Coping with Voices
Many people with schizophrenia experience hearing voices or auditory hallucinations as psychiatrists call them. These voices are usually nasty or persecutory and can cause the sufferer enormous distress. Often the voices will be in the third person and will constantly criticise the sufferer but sometimes they may also give the person direct instructions in which case they are known as command hallucinations. (See our information sheet on Understanding Voices for more about voice hearing).
It would be wonderful if we could give some hot tips that people could use to help deal with their voices but unfortunately voices aren’t like that. As anyone who has suffered with persecutory (nasty) voices will testify, voices can often be difficult to get rid of. But it is possible to learn how to cope with the voices better or manage them so that they do not dominate your life as much.
Effects of antipsychotic medication on voice hearing
The first and most important defence you have against nasty voices is antipsychotic medication (also called neuroleptics). Modern antipsychotics are 70 % effective in relieving the voices and will often make them disappear altogether. This is about the same effectiveness as penicillin has in treating an infectious illness such as pneumonia.2
Antipsychotic medication can help in a number of ways. First of all it will tend to reduce the amount that you hear your voices. In addition it will reduce the compulsion that you have to engage with the voices. That is to say that you will still hear the voices but you will not feel the overwhelming need to obey them that you used to feel. Similarly with voices that are critical of you, you may feel more detached from the voices and although you will still hear what they are saying about you, you will not feel so badly affected by their criticisms.1
The third way that antipsychotics help is by reducing the anxiety that the voices cause. This is because many antipsychotics also have a mild tranquillising effect.
However one of the biggest problems that doctors face when prescribing antipsychotics is that different medicines work differently on different people. A drug that works well for one person may have little or no effect on another. For this reason it is important to cooperate with the doctor in the prescribing process and to be pro-active in monitoring your condition.
It would help the doctor if you keep a diary of how your voices are from day to day. You should note how frequent they have been during the day and also how nasty or nice they have been. It will also help if you note how strongly you have felt compelled to engage with the voices: that is to do what the voices have been telling you to do.
You can take this diary along with you when you see your GP or psychiatrist but also try to sum up briefly how the voices have been recently and whether you think the medication you are on is working well or not. If you do not think it is working well do not be afraid to suggest to the doctor that they try an alternative medication or change the dose. However, do give your current medication a chance to work. Sometimes people with voices will show a marked improvement within a few weeks of starting on an antipsychotic whereas for others it may take a little longer.1
Your aim is to work with the doctor to find the medication that works best for you in relieving your symptoms and to take that medication at the minimum effective dose.
Most psychiatrists now have first hand experience of cases where two or three different drugs have been tried without beneficial effect before finding the right one that has brought about a dramatic improvement in the sufferer’s symptoms.6
Of course like all medications antipsychotics have side effects and managing the side effects is something that everyone living with schizophrenia has to learn about (see our information sheet on Managing Side Effects).
Can talking therapy help with voice hearing?
There are three types of talking therapy that can be useful in helping you to cope with your voices: counselling, support groups and cognitive behavioural therapy.
One-to-one counselling with a professionally trained counsellor can be extremely helpful. Sometimes it is easier to talk about strange or bizarre thoughts or experiences with a stranger than it is with your carer or one of your relatives. Counselling is available from the National Health Service in some areas and at some other health care providers at low cost or no cost. You can find out about these services from your family doctor, the local library, or your local Mind or Rethink centre. Typically these services are easier to access in cities than in rural areas.
There are also professional counsellors who operate in private practice but they will charge for their services. They are listed in Yellow Pages and can be found on the internet. Charges are usually around £30 to £50 for an hour session. If you have difficulty funding this yourself think about applying for the Personal Independence Payment (which has recently replaced Disabled Living Allowance) from the Department of Work and Pensions. Try to use a counsellor who is a member of the British Association for Counselling and Psychotherapy which is the UK professional body for counselling. Their website includes a useful directory of counsellors across the UK.
In some areas support groups for voice hearers are provided by the NHS or by the local branches of organisations like Mind or Rethink. They can be an extremely valuable resource for someone who hears voices but bear in mind that there are no national standards for such groups and their membership may vary from week to week meaning that some may be more useful than others.
That said a support group will give you the chance to meet with and talk about your voices and other experiences with other people who have experienced the same kinds of things. And by meeting other people with the same kinds of problems you will learn that you are not alone and that your struggle is one that others have gone through before you. You will also be able to pick up helpful tips in coping with the voices.
In addition to sharing about the voices a support group will give you the chance to discuss other sorts of problems that people living with schizophrenia face from day to day: problems with medication and side effects, problems with doctors and nurses, problems with friends and neighbours, problems with claiming benefits and with housing. All those things that can make life more complicated for someone with this condition.1
Cognitive behavioural therapy (CBT)
The other type of talking therapy that is useful is cognitive behavioural therapy which is a form of psychotherapy. Cognitive behavioural therapy cannot make your voices disappear but some people find that it is successful in helping them to control or manage their voices. CBT has been used for some years in the UK to treat a variety of mental health problems with varying results. Some studies have found very good improvements whereas others have not been as convincing. It may be that CBT is more effective with delusions than hallucinations like hearing voices.
One method involves encouraging the person to analyse the voice to try to work out whether it is coming from inside or outside their head. Another method involves the use of distraction techniques to encourage the person to resist the compulsion to engage with the voices. There is no evidence that CBT alone can cure schizophrenia but some people find it beneficial when used in conjunction with medication. There is modest evidence that CBT can help patients to manage their hallucinations and delusions when used in conjunction with antipsychotic medication.3 CBT tends to work best in people who have had their voices for a long time and find them distressing. It will have little effect in people who lack insight into their condition.
In the UK standards of care provided by doctors are laid down by the National Institute for Health and Care Excellence commonly known as NICE. From 2002 it has been part of the NICE guidelines to doctors that all people with persistent symptoms of schizophrenia should be offered CBT.
Self help for voice hearing
Distraction and occupation
Many people who are troubled by voices find that distraction is an effective way of managing them. Some use personal stereos or I Pods to try to drown out the voices. Some people have found that this is even more effective if they listen in only one ear at a time.
However others find that some occupation that helps to focus their mind on other things can also help. In the early stages of recovery from a psychotic episode it may be difficult to find something that you can concentrate on. Reading or watching TV may not help as those activities often feed the delusions or hallucinations, however something simple like jigsaw puzzles or a little light gardening may be a good start.
Many people find that voices are less troublesome when they themselves are talking. It is thought that the act of talking somehow prevents the voices in the head being heard. So any activity that involves using the voice such as singing, humming or reading out loud can sometimes help to control the voices.10
This is a technique that Gwen Howe describes in her book and which was developed by one of her patients. It consist of agreeing with your carer or partner that you will tell them about the voices when you hear them and ask them if it is true. For instance if you heard a voice say: “he stinks today” you could tell your carer what the voice had said and ask them if it was true. The carer would then respond that it wasn’t true and that in any case you had showered that morning and that all your clothes were clean.
It is important in this technique that the carer is completely honest and gives the person sufficient time to discuss it. By getting constant feedback in this way about what the voices are saying you gradually over time reinforce those natural doubts that you have about the voices and begin to distrust them.
This technique is to be much preferred to the alternatives of either humouring the person with schizophrenia and not challenging their mad thoughts at all or alternatively criticising and ridiculing these ideas.4
Keeping a diary
This is an important tool in your coping tool box. Being able to assess how your voices have been each day and then at the end of the week to reflect on their effect on you will help you to understand the voices and understanding them is the essential first step in coping with them. You can discuss your diary when you meet your doctor or try to find some trusted friend or counsellor to discuss it with.7 The things you should record in your diary include:1
· How active have the voices been? Have you heard them a lot or just occasionally?
· Have the voices been critical or have they given you instructions?
· How have you felt because of the voices?
· Did anything appear to trigger particular episodes of voices e.g. stress?
· How anxious did the voices make you feel (on a scale of one to ten)?
· How compelled have you felt to carry out the voices’ instructions?
· Have you done anything risky because the voices told you to do it?
· What have you done to cope with the voices and how much did it help?
Drugs and alcohol
We have known for some time that people living with schizophrenia will experience worse symptoms when they use street drugs. Unfortunately many people living with schizophrenia and for whom their voices are still a painful part of their life despite their medication, may resort to using alcohol or street drugs in an attempt to blunt the symptoms. This relief is only temporary and in the long term people with schizophrenia who use alcohol and particularly street drugs like cannabis will experience more relapses and will spend more time in hospital.9 You can read more about schizophrenia and drugs on our page about Schizophrenia and Street Drugs.
Like most of the other psychotic symptoms, voices will often get worse when the sufferer is under stress. Relaxation techniques sometimes help the sufferer by not only reducing the voices but also helping them to cope with the anxiety that goes with them.
Distrust the voices
Some therapists like to advise their clients to make friends with their voices. In our view such advice is unproductive for someone hearing persistent persecutory (nasty) voices and won’t help them to cope with their experience. It may be that some people experience voices that are benign or friendly but for someone with schizophrenia who is plagued by persecutory voices they can make their life hell. It is far better to develop a strategy of continuously questioning and distrusting the voices in order to eventually be in a position where you are controlling the voices and not the other way around.
This process of constantly questioning the voices can be surprisingly successful. Here is what Vera said about her voices: “after a while I found that the voices didn’t know the answers to the questions that I also didn’t have answers to and then I realised that they must be coming from within me. So I realised that they were only auditory hallucinations. You can also ask them a word in Chinese or the solution to a math problem that you don’t know the answer to. If the voices don’t know the answer then they must be halucinatiions.”
How effective Are these techniques?
It has to be said that although some of these techniques will be effective in the short term, voices are very skilful at “moving the goal posts” and the techniques may become less effective over time. It is therefore necessary to keep up the counter-attack against the voices by trying new techniques when this happens.
How can carers help with voices?
Talking about delusional thoughts
For a long time many people working in the field of mental health held the view that trying to challenge tenaciously held psychotic thinking was pointless. However, modern research has shown that it is in fact very productive to talk to people about their mad thoughts.5 This will enable the carer to better understand what the person with schizophrenia is experiencing and give them the opportunity to gently challenge that thinking. It is vital that carers do not collude with psychotic thinking by just humouring their loved one when they express psychotic thoughts.
Some New Developments
Repetitive Transcranial Magnetic Stimulation (RTMS)
In this method of treatment which was developed in the 1990s electromagnets are attached to the outside of the patient’s skull and thus a weak magnetic field is induced in the brain. It is painless and non-invasive and does not require sedation nor does it appear to have any significant side effects. This treatment should not be confused with electro convulsive therapy. Research work into the efficacy of this therapy for auditory hallucinations continues with some but not all studies indicating that it may be useful in reducing both the intensity and the frequency of voices. A recent study at the University of Caen in France and reported in the Daily Telegraph newspaper in the UK in 2017 11 indicated very favourable results in reducing voices albeit in a fairly small number of participants.
The American psychiatrist Edwin Fuller Torrey estimates that one RTMS treatment may be effective in reducing voices for up to three months following treatment 12 however other studies have found that the effect may be much shorter-lived. This is another treatment that is currently showing some promise but requires much more extensive research before we can be sure about it.
One new development in the field of treating voices was made in the UK in 2017 by a team of researchers from Kings College and University College in London17 and involved the use of Avatar therapy for people who still hear voices despite their medication. In this method computer technology was used to enable the study participants to create a visual representation of the entity represented by their voices. This entity could be human or non-human. Using feedback from the patient the technology is able to mimic fairly closely the gender, tone and accent of the person’s voices. The participant can then use this image on the screen to practice interacting with the voice and with the aid of a therapist develop ways of resisting them; ultimately if possible gaining the upper hand.
A number of the patients in this study found that after this therapy their voices became less frequent and they experienced less distress caused by their voices. This was a fairly small study of only 142 participants but the research team included eminent scientists in this field and it did indicate that further work to explore this method would be justified.
1. Author’s personal experiences.
2. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial p181.
3. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial. p207.
4. Howe G, 1986, Schizophrenia a Fresh Approach, David and Charles, P90.
5. Warner R, 2000, The Environment of Schizophrenia, Brunner Routledge, P32.
6. Cutting J and Charlish A, 1995, Schizophrenia, Thorsons, P168.
7. Burton N, 2012, Living with Schizophrenia, Acheron Press, P78.
8. Reveley A, 2006, Your Guide to Schizophrenia, Hodder Arnold, P66.
9. Burton N, 2012, Living with Schizophrenia, Acheron Press, P18
10. Place C, 2003, Simple Coping Strategies for People who Hear Voices, Nursing Times.Net, at http://www.nursingtimes.net/nursing-practice/clinical-zones/mental-health/simple-coping-strategies-for-people-who-hear-voices/202679.article, viewed on line 1/08/2018.
11. Scientists identify part of the brain that makes schizophrenia sufferers hear ‘voices’, Daily Telegraph 5th September 2017, viewed on line 3rd August 2018 at https://www.telegraph.co.uk/news/2017/09/05/scientists-identify-part-brain-makes-schizophrenia-sufferers/.
12. 2013, Edwin Fuller Torrey, Surviving Schizophrenia, p204
17. Craig T, Rus-Calafel M, Ward T, Leff J, Howarth E, Emsley H, Garety P. AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial, published in Lancet Psychiatry January 2018.
©Living with Schizophrenia, August 2018.