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We spoke to the pioneer of Relating Therapy, Professor Mark Hayward from the University of Sussex and the Sussex Partnership NHS Foundation Trust, about how the approach works – and how to do it.

Teaching people who hear voices to respond assertively to them can help reduce distress, studies have shown.

Responding to voices passively or aggressively is linked to poorer mental health: passive responses can leave the accuracy of critical voice comments unquestioned, while aggressive responses can invite aggression from the voice and make it seem more powerful.

In contrast, responding to negative voices in an honest, calm and respectful manner – as taught in Relating Therapy – can help clients to separate themselves from what the voice is saying about them. Relating Therapy is also an acceptance-based approach; the goal isn’t to get rid of the voice, but to change the way they respond to it. In doing so, people can consider alternative views of both themselves and the voice.

“Relating Therapy seeks to create an experience of what it’s like to behave differently in relation to the voice,” said Professor Mark Hayward, who has been developing the treatment over the last 20 years. “It’s very much about having a different experience of the self – being able to stand up [to the voice] and see what that feels like, physically and emotionally.”

By changing the way they respond, clients are reminded that “actually the opinion that voice has of me, that picture the voice is painting of me, is maybe a little inaccurate, maybe it’s a little bit out of date, and I’m trying to move away from that”, said Professor Hayward.

Now he and colleagues from the University of Hamburg have published the first treatment protocol for Relating Therapy, in the journal Psychology and Psychotherapy: Theory, Research and Practice.

The protocol

Relating Therapy is delivered across 4 phases – each of which builds upon the learning from the previous phase – over an average of 16 sessions.

In the first phase, the therapist supports the client to explore all their relationships to identify their patterns of relating (studies suggest the ways that clients relate to both voices and other people are similar). Natural but sometimes unhelpful patterns of responding, like being passive or aggressive, are noted without judgement, and assertiveness is offered as a possible alternative.

In the second phase, the client chooses a specific relationship to be the initial focus of intervention; a typical conversation within that relationship is then scripted, which includes developing an assertive response that honestly and respectfully expresses the differing point of view of the client.

The third phase is when the re-scripted conversation is taken into role play. At first, role plays focus on practising the words of the assertive response before adding in assertive body language. Cognitive therapy techniques are used between role plays to generate evidence from the client’s personal experience that support their different view and help them mean what they are saying. For example, if the voice is very critical, this might be noticing times when they receive positive feedback from other people. As therapy progresses, the role plays get longer so the client can practice remaining assertive.

Once the client has expressed their view to a sufficient extent within the role play, it’s important for them to leave the conversation on their terms, as “the voice will just continue, it will just keep talking”, said Professor Hayward. An example statement that the client could use is: “I’m starting to repeat myself and I feel like I’ve clearly expressed my view. I don’t want to talk about this anymore.” They can then shift their attention to another activity and, as best they can, try not to re-engage with the conversation.

Therapist concerns

The role play stage is the part that therapists who are being trained in Relating Therapy tend to be the most concerned about, said Professor Hayward, with many fearing it will be too intense for clients. But this phase only starts around the seventh session, “so there’s a good lead-in, the therapeutic relationship and trust are building, I think that’s really important. And then time is taken to set up the role play, making it really clear how it begins, how it ends, and how to manage safety within it.” For example, clients and therapists can agree that the role play only starts when one of them has moved to the chair that represents the voice or the other person, and that the use of a specific hand signal will stop the role play at any time. “We don’t want any confusion as to ‘who am I, who are you, and what do you or I represent at this present time’,” said Professor Hayward. “Those boundaries are really important – being able to step into, and out of, the role play frame.”

Still, even with these boundaries, role play can be too challenging for some clients, particularly if they are invited to play the role of the voice. For this reason, the protocol makes it clear that all aspects of the role plays are negotiated and engaged with collaboratively, and that it is not essential for them to play the role of the voice.

The last phase of the treatment, which typically starts around session 14, is where reflection and consolidation of learning takes place. The therapist encourages the client to think about how they will use what they have learned in the future, what support the client needs to sustain their learning, and who can provide it. Relating Therapy itself should always be delivered by highly trained therapists, said Professor Hayward, but other healthcare practitioners or family members can be enlisted to help at this stage to encourage assertive responding and regular reflection.

The protocol also suggests ways to tailor Relating Therapy to individual circumstances, and emphasises that there are times when it may not be appropriate, such as when the client fully agrees with the voice's perspective.

The evidence

Relating Therapy has been in development for 20 years. While there have only been 3 trials on it, they have shown promising results. For example, a randomized controlled trial of 29 people carried out by Professor Hayward and his team, published in 2017, showed significant reductions in voice-related distress, with the improvements maintained at 5-month follow-up.

Relating Therapy isn’t the only Relational Therapy for distressing voices that’s available, however (although it was the first); talking with voices therapy, and AVATAR therapy – which uses a visual depiction of the voice – are also being developed and evaluated.

While Relating Therapy is about separating from distressing voices, the talking with voices approach is about “reconnecting compassionately with disassociated and disconnected parts of self”, said Professor Hayward. “So being kinder to parts of self that one has previously had to move away from in order to survive.”

AVATAR therapy, however, works on an exposure paradigm. “Having exposure to the voice in the form of an avatar and, during that exposure, noticing that nothing bad happens, provides evidence to support a view that the voice may not be very powerful and isn’t able to make bad things happen and carry out its threats. In an ideal world, where we all had the funding and resources required, each of these therapies would move forward, be developed, and tweaked to maximize benefits and then made available to clients who could then make their own choices.”

Client choice

Choice is important, he said, because the treatments differ in their emotional intensity, or what he calls the ‘heat’. “Within the talking with voices approach, you’re calling up the voice and bringing it online. You’re actually talking with the voice in the session, the therapist is talking to the voice through the client, so I think it’s potentially quite hot for the client and the therapist. I think AVATAR therapy is also quite hot because you’re creating this visual representation of the voice and it’s quite challenging for the therapist to toggle in a separate room between coaching as the therapist and speaking the comments of the voice. I think Relating Therapy is a little cooler in contrast, because we are just doing brief role plays, just pretending to be the voice and bringing a script to life. We can also focus upon difficult relationships with other people for a while if working on the relationship with the voice feels too hot at that stage of the therapeutic process.

“We need choices so that therapists can offer the therapy that they’re comfortable with, [and] clients can choose a version of a Relational Therapy that aligns best with their needs and preferences.”

Professor Hayward’s key takeaways:

• It can be helpful to talk back to voices – in certain ways.

• Experiential learning opportunities, such as role play, can be challenging for clients but are a key part of Relational Therapies.

• Assertive responding is multi-faceted and involves verbal and non-verbal communication, use of evidence, and knowing when and how to leave the conversation.

• There is still a lot to learn about which Relational Therapies work for whom.

Read the full article

Read the full article in Psychology and Psychotherapy: Theory, Research and Practice

Citation: Hayward, M., Pilny, M., & Lincoln, T. (2025). Relating Therapy for distressing voices: A treatment protocol. Psychology and Psychotherapy: Theory, Research and Practice, 00, 1–10. https://doi.org/10.1111/papt.12595