Cognitive Therapy for Reducing Distress and Harmful Compliance with Powerful Voices

1. Cognitive Therapy for Reducing Distress and Harmful Compliance with Powerful Voices Dr. Alan Meaden Consultant Clinical Psychologist COMMAND Trial

2. Why get distressed and act on voices?

3. Do as I say or else!

4. “All things are subject to interpretation whichever interpretation prevails at a given time is a function of power and not truth.” Friedrich Nietzsche 1844–1900

5. CTCH: The Theory in Brief A Cognitive Model of Distress and Behaviour within an Interpersonal Relationship

6. The Cognitive Model of Voices • In CTCH we view the voice as an activating event (A) • The significance of which is interpreted by the individual in terms of their belief system (B); the voice hearer develops further beliefs as part of an on-going process to make sense of this experience • Distress and behaviour are the consequences (C) which follow from these beliefs

7. The Cognitive Model of Voices • This belief system is underpinned by the development of a quasi-interpersonal relationship • The voice hearer is often subordinate in this relationship • Compliance with this powerful ‘other’ means that the validity of the voices commands is never tested out • This constitutes a type of ‘safety behaviour’

8. Subordination to others and Core Beliefs BELIEFS [Power; intent] Emotional Consequences: Fear, guilt, elation, depression Voice Activity EVIDENCE Behavioural Consequences (Safety Behaviours) Control Omniscience: shame; predictions Threat Mitigation Full Compliance Partial (appeasement)

9. The VOICE Power Schema Power and authority are summarised and evidenced by 4 core beliefs about voices: IDENTITY (devil) MEANING / PURPOSE (punish or destroy) COMPLIANCE (disastrous consequences) CONTROL (inescapable)

10. Power & Intention • Malevolence/Benevolence = the intention of the voice • Power = the perceived ability of the voice to carry out this intention and is the driver of distress and behaviour

11. Compliance Beliefs • If I don't do what my voices say... • Others I care about will be harmed • I will be harmed • The voices will go on and on at me • They will reveal bad things about me to others: publicly shame and humiliate me

12. Safety Behaviours Prevent Disconfirmation of The Voices Ability to Carry Out the Threat

13. CTCH aims to reduce motivation to comply or appease by: • Undermining the power of the voice especially its perceived ability to harm or shame • Increasing the power of the voice hearer • Improving interpersonal effectiveness

14. Overview of the Therapy • 8 Levels • Offered flexibly – need adapted • (current trial up to 42 sessions – average of 24) • May spend more time on some levels • May not work on all levels – led by the person

15. Aim is to Reduce Distress & Harmful ComplianceVs Reducing or Removing Voices

16. CTCH Level 1 Assessment & Engagement

17. Engagement Issues • Focus on development of a sound therapeutic alliance: empathy, trust, genuineness, non-judgemental, flexibility, • Anticipating problems: • Pace of therapy • Worsening of symptoms • Further restrictions being applied when disclosing information about symptoms

18. Level 1 Strategies • The “panic button” gives the voice hearer control over the therapy and models taking control back and promoting the hearers own power • Inoculating the voice hearer against the voices commenting negatively about the therapy and therapist

19. Level 1 Strategies • Keep focused on the purpose: reduction of harmful behaviours and distress • Carefully listen to and eliciting the hearers story and experience of voices

20. CTCH: Level 2 Promoting Control

21. Promoting Control Aims • Bolster the person’s strengths in coping with their voices and ability to have some control • Start to build evidence against their powerlessness and against the voice’s power • Develop an understanding of factors that increase/ decrease the presence of voices • Bring some immediate relief and thereby underpin engagement

22. Promoting Control • The process of promoting control involves developing or reinforcing a coping repertoire for reducing the distress associated with their voices • Introduce novel ideas that have been tried successfully by other voice hearers, such as humming

23. Common Strategies for Voice Control • TV/Radio/Reading • Headphones • Humming/Gargling • Following lyrics to favourite songs in ones head • Ear plugs • Time-limiting contact • Only speaking to benevolent voices • Assertively addressing the voice • Negotiating with voices

24. Developing Initial Boundaries • We view the voice-hearer as being in a relationship in with their voices over which they can develop boundaries • The nosy neighbour and other analogies are used to along with coping strategies to: • help the hearer have their own time (turn the voice off) • make their own decisions, rather than always listening to and waiting for the voice to make them

25. Naomi (from our first trial) • The therapist supported Naomi to develop a variety of ways of coping with the voices, enabling her to have more control over them: • Distraction techniques included: • keeping occupied (regularly attending college, going out for a walk, shopping, tidying her room, cooking) • talking with or being in the company of trusted others • reading a good book • listening/dancing to music

26. Naomi • By learning to ignore the voices as much as possible, and get on with other things, rather than engage in conversation with them • Naomi found that she was able to have more control over the voices and gain respite from them • This further reinforced her use of such coping strategies

27. CTCH: Level 3Developing a Shared Understanding Building Optimism for Change

28. Level 3 Strategies • Here we introduce the ABC model formally and offer it as an alterative way to look at the experience of voices and why they can be so distressing and lead to unwanted actions • Voice activity is a fact (A) but it’s power and the need to act on it is not (B)

29. Introducing the ABC Model Scenario a) Scenario b) Tom hears a voice say “you are on your way.” He thinks that he is on the way to great things. How does he feel? What does he do? • Tom hears a voice say “you are on your way.” He thinks that the voice is going to kill him. • How does he feel? • What does he do?

30. Consider the advantages and disadvantages of the beliefs being true or false Alternative Belief If listen the voices get worse and they only go away for a short while and then they come back I am the one in control here they can’t make me do anything! Actually they do seem to be all mouth as they can’t hurt me – if they want me to do something they have use me to do it they can’t do it. Current Belief They are here again they are going to make me do stuff I don’t want to do I cant stand this!

31. Consequences of the Current Belief I get wound up, start pacing the adrenalin starts going I become more aroused and start to listen to them I harm myself or carry out what they want me to do because It will them shut up – they will be satisfied (Compliance Belief) Consequences of the Alternative BeliefIf I believe this then I could get on with my life and go out when I want to I could get on the bus without feeling as though I am being watched (keeping occupied changes the A) When I stay relaxed the voices get bored and stay away….. The voices will eventually go away when they know I am not playing their game

32. So There are benefits to Resisting!

33. Training the Inner Detective • As part of teaching the ABC model the therapist might suggest adopting the persona of a fictional detective. • In collaboration with the therapist, the voice hearer is invited to collect evidence in support of the voice and alternative (less distressing) beliefs

34. CTCH Level 4: Reframing and Disputing Beliefs About Voices

35. Redressing the Power Imbalance • The overall aim is to address the power imbalance which underpins compliance and distress by: • Questioning the power of the voice • Weakening the conviction that the voice hearer is being and will be punished or harmed • Revealing its fallibility

36. CTCH Strategies • The therapist draws upon the voice hearers: • Own doubt, past or present • Own contradictory evidence and behaviour • Own concerns about the possibility that their beliefs about the voices may be wrong

37. CTCH Strategies • Explore the origin or source of the belief • List and critically examine reasons and evidence for the belief: • I can’t start or stop it (control) • It is all seeing and knowing (omniscience)

38. CTCH Strategies • Develop and critically examine the implications and consequences of the belief: “so you believe that you have to do what it says otherwise you will be punished?” • Seek and fairly examine conflicting views (alternative points of view): “so sometimes you can stop it or ignore it then (disputing control)?”

39. CTCH Strategies • Disconfirming evidence can be built up from anything the voice hearer has noticed in the past that seemed to be inconsistent with what the voices said • By subsequently following a line of logical reasoning further inconsistencies can be exposed

40. David • David and his therapist carefully explored, and was unable to find, any evidence that the voice had ever harmed him, or indeed as a ‘spirit’ could possibly physically do so • He slowly came to realise there was no basis for his belief that the voice could physically harm him and he could therefore ignore its commands without fear of punishment

41. Challenging Claims Made by the Voices • We further try to discredit the voices by pointing out mistakes or lack of evidence – to reveal the fallibility of the voices (thereby down-ranking them) • JC whose voices told him that the end of the world was coming in the year 2000 • SS whose voice told him shave your head and you will get respect from others

42. So – Voices make lots of claims but cannot back them up!So... if they lie about this………?

43. Kevin • Kevin believed that he had to comply with the voices’ commands because he feared that the voices might harm him or someone he cared about if he resisted • This belief was challenged in therapy: • It was proposed that only something physical, like a knife or a bullet, can harm the physical body • Gradually Kevin began to develop the belief that the voices were not physical objects, thus concluding that they cannot do him any physical harm

44. Kevin • It was observed that the voices seemed to rely on Kevin to do what they said • The therapist explored what happened when Kevin chose not to act • Kevin began to realise that he had resisted the voices’ commands many times without him or his family coming to any harm • He concluded that the voices could not physically make him comply and that they were powerless to act themselves

45. So They cannot do any harm .. Therefore they cannot carry out their threatsandThey have not done anything when resisted – Kevin did not use a safety behaviour with no feared consequences

46. CTCH: Level 5 Reducing Safety Behaviours & Compliance

47. Testing Compliance Beliefs • Once the voice hearer can • Challenge the truth of what the voices say • Challenge their omniscience • Recognising their true capacity to carry out their threats • Have more control • They can then consider dropping their safety behaviours

48. Using Stories: The Elephant on the Tracks John is taking his usual train trip to work and notices that another man on the train is throwing small pieces of paper out of the window. He watches the man for a few minutes and switches his attention back to his book. They both get off at the same stop and nothing is said.

49. The Elephant on the Tracks The next day John notices that the man from the previous day is doing the same thing again. He becomes fascinated by the man throwing paper out of window and decides to ask him what he is doing. The man says that he’s throwing paper out of the window to keep elephants off the tracks. John states that there are no elephants on the track.

50. The Elephant on the Tracks • The man responds by saying - ‘well, it must be working then!’ • The voice hearer is asked to assess the story: • “What are the reasons the people in the story are behaving as they are? “ • “What would the person in the story need to do to test out their beliefs?”