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Section 18
Using Cognitive Therapy to Treat Hallucinations

Question 18 | Test | Table of Contents

Cognitive Focus in Hallucinations
While auditory hallucinations are the most frequently reported symptom in schizophrenia, they are also present in several other psychiatric conditions. For instance, auditory hallucinations are commonly reported during periods of bereavement, following significant sleep deprivation, and in adverse situations such as solitary confinement or hostage taking. Community-based studies indicate that from 5% to 25% of the general population report experiencing auditory hallucinations at some time. Studies have shown that some people experience auditory hallucinations but do not regard themselves as either psychiatrically ill or requiring help; neither are they regarded by others as ill. For instance, in a community-based study, Romme and colleagues found that 39% of respondents experiencing auditory hallucinations were not actually receiving treatment. Other research has demonstrated that stress, cultural norms, expectancy sets, and sex affect the occurrence (and interpretation) of auditory hallucinations. These studies suggest that hallucinatory phenomena may lie on a continuum with normal experiences.

Theorists agree that auditory hallucinations may result from a problem discriminating between internally generated and externally generated events. Some theorists have proposed that hallucinators have a neuropsychological deficit in their internal monitoring system that causes internal cognitive events to become misattributed to an external source. Other theorists have recognized the possibility of a neuropsychological deficit but allotted greater importance to the role of cognitive biases, such as the patient's beliefs and expectations. For instance. Bentall and Slade tested patients with and without hallucinations in a signal detection paradigm in which the task was to listen to white noise and determine whether a voice was present (a voice was present 50% of the time). Those with hallucinations showed the expected bias of assuming that a voice was present when, in fact, it was not. In an extension of this work, Young and colleagues suggested, "Close your eyes and listen to the recording ‘Jingle Bells’," to patients with and without hallucinations. They found that those with hallucinations were more likely than those without to report hearing the music, although it was never played. A more recent study by Morrison and Haddock showed that, in a word association task, patients with hallucinations, compared with delusional patients without hallucinations and normal control subjects, were more likely to attribute their own thoughts to the investigator. Further research by Chadwick and Birchwood suggests that the disturbance associated with hearing voices in part depends on the idiosyncratic beliefs the person has about the voices' identity. For instance, the extent to which the agent of the voice is perceived as powerful, controlling, and all-knowing has been found to be more predictive of the emotional and behavioral consequences of the voices than their frequency, duration, and form.

These findings have provided the impetus for developing a cognitive therapeutic intervention that helps patients: first, identify, test, and correct cognitive distortions in the content of voices with the assumption that voice content is similar to their own (negative) thinking (which has been externally attributed); and second, identify, question, and construct alternative beliefs about the voices' identity, purpose, and meaning.

Cognitive Therapy of Hallucinations
While patients report a range of auditory phenomena (including nonverbal material such as music, buzzing, and tapping) cognitive therapy specifically aims to help patients with the distress that is created by voices. Before implementing cognitive and behavioral strategies to help patients construct an alternative view of their voices, the therapist undertakes a thorough assessment, with careful questioning of the frequency, duration, intensity, and variability of the voices. For example, the therapist investigates what situations or circumstances are likely to trigger the voices and whether in some circumstances the patient either does not experience voices or they are attenuated. Stressful situations are most likely to trigger voices. For instance, patients report hearing voices more frequently in the context of interpersonal difficulties, daily hassles, and negative life events (for example, financial strain, or housing crises). Internal cues (particularly emotional upset) can also trigger voices. As part of the early assessment phase, patients can use a modified thought record to monitor the relation between situational triggers, mood states, and the activation of voices. The cognitive therapist attempts to get verbatim accounts of what the voices say. Typically, patients will report hearing critical 1-word utterances, such as "jerk" and "loser," or similar 2-word utterances, such as "you're worthless," "go on," and the like. At other times, voices may speak in phrases, such as the daily repeated phrase, "Are you sure you are who you say you are?" Voices might offer a running commentary on the patient's activities or command the patient to perform certain activities ranging from the mundane (such as, "Pick up those clothes") to more dangerous and potentially violent edicts. Patients are taught to record the specific voice content between sessions, using the modified thought record. The therapist also aims to elicit all of the beliefs the patient has about the voices. For example, what agents—God, the devil, or dead relatives—are purportedly talking to the patient? Beliefs about the voices can range from the bizarre to the ordinary and vary from known, unknown, and deceased persons to supernatural entities, and even machinery. A significant number of patients interpret their voices positively and experience positive emotions when they occur. For instance, receiving direct communication from God, Jesus, or a Knight of the Round Table sets the person apart from others and confers feelings of excitement and power. The therapist asks how the patient would feel if the voices were not present to unmask the underlying feelings of loneliness and inadequacy from which these voices may be providing compensatory protection (unpublished study). All beliefs are identified and the evidence that has been interpreted as supporting these beliefs is recorded.

Just as when assessing delusions, the therapist tries to identify the life circumstances both distal and proximal to the initial voice onset; of interest are events occurring just prior to their onset and how the specific voice content and beliefs about the voices reflect the person's prehallucinatory fears, concerns, interests, preoccupations, and fantasies.

Finally, the therapist assesses the patient's reactions to the voices. Frequent repetition of criticisms, insults, commands, and other attacking comments often leads to feelings of sadness, despair, anger, and helplessness. Patients' behavioral responses can include shouting back at the voices or escaping specific situations to extinguish them. While patients first respond to their voices with surprise and puzzlement, over time they tend to establish an interpersonal relationship with them. Their beliefs about the voices determine their emotional reaction and behavioral responses. If the voices are seen to be benevolent, they are frequently followed by positive emotions, and the patient engages with them. Conversely, if they are seen as malevolent, patients are likely to experience a range of negative emotions and cope by resisting them.

Following the assessment phase and the establishment of a strong therapeutic alliance, the therapist begins to employ gentle questioning to elicit alternative perspectives on both the voice content and the patient's beliefs about the voices. With some patients, it is better to start by focusing on the beliefs about the voices, while with other patients it may be better to first target the voice content. For instance, the content of the voices in one of our patients led directly to despair and suicidal thoughts, and the initial focus was therefore the demeaning content. Another patient experienced command hallucinations to steal from stores, and the focus was therefore on the interpretations of the voice as powerful and on the beliefs about the consequences of not complying with the commands.

The approach to undermining the beliefs about voices is similar to the cognitive approach in treating delusions. The therapist begins by gently questioning the evidence that patients offer to support their interpretation. For instance, a patient who believed that his neighbors were conspiring to have him removed from the apartment complex heard them speaking to him daily. As the neighbors arrived home from work and ascended the building's stairs, the creaking of the stairs would activate the voices. When asked in session how he knew it was his neighbors' voices, he responded,"They sound just like my neighbors, and they speak to me every time they pass my door." To generate alternative explanations for the evidence, the therapist asked the following questions: "Are there any possible alternative explanations?" "Has it ever been the case that you heard the creaking stairs and not the voices?" "Has it ever happened that you heard the creaking stairs, then the voices, and then checked and found that it wasn't your neighbors passing your door?" "If this did, by chance, happen would it change your view?" The therapist could also have asked: "Do you ever expect to hear the voices when people come up the stairs?" and provide education (and normalizing) about the role of expectations and hearing voices. It is important to address inconsistencies in the network of beliefs in a gentle and collaborative way and not as a direct challenge. Behavioral experiments can also be incorporated to test whether the voice heard as someone passed the door actually corresponded to the person passing by the door at that moment.

In addition to working with the evidence, patients are asked whether they have ever considered other explanations for their voices. Through collaboration, the therapist and patient attempt to generate as many alternative explanations as possible. The therapist also highlights any inconsistencies in the beliefs (for example, by questioning whether a Chinese warlord from the 15th century would really speak English). Often, the consequences of the voices are taken as proof of their interpretation. For instance, one patient heard the voices of 2 men with whom he had fought. He believed that the voices were a form of punishment for fighting. The activation of the voices led to feelings of frustration and anger that, in turn, he took as evidence that he was being punished. Alternative explanations for these feelings (for example, not being able to control the voices) helped to reduce what would otherwise be taken as confirmatory evidence. As suggested, beliefs pertaining to the omnipotence, omniscience, and uncontrollability of the voices are especially important and can be alleviated by several strategies. The uncontrollability belief can be addressed by demonstrating to the patients that they can initiate, diminish, or terminate the voices. Using knowledge from the assessment phase, the therapist presents the patient with the cues that activate the voices (for example, imagining an upsetting event from the past) and then directs the patient to engage in an activity that is known to terminate the voices (for example, engaging in conversation). This experiment not only helps to chip away at the belief that the voices are uncontrollable but also provides further evidence that they are generated internally. Omnipotence and omniscience issues are tackled by setting up experiments that will demonstrate that the patient can ignore commands without consequence.

Alternative perspectives to the voice content are generated by exploring the evidence for what the voices actually say. For instance, a patient heard several voices, including one that was believed to be the "devil spirit," frequently telling her that she was "worthless." The patient was first asked, "What evidence do you have that supports the truth of this statement made by the voices?" Her response included feeling that she sometimes disappointed her parents and could not always cope with her illness. However, she was also able to consider a range of evidence that did not fit with what the voices said, including the fact that she was a good friend, daughter, student, and volunteer. With repeated practice she became adept at identifying the cognitive distortions in the voices' comments (for example, all-or-none thinking, catastrophizing, and labeling) and generating an alternative perspective when they occurred. This, in turn, led to less hopelessness and withdrawal.

The final aim in working with the voice content is to help patients recognize that the voices simply reflect either their own attitudes about themselves or those they imagine others to have about them. By having patients keep separate thought records—one for their automatic thoughts in response to distressing situations and another for recording what the voices say—the parallel records convincingly demonstrate the overlap (Here, the therapist could ask, "Do you see any similarities in the columns that you have recorded on the 2 forms?")
- Rector, Neil A.; Beck, Aaron T; Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention; Canadian Journal of Psychiatry; Feb2002, Vol. 47 Issue 1

Personal Reflection Exercise #4
The preceding section contained information about using cognitive therapy to treat hallucinations. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia

Agrawal, A., Kaur, R. D., & Sidana, A. (2022). Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia. Industrial psychiatry journal, 31(2), 376–377. https://doi.org/10.4103/ipj.ipj_137_21


Peer-Reviewed Journal Article References:
Barrios, M., Guilera, G., Hidalgo, M. D., Cheung, E. C. F., Chan, R. C. K., & Gómez-Benito, J. (2020). The most commonly used instruments in research on functioning in schizophrenia: What are they measuring? European Psychologist, 25(4), 283–292.

Bechi, M., Bosia, M., Agostoni, G., Spangaro, M., Buonocore, M., Bianchi, L., Cocchi, F., Guglielmino, C., Mastromatteo, A. R., & Cavallaro, R. (2018). Can patients with schizophrenia have good mentalizing skills? Disentangling heterogeneity of theory of mind. Neuropsychology, 32(6), 746–753.

Diamond, D. (2018). Changes in object relations in psychotherapy with schizophrenic patients: Commentary on Carsky and Rand (2018). Psychoanalytic Psychology, 35(4), 410–413.

QUESTION 18
What is the final aim in working with voice content in cognitive therapy for hallucinations? To select and enter your answer go to Test.

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