Mental Health Today (magasine) feb 2009 feature by Adam James
In 1993 ‘Accepting Voices’, by Professor Marius Romme and Sandra Escher, was published. The book argued that the voices (also known as aural hallucinations) experienced by people diagnosed with psychosis should be accepted as real. Don’t pathologise and seek to rid people of voices, the authors argued. Better to help people cope with them. Some professionals were truly alarmed by this argument. In the British Medical Journal, Raymond Cochrane, a professor of psychology, slammed the book’s message as ‘potentially dangerous’, arguing that this new approach colluded with delusions.
In April 2008, the scientific community was similarly perturbed, this time after a television documentary showed clinical psychologist Dr Rufus May using ‘voice dialogue’ to help a voice hearer. Directly communicating with the voices of a woman diagnosed with bipolar disorder was one of a number of psychological interventions used by Dr May. Dr May was ‘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 Dr May of ‘flagrant selfpromotion’. Lisa Brownell, a psychiatrist at Queen Elizabeth Psychiatric Hospital in Birmingham also weighed in, saying: ‘Don’t let him [Dr May] near me if I become mentally ill.’
But supporters of voice dialogue – which involves conversing with a psychotic person’s voices to understand that individual’s life experiences and the voices’ ‘motives’ – point to some similarities it has with both traditional cognitive behavioural therapy (CBT) and a new wave of CBT techniques. These include personbased cognitive therapy (PBCT), dialectical behaviour therapy, acceptance and commitment therapy, and relating theory. The solid evidencebase of CBT was recognised six years ago when the National Institute for Health and Clinical Excellence (NICE) recommended that it be made available for all people diagnosed with schizophrenia.
PBCT is largely being developed by Paul Chadwick, professor of psychology at the University of Southampton. It ushers in ‘substantial developments’ on traditional CBT for psychosis, he says. Notably, it’s a further demedicalisation of therapy, because PBCT aims to alleviate distress, not disease symptoms. PBCT – while using core CBT tools – also employs a Buddhist form of meditation called mindfulness to help a voice hearer create distance between themselves and the voice(s).
Relational therapy, being developed by researchers such as Mark Hayward, a clinical psychologist at the University of Surrey, is another CBT spinoff. When applied to voice hearing, a therapist uses Socratic dialogue, guided discovery and mindfulness to help someone gain a more balanced and interpersonal relationship with their voice(s). Like voice dialogue – and indeed CBT and PBCT – relation therapists accept a person’s voice(s) as real and meaningful. But, unlike voice dialogue therapists, they need have no direct conversation with a person’s voice(s), and instead use role play. ‘Relating 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. Rather than step into a relationship with the voice, I encourage someone to step back from the voice.’
But 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 to be alone with their voice. With someone else hearing what the voice says, the voice is being witnessed. This can be validating and reassuring. 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 someone.’
Voice dialogue therapists encourage the hearer to respond more assertively to a hostile voice.
Dr Dirk Corstens, a psychiatrist and psychotherapist from Maastricht, in the Netherlands, 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 life.’
But what is the evidence base for these approaches? Well, only smallscale studies have been completed on the therapies evolved from CBT. But Dr Haywood is planning a bigger sixgroup 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.’
As for voice dialogue, there have been no formal studies so far. However, Dr Corstens is putting together research on 30 people with schizophrenia. ‘I hope that in four years’ time I’ll have something to show,’ he says.
All this will be too late for the NICE guidelines on schizophrenia, due to be reissued next year. Again only traditional CBT is expected to be discussed. Some CBT adherents, such as consultant psychiatrist Lynne Drummond, head of the CBT unit at South West London and St George’s Mental Health NHS Trust, remain mightily wary of newwave 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,’ says Ms Drummond. ‘I could have a theory that voices are caused by caffeine and that 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.’
Dr May, meanwhile, argues that Professor Romme and Ms Escher’s smallscale 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. Dr May, who was himself diagnosed with schizophrenia when aged 18, says that voice dialogue is supported by many in the service user movement. And it provides carers, relatives, friends and users with a jargonfree method for helping people. ‘A caring relative or friend can use voice dialogue after 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 than being something only professionals have.’
While many service users and professionals rallied to support Dr May after the television documentary, the hostile responses served to underline the deep divisions in mental health. As if to confirm this, Mind, the UK’s largest mental health charity, shortlisted Dr May as its Mind champion of the year for ‘challenging discrimination, against people with mental health problems’.
18 February 2009 mentalhealth today