'It's like having a core belief that's able to speak back to you': Therapist accounts of dialoguing with auditory hallucinations

Purpose To investigate the clinical perspectives and experiences of therapists when engaging in direct dialogue with auditory hallucinations. Method Therapist accounts were explored via a qualitative study nested within a pilot randomized controlled trial of a novel intervention for supporting distressed voice-hearers (Talking with Voices). Five therapists were involved, none of whom had substantive previous experience of the technique. All agreed to take part in two semi-structured, in-depth interviews which were arranged prior to delivering therapy and again after therapists had experience of conducting dialogues. Data were analysed using inductive thematic analysis. Results Participants described their impressions of seeking to improve the relationship between voice(s) and voice-hearer using dialogue. The findings are organized within three main themes and associated subthemes: (1) Commitment to delivery (professional values, mentorship, professional growth); (2) Communication and collaboration (therapeutic alliance, relationships with voices, managing clinical perceptions); and (3) Challenges of delivery (client/voice engagement, impact of trauma, systemic issues). A series of recommendations are derived from the findings to support implementation and guide the practice of therapists undertaking dialogue work with clients who hear voices. Conclusion Despite clinical challenges, therapists also identified professional gains from conducting their work. Their accounts demonstrate that it is possible for practitioners with no previous formal experience to engage in direct communication with voices within a context of appropriate training and supervision. Practitioner points Therapists with no previous experience of dialogue work can be trained and supported to verbally engage with the voices heard by people experiencing psychosis. Therapeutic alliance and therapist values are important components of successful therapy. Confidence for dialoguing with voices can be increased through drawing on therapist's existing transferable clinical skills. The emotional and practical needs of therapists undertaking such work should be addressed through training and regular group supervision.