Cognitive Therapy for
Reducing Distress and
Harmful Compliance with
Powerful Voices
Dr. Alan Meaden
Consultant Clinical Psychologist
COMMAND Trial
Why get distressed and
act on voices?
DO AS I SAY
OR ELSE!
“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
CTCH:
The Theory in Brief
A Cognitive Model of Distress and
Behaviour within an Interpersonal
Relationship
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
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’
BELIEFS
Subordination to others
and Core Beliefs
[Power; intent]
Voice
Activity
EVIDENCE
Emotional
Consequences:
Fear, guilt, elation,
depression
Behavioural
Consequences
(Safety Behaviours)
Omniscience: Control
shame; predictions
Threat Mitigation
Full Compliance
Partial (appeasement)
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)
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
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
Safety Behaviours
Prevent Disconfirmation
of The Voices Ability to
Carry Out the Threat
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
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
Aim is to Reduce Distress
& Harmful Compliance
Vs
Reducing or Removing
Voices
CTCH
Level 1
Assessment & Engagement
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
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
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
CTCH: Level 2
Promoting Control
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
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
Common Strategies for Voice Control
► TV/Radio/Reading
► Headphones
► Humming/Gargling
► Following
► Ear
lyrics to favourite songs in ones head
plugs
► Time-limiting contact
► Only speaking to benevolent voices
► Assertively addressing the voice
► Negotiating with voices
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
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
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
CTCH: Level 3
Developing a Shared
Understanding
Building Optimism for Change
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)
Introducing the ABC Model
Scenario a)
► 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?
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?
Consider the advantages and disadvantages of the
beliefs being true or false
Current Belief
They are here again
they are going to
make me do stuff I
don’t want to do
I cant stand this!
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.
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
Belief
If 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
So There are benefits to
Resisting!
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
CTCH Level 4:
Reframing and Disputing
Beliefs About Voices
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
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
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)
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)?”
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
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
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
 SS
whose voices told him that the end of
the world was coming in the year 2000
whose voice told him shave your head
and you will get respect from others
So – Voices make lots of
claims but cannot back
them up!
So... if they lie about
this………?
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
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
So
They cannot do any harm ..
Therefore they cannot carry out
their threats
and
They have not done anything
when resisted – Kevin did not use
a safety behaviour with no feared
consequences
CTCH: Level 5
Reducing Safety
Behaviours & Compliance
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
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.
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.
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?”
Behavioural Experiments
►Behavioural
experiments are then
devised to test the voice hearers belief:
 Carrying out or withholding a behaviour in
order to test a prediction that something
bad will happen
 The person is encouraged to reduce the
use of the safety behaviour and note that
the feared outcome does not occur,
hence weakening the belief
David
► Having
doubted his belief that the voice
could harm him David put this to the test by
ignoring the commands
► After
several such tests, he discovered there
were in fact no consequences
CTCH: Level 6
Raising the Power of the
Individual
Questioning the Voice’s Command
► Questioning
the voice’s command directly is
an extension of the behavioural test and
builds upon earlier boundary setting work
► At this stage the voice may be challenged
more assertively:
 “Why should I do that?”
 “Why don’t you do it yourself?”
► Ray
told his voices: “YOU go in walk in the
road if you want to!”
Raising Awareness of the Power Shift
►Most
of the preceding interventions are
aimed at challenging beliefs about the
power of the voice
►These will simultaneously and
necessarily be proving that the voice
hearer now has mastery and control,
not the voice
►By careful questioning, the voice
hearer can be made aware of this
Developing Powerful Self Beliefs
Powerful Voice beliefs
► I must comply (at least
partially) to prevent the
voice harming me
►
I have no control over my
voice
►
My voice is powerful and
therefore should be
obeyed
Powerful Self beliefs
► The voice cannot harm
me, therefore, I can
choose to resist or ignore
its commands
► I have learnt to have
control over my voice by
using the following coping
strategies………
► My voice is not powerful,
and so I do not have to
obey it
Advanced CTCH
CTCH Levels 7 & 8
Working with Personal
Meaning and Core Beliefs
Why Advanced CTCH?
► Voice
Hearers may not respond to
interventions aimed just at power beliefs work at the core belief level may be needed
to effect longer term change
► Advanced CTCH builds on progress made at
earlier levels and attempts to inoculate the
person against future relapses
Level 7 and 8 Work
► Examines
voices:
the possible personal meaning of
 Why this voice
 Why now
 Why this content
► Sometimes
it is possible to explain voices in
terms of their psychological origins
► This work if carefully handled and timed,
can be a powerful move to finally
deconstruct power beliefs
Level 7 and 8 Work
► REBT
theory and ABC model suggest that
core beliefs and beliefs about voices may be
connected and reflect early adverse
experiences and other traumas
► Negative core belief work may be needed:
person evaluations
► May also need to work on trauma issues
Does it Work?
Service Hearers Accounts: J
►I
was doing some really stupid things
before I started to work with the
therapist.
►I was walking in front of cars and
cutting myself.
►I was doing lots of stuff that the voices
wanted me to do.
J’s Story
►I
remember thinking that if I did what
they wanted things would get better –
but they didn’t. They just kept going
on. When I harmed myself this upset
me, my family and my CPN was
worried as well.
J’s Story
► When
I went to the next appointment on
my own this was really difficult for me. The
voices wanted me to harm the therapist.
They kept swearing at me and kept going
on.
► Once therapy got going .... the therapist
encouraged me to use some strategies to
distract myself from the voices.
J’s Story
►I
noticed that when I did art work I didn’t
hear the voices so much. They went into
the background. I also found the same
thing when I went to my support group.
J’s Story
►I
came to realise that the voices only new
the things I did. They didn’t know anything
else.
► I can’t express how powerful this was. I felt
so good. The voices weren’t magical ...they
weren’t as powerful as I had thought they
were. This is something I still remember
and it makes me realise that they are
normal like me. They are not special.
J’s Story
► In
my past quite a few different things have
happened .... I learned from the therapist
that when I had flashbacks, nightmares or
thought about all these bad things it would
be very upsetting. This meant I tried not to
think about these things. Over time I have
sorted out what the voices bring up about
my past and have sorted and filed them
away. This means I am upset less of the
time.
J’s Story
►I
have now stopped cutting myself. I realise I
don’t need to do what the voices tell me to do ....
even if I did .... they wouldn’t stop going on –
they never did.
► I also recognise that I can resist them and when I
go against them nothing bad happens.
► I remind myself of the value of not doing what
they want: I stay in control and I don’t upset any
of my family – this is really important to me.
J’s Story
► It
was difficult to stand up to them the first
time. I guess I had listened to them for so
long. I was very nervous. But I began to
question them and challenge them.
► I won, I had control and I had the power –
they didn’t! They lost their power when I
realised that they only new what I did. This
was such an important moment for me.
J’s Story
►I
think I am a braver person now and more
confident. I do have some days when I
don’t do so well, I lose confidence a little
and can get low. But I am able to stay
positive. Things don’t seem to affect me so
much. What they say to me doesn’t take
hold as much.
J’s Story
► It
was a good job the project came along
when it did. I was very nervous doing it but
it was worth it. It really paid off. Without it I
might be six foot under.
► I now accept the voices. I don’t know
whether they will stop or not. I can still live
my life and have a positive future. I am
confident about things now and this will
help me get the most from my life.
Angel’s Story
► Therapy
involved concentrating on the
voices which I had actively avoided doing
for fear of them overpowering me.
► I kept diaries of when I experienced the
voices, times when they were more
distressing and times when they were less
distressing.
► We also looked at what was going on in my
life and how this had an impact on the
severity of the voices.
Angel’s Story
► This
gave me an awareness that there were
times when I did not actually hear the
voices ..... how I could use various coping
strategies
► Challenging the voices by not complying ....
was a frightening thought but in practise
was very powerful.
Angel’s Story
► By
using the resistance diaries I could see
at a glance how non-compliance over a
period reduced the frequency of the
commands and tested the voices threats
and questioned their power and transferred
power to me.