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

Introduction

• British Journal of Psychiatry (1994), 164, 190—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.

Method

• Fourteen men and 12 women were selected who had heard voices for at least two years; their average age was 35 years (range 23—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.
• €˜¿ 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 (S13—Sl8) believed the voices to be benevolent.
• The final three people (S24—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.

S16

• 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. “¿ Wewant tojealous friends and thought Jealousfriendslisteningknow youâ€M.
• The stars want to stopping Upset and angryFriends: shoutback“She's beautifulâ€know me and C. Reluctant“Sit where the authors canperhaps marry me.
• And my thoughtspartialcompliances e youâ€The friends prevent andfuturePair 2. “¿ She'suglyâ€this and want to kill A.

Avoidance ofcuesS26ImperativeI.

• They read my mindIrritatedIgnoreM, 50 years“Kill yourselfâ€spirits and know my pastNevercomply>20 years“.
• 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 —¿ 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.

Comment

• 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 “¿ collaborativeempiricism†(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 beliefs

• 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: “¿ 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: “¿.

Case reports

• 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 DSM—IlI—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 ‘¿ copingstrategy' approach (Falloon & Talbot, 1981; Brier & Strauss, 1983; Tarrier, 1987) which rather assumed that behavioural and affective responses (‘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.

Figures

Table 2). Severe commands were given by 12 voices (one benevolent, 11 malevolent) and all were currently being resisted. However, 10 of the 12 voices that gave severe commands also gave mild ones, and in all 10 cases these were obeyed at least occasionally. It is as if compliance with mild commands was an attempt to appease the voices'

Table 1 lcontinued)

Full text

British Journal of Psychiatry (1994), 164, 190—201
The Omnipotence of Voices
A Cognitive Approach to Auditory Hallucinations
PAUL CHADWICK and MAX BIRCHWOOD
We offerprovisionalsupportfora new cognitiveapproachtounderstandingand treatingdrug
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.
Auditory hallucinations have a powerful impact on
the lives of those who experience them (Falloon &
Talbot, 1981). However, the experience is also
personal: some people experience them as immensely
distressing and frightening whereas others are
reassured and amused and many actually seek
contact. Where some people shout and swear at
voices and resist commands, others may harm
themselves or other people at the voices' behest.
This diversity begs the question, how are the content
and form of the voice, and the person's cognitive,
affective and behavioural response, connected? That
a link exists is well established. Romme & Escher
(1989) used innovatory sampling methods to study
hallucinations in clinical and non-clinical groups, and
they showed how a person's ability to cope with
voicesvariedaccording to his/herappraisalof the
voices. Benjamin (1989) studied 30 hallucinators and
found that all had meaningful, integrated and inter
personally coherent relationships with their voices. In
people diagnosed as schizophrenic these relationships
were orderly and interpersonally ‘¿normal',but not
always complimentary; these patients might claim
that their voices liked them even though the content
was hostile and attacking. Benjamin's clearly stated
position (p. 293) is that the content of the voice is
“¿directlyresponsible― for the person's behavioural
and affective response.
The question arises as to why the individual should
feel compelled to behave and respond affectively in
such an apparently congruous manner. Recent work
has suggested that essentially normal thought
processes are involved in the way that delusional
ideas are formed (Maher, 1988) and given up
during recovery (Brett-Jones et al, 1987). Indeed
psychological research shows that whether ordinary
people accept comments and advice, and comply
with commands, depends in large part on their
appraisal of the situation. For example, in Milgram's
famous studies, whether ordinary individuals could
be persuaded to administer what they believed to be a
lethal electric shock to other subjects was strongly
influenced by their beliefs about the experimenter's
authority and power, their own degree of control,
and the presumed consequences of disobedience
(Milgram, 1974).
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. For example, the belief that a voice comes from
a powerful and vengeful spirit may make the person
190

191
OMNIPOTENCEOF VOICES:COGNITIVEAPPROACH
terrified of the voice and comply with its commands
to harm others; however, if the same voice were
construed as self-generated, the behaviour and affect
might be quite different. This cognitive formulation
of voices was inspired by Beck's cognitive model of
depression(e.g. Becketa!, 1979)whichproposesthat the
behavioural and affective symptoms are consequences
of particular negative beliefs (e.g. “¿Iam worthless―)
and not antecedents (e.g. “¿Shedisagreed with
me―). This premise gave rise to cognitive therapy
(CT) for unipolar depression (Beck et a!, 1979), an
effective treatment approach that relies heavily
on the disputing and testing of beliefs. 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.
Useful progress in the cognitive—behavioural
management of schizophrenic symptoms has been
made in recent years, largely concentrated on positive
symptoms (Birchwood & Tarrier, 1992). There is
growing evidence that secondary delusions may be
weakened using CT (e.g. Fowler & Morley, 1989;
Chadwick & Lowe, 1990). Again, Kingdon &
Turkington (1991) have described how a number of
established cognitive techniques may be used to
help clients construe their symptoms and experience
in non-psychotic terms. However, research has
yet to investigate the clinical utility of such
techniques in systematically identifying and categor
ising the types of belief people hold about their
voices, and then making these beliefs the target
of treatment. This is the purpose of the present
two studies: if successful, the cognitive approach
holds promise of a new method of easing distress
and problem behaviour associated with drug
resistant voices.
Study 1. Applicability of the cognitive model
to voices
The first study tested the prediction that the degree
of distress and problem behaviour are consequences
of beliefs about voices, and not of antecedents such
as voice content. Twenty-six chronic hallucinators
with a diagnosis of schizophrenia or schizoaffective
psychosis were interviewed within a cognitive
framework, in the manner in which Hibbert (1984)
approached panic disorder. Specifically we assessed:
(a) whether there exist beliefs that are held about
voices; and, if so (b) the reasons (evidence) for these
beliefs, including voice content; and (c) to what
degree these beliefs are tied to individuals' behavioural
and affective responses.
Method
Fourteen men and 12 women were selected who had
heard voices for at least two years; their average age was 35
years (range 23—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
satisfied DSM—III—Rcriteria for schizophrenia or schizo
affective diSOrder(American Psychiatric Association, 1987).
All participants volunteered for the study, with no
refusals. Each was asked whether he or she would be willing
to meet with a psychologist to discuss the experience of
hearing voices. It was made clear that the discussion would
be confidential, and that information disclosed would
neither be entered in the main case notes nor lead to a
change in medication.
Interviewswereconductedby eitherone of theauthors;
in severalcasesit took more than one interviewto collect
all relevant information. Information was gathered using
a semi-structured interview (details available from the
authors on request). Interviews assessed the content of the
voices, beliefs about voices, other collateral symptoms that
were regarded as supporting the beliefs, other confirmatory
evidence, and influence over the voice. ‘¿Confirmatory
evidence' refers to actual occurrences that are perceived to
support a belief: for example, a belief that voices give good
advice would be strengthened if complying with a command
led to a desired outcome. ‘¿Influence'concerns whether the
individual could determine the onset and offset of the voice,
and could direct what was said. The behavioural and
affective responses were also elicited.
Results
A cognitive analysis of each individual's experience of
voiceswas completedon the basisof 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, we
describe 12 people's experience of hearing voices; information
about all 26 patients' experience is available from the
authors on request.
Beliefs about voices
Omnipotence. All voices were perceived as being extra
ordinarily powerful. Nineteen patients (73%) reported
collateral symptoms (e.g. visual hallucinations) that
contributed to the sense of omnipotence. In six instances
the experience of control was attributed to the voices.
However, not all the evidence was of this type: 11people
(42°lo)gave examples of how they attributed events to their
voices, and then cited the events as proof of the voices' great
power. For example, although S14 and Sl6 both cut their
wrists under their own volition, they subsequently deduced
that the voices had somehow made them do it. Similarly,
S17 attributed responsibility for his having sworn out loud
in church to his satanic voices. This ‘¿superhuman'quality
was reinforced in all cases by ‘¿hard'evidence that the voices
wereomniscient—¿that is, knowing(i.e.commentingon the

192
CHADWICK & BIRCH WOOD
person's present thoughts and past history, and predicting
his or her future. Finally, 21 people (8lWo) were unable to
influence either the onset and offset of their voices or what
was said, once again suggestive of the voices' power.
Malevolence and benevolence. Four broad classes of
belief emerged, and three representative examples of each
appearin Table 1. Twelvepeople(Sl—S12)believedthe
voices were malevolent. 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. For example, Sl believed he was
being punished by the Devil for having sinned, and S3
believed he was being persecuted without good reason by
an ex-employer. Six people (S13—Sl8) believed the voices
to be benevolent. Benevolence, the wish to do good, took
a number of forms: to help the person maintain mental well
being; to protect the person, often from malevolent voices;
an advisory role; to help the person develop social power;
to develop a personal interest in the person (e.g. marriage).
For example, Sl4 believed that the voices were from God
and were there to help develop a special power.
The third group (S19—S23)comprised five people who
believed they heard a mLxture of benevolent and malevolent
voices; a paradigm of this group was S23, who was
tormented by a group of evil space-travellers and yet
protected and nurtured by a guardian angel. The final three
people (S24—S26)were uncertain about their voices because
of an inconsistency or incongruity in what was said.
‘¿Uncertainty'was defined as having a strong doubt about
the voice's identity, meaning or power, where this doubt was
the result of the person's deduction. For example, S26 was
certain that his voices wanted to help but observed that they
had got things wrong: they wanted him to kill himself and
move on to the next and better life, yet his religion told
him that suicide is a sin and those who commit it go to hell.
Connection with voice content. The voice content was
frequently put forward as evidence for a particular belief.
Thus it was commonly said that evil commands were
evidence that the voice was bad, and kind protective words
were evidence that the voice was good. Also, as we have
seen, the belief in omnipotence was supported in all cases
by the apparent omniscience of voices; they all ‘¿knew'about
the person's private thoughts and actions, and many
accurately foretold the future.
However, the classof beliefwas not alwaysunderstandable
in the light of voice content alone —¿that is, in eight cases
(31%) the beliefs appeared to be at odds with what was
said. In the case of S2 and Sl2 the voice content was benign,
yet these voices were construed as malevolent. The reverse
was true of S26, whose voice called him a fool and told
him to commit suicide and yet was construed as benevolent.
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.
Again, S25 believed his voices to be benevolent in spite of
them telling him to kill his daughter. S 15's voice told him
to commit suicide and yet still was thought to be a
benevolent goddess. 5 18's voices insulted her and told her
to kill and yet were seen as benevolent. Perhaps most
strikingly, S Il's voice identified itself as God and yet she
disregarded this and believed it to be an evil force.
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. Engagement may
be defined as elective listening, willing compliance, and
doing things to bring on the voices (e.g. watching television,
being alone, calling up voices). Resistance was a second
category and may be defined as arguing and shouting (overt
and covert), non-compliance or reluctant compliance when
pressure is extreme, avoidance of cues that trigger voices,
and distraction. A final category, indifference, was defined
as ignoring and disregarding the voice.
At times people who habitually engaged with voices tried
to ‘¿shutthem up to get some peace' or shouted at them
when they became a nuisance. 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.
When these behavioural categories are compared with
beliefs about malevolence and benevolence, the results are
striking. Without fail, when a voice was believed to be
benevolent the person willingly engaged with it, and when
a voice was believed to be malevolent it was resisted. Those
people who were uncertain about their voices displayed no
clear pattern between beliefs and behaviour. Affective
responsesto voicescorresponded verycloselyto behavioural
responses. All 17 malevolent voices habitually provoked
negative emotions (anger, fear, depression, anxiety). 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.
All three people who were uncertain about their voices
experienced negative affect when these voices spoke.
Compliance with commands
Although people had clear intentions about whether to
comply with commands, at times these were compromised.
Compliance is governed by at least five factors. Firstly,
compliance can be total (all commands obeyed in full),
partial (onlycertain commands obeyed), or absent. Secondly,
there is the general disposition to consider; malevolent
voices are to be resisted and benevolent voices are to be
courted. However, and thirdly, all people interviewed who
heard imperative voices had additional beliefs about the
consequences of obedience and disobedience (see Table I).
Beliefs about disobedience varied in severity from being
nagged to being killed. A fourth factor is the commands
themselves —¿voices may give innocuous commands (“make
a cup of tea―,“¿watchyour step―),or severe commands
(“killhim―), or both. Finally compliance would seem to
be influenced by extra factors such as the person's mood,
and the pressure and persistenceof the voices—¿patients who
respond to such factors often present as losing tolerance
for their voices.
We feel it is helpful to classify commands as mild or
severe (i.e. life-threatening). Immediately one parameter
can then be established. Fourteen voices (eight benevolent,
six malevolent) gave only mild commands; all these

Patient no., Voice content Beliefs: identity, (I)Evidence:
content(C),AffectiveresponsetoBehavioural
responsesex,
age,meaning
(M), andsymptom (S),attri voicestovoicesduration
ofeffect
of compliancebution
(A), influence(I)illness(C)
OMNIPOTENCEOF VOICES:COGNITIVEAPPROACH 193
Table 1
A cognitive analysis of voices: a sample of 12 from the 26 patients (all diagnosed schizophrenic)
I. Voice of Devil C. Content is evil and Frightened
M. Beingpunishedfor knows my thoughts Angry
killing someone and past
C.Devilwilldriveme S.Delusionofcontrol
mad if I don't obey I. None
I. First and only C. Readsthoughts Irritated
employer and knows my past Depressed
M. Controllingme and S.Delusionofcontrol
holdingme back in A. Voice gets worse
life if I makeprogress
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. Their advicestops
developmy powers conflict
C.IfIobeybadthingsS.Experienceof
will not happen control
I. No influence
I. Powerful witchesA.
RecognisevoicesExhaustedwho
usedto beC. ReadthoughtsandTormentedneighboursknow
pastScaredM.
PunishmentforI.Nonebeing
noisyandstopping
studyingC.
IfIdisobeytheykeep
on atme
I. An ex-girlfnend,
who isa goddess
M. She protects me.
I hear becauseI've
great power
C.She nagsme ifI
don'tcomply
I.A deadfriend
M. Iam intouchwith
anotherdimension
C.IfIresistIwillfall
victim to the other
side
Si
M, 49 years
>20 years
S2
M, 43 years
>20 years
S3
M, 31 years
10 years
S14
M, 32 years
8 years
Si5
M, 24 years
3 years
S16
F, 23 years
2 years
Imperative
Told to rapeand kill
Imperative
“¿Becareful―
‘¿Tryharder―
Imperative
“¿Beuntidy―
“¿Don'twash―
Imperative
Voices give
marvellous advice
Imperative
“¿Killyourself―
“¿Giveup smoking―
“¿Don'tgo to church
today―
Imperative
Not to trust people
Giveswarnings
C. Know thoughts
and past
A.Grandiosedelusion
I.Can callup voiceand
influencecontent
S.Derealisation
Delusionof reference
C. Soundslike friend
andidentifieditself
C.Predicteddeathof
friend
C. Voice saysso
Knows what I'm
thinking
A.Feltpinpricksand
passedouton
ward—¿influenceof
voice2
S.Theyappearas
Strong
Confident
Happy
Interested
Some irritation
Anxious
Voice1.Reassured
Voice2.Fear
Shoutsbackand
swears (covert)
Compelledtolisten
No compliance
Shoutsbackand
swears(covert)
Compelledtolistenand
compliesunwillingly
Listensandargues
with voice
No compliance
Electivelisteningand
compliance
Elective listening
Selectivecompliance
Listenscarefully
Avoids certain people
Compliesfully
Voice 1. Listensatten
tively
Obeyswillingly
Voice 2. Shoutsback in
mind. Distracts (TV,
talksover).Some
reluctant compliance
Si9 Voice1.Advisesand I.Voice1 ismy
F, 34 years imperative boyfriend. Voice 2
10 years “¿Maketea―,“¿Youare is Russiansand
the bride in Bible― Germans
“¿That'spossessed― M. I havea mission
Voice2.Imperative fromGod tomarry
“¿Killher―“¿Stabher―my boyfriend
“¿Eatearth― C. Russianswill nag
and kill me if I resist shadows on the wall

194 CHADWICK & BIRCHWOOD
Table 1 lcontinued)
Patient no., Voice content
sex, age.
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. ImperativeI. Two male film stars, S. Reference and Stars: feel happy andStars:
electiveF,
20 yearsand
commentand their two visual hallucinations excitedcompliance
and2
yearsPair
1. “¿Wewant tojealous
friends and thought Jealousfriendslisteningknow
you―M.
The stars want to stopping Upset and angryFriends:
shoutback“She's
beautiful―know me and C. Know my historyand
swear.Reluctant“Sit
where we canperhaps
marry me. and my thoughtspartial
compliancesee
you―The
friends prevent andfuturePair
2. “¿She'sugly―this
and want to kill A. They arepowerful“Do
it properly―me
and won't goaway“Kill
her―C.
If I comply with the I.Nonestars
I feelbetter.Jealous
friendspunish
disobedienceS21Voice
1. ImperativeI.
Devil and God C. 1 good, 1 bad AnnoyedDevil:
avoid andresistF,
26 years“Hit
him―“¿Killhim―M.
Devil punishing for C. Know thoughts FrightenedSometimes
give inand10
yearsVoice 2. Imperative
Tells to resist Voice 1,
and to do good thingscausing
parents' and past
divorce. God S. Delusion of
protecting me reference
C. Devil nagsif I
resist. God wants
me to resistcomply
ObeyGodS24ImperativeI.
God. but God S. Visual FearAppeases
voice;partialF,
59 years“You must kill Cathy,wouldn't tell to kill hallucinations (dead Reverencereluctant
compliance35
yearsyour family and
yourself―M.
Punishment for daughter; seen her
past misdemeanour ‘¿age'over 30 years)
C. If I comply I'll go C. Know what I'm
to heaven and see thinking
my daughter anddogS25ImperativeI.
God and Devil have S. Delusion of control ScaredListen
unwillinglyandM,
54 yearsKill
daughter, steal,entered
my body. C. Know thoughts and Nervoussome
unwilling>
20 yearsread BibleBut
God wouldn't past Miserable
teach bad things I. None
M. They want to help;
they ordain what we
must do
C. If I resist they bite
mecompliance
Avoidance ofcuesS26ImperativeI.
Two benevolent They read my mindIrritatedIgnoreM,
50 years“Kill
yourself―spirits
and know my pastNever
comply>20
years“He's
a fool―
Told to commit
suicideM.
Want me to go to Fantastic visual
next, better world hallucinations.
C. But I don't obey Suicide is a sin
because they don't I. 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 —¿the one exception was S3 (see
Table 2). Severe commands were given by 12 voices (one
benevolent, 11 malevolent) and all were currently being
resisted. However, 10 of the 12 voices that gave severe
commands also gave mild ones, and in all 10 cases these
were obeyed at least occasionally. It is as if compliance with
mild commands was an attempt to appease the voices'
requirement for sterner actions. Of those people who were
uncertain about the voice, two complied partially and one
not at all.
Comment
The study offers striking support for the cognitive
model. All the patientsdisplayedmuch “¿effortafter

Frequently asked questions

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 —¿ 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 †stress-vulnerability'model?

There is now considerable empirical backing for the ‘¿ 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.