Psychosocial Interventions for

Auditory Hallucinations
Jessica L. Murakami-Brundage, Ph.D.
Licensed Clinical Psychologist
Oregon State Hospital
12/27/16
 Purpose
y Provide useful information and tools that you
can use to improve your patients’ voice hearing
experience(s)
 Definition: Hallucination
“…a false sensory perception that has the
compelling sense of reality despite the absence
of an external stimulus”
-APA Dictionary of Psychology
 Brief History of Voice Hearing
y Socrates (4th century BC)-founder of Western
philosophy and early voice hearer

y 1817-French psychiatrist Jean-Etienne Esquirol

introduced concept of hallucinations into psychiatry

y 20th century—predominance of the medical over the

psychological viewpoint

y 1980’s—start of the Hearing Voices Movement

Source: Harry Potter and the Chamber of Secrets (2002)
 AVHs in the General Population
y 4-25% of the population report a history of AVHs (Johns,
Nazroo, Bebbington, & Kiupers, 2002; Slade & Bentall, 1988; Tien, 1991)

y The majority of college students report a history of

AVHs (Barrett & Etheridge, 1992; Posey & Losch, 1983)

y “Healthy voice hearers” hear more positive voices and

feel more in control of their voices than psychiatric
patients (Daalman et al., 2010; Honig et al., 1998)
 AVHs in Psychotic Disorders
(Nayani & David, 1996)

100 psychotic patients w/ auditory hallucinations

y Average of approximately 3 y Frequency
voices
y 12% 1-2x/day
y Voices mostly male and
middle-aged y 36% several times a day
y 61% knew the identity of one y 37% most of the time
or more of their voices y 15% all of the time
y Content
y Explanations for voices
y 77% critical voices
y 70% abusive voices
y 51% clash of Good and Evil
y 66% threatening voices y 16% plot (e.g. CIA)
y 48% pleasant voices y 5% ghosts, spirits, or aliens
 AVHs in Psychiatric Conditions
(McCarthy-Jones, 2012)

y Dissociative Identity Disorder (70-90%)

y Schizophrenia (70%)
y Posttraumatic Stress Disorder (50%)
y Borderline Personality Disorder (32%)
y Bipolar Disorder (7%)
 The Role of Trauma
y 70% of voice hearers from the general population reported
that their voices began after a traumatic event (Romme &
Escher, 1989)

y 13-30% of bereaved people heard the voice of their

deceased spouse (Grimby, 1993; Rees, 1971)

y Dose-response relationship between childhood abuse and

“pathology level” psychosis (Janssen et al., 2004)
y Mild abuse (2x)
y Moderate abuse (11x)
y Severe abuse (48x)
AVHs: A Simplified Model

Source: http://pelajaribiologi.blogspot.com/2012/05/area-broca.html
 Voices Over Time
y Mitchell and Vierkant (1989)
compared hallucinations in
patients admitted to an East
Texas hospital in the 1930s
and 1980s
y 1930s-hallucinations
reflected desire for material
goods; made benign
commands (e.g. “be a better
person”)
y 1980s-technological
concerns w/ negative and
destructive commands (e.g.
kill oneself or others)
Voice-Hearing in Three Different Countries
(Luhrmann, Padmavati, Tharoor & Osei, 2015)

y Structured interview-based
comparison of hearing voices in the
USA, Ghana, and India (n=60)

y In USA
y Identified as symptoms of a brain
disease
y Few described personal
relationships with their voices

y In Ghana and India

y More positive voice-hearing
experience
y Experienced their voices as
people—had human relationships
with their voices
Assessment
 Cognitive Assessment of Voices:
Interview Schedule
(Chadwick & Birchwood, 1994)

y Characteristics of y Behavior
voices y Identity
y Content y Meaning
y Antecedents y Power
y Affect y Compliance
 BAVQ-R
(Chadwick, Lees, & Birchwood, 2000)
Disagree Unsure Slightly Strongly
Agree Agree
1. My voice is punishing me
for something I have done
2. My voice wants to help me
3. My voice is very powerful
4. My voice is persecuting me
for no good reason
5. My voice wants to protect
me
6. My voice seems to know
everything about me
7. My voice is evil
 Reaction to Hypothetical
Contradiction (RTHC)
y Person is asked how, if at all, a specific hypothetical
and contradictory occurrence would affect his/her belief
y “What if on this date… the world did not end like the
voices predict?”
y “What if a priest told you that God would not want you to
kill yourself?”
Interventions for Hallucinations

Source: http://psychcentral.com/lib/schizophrenia-basics-delusions-hallucinations-onset/
 Common coping strategies
y Fight (e.g. yell at voices, attack perceived source)
y Flight (e.g. sleep, drink alcohol)
y Freeze (e.g. isolate self, stay in bed)
y Submit (e.g. comply w/ voice commands)
 Cognitive Behavioral Therapy
for Psychosis (CBTp)
y Meta-analysis (Wykes, Steel, Everett, & Tarrier, 2008)
y 33 randomized clinical trials (N=1964)
y Patients were on antipsychotics but continued to endorse
symptoms of schizophrenia
y Reduction in positive symptoms, negative symptoms,
depressive symptoms, and social anxiety
y Improvement in functioning
y Small to medium effect size
y Group CBT for voices
y Reductions in convictions in beliefs about omnipotence and control
of voices (Chadwick, Sambrooke, Rasch, & Davies, 2000)
y Improvement in social functioning 6 months post-therapy
compared to TAU (Wykes et al., 2005)
 The Cognitive Model
„ “It’s not one’s life
situations that cause
distress but rather
one’s interpretations or
appraisals of them.”
-Aaron T. Beck, MD
 CBT Triangle
Automatic
Situation
Hears voice Thoughts
say, “You’re “It’s happening. I will
the queen.” rule soon.”

Behavior Emotions
elated,
Smile benevolently to
excited,
others, speak in a
powerful
condescending manner
Cognitive Model of Hallucinations
BELIEFS
INTERPRETATION
Voices are
“It’s God. He’s EMOTIONS
powerful,
trying to save me.” Fear, Anger
credible,
“They’re trying to
external,
poison me.”
benevolent BEHAVIOR
Don’t eat,
yell at staff
STIMULUS members
Hears voice say,
“Don’t eat.”
SUSTAINED
FOCUS
Unstructured
time alone;
hungry; voices
increase
Interactions between beliefs
(Hayward, Strauss, & Kingdon, 2012)

Voices are Voices

powerful intend harm

I am powerless Associated
with
the most
distress
 Targets of Treatment
y Beliefs about voices
y Beliefs about the self
y Safety behaviors
y Relationship with voices & others
y Depression & anxiety
y Illness beliefs
 Normalization
y Psychoeducation (e.g. rates in the general population,
throughout history, etc.)

y Famous people who hear/heard voices

y Self-disclosure
y Our shared potential for voice hearing
 Famous People Who Have Heard Voices
Source: http://hearingvoicescymru.org/positive-voices/famous-voice-hearers

y Hearing Voices Network

y Famous people who’ve heard voices
Guided Discovery

Painting by Jacques-Louis David (1787)

 Voices Diary
Date/ Situation Content of Feelings (How Actions
Time (Where were voices (What did you feel in (What did you
you? Who were did the response to do? How did
you with?) voices say?) the voices?) you cope?)

12/1/15 Eating dinner w/ “You’re a sad (85%), didn’t really

parents, mom loser.” lonely (60%) answer mom’s
tried to talk to me questions,
went to room

12/2/15 Watching TV in “Pathetic. angry (40%) blasted music

room alone You’re (mom knocked
pathetic.” on my door
and I ignored
her)
 3Cs (CatchÆCheckÆCorrect)

What is the thought? • Is it totally true? (Evidence If not, correct the thought so
for/against? Any other/better that it’s totally true & helpful.
explanations?)
• Is it helping you reach your
goals and feel better?
God wants me to be with • Not totally true; God God wants me to be safe. He
him. He wants me to kill wouldn’t want me to hurt wants me to be there for my
myself. myself or cause pain to my family.
family.
• Not helpful; It just makes
me want to kill myself.
 Behavioral Experiments
y With your patient
y Identify the problematic belief
y Collaboratively design a specific and
reasonable experiment to test it out
y Carry out the experiment
y Reflect and draw conclusions
LOOK, POINT, NAME
 Coping Strategies
(Kingdon & Turkington, 2005)
y Behavioral control (e.g. taking a warm bath)
y Socialization (e.g. talking to a friend)
y Mental healthcare (e.g. taking meds)
y Symptomatic behavior (e.g. shouting at voices)
y Cognitive control
y Distraction (e.g. listening to music)
y Focusing (e.g. letting the voice be)
y Rational responding (e.g. making an appt. to listen to
voices, normalizing explanations, being assertive)
 CBT Triangle
Automatic
Situation
Hears voice Thoughts
say, “You’re “It’s happening. I will
the queen.” rule soon.”

Behavior Emotions
elated,
Smile benevolently to
excited,
others, speak in a
powerful
condescending manner
 Compassion Focused Therapy
y Developed by Prof. Paul Gilbert for individuals who
experience high shame and self-criticism

y Roots in Evolutionary, Social, Developmental, and

Buddhist Psychology

y Braehler, et al. (2013)

y RCT comparing group CFT (16 sessions) to TAU
y CFT associated with greater clinical improvement and
increased compassion, reductions in depression and
perceived social marginalization
Dr. Eleanor Longden (TED Talk)
 Hearing Voices Groups
y Group principles
y Hearing voices is a natural and meaningful part of
the human experience
y Diverse explanations for voices are both accepted
and valued
y Voice-hearers are encouraged to take ownership of
their experiences and define it for themselves
y Voices can be interpreted in the context of life events
and interpersonal narratives
y Importance of peer support
 Voice Dialogue Method
y Developed by Drs. Hal and Sidra Stone in 1993
y Based on the assumption that we all have various sub-
personalities that make up ourselves

y Voices are asked questions about their characteristics

and their role(s)

y Can lead to re-framing of voices

 Summary
y How we conceptualize voices has an impact on the
voice hearing experience

y Psychosocial interventions can ameliorate the distress

associated with hearing voices

y Voices can be viewed as symptoms to eliminate,

symptoms to cope with, or experiences to better
understand—which view is likely to cause/ameliorate
the most distress?
Further resources
 On-line resources
y http://www.hearing-voices.org/
y http://www.intervoiceonline.org/tag/hearing-voices-groups
y https://copingtutor.com/
y http://www.cci.health.wa.gov.au/docs/Psychosis%20Manual.
pdf
y http://recoveryfromschizophrenia.org/cbt-for-psychosis-
trauma-psychosis-handouts/
y http://voicedialogueworld.com/en/knowledge-center/talking-
to-voices/
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