Cognitive Therapy for command hallucinations

Alan Meaden, Max Birchwood and Peter Trower

in Hallucinations

Published on behalf of Oxford University Press

Published in print June 2010 | ISBN: 9780199548590
Published online February 2013 | e-ISBN: 9780191754623 | DOI:
Cognitive Therapy for command hallucinations

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Working with people experiencing command hallucinations can seem daunting for many practitioners. Histories of risk behaviour and associated media coverage may lead clinicians to avoiding working with this group; seeing them perhaps as largely the domain of forensic services. In truth, such symptoms are common and individuals who experience them frequently seek help. In this chapter, we illustrate an evidence-based approach to working with command hallucinations based on our extensive clinical and research experience and findings.

The key feature that distinguishes command hallucinations from ‘ordinary’ hallucinations is that the voice is experienced or interpreted as commanding rather than commenting. These perceived commands range from making a harmless gesture (turning the lights off) to behaving in ways that are potentially injurious or lethal to self or others (stabbing another person, cutting ones wrists).

Command hallucinations occur at a high rate in both adult psychiatric and forensic patients but vary considerably from study to study (e.g., 18 to 89%), with a reported median rate of 53% across eight studies (Shawyer et al., 2003). These authors further report a median prevalence of 48% for harmful commands in non-forensic patients, but again the range was considerable: from 7 to 70%. Forensic groups are likely to be higher, with 83% of voice hearers found to have so-called command hallucinations with ‘criminal’ content. Command hallucinations that command violence are held by some to be an increased risk factor for violence (Monahan et al., 2001). At least partial compliance to these harmful commands was reported by Shawyer et al. (2003) in 31 % (median rate across studies) in community samples, but with a very wide range: 0–92% suggesting methodological difficulties in the studies reviewed. Compliance with voice commands has been found to be associated with identification of the voices as real people or identities, hallucination-related delusions, and emotional involvement with the voices (Erkwoh et al., 2002). In a recent study, we found that acting on voices was predicted by the voice hearer's beliefs about the voice (Hacker et al., 2008).

Cognitive Therapy for Command Hallucinations (CTCH) like all cognitive therapies for psychosis conceptualizes cognitive processes as central to understanding psychotic experiences and working with them. It also, perhaps uniquely, clarifies the psychological processes that underlie many of the risk behaviours tenuously linked to command hallucinations and offers a set of therapeutic principles for reducing such risk. This very clear explanatory model, in the ABC framework, is outlined in Trower, Birchwood, and Meaden (this volume). Therapeutic change is targeted at C, i.e., the focus is on voice-related distress and compliance behaviour, which is a consequence of dysfunctional beliefs at B. In this regard, our model owes much to Rational Emotive Behaviour Therapy (REBT) as first practiced in 1955 by Albert Ellis (Ellis, 2004). We have also adopted concepts from Social Rank Theory (Trower, Birchwood & Meaden, this volume) in deepening our understanding of the unique power some voices appear to have over the individuals who experience them. Understanding this power relationship holds the key to explaining the subordinate compliant behaviour individuals engage in. This overarching theme of power runs through all therapeutic efforts and is used both implicitly and explicitly in the therapeutic relationship. The perceived need to obey seemingly powerful voices is crystallized in what we have termed the voice power schema (a set of inter-related voice beliefs). The target of therapy is to deconstruct these power schema and reduce distress and compliance behaviour and thereby risk.

Chapter.  8913 words.  Illustrated.

Subjects: Psychiatry

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