The omnipotence of voices. A cognitive approach to auditory hallucinations.
TL;DR: It is shown that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices, and how these core beliefs about voices may become a new target for treatment.
Abstract: We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations.
Summary (4 min read)
- British Journal of Psychiatry (1994), 164, 190â€”201 The Omnipotence of Voices A Cognitive Approach to Auditory Hallucinations PAUL CHADWICK and MAX BIRCHWOOD Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and, unexpectedly, a fall in voice activity.
- Auditory hallucinations have a powerful impact on the lives of those who experience them (Falloon & Talbot, 1981).
- Likewise, it is possible that the degree of fear, acceptance and compliance shown to voices might be mediated by beliefs about the voices' power and authority, the consequences of disobedience, and so on.
- The applicability of the cognitive model to voices could have similar important implications for treatment, in that if beliefs about voices could be weakened, this might reduce associated distress and problem behaviour.
- Fourteen men and 12 women were selected who had heard voices for at least two years; their average age was 35 years (range 23â€”59).
- All except one were receiving depot neuroleptic medication at All Saints' Hospital, Birmingham; one was in hospital and the remainder were out-patients.
- All participants volunteered for the study, with no refusals.
- Interviewswereconductedby either one of the authors; in severalcasesit took more than one interviewto collect all relevant information.
- Â€˜¿ Influence'oncerns whether the individual could determine the onset and offset of the voice, and could direct what was said.
A cognitive analysis of each individual's experience of
- Voiceswas completed on the basis of the interviewdata.
- The beliefs elicited fell into distinct categories: those about a voice's identity, power, and meaning, and those about compliance.
- While limited space prevents information for all 26 participants being given in detail in Table 1, the authors describe 12 people's experience of hearing voices; information about all 26 patients' experience is available from the authors on request.
Beliefs about voices
- All voices were perceived as being extra ordinarily powerful.
- Malevolence, the wish to do evil, took one of two forms: either a belief that the voice was a punishment for a previous misdemeanour, or an undeserved persecution.
- Six people (S13â€”Sl8) believed the voices to be benevolent.
- The final three people (S24â€”S26)were uncertain about their voices because of an inconsistency or incongruity in what was said.
- Similarly, S24's voice told her to kill her family and herself; she believed the voice was God's and that he was giving her the chance to see her dead daughter by going to heaven.
Behaviouraland affective consequences
- The behavioural responses to voices may be organised into different categories.
- One important criterion is whether the person willingly engages with the voice.
- Therefore engagement, resistance and indifference are probably best thought of as predominant behavioural dispositions that describe the person's response to voices most of the time.
- Those people who were uncertain about their voices displayed no clear pattern between beliefs and behaviour.
- Ten of the 11 benevolent voices habitually provoked positive emotions (amusement, reassurance, calm, happiness) when they spoke; the one exception was S16 who felt predomi nantly anxious on hearing a benevolent voice, perhaps because the voice issued warnings about possible danger.
Compliance with commands
- And thirdly, all people interviewed who heard imperative voices had additional beliefs about the consequences of obedience and disobedience (see Table I).
- Immediately one parameter can then be established.
- Voice gets worse life if I make progress C.My intelligenceis I.None better than his so I don't obey I. Voices from God C. Know thoughts and have his power and history M. To protect me and A.
- An ex-girlfnend, who isa goddess M. She protects me.
- No compliance Electivelisteningand compliance Elective listening Selectivecompliance Listens carefully Avoids certain people Compliesfully Voice 1. Advisesand I.Voice1 ismy F, 34 years imperative boyfriend.
- Duration of illness Beliefs: identity (I), meaning (M), and effect of compliance (C) Evidence: content (Cl. Affective response to symptom (SI, attri- voices bution (A), influence (I) Behavioural response to voices S20Two pairs.
- Two male film stars, S. Reference and Stars: feel happy andStars:electiveF,.
20 yearsand commentand their two visual hallucinations excitedcomplianceand2
- YearsPair 1. â€œ¿ Wewant tojealous friends and thought Jealousfriendslisteningknow youâ€M.
- The stars want to stopping Upset and angryFriends: shoutbackâ€œShe's beautifulâ€know me and C. Reluctantâ€œSit where the authors canperhaps marry me.
- And my thoughtspartialcompliances e youâ€The friends prevent andfuturePair 2. â€œ¿ She'suglyâ€this and want to kill A.
- They read my mindIrritatedIgnoreM, 50 yearsâ€œKill yourselfâ€spirits and know my pastNevercomply>20 yearsâ€œ.
- None make sense benevolent voices were complied with willingly and in full, and all but one malevolent voice was complied with in full, although reluctantly â€”¿ the one exception was S3 (see requirement for sterner actions.
- Of those people who were uncertain about the voice, two complied partially and one not at all.
- The study offers striking support for the cognitive model.
- The voicesarehelpingme throughpersonaldifficulti s10000I cannot hinkformyselfwithouthevoices852025I cannotcontrolthevoices1002015NGod istalkingtome10055.
- It has already been suggested that powerful beliefs and emotions characterise patients' relationships with their voices.
- The patient is asked to consider the advantages and disadvantages of these beliefs being false; because the meaningâ€(Bruner, 1957)and this meaning frequently went well beyond the information given by the voices.
- Also, the methodology needs to be operationalised and the measurements more objective.
196 CHADWICK & BIRCH WOOD
- Former usually outweigh the latter, this discussion may be used as an inducement to engage in therapy.
- It is emphasised that one acceptable outcome of therapy would be that the patient continue to hold his or her beliefs.
- Indeed, the whole therapy is conducted within an atmosphere of â€œ¿ collaborativeempiricismâ€ (Beck et a!, 1979) in which beliefs are considered as possibilities that may or may not be reasonable.
- Very early on in the therapy, the patient is introduced to other people who hallucinate, and views videos of clients (at least some of whom have completed therapy successfully) discussing their voices.
- Information about voices is provided to back this up.
- Disputing a belief's veracity involves the use of two cognitive techniques: hypothetical contradiction and verbal challenge.
- In the present study one woman heard a voice commanding her to kill, which she believed to come from God.
- At first, the patient is asked to question the evidence for his/her beliefs and to generate other plausible interpretations.
Testing beliefs empirically
- In all the cognitive therapies, beliefs are subject to empirical test.
- On the one hand, the authors have a set procedure for testing the ubiquitous belief: â€œ¿ Icannot control my voicesâ€.
- The therapist then engineers situations to increase and then decrease the probability of hearing voices.
- An initialthorough cognitive assessment should identify the cues that provoke voices, and one technique with a high likelihood of eliminating voices for its duration is concurrent verbalisation (Birchwood, 1986).
- With all other beliefs the empirical test was negotiated by the patient and the therapist: for example, the therapist might ask: â€œ¿.
- Three out-patients and one in-patient were referred by psychiatrists because of drug-resistant and troublesome auditory hallucinations (all had participated in Study 1).
- One was not on medication, one had medication withdrawn shortly after the intervention started and reinstated at a lowerdosejustbeforeitclosed,and two wereon established and stableregimesthatwere notalteredatallduringthe study.
- All satisfied DSMâ€”IlIâ€”Rcriteria for schizophrenia or schizoaffective disorder.
M is a 34-year-old married woman of Iranian origin with
- COGNITIVE APPROACH 197 followedthedissolutionof herfirstmarriageandwasmarked by visualhallucinationsof the IslamicprophetMasumaand accompanying auditory hallucinations in Arabic, also known as Onset OMNIPOTENCE OF VOICES.
- The voice was ever present and offered advice on her functioning as housewife (e.g. telling her to try new recipes), mother (e.g. telling her when to change a nappy) and wife (e.g. advising how to please her husband).
- The most potent advice was novel recipes.
- During her stay in hospital she was treated with neuroleptics, electroconvulsive therapy (ECT) and antidepressants, with no effect.
- N believed the voice to be God, although she was puzzled why God should compel her to murder and suicide.
198 CHADWICK & BIRCH WOOD
- Also, she came to doubt strongly the identity of the visions, and on those nights when these troubled her she was able to turn over and ignore them.
- Again, on the one hand she believed that repeating the Devil's commands would destroy the economy and yet she reluctantly did repeat the commands on many occasions.
- Also, she reported feeling less guilty and depressed, and a reduction in voice activity.
- The possibility that malevolent and benevolent voices are maintained through different psychological processes begs the question of whether challenging beliefs about voices is always beneficial.
- This cognitive perspective is in contrast to the â€˜¿ copingstrategy' approach (Falloon & Talbot, 1981; Brier & Strauss, 1983; Tarrier, 1987) which rather assumed that behavioural and affective responses (â€˜copingstrategies') are as it were randomly assigned to hallucinators.
Parkinson & Manstead, 1992).
- What can be asserted is that the affective, cognitive and behavioural responses evolve together and are always meaningfully related.
- Against this, the present research strongly suggests that degree of distress is inextricably bound to subjective meaning, and that weakening critical beliefs about the voices might alleviate much of the associated distress and difficulty.
- The cognitive behavioural treatment of hallucinations and delusions: a preliminarystudy.
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Cites background from "The omnipotence of voices. A cognit..."
...The majority of a sample of patients with auditory hallucinations interviewed by Chadwick and Birchwood (1994) reported being unable to exert any influence on their voices....
...Our cognitive model builds on the work of other researchers (e.g. Maher, 1988; Frith, 1992; Hemsley, 1993; Bentall et al. 1994; Chadwick & Birchwood, 1994; Morrison et al. 1995) and our own clinical and theoretical studies....
Cites background from "The omnipotence of voices. A cognit..."
...In their studies of hallucinations Chadwick & Birchwood (1994) and Close & Garety (1998) have examined how appraisals of the content and meaning of hallucinations predict distress....
"The omnipotence of voices. A cognit..." refers background in this paper
...Firstly, it has been suggested that a common and beneficial therapeutic process is â€˜¿ universality'(Yalom, 1970) â€”¿ that is, the recognition that many others experience the same or similar problems....
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Frequently Asked Questions (17)
Q1. What have the authors contributed in "A cognitive approach to auditory hallucinations" ?
The authors describe the application of an adapted version of cognitive therapy ( CT ) to the treatment of four patients ' drug-resistant voices.
Q2. What are the three main behavioural dispositions of S Il?
Therefore engagement, resistance and indifference are probably best thought of as predominant behavioural dispositions that describe the person's response to voices most of the time.
Q3. What is the effect of the weakening or loss of beliefs?
The weakening or loss of these beliefs is predicted to ease distress and facilitate a wider range of more adaptive coping strategies.
Q4. What is the position of the authors in relation to voices?
In relation to voices, their position is that beliefs are vital to the maintenance of affective and behavioural responses and render them understandable.
Q5. What is the general disposition to consider when a person is uncertain about their voices?
there is the general disposition to consider; malevolent voices are to be resisted and benevolent voices are to be courted.
Q6. What was the important determinant of compliance?
In their group theseverity of the command, and not beliefs, was the single most important determinant of compliance â€”¿ there was no compliance with life-threatening commands, and compliance with mild commands was commonplace.
Q7. What is the common assumption of previous approaches to voice management?
An assumption of previous approaches to voice management has beenOMNIPOTENCE OF VOICES: COGNITIVE APPROACH 201that alleviating distress is contingent upon eliminating the experience, and this has led to therapies such as monaural occlusion and distraction (Birchwood, 1986) or indeed pharmacotherapy.
Q8. What is the role of the CT with voices?
A critical part of CT with voices is to refute the belief in omnipotence and to test the possibility that the patient may learn to regulate the activity of the voices.
Q9. What was the main evidence that the voice was a prophet?
The main evidence that the voice was a prophet was that it spoke in Arabic, directed her to pages of the Koran, and knew her thoughts.
Q10. What was the evidence of verbal regulation of behaviour?
There was also evidence of verbal regulation of behaviour, a normal process whereby strongly held beliefs can drive the way in which the authors behave, feel, and interpret events (Vygotsky, 1962).
Q11. What was M's belief about the voice?
Belief 2, that the voice helped her through personal difficulties, rested on two points: that it gave good advice and that it predicted the future.
Q12. What was the attribution of the therapists?
For many patients this attribution was supported by an experience of control, by fantastic visual hallucinations, and by the patient having no influence over the voice.
Q13. What is the implication of the cognitive model of voices?
A second impli cation is that a lot of effort needs to go into establishing rapport, trust, and confidence, because the voices have a strong emotional and cognitive hold over the patients.
Q14. Why are the authors interviewing people who have acted on serious commands?
At present the authors are interviewing people who have acted on serious commands, to investigate whether such compliance is associated with factors specific to the hallucinatory experience (e.g. total certainty in the beliefs) or more general predictors of violence (e.g. previous history).
Q15. What is the evidence for the â€ stress-vulnerability'model?
There is now considerable empirical backing for the â€˜¿ stress-vulnerability'model, which asserts that acute or chronic stress can precipi tate or exacerbate episodes of disorder (Clements & Turpin, 1992).
Q16. What is the cognitive treatment approach to hallucinations?
The cognitive treatment approach to hallucinations involves the elucidation and challenging of the coreformer usually outweigh the latter, this discussion may be used as an inducement to engage in therapy.
Q17. What was discussed about the eye rolling?
It was discussed how the eye rolling might be a spasm provoked jointly by tension and her coping strategy of fixed staring when hallucinating.