difference (SE)
techniques to facilitate an improved relationship between client and M(SD); n M(SD); n
voice(s), ‘time-sharing’ and ‘developing short replies’, were achieved by
PANSS total
14 (66.7 %) and 17 (80.9 %) respectively. Baseline 67.5 63.2
In our intention-to-treat analysis of clinical outcomes, pro-rated (13.5); 24 (9.0); 26
scores for the secondary measures at 26 weeks were assessed for all 26 weeks 59.7 56.3 2.79 (3.80) − 4.91,
participants still retained by this endpoint. Descriptive statistics, point (15.6); 21 (15.3); 19 10.49
PANSS positive
estimates of the adjusted mean difference, standard errors and associ­ Baseline 18.8 17.6
ated 95 % confidence are presented in Table 2 for each randomised (4.9); 24 (3.5); 24
group. 26 weeks 17.1 15.7 0.40 (1.35) − 2.34,
The safety assessment is summarised in Table 3 and indicated that (5.2); 21 (5.0); 19 3.14
PANSS negative
twice as many participants experienced SAEs in the TAU arm than those
Baseline 13.3 12.8
receiving therapy, most notably voluntary admissions to psychiatric (4.0); 24 (4.2); 26
hospital. No SAEs in either group were deemed related to trial proced­ 26 weeks 12.0 11.7 0.44 (1.32) − 2.23,
ures. Other non-serious AEs were experienced in comparable rates (4.2); 21 (5.9); 19 3.11
across groups, the majority of which were incidents of self-injury. PANSS general
Baseline 35.5 32.8
(7.2); 24 (5.3); 26
4. Discussion 26 weeks 30.5 28.9 1.29 (1.90) − 2.56,
(8.1); 21 (7.4); 19 5.14
The TwV trial shows that it is possible to recruit, retain and engage PANSS anxiety item
Baseline 4.4 (1.2); 4.3 (1.2);
service-users who meet criteria for schizophrenia spectrum disorders to
24 26
evaluate a dialogical intervention for auditory hallucinations under 26 weeks 3.7 (1.4); 3.3 (1.6); − 0.41 (0.43) − 1.29,
randomised controlled conditions, thus providing indications of both 21 19 0.46
feasibility and acceptability. This is a promising development, given the PANSS depression
item
growing evidence which suggests that auditory hallucinations, at least
Baseline 4.4 (1.0); 3.8 (1.3);
for some individuals, are psychologically meaningful events in which 24 26
demonstrable links exist between adversity exposure and the responses 26 weeks 3.4 (1.6); 3.5 (1.4); 0.39 (0.43) − 0.49,
to, and content of, the voices people hear. However, while addressing 21 19 1.26
the interpersonal and relational dynamics of voice-hearing may be an PANSS
hallucinations
encouraging treatment strategy, more definitive evidence is needed
item
before such interventions can be routinely offered within healthcare Baseline 5.2 (0.6); 5.2 (0.6);
services. 24 26
The trial had low attrition (20 % at six months) and therapy delivery 26 weeks 4.7 (1.2); 4.0 (1.8); − 0.61 (0.47) − 1.57,
21 19 0.34
was highly satisfactory, with a sizeable proportion of participants
DES-II
receiving their allocated intervention. Although withdrawal rates can be Baseline 30.9 28.1
in the approximate region of 18 % for therapies which include some (20.4); 20 (20.9); 20
element of aversive exposure, including trauma-focused treatments 26 weeks 25.8 28.6 7.22 (7.17) − 7.65,
(Imel et al., 2013) and direct work with voices (Craig et al., 2016), only (25.5); 14 (23.6); 16 22.08
QPR
three participants (12.5 %) attended less than eight sessions of TwV,
Baseline 32.3 31.9
only one of whom withdrew from the trial (4.2 %). Participants (10.8); 22 (11.9); 23
receiving therapy additionally had fewer SAEs than the control arm, 26 weeks 38.5 30.8 − 6.94 (4.41) − 16.00,
none of which were considered related to the treatment or trial pro­ (12.2); 16 (15.9); 16 2.12
ceedings. These findings must be considered in the context of the small VAY dominance
Baseline 13.8 12.7
sample, yet suggest that direct therapeutic engagement with voices, (6.0); 20 (5.7); 23
including their association with adverse life events, may be a safe and 26 weeks 10.9 13.4 2.72 (1.85) − 1.08,
acceptable treatment option for many service-users with psychosis. In (6.0); 15 (6.8); 16 6.53
this regard, the sample appeared broadly generalizable to community- VAY intrusiveness
Baseline 10.2 8.0 (3.7);
based populations in terms of elevated rates of positive symptoms,
(4.0); 19 22
high medication usage and low rates of employment, although an 26 weeks 8.8 (3.6); 10.3 1.49 (1.30) − 1.20,
additional finding of note may be that a third of participants did not 15 (4.3); 15 4.17
identify as White. This is a higher proportion than CBTp trials recruiting VAY dependence
from the same geographic region (8.6 %–14.2 %: Law et al., 2017; Baseline 9.4 (6.8); 7.3 (5.3);
20 21
Morrison et al., 2018; Morrison et al., 2020; Morrison et al., 2013) and, if 26 weeks 10.3 9.0 (8.0); 1.36 (2.57) − 3.98,
replicated in a larger sample, may have implications for diversity and (8.1); 13 16 6.69
inclusion in that an intervention premised on relational strategies may VAY distance
appeal to such service-users; possibly because they are more likely to Baseline 12.9 11.2
(4.8); 18 (5.3); 22
perceive their experiences as having a spiritual/cultural origin (Singh
26 weeks 11.5 12.3 1.63 (1.55) − 1.59,
et al., 2015) and may, therefore, be particularly receptive to dialogical (5.2); 14 (6.1); 16 4.86
engagement. BAVQ-R
A definitive randomised controlled trial is now required to determine omnipotence
the clinical and cost-effectiveness of the TwV intervention. Although the Baseline

study was not powered to detect treatment effects, the results suggest (continued on next page)

176
E. Longden et al. Schizophrenia Research 250 (2022) 172–179

Table 2 (continued ) these effects, as well as how they relate to more established clinical and
TwV(N = TAU (N Adjusted mean 95 % CI functional outcomes such as quality of life and other psychiatric symp­
24) = 26) difference (SE) toms. Future research could also help facilitate preference and informed
M(SD); n M(SD); n
choice for therapies, dependent on the personal treatment goals of an
individual service-user, by examining the relative effectiveness and
12.0 10.8
differential impact of TwV on different treatment targets (e.g., re­
(4.2); 21 (3.9); 23
26 weeks 11.5 9.4 (2.9); − 0.94 (1.38) − 3.78, lationships with voices, voice-related distress, voice frequency and
(4.6); 16 16 1.90 duration, and quality of life and functioning) compared with other
BAVQ-R evidence-based psychological interventions (e.g., CBTp, Avatar ther­
malevolence apy). In this regard, future research could also seek to identify who TwV
Baseline 11.1 8.6 (4.4);
(5.3); 21 23
is most suitable for (including whether certain subtypes of voices
26 weeks 9.3 (6.2); 8.3 (5.1); 2.03 (1.58) − 1.21, respond better [Smailes et al., 2015], and whether there are any sub­
16 16 5.27 groups of client for whom it may be contra-indicated).
BAVQ-R There are a number of design considerations for a future definitive
benevolence
trial that have been identified by our feasibility study. Although
Baseline 4.1 (4.3); 5.8 (5.6);
21 23 resource limitations prohibited more than two assessments, a definitive
26 weeks 6.2 (5.3); 4.5 (6.2); − 3.93 (1.63) − 7.27, trial should include a longer-term follow-up in order to evaluate the
16 16 − 0.58 longevity of any treatment effects. Secondly, flexibility regarding the
BAVQ-R emotional timing and venue for assessment/therapy appointments proved crucial
resistance
Baseline 8.4 (3.3); 7.3 (2.9);
for engagement, meaning sufficient staffing capacity should be planned
21 22 to facilitate this in the future. In terms of therapy delivery, one partic­
26 weeks 6.9 (4.5); 7.3 (3.1); 2.00 (1.09) − 0.25, ipant commented on feeling unprepared for TwV's emphasis on adverse
16 16 4.24 life events, whereas a second stated strong opposition to its premise of
BAVQ-R behavioural
improving the relationship with one's voices. These elements should
resistance
Baseline 10.0 10.4 receive a greater emphasis prior to consent, with both verbal briefings
(4.3); 21 (4.9); 23 and written materials being clear about the presence and purpose of
26 weeks 8.8 (4.4); 9.9 (4.4); 0.89 (1.30) − 1.78, discussions regarding traumatic events and that the therapy does not
16 15 3.56 explicitly aim for voice cessation. An additional participant also
BAVQ-R emotional
engagement
revealed post-randomisation that he had entered the trial to educate
Baseline 3.0 (3.1); 3.4 (3.7); professionals about his personal theory of hallucinations rather than to
21 22 receive the intervention. Adding ‘help-seeking’ as an inclusion criterion
26 weeks 5.6 (4.4); 2.8 (4.4); − 3.07 (1.40) − 5.94, may reduce the likelihood of recruiting those who are unmotivated for
16 16 − 0.20
therapy, with more focussed screening by assessors additionally helping
BAVQ-R behavioural
engagement to identify whether participants intend to engage with TwV and un­
Baseline 3.3 (2.3); 3.5 (2.9); derstand its premise. It was further noted that participants required
21 21 substantial time and appointment flexibility to engage in, and feel safe
26 weeks 4.6 (3.3); 3.1 (3.8); − 1.62 (1.10) − 3.88, with, the therapeutic process. It may therefore be a worthwhile
16 15 0.64
amendment to extend the therapy window from 6 to 9 months (and/or
incorporate periodic booster sessions) to facilitate the consolidation and
reinforcement of therapeutic gains. In turn, while it is striking that most
Table 3 participants were referred from CMHTs relative to other services we do
Incidence of adverse events across groups. not have data to explain why this occurred. Speculatively, it may reflect
Therapy N = TAU N = low access to psychological therapies in community teams, or possibly
24 26 from participants' voice characteristics and their resulting beliefs and
Serious Adverse Events responses to them; both of which may have motivated referrals, either
Participants with an SAE 4 (16.7 %) 8 (30.8 %) separately or in combination. A future trial could capture these factors
Number of SAEs 5 13
more precisely. Final considerations for a definitive trial also regard the
Types of SAE
Death 1 1 choice of outcome measurement. The PANSS did not adequately capture
Voluntary psychiatric admission 1 6 the intended voice-related targets of the intervention (namely rela­
Involuntary psychiatric admission 2 3 tionship with, and impact of, the voices) and a more sensitive scale for
Otherwise medically significant (overdose) 1 2 assessing voice severity (e.g., the PSYRATS: Haddock et al., 1999)
Otherwise medically significant (aspiration 0 1
during ECT)
should be employed.
Adverse Events
Participants with an AE 5 (20.8 %) 7 (26.9 %) 5. Conclusions
Number of AEs 14 16
Types of AE
As an under-powered feasibility study the clinical implications of this
Self-injury 9 9
Suicidal ideation with behavioural component 2 3 research are limited, and a sufficiently resourced effectiveness trial will
Seizure/loss of consciousness 1 1 now be required to obtain more definitive evidence of TwV's clinical
A&E attendance 1 1 impact. However, it is apparent that clinicians can engage in therapeutic
Deterioration in mental state 1 2
dialogues with voices and that such voices, at least for some service-
users, can be conceptualised, engaged with, and ameliorated within
TwV may have beneficial outcomes for how voices are perceived the context of individual life histories. Based on this study, it is
(particularly in terms of increased benevolence), as well as facilitating reasonable to propose that relational dynamics can be an important
recovery and reducing dissociation. Additional research is now neces­ component of the voice-hearing experience and, beyond actual dia­
sary to investigate potential treatment mechanisms that may explain logue, should still be considered when supporting clients who are dis­
tressed by the voices they hear.

177
E. Longden et al.
Role of the funding source
The study was funded by a National Institute for Health Research
(NIHR) Postdoctoral Fellowship Scheme for EL (PDF-2017-10-050). RE
is part funded by the NIHR Biomedical Research Centre at South London
and Maudsley NHS Foundation Trust and King's College London and is
supported by an NIHR Research Professorship (NIHR300051). The
funders had no involvement in either the conduct of the research or the
preparation of the article.
Declaration of competing interest
Three authors (EL, DC and AB) have received financial payments for
delivering teaching or supervision for the Talking With Voices approach.
There are no other reported conflicts of interest.
Acknowledgements
We would like to thank all participants who agreed to take part in the
trial and the healthcare professionals who supported their recruitment.
In addition, we are extremely grateful to our combined Trial Steering
and Data Monitoring and Ethics Committee (Craig Steel, Jemma Hud­
son, and Andrew Grundy) for their oversight; and to the Psychosis
Research Unit's Service User Reference Group and Jacqui Dillon of the
English Hearing Voices Network for their valuable feedback on the trial's
design and research materials. The study was facilitated by the Greater
Manchester Local Clinical Research Network and was funded by a Na­
tional Institute for Health Research (NIHR) Postdoctoral Fellowship
Scheme for EL (PDF-2017-10-050). RE is part funded by the NIHR
Biomedical Research Centre at South London and Maudsley NHS
Foundation Trust and King's College London and is supported by an
NIHR Research Professorship (NIHR300051). This article presents in­
dependent research funded by the NIHR: the views expressed are those
of the authors and not necessarily those of the NHS, the NIHR or the
Department of Health and Social Care.
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