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Cognitive Focus in Hallucinations
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.
Cognitive Therapy of Hallucinations
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.
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?”)
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