New Therapies May Offer Hope to People Who Hear Voices

A woman talks to herself on a train. She yells, barters, and converses with someone no one can see. Some people stare, while others avoid her gaze. Others understand; maybe they've had the same experience. It's not as uncommon as some may think.

People who hear voices often talk back to those voices. For many decades, clinicians were coached to identify talking to voices as a "symptom," and warned against talking to people about their voices as this would pull a person further into their psychosis. It can be troubling to watch, particularly when someone is clearly pained in their experience, shouting back, or covering their ears. It's natural for an onlooker to wish to take the experience away.

For many, hearing voices can be distressing. Voices can taunt a person in a way that is highly personal. Voices can be loud and commanding. Sometimes it can be hard to tell what someone's thoughts are from the voices. Is it any wonder why people sometimes talk back?

Still, some report meaning in their voices. While not all voices are related to mental illness, several mental health conditions are associated with hearing voices, including schizophrenia and bipolar disorder. In addition, not everyone who hears voices finds the experience negative. Some may speak of comfort in hearing the voice of a deceased loved one, for example.

Yet, many individuals with the lived experience of hearing voices share that talking back to voices can be a release, a way to work through things, and to keep grounding (Clements et al., 2020). In an experience that can be extremely isolating, within a self-help group known as the Hearing Voices Network, people who hear voices have gathered together to talk about their experiences. For decades, voice-hearers have shared the value of talking to their voices. While limited, qualitative research reveals that many who attend hearing voices groups find these therapeutic (Longden et al., 2018). Even knowing one is not alone can mean a lot.

Voice Dialogue in Therapy

Voice dialogue is a strategy that has been employed in several psychotherapies for individuals who hear voices. Among these is avatar therapy. In avatar therapy, digital avatars are co-created with a therapist to symbolize a person's voice. The person is then allowed to confront the voices while the therapist controls a response from the avatar. While not yet considered an evidence-based treatment, initial evidence on avatar therapy has been promising. A study investigating the effects of avatar therapy on clients diagnosed with treatment-resistant schizophrenia who heard voices found improvements in self-esteem, a decrease in psychotic symptoms, and improvements in mood (Beaudoin et al., 2023).

Compassion-focused therapy has also utilized voice dialogue to assist clients who hear voices. Unlike avatar therapy, compassion-focused therapy focuses initially on building up a compassionate core self through specific exercises to improve self-compassion. The person is then given means to engage in dialogue with their voice through activities such as chair work and letter writing. In chair work, the person might visualize the voice in another chair and move back and forth from their chair to the other symbolizing a switch between self and the voice throughout the dialogue. The therapist can assist with this process through questions and mediation. When it is not feasible to dialogue with the voice, these exercises can also be engaged to work through critical thoughts.

Along with working through the experience of hearing voices, compassion-focused therapy can help a person identify their defenses, and deepen a positive relationship with one's self and others. It is an approach that has been utilized for a spectrum of challenges ranging from eating disorders to trauma.

The evidence base for compassion-focused therapy as an intervention for voices is still emerging. Still, the findings have so far been positive: 14 studies have explored the effects of compassion-focused therapy on voices with results suggesting that through this process many find a greater sense of peace with their voices (Leach et al., 2014).

It should be noted that these psychotherapies are not meant to take the place of medication or other psychiatric interventions for conditions such as schizophrenia.

Closing

While dialogue with voices in therapy remains somewhat controversial, some research shows that psychotherapies involving voice dialogue may offer some relief. These are emerging treatments with a growing evidence base. This is in addition to established evidence-based psychotherapies such as cognitive behavioral therapy for psychosis (CBTp) and psychiatric interventions.

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