Morrison 2001 CT for Voices

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Clinical Psychology and PsychotherapyClin. Psychol. Psychother.8, 136147 (2001)

PractitionerReport

Cognitive Therapyfor AuditoryHallucinations as anAlternative toAntipsychotic

Medication: A CaseSeriesAnthony P. Morrison1,2*1 Psychology Services, Mental Health Services of Salford, Manchester, UK2 Department of Psychology, University of Manchester, UK

Antipsychotic medication is the main focus of current treatmentapproaches to schizophrenia and psychotic symptoms. However,there are some disadvantages to such treatments including side-effects, non-response and non-compliance. Cognitive behaviouralinterventions have been employed successfully as an adjunct tomedication, and two case studies suggest that such interventions canbe of benefit to patients as an alternative to antipsychotic medication.Four patients received cognitive therapy for auditory hallucinationsas an alternative to antipsychotic medication and were assessedweekly used a semi-structured interview that quantifies dimensionsof psychotic symptoms. Measurements occurred over a two weekbaseline period, during intervention and at follow-up. Three of thefour patients seemed to find the treatment acceptable. Two patientsachieved significant decreases in conviction, distress and frequency.Cognitive therapy may be a useful alternative to medication forauditory hallucinations. A more controlled evaluation is required.Copyright 2001 John Wiley & Sons, Ltd.

INTRODUCTION

Antipsychotic drugs continue to be the treatmentof choice for schizophrenia, although they havecertain difficulties associated with their use. A pro-portion of patients will continue to experience

* Correspondence to: Dr. Tony Morrison, Psychology Ser-vices, Mental Health Services of Salford, Bury New Road,Manchester M25 1BL, UK.E-mail: [email protected]

symptoms despite drug therapy, and 6070%will relapse within two years (Ram et al., 1992).In addition, distressing side-effects are common.There are also significant difficulties associatedwith patients compliance with such antipsy-chotic medication (possibly as a result of thecombination of unpleasant side-effects and inef-fectiveness for some individuals, see Hoge et al.,1990).

Recent studies examining cognitive behaviourtherapy (CBT) with this client group have shown

Copyright 2001 John Wiley & Sons, Ltd.DOI: 10.1002/cpp.269


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Cognitive Therapy for Auditory Hallucinations 137

it to be effective in reducing residual positivesymptoms on an outpatient basis, and maintainingthese gains at follow-up (Tarrieret al., 1993; Garetyet al., 1994; Chadwick and Birchwood, 1994; King-don and Turkington, 1991). CBT has been shownto be superior to other psychological treatmentssuch as supportive counselling (Tarrier et al., 1998)and to treatment as usual involving case manage-ment and antipsychotic medication (Kuipers et al.,1997) and routine psychiatric care (Tarrier et al.,1998). A reduced stay in hospital (by 54% in com-parison with control group) has also been shownfor CBT of acute schizophrenic patients (Druryet al., 1996) and recovery time for symptom reduc-tion was also improved, suggesting that CBT isof benefit for in-patients as well as outpatients.Therefore, it appears that CBT methods can beused to promote symptom reduction and reducetime spent in hospital, as well as promoting relapseprevention.

Whilst CBT has been shown to be superiorto standard psychiatric care, the specific benefitsthat it yields are less clear; this is particularlythe case for patients experiencing auditory hal-lucinations. Kuipers et al. (1998) found that globalsymptomatology was significantly better at end oftreatment, but that hallucinations and delusions

did not become significantly better until 18 monthfollow-up. Tarrier et al. (1993) found that hallu-cinations did not improve significantly whereasdelusions did, and this is consistent with the dif-ficulties found in another study examining CBTfor hallucinations (Haddock et al., 1998). How-ever, Chadwick and Birchwood (1994) reportedencouraging findings using cognitive therapy forvoices and Tarrier (1999) reported that CBT pro-duced a greater change in hallucinations thandelusions in comparison with supportive coun-selling.

Given the difficulties outlined in relation toantipsychotic medication, it may be important to

assess the effectiveness of cognitive behaviouralinterventions for psychotic symptoms in the minor-ity of patients who are unable to tolerate suchmedications, who do not benefit from such medica-tions or who are non-compliant with such medica-tions. In addition, the delivery of such services andapproaches to psychosis is consistent with serviceusers views as identified by Hansson et al. (1995)and current healthcare policy regarding promotionof choice for service users.

There is some evidence to suggest that cognitivetherapy for auditory hallucinations can produceclinically significant benefits in patients who are

not currently receiving antipsychotic medication.Morrison (1994) reported a single case study inwhich a 38 year old patient with a diagnosisof schizophrenia, not currently on any medica-tion (because of past unpleasant side-effects andineffectiveness), received cognitive therapy for herauditory hallucinations. Significant decreases inconviction, frequency and distress associated withthe voices were achieved and these gains weremaintainedat follow-up. Chadwick and Birchwood(1994) reported a caseof a 34 yearold woman with adiagnosis of schizoaffective disorder who receivedcognitive therapy for her voices in the absence ofany medication. Conviction in her beliefs about thevoices was considerably weakened,and her psychi-atrist also noted improvements in mood,confidenceand self-initiated behaviour. This study aims to fur-ther investigate the acceptability and effectivenessof cognitive therapy for auditory hallucinationsas an alternative to antipsychotic medication inpatients who are unable or unwilling to take suchmedication or patients for whom such medicationis ineffective.

METHOD

Subjects

Four patients were referred for cognitive therapyfor their auditory hallucinations. Details regardingthe patients age, source of referral, diagnosis(using DSM-IV criteria, APA, 1994), length ofillness, reasons for not being on any antipsychoticmedication, antipsychotic medication history andcurrent medications are given in Table 1.

Measures

PSYRATS AH Subscale (Haddocket al., 1999)

A clinician administered a semi-structured inter-view consisting of 11 items assessing dimensionsof auditory hallucinations. All items are scored 0to 4, with higher scores indicating more severephenomena. The items assess frequency, preoccu-pation, location, loudness, conviction, amount ofunpleasant content, severity of unpleasant content,amount of distress, intensity of distress, degree ofimpairment and control. All 11 items have goodinter-rater reliability (coefficients were all greaterthan 0.78) and the scale total was significantlyassociated with the hallucination item from a com-monly used psychiatric assessment, demonstrating

Copyright 2001 John Wiley & Sons, Ltd. Clin. Psychol. Psychother.8, 136 147 (2001)


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138 A. P. Morrison

Table 1. Descriptive information regarding patients

Reason forno Current History of

Referral DSM-IV Length of Antipsychotic Antipsychotic CurrentPatient Age Source Diagnosis Illness Medication Medication Medication

A 58 consultantpsychiatrist

schizophrenia 21 years failure to respondto all typicaland atypicalantipsychoticstried

5 oral typicals, 2depot, 2atypicals (inc.clozapine)

none

B 38 S. R. inpsychiatry

schizoaffective 16 years adverse reactionto antipsychoticmedication

3 oral typicals,sulpiride

lithium

C 75 consultant

psychiatrist

schizophrenia 55 years adverse reaction

to antipsychoticmedication

trifluoperazine none

D 57 generalpractitioner

schizophrenia 9 months refusal to takeantipsychoticmedication

none none

some validity (Haddock et al., 1999). Whilst thescale has empirically derived subscales consistingof emotional characteristics, physical characteristicsand cognitive interpretations, it was decided topresent the results using composite measures forsome dimensions of thepatients voices: thedistressand disability composite measure was created by

summing the scores for amount of distress, inten-sity of distress and amount of impairment, and thefrequency composite was created by summing thefrequency and duration scores. These provide datathat are clinically more meaningful at the level ofindividual cases.

Procedure

All patients were assessed over the first two weeksusing the PSYRATS AH subscale and a cogni-tive behavioural interview. The baseline mea-sures were taken during this period. Active inter-

vention commenced at session three. Patients wereoffered time limited contracts which were renewedor not as a result of negotiation between therapistand patient (patient A was offered ten sessions,patient B was given two six session contracts,patient C was offered six sessions but decided thathe did not want any further involvement afteronly five sessions and patient D was offered twoten session contracts). All patients were offered

booster sessions, which were used to consolidatetreatment gains and to collect follow-up data at twoweeks and six weeks after termination of therapy.In addition, patient D was followed up at 12 weeks

post-therapy. All ratings were made by the thera-pist who has been trained specifically in the use ofthe PSYRATS scales.

The choice of intervention strategies was deter-mined by an individual formulation of the patientsvoices and the responses to their voices that was

based on the cognitive approach to auditory hallu-

cinations outlined by Morrison et al. (1995) andMorrison (1998a). The intervention is based onthe assumption that a combination of the inter-pretations of voices and the content of voicescause the majority of the distress and disabil-ity associated with voices and that metacogni-tive beliefs (beliefs that people hold about theirmental processes) are implicated in the develop-ment of hallucinations. This approach also assumesthat mood, physiology, safety behaviours, selec-tive attention and other cognitive and behaviouralresponses are involved in the maintenance of hallu-cinatory experiences. Common strategies included

examining the interpretations of voices, challeng-ing the content of voices and modifying focus ofattention. The intervention was based on the gen-eral principles of cognitive therapy (Beck, 1976;e.g. problem orientated, time-limited, educational,use of the Socratic method). Each session fol-lowed the recommended structure of cognitivetherapy (e.g. setting an agenda, reviewing home-work,specific session targets, eliciting feedback andcollaboratively setting new homework in relationto the session content). A more detailed descrip-tion of the clinical strategies used and the overallstructure of therapy can be found in the work



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of Morrison (1998b), but a brief description ofthe elements of therapy for each of the casesfollows.

Case AA believed that hisvoices were coming from outer

space and that he was able to hear them becauseof a receiving device that had been planted in hisneck. The content of the voices was insulting (oftencalling him a bastard and racially abusing him).The voices also commented on world affairs (par-ticularly when he was reading a newspaper). Healso experienced delusions of reference, believingthat people were talking about him and that peo-ple could read his mind. Largely because of thesepsychotic symptoms, he had considerable levelsof anxiety and depression. At initial assessment,he identified these concerns on his problem list,and he prioritized the voices as being the mostimportant (he also put a number of physical achesand pains on this list). The goals that were setin relation to his voices were to reduce the dis-tress associated with them and/or the frequencyof them and/or the degree of conviction that hehad in them being externally generated. Formula-tion was based on the cognitive models of auditoryhallucinationhe interpreted his voices as being

of malicious intent, believing that the aliens weretrying to torture him. This interpretation, in combi-nation with the unpleasant content (that at times heagreed with), appeared to account for the majorityof his distress. On this basis, intervention consistedof attempting to challenge his interpretation byreviewing evidence, attempting to generate alter-native explanations (such as stress), manipulatinghis responses to the voices as behavioural experi-ments to test different predictions and helping himto challenge the content of the voices. The inter-vention was unsuccessfulthis could be related tohis hopelessness and pessimism, which interferedwith homework compliance and it also appeared

that the chronicity of his difficulties and their pastconsequences also interfered (he had lost his job,his relationship and contact with his family becauseof thisit could be speculated that this would bedifficult to accept if he were to become symptomfree).

Case BB believed that his voices were from his father.

They were often very critical in content, frequentlychallenging decisions that he made and suggestingthe opposite course of action. At assessment, hereported his concerns to be largely related to the

experience of these auditory hallucinations, view-ing them as causing much distress. He also believedthat he was able to read minds at times, and occa-sionally experienced ideas of reference concerningmessages from the television. He identified thevoices as his number one priority on his problemlist and goals were set in relation to this in a similarmanner as for case A. A review of his life his-tory indicated that the onset of his psychosis had

been in a period when he experienced several lifeevents within one month of each other and alsohad severe sleep disturbances. He typically inter-preted his voices as being his father, although hesometimes thought they might be aliens or relatedto his thoughts. He viewed them as unfriendly,and this appraisal had consequences emotionally(annoyed, irritable, angry), physically (muscle ten-sion, sleep difficulties), behaviourally (talking back,trying to shut them up by suppressing) and cog-nitively (poor concentration, pre-occupation andconfusion). This information was collaborativelydeveloped into a formulation, and it was hypoth-esized that these reactions could contribute to themaintenance. He agreed that the distress resultedfrom his interpretation of the voices, and thereforethe initial target for intervention should be this.Alternative explanations for the voices were gener-

ated within session andthe evidence forand againsteach were reviewed (including the content of thevoices from the weeks diaries and how compatiblemodulators were with each explanation) and beliefratings were taken for each. Education about nor-mal thought processes and intrusive thoughts wereused to facilitate reattribution to an internal source,as was exploration of the links between his previ-ous experiences and the content of the voices, andhis relationship with his dad and how this might

be connected with the critical nature of the voices.

Case CC identified three major concerns at assessment.

These were his voices (which he believed to bea young Irish woman who was sexually attractedto him), touching sensations in his genital region(which he believed to be the woman touchinghim intimately) and anxiety regarding a forthcom-ing operation for cancer. The sessions with himwere used to gather information about the voicesfrom diary measures and to begin to examine thenature of his interpretations of his voices (alter-native explanations that were generated followingpsychoeducation included them being caused by aknock on the head some 55 years ago, his imagi-nation, his thoughts, sleep deprivation and stress).



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Diary measures indicated that attempts at sup-pression of the voices proved counter-productive,so he was encouraged to experiment with this,alternating focusing (see Haddocket al., 1998) withsuppression. The diaries also indicated that thevoices were exacerbated by low mood, so activityscheduling was also encouraged. He was also askedto identify worries about his operation so that thesecould be dealt with, but he denied having any.However, at this point he cancelled a couple ofappointments and then requested that no furtherappointments be sent.

Case DD had been hearing two abusive and persecutory

male voices for the past year. He had associateddelusions of persecution, believing that the voiceswere real people intent on causing him harm. Davoided going out of the house as he feared beingassaulted, but sometimes did escape from thehouseif he feared an imminent attack from the voices(usually based on what they were saying). Whenhe did go out he was extremely wary (and oftendrank alcohol in an attempt to remain calm). Healso reported panic attacks when concerned about

being attacked this appeared to be linked to hisalternative interpretation of the voices, which was

that he is losing his marbles. This informationwas incorporated into a formulation for a recentspecific incident and then used to generate amore general formulation. Intervention with Dwas based upon such a cognitive formulation.Alternative explanations were generated for theappraisal of his voices; thus, in addition to them

being real persecutors or a sign that he was goingmad, the possibilities that they were stress related,related to a traumatic road accident in whichhe had been involved or related to strong painrelieving medication he had taken in the past wereconsidered. The evidence for and against each ofthese possibilities was also considered. Clearly,

when generating alternatives and examining theevidence, it was important to provide educationregarding the frequency of voice hearing, the factthat certain stressors can induce hallucinationsand the fact that hearing voices is not alwaysassociated with mental illness. The content of thevoices was monitored using shadowing in sessionsand diaries between sessions, and this content wasexamined with regard to its consistency with eachof the explanations. It was agreed that it would

be useful to provide a test of the most distressingappraisal, which was that there were real peopleattempting to persecute him. He decided that an

appropriate experiment would be to cease all of hissafety behaviours that were designed to preventhim being attacked (such as sitting near the doorand checking in the attic or under floorboardsfor the potential assailants), and to sit still in hishouse and wait for one hour to see if they didcome to attack him; it was particularly importantto stop the safety behaviours as they appearedto have prevented cognitive change in the past.In other words, he attributed the fact that hehad not yet been attacked to having performedthese behaviours in the past. It seemed thatmodifying the interpretation of the voices reducedthe distress associatedwith the experience. Anothermethod that was employed to reduce distress andconviction was using a modified DTR to challengethe content of the voices on an ongoing basis; MrD was encouraged to examine the evidence forand against what the voices said, and to record hisassociated mood (this appeared to be particularlyeffective in altering his emotional response whenthe voices were being abusive and insulting abouthim as a person). These rational responses to hisvoices were practised in session using role-play(with the therapist modelling appropriate verbalchallenges initially). He was also helped to workwith some of the other problems he identified

on his problem listthese included relationshipdifficulties, low mood and alcohol abuse (the latterwas also targeted as a safety behaviour in relationto his interpretation of the voices as meaning hewas about to go madhe drank to stay calm andavoid this possibility.

Factors Specific to Cognitive Therapy withUnmedicated Patients

There are actually surprisingly few adaptationsor differences for using cognitive therapy withpatients who are not receiving antipsychotic medi-cation. Pessimism and hopelessness can be a factor

because of the failure of medical approaches in

the past; however, this is not uncommon in allpeople with serious mental illness (see Birchwoodet al., 1993). Thus, some increased emphasis onthe assessment and treatment of such factors isuseful in working with unmedicated patients, butthis should possibly be stressed more for all psy-chotic patients receiving cognitive therapy. Withthese four cases described above, only for case Adid hopelessness interfere significantly this couldhave been addressed explicitly, assessed using theBeck Hopelessness Scale (Becket al., 1974), and theevidence for such beliefs examined closely. Alter-native explanations for previous lack of change



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could be generated, behavioural experiments tar-geting very small improvements could be used andthe importance of early success in therapy couldhave meant focusing on more easily achievablegoals initially. Engagement can also be a difficultissue with people experiencing psychotic symp-toms, but, again, this is not specific to unmedicatedpatients. This was problematic with case C only,and it is unlikely that this was related to his

being unmedicated; rather, he probably had morepressing concerns that he did not see as beingamenable to psychological intervention (his can-cer). Therefore, the lack of a shared agreementabout problems and goals may have accounted forhis decision to terminate therapy. In general, cog-nitive therapys focus on shared problems and goallists, collaboration, guided discovery and a sharedunderstanding of the development and mainte-nance of problems seemed to help engage the otherpatients.

Working with patients who are not receivingmedication can in some ways be easier. Thereis no possibility of medication being used asa safety behaviour (e.g. If I hadnt taken extratablets I would have been possessed by the devil),there are no side-effects to contend with (some ofwhich can interfere with therapeutic progress, e.g.

poor memory or concentration) and there is nopossibility of patients attributing their own successexperiences to medication (therefore facilitating anincreased perception of control).

RESULTS

In analysing the data, composite measures wereused for some dimensions of the patients voices;the distress and disability composite measure wascreated by summing the scores for amount ofdistress, intensity of distress and amount of impair-ment, and the frequency composite was created by

summing the frequency and duration scores. Theratings concerning the distress and disability, fre-quency, conviction and control in relation to thepatients voices are shown in Figure 1.

The total PSYRATS (AH Subscale) scores for eachpatient at baseline, end of treatment and six weeksfollow-up are shown in Table 2.

An attempt to assessthe clinical significance of thechanges observed was also made. The proportionsof patients scoring within a range that wouldseem to represent minimal frequency, distress andimpairment pre- and post-treatment are shown inTable 3.

CONCLUSIONSIt would appear that cognitive therapy for voicesis an acceptable treatment as an alternative to anti-psychotic medication (only one of the four patientsdropped out, and that appeared to be becausehe was extremely preoccupied by major surgerythat was due to be performed in the near future).In addition to being acceptable, it appears that aproportion of patients receiving cognitive therapyas an alternative to antipsychotic medication canachieve clinically significant gains. In particular,two of the four patients achieved significantreductions in frequency of voices, the distress and

disability associated with the voices and convictionin the belief that their voices were real (indeed,one of the patients was free of voices for thelast four weeks of therapy and at all follow-upappointments). Such findings are consistent withthose from the case studies reported by Chadwickand Birchwood (1994) and Morrison (1994). Itappears that cognitive therapy can increase theperception of control over voices for some patientsnot on antipsychotic medication. An increase inperceived control over illness could be importantclinically as it has been found to be associated withdepression and suicidal ideation (Birchwood et al.,

1993). It is also worth noting that cognitive therapydid not appear to produce any significant increasesin any of the patients symptomatology.

This data is clearly only a preliminary steptowards evaluatingthe efficacy of cognitive therapyas an alternative to antipsychotic medication, andmore thorough investigations are clearly requiredas a number of possible factors could account forsome of these results (for example, spontaneousrecovery or non-specific factors such as contacttime). The baseline period was short (only twoweeks) and future research should incorporatelonger baselines to control for some of these factorsand would also allow the application of appro-

priate statistical techniques (such as interruptedtime series analysis; Crosbie, 1993). In addition,ratings were conducted by the therapist and there-fore were not blind or independent. However, itis also worth noting that the two patients whoshowed no response to CT had chronic historiesand one of them had been tried on a huge varietyof medications (none of which had any effect) andhad also received previous CBT with no response;therefore it is possible that CT as an alternative tomedication may be more effective in a less chronic,drug-resistant population. The small number ofpatients within this study also makes the findings



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Figure 1. PSYRATS AH ratings for each patient



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Figure 1. (continued)



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Table 2. Total PSYRATS (AH) scores

Total PSYRATS(AH) scores CaseA CaseB CaseC CaseD

Pre 31 33 32 34Post 32 22 33 0Follow-up 32 17 0

Table 3. Percentage of patients meeting criteria forminimal pathology status

Criteria for minimalN(%) of patients N(%) of patientspathology status pre-treatment post-treatment

Voices occur oncea week or less

0 (0) 2 (50)

Voices cause milddistress or less

0 (0) 2 (50)

Voices causeminimalimpairment orless

1 (25) 3 (75)

difficult to interpret; larger numbers of unmed-icated or neuroleptic-naive patients would haveimproved this study but there are very few suchpatients in routine psychiatric services. Despitethese methodological weaknesses, these initial find-ings are mildly encouraging and could be used to

justify a more controlled evaluation of cognitivetherapy as an alternative to antipsychotic medi-cation (particularly given some of the difficultiesassociated with traditional antipsychotics such asnon-compliance, unpleasant side-effects and non-response).

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Morrison 2001 CT for Voices