Relational Therapies for People Who Hear Voices: Operationalisation and Current Status of an Emergent Group of Psychological Therapies.
Neil Thomas, Thomas Ward, Eleanor Longden, Imogen H Bell, Rachel M Brand, Mads J Christensen, Louise B Glenthøj, Mar Rus-Calafell, Mark Hayward
Schizophrenia Bulletin January 16, 2026 DOI: 10.1093/schbul/sbaf142 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Systematic review and collaborative discussion Randomized Peer reviewed |
|---|---|
| Keywords | Auditory verbal hallucinations Avatar therapy Psychosis Psychotherapy Relating therapy Schizophrenia Talking with voices Virtual reality Voice dialogue |
| Key findings | Relational therapies for voices can be operationalized as those that target patterns of interaction between hearer and voice and use experiential dialogue as a primary method, with AVATAR Therapy showing efficacy in multiple randomized controlled trials. |
Abstract
A recent theme in the development of psychological interventions for hearing voices (auditory verbal hallucinations) has been the emergence of a group of overlapping approaches increasingly referred to as relational therapies: Relating Therapy (RT), Talking with Voices (TwV), and AVATAR Therapy (AT). Collaborative discussion among a group of researchers involved in developing these interventions combined with a systematic literature search were used to review this new genre, aiming to develop an agreed operationalisation; and identify common and distinctive aspects; potential mechanisms; and collective research directions. Relational therapies for voices can be operationalised as those that "consider patterns of interaction, and/or the relational dynamics between hearer and voice, as targets for therapeutic change, and use an experiential process of dialogue with identities associated with voices as a primary therapeutic method." Key differences involve the type of experiential hearer-voice dialogue used (ie, role-play chair work, direct dialogue with voices, and recreations of voice hearing using a computerised avatar), plus varying emphasis on models of interpersonal relating, broader relationships, and meaning encapsulated within voice-hearing experiences. AT has been found efficacious in several randomised controlled trials, with RT supported by evidence from two trials, and a multicentre trial for TwV underway. Mechanism domains include hearer-voice relating; habituation; threat and safety appraisals; and reformulation and integration of experiences. Common features and mechanisms can be identified across the relational therapies. Key future directions include considering what works for whom; how therapy influences voice phenomenology; the role of relational models; and implementation.