Apr 16, 2019
Hearing voices is much more common than used to be thought, but what if they're cruel voices that seem to try to stop you from living your life?
Chris Shoulder talks to Dr Lucy Maddox about how he uses CBT techniques to manage his experience of voices and Dr Emmanuelle Peters explains the theory behind the treatment.
Show Notes and Transcript
Here are some resources if you'd like to find out more information.
If you'd like to know more about BABCP check out the website: http://babcp.com
If you want to find an accredited therapist look here: http://www.cbtregisteruk.com/
Chris has also written about his experience of CBT on the BABCP website:
Hearing Voices Network is an organisation providing a network for people who hear voices.
PICuP Clinic where Emmanuelle and Chris work is here:
NICE guidelines for service users/relatives are here: www.nice.org.uk
UK based organisation the Paranoia Network is here: www.asylumonline.net/paranoianetwork.htm
Mad Pride campaigns against misunderstanding and discrimination experienced by people who are seen as ‘mad’ or mentally ill www.madpride.org.uk
This website offers an alternative perspective, practical advice and email support to people who are interested in exploring the idea of spiritual crisis. There are some local groups, for example in London. www.SpiritualCrisisNetwork.org.uk,
Books and articles
Overcoming Paranoid and Suspicious Thoughts. Research suggests that 20–30 per cent of people in the UK frequently have paranoid thoughts. This is a practical self-help guide.
Overcoming distressing voices, Mark Hayward, Clara Strauss, and David Kingdon, 2012, London: Constable and Robinson. A self-help guide based on a cognitive behavioural approach.
For an article about CBT for psychosis by Lucy click here: https://www.theguardian.com/science/sifting-the-evidence/2014/may/20/cbt-psychosis-cognitive-behavioural-therapy-voices
A History of Delusions - radio 4 series by Dr Dan Freeman
Voice hearer and psychologist Eleanor Longden talks about her experiences in this TED talk.
Editing consultation from Eliza Lomas
Music by Gabe Stebbing
Image by Justin Lynham via Flikr Creative Commons
Produced by Lucy Maddox for BABCP
Lucy: Hello, and welcome to Let’s Talk About CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not, and how it can useful.
In this episode we’re going to find out about CBT for psychosis.
I went to a specialist clinic in London called the PICuP Clinic which stands for Psychological Interventions Clinic for Outpatients with Psychosis.
I spoke to Chris who works there and who’s experienced psychosis himself and the treatment for it.
Chris: I am Chris Shoulder and I manage the peer support network. I get together with people as well and we sort of kind of try to see what we can do for people who are waiting for the therapy, and with people who’ve had their therapy and get them together. A bit of mentoring kind of thing really.
But it’s also that they can speak to somebody who actually knows that the therapy’s about and they’ve been through the whole process. And they can allay any fears that anybody might have.
Lucy: Oh that sounds great. So it’s perfect to be speaking to you because this podcast is trying to sort of help explain to people what CBT for different sorts of problems is like. Some people might not know what psychosis is actually, and it’s quite a kind of technical word. Would you give your definition of it?
Chris: Well, psychosis I think is like the umbrella term for lots of different things. You may be experiencing kind of things that are not considered the norm, whatever I guess what the norm is. You might feel like you’re being watched or as one person I worked with thinks they’re being “surveilled” as she puts it. Or you might be hearing voices. You just don’t feel right. You feel kind of maybe that you're being victimised or there’s people talking about you or people can read your mind.
I mean there’s so many kind of anomalous things that make up what psychosis is. And then apart from that you might feel really anxious. You feel depressed. You feel confused as well with it.
And it’s quite a baffling thing to experience and to kind of describe because there’s a myriad of things that go with psychosis. Yeah.
Lucy: For people who aren’t sure what a dissociative episode sort of means or kind of feels like, would you mind explaining a bit what it’s like?
Chris: Yeah. It’s this kind of feeling that you become detached from the environment around you. And I’d feel sometimes that I was almost like watching myself. It was like, I always describe it like being the star of the film and watching the film at the same time.
You feel like the solid objects, maybe I’m quite solid and everything’s kind of like knocked slightly sideways. I always have difficulty describing it because it’s very abstract but it’s very terrifying when you don’t know what it is.
And I still occasionally have them but now I’m kind of like twiddle my thumbs. I’m like, “Do-do-do-do-do, get on with it.” And carry on because I’m in charge of it. Even though it can come on randomly, I am in control of these things now, I feel.
I mean I think the first time I had it I thought… I felt like there was another entity inside my body. That’s how strange it feels and it’s very disconcerting. It’s horrific actually the feeling, it’s terrifying.
But with some quality CBT you can take it on head on and you can think, “Right, well I’m not having it, it might happen still but I’m going to own it and I’m going to be me.” And I let it kind of wash over me now if it happens occasionally and that’s it. It’s gone. I feel tired afterwards because it’s quite an exhausting experience. But afterwards that’s it and I get on with whatever I was doing at the time.
Lucy: Wow. It sounds really intense actually and very frightening and, yeah, so to be able to kind of ride that instead.
Chris: That’s a really good kind of way to describe it. You’re riding it. When it first happened it was like being on the top of a rollercoaster and you’re peaking at the top and you never quite go over the edge. It’s this feeling of, “Urgh, uh, uh.” And I could feel it. It’s like physical in the back of my head.
And then I got to the point where I could actually tell when they were going to happen by this feeling in the back of my head. And I’d be like, “Okey dokey, right,” you know like? “Buckle up, it’s going to happen in the next day or two.” It’s still a little bit like that but it’s very, very rare now that I have it. But I manage it.
I think it’s about talking about what like a healthy brain is. It’s whatever’s healthy to you I think and what you're managing, what you can live with and what you deal with properly and feel safe about.
And I feel great. I feel like a changed person because I was absolutely so chronically ill with a various array of mental health issues. I feel great now though.
Lucy: Yeah, you look great.
Chris: Yeah, thank you.
Lucy: Really spunky.
Chris: Yeah, I feel it. (Laughter)
Lucy: I also spoke to Dr Emmanuelle Peters, clinical academic psychologist and director of the PICuP Clinic.
I asked Emmanuelle how common it was to have unusual experiences like those that Chris describes.
Emmanuelle: So more people have anomalous experiences such as hearing voices in the general population than you might think. Most of them do not go onto develop psychosis. And for many people they have these experiences without actually causing distress. And that’s very important to know because it’s not necessarily the nature of the experiences which is abnormal. But it’s more the fact that they lead to distress that as therapists we need to take into account.
The fact that we know that people have experiences without distress means that people that we see can actually learn to perhaps deal with their experiences differently or think their experiences differently if they want. So we’re not about just necessarily eradicating these experiences because people in the general population do have them and can live with them and be perfectly healthy.
Lucy: Great. So it’s more about their kind of the meaning making, the sense that people make of their experiences rather than necessarily getting rid of them?
Emmanuelle: Yes, absolutely. So we don’t aim to change anybody’s view necessarily. We don’t aim to change their view of the world. We don’t aim to necessarily get rid of voices although for some people that’s what they’d like. But what we aim to do is help people to cope with them, to think about them slightly differently, to learn to have a different relationship with them. And basically to try and reach the valued goals that they have and decrease the amount of distress that these experiences cause in their daily life.
Lucy: Chris told me more about what hearing voices is like for him.
Chris: The voices when they started, they were in – it was kind of in my head. However, my head felt the size of the TARDIS. It was like huge. It felt like it had expanded.
A lot of people say the same thing. They’re down on you and they kind of say, “You're useless, you’ll never amount to anything,” or mine used to, I’d be doing something and they would say like, “You were trying to put the kettle on, weren’t you?” or something really random. And it would be, “Well I’m not going to let you. You’re not going to do that. You’re useless. You can’t even put the kettle on.” And there would be a lot of blue language as well that came with it obviously.
And then it kind of, there was a mixture of stuff as well which is also hard to explain. It would say things but there wouldn’t be any words. It was just like you’d understand it as a whole without the thing. So you’d understand the meaning of what it was but there wouldn’t be any words. But it would be still kind of… that was still kind of negative. A lot of it was negative.
And then there would be sometimes random sounds as well. So I can remember I was out once walking with my dogs when I had this episode came on. And it started to go, “Squish, squish, squish, squish, squish,” making this sound because it had been raining. So it was making these random noises.
And then on the other hand, which was quite funny, I was walking down the road and I was thinking, “That’s odd, I’ve got my own personal stereo now.” And it started singing of all things a Fleetwood Mac song to me. And I was kind of like, “Oh yeah, this isn’t so bad.” Like then. So I was walking down the road, I was thinking, “That is just bizarre.” So it’s kind of, it was from one extreme to the other.
And now it’s kind of I get it. The voices. It’s just such a strange thing to say ‘it’ but when the voices happen occasionally they come now with the dissociative episode at the same time. And I kind of let them say what they like because I know it’s all tosh, frankly.
For me now it’s more interesting to think which part of my brain is doing this? I would love to know that. I’m more interested in kind of learning about where it happens than the actual event itself now.
Lucy: I asked Emmanuelle what happens in CBT for psychosis.
Emmanuelle: So cognitive behavioural therapy for psychosis is basically looking at the types of experiences that people have, seeing what kind of goals they want to reach, and trying to work together with the person to look at how they’re dealing with their experiences, how they’re thinking about their experiences. And perhaps learning together to find a new way of thinking about them or new ways of dealing with them such that they cause less distress.
So a lot of CBT is about identifying the vicious cycles that people find themselves in and helping them to get out of these vicious cycles. And in psychosis often these vicious cycles will include hallucinations and paranoia and other distressing anomalous experiences.
And so it’s quite similar to other types of CBT but the nature of what you’re working with can be different.
Having said that, also for a lot of people who hear voices, for instance, they also have other emotional difficulties. Sometimes they’re very lonely or anxious. And sometimes they can deal with their voices better than actually waking up in the morning and sort of feeling despair of having no socially valued roles, sort of a lack of relationships and that can be more distressing for them. And we will always engage with the person with what is distressing for them, not necessarily what’s abnormal.
So sometimes people will say the voices are fine but I would like some help with being able to go to the shops on a regular basis, to find some work perhaps or find ways of having more meaningful relationships with people.
We’re very much about empowering people to lead the lives that they want to lead.
And I guess one of the differences in CBT for psychosis and perhaps other types of problems is that it can be sometimes trickier or take a bit longer to engage people because they may not trust you, they may worry that you’re going to get them sectioned, or they may think that you can read their thoughts or that you’re part of the conspiracy. So we do work very hard at engaging people and seeing things from their point of view. Perhaps more so than you need to do with people who come with say my main problem is depression or anxiety.
Lucy: You mentioned about vicious cycles that people can get into. Would you be able to give an example of a type of vicious cycle that might crop up with this type of problem?
Emmanuelle: Often people get into vicious cycles because of what we call safety behaviours. So a safety behaviour is something that you do when you're scared of something to keep yourself safe.
So, for instance, if you believe that you’re going to be killed when you go outside because there’s a conspiracy against you and there’s people outside waiting to basically kill you in some way, then the likelihood is that you’re going to keep yourself at home and you’re going to keep yourself safe.
You’re going to be looking out for noises of people perhaps surrounding your house, or unusual noises that mean that there’s somebody outside with a gun.
So, of course, if you're staying at home to keep yourself safe and you’re hypervigilant as we would call it, you’re looking out for noises, two things are going to happen. One is that the more you look out for noises the more you're going to hear them. And of course if you’re in a state of fright and state of being really anxious you’re going to notice all sorts of noises and they’re going to have a really sinister meaning. And that’s going to confirm your view that there’s likely to be somebody outside.
And, of course, if you don’t go out then you never disconfirm your fear. So you never find out that actually there is nobody outside to kill you. And the more you then stay indoors, the more isolated you get and the more depressed you get. And you get caught up in this vicious cycle.
So our job as therapists is to try and get the person to take risks so that they’re able to expose themselves to their fear situation so that they learn that their fears aren’t true.
Now, of course, when somebody believes that they’re going to be killed that’s a tall ask and that’s why you have to go very slowly with people with paranoia. But nevertheless what it is is a vicious cycle.
Lucy: That’s really useful. I was just thinking about voices and are there any particular strategies that CBT offers to help people manage voices? That must be just so hard having voices sort of chatting in your ear all the time, particularly if they’re saying things that aren’t very nice.
Emmanuelle: We would work with coping strategies, helping people with coping strategies. But also very importantly with voices we would try to change their meaning.
So you might have day-to-day coping strategies that might just be able to counteract the sort of voices that are going on and on and on at you. So you might, for instance, hum. Just the process of humming slightly might actually interfere with hearing the voice and might be able to get a bit of respite from the voices.
Depending on which kind of situations people hear voices, you might be able to just listen to music to drown them out, listen to the TV or basically having another noise that counteracts them.
And that can happen for a short-term basis. But of course you can’t hum all day long. And you can’t wear headphones all day long. So although they can offer some respite, it’s not necessarily a long-term strategy.
And what’s very important though is to use the fact that people can actually stop the voices even if that’s temporarily to increase their sense of control over them.
Similarly, the beliefs that people have about powerful voices can be extremely distressing. So they have the power to make things happen against you. So not only are they malign voices that mean you harm, but if they have the power to actually carry out their intent then that can be extremely distressing for people. And then they spend a lot of their time trying to mitigate the power of the voices.
So there’s all sorts of different ways in which you can learn to cope with the voices with the ultimate aim of changing the beliefs that you have about the voices. And changing the relationship that you have with the voices that will allow you to be able to live with them in a less distressing way and in a better way and get on with your life despite the voices.
Lucy: What is Chris’s experience of this? Was it enough for him to control the voices rather than get rid of them?
Chris: I don’t think you ever get rid of things. It’s about accepting them and learning how to deal with them. And that’s what a good therapist does and that’s what CBT does, whether it’s bipolar or kind of hearing voices or kind of all the rest of it, psychosis.
Lucy: Could you say a little bit about your experience of CBT?
Chris: My experience of CBT, actually at the PICuP Clinic was incredible. It turned my life around. It revolutionised my recovery. And I mean I’ll always be in recovery. But it was just incredible and it was like a… it became less of a therapy session and more of a learning session. And it was a collaborative session.
There was kind of a lesson plan, if you like, from the therapist. And we would decide what we were going to do each session. I began to feel really engaged with it. Because I was having things like dissociative episodes, and I was kind of hearing voices and I’d be kind of… or sometimes it was just like sounds. Occasionally I was having these kind of really weird delusions and imagining that I was being touched and stuff like this.
And it made me make sense of that. And I think for the first time I understood that it was down to me to make myself better with the help of a therapist.
Lucy: So it sounds like sort of quite hard work actually, isn’t it, along with it being a really beneficial experience. It sounds like there’s quite a lot you have to put in.
Chris: Yeah. I mean, yeah, you can’t just kind of like sit back and kind of think, “Okay, well I’m feeling a little bit better.” You’ve got to keep on top of it.
Lucy: Yeah. Yeah. So I’m really interested in how you describe it because recovery is sometimes a bit of a controversial word actually. I’ve read some stuff about people saying they don’t like the word because it feels like you have to get better, whatever better is. And if that doesn’t happen to you then you’ve kind of failed at that.
But it sounds like the way you describe recovery it’s actually not like the things have gone away totally. It’s more like you have a different relationship with them.
Chris: Yeah. I think it varies from person to person. And, like I said before, it’s what you can, not tolerate, but I guess what you can live with.
It’s not about recovery because I don’t think you ever necessarily recover. But you learn to deal with it. Or you can learn to deal with it. And I think it’s one of these things that it doesn’t just happen. And even for me, I have to do a little check, think, “Oh yes, brain, how are you feeling today? How’s it functioning?” and things.
Obviously I do still get depressed and I do get down. But I would think now it’s within normal parameters. I think it’s what generally most people would feel.
Lucy: And are there any sort of particular strategies that you found really helpful?
Chris: Mindfulness. And feeling like I’m in the present as well. And I think often people think too far ahead. I was talking to somebody yesterday who was having a really bad anxiety attack. And she was saying, “Oh I’m terrified about the future.” And I said, “Well the future hasn’t happened yet. Don’t think about it.” I said, “Do it in kind of like bite sizes if you like, small sizes. You don’t have to think about what’s going to happen in like 2021. Think about just what’s happening now.”
So I think it’s taking charge of what’s happening in the present a little bit and that helps to kind of ground you, it helps to ground me because I was the same. I used to think, “Oh my God I’ll never work again, I’ll never do this, I’ll never do that.” That was all about thinking too far ahead. And now I'm in a place where I think, “My God, I never expected to be here.” And I actually love it. And it’s perfect for me. Completely different to what I was doing previously.
Lucy: So what sort of evidence base is there for CBT for psychosis?
Emmanuelle: So there is a reliable and consistent evidence base about CBT for psychosis. Most of the studies that have been done are for people who are already taking antipsychotic medication. So CBT for psychosis is very much adjunctive or on top of taking antipsychotic medication.
And on the whole not everybody will benefit but around 50% of people will benefit in some way from CBT for psychosis. Whether that’s in terms of reducing the distress with their voices, or reducing them complying with threats or orders from their voices, whether it’s reduction of paranoia. But also reduction in depression or sometimes anxiety. Or other types of problems depending on what focus the CBT had.
So in more recent trials people have used the outcomes that actually measure what’s happening in therapy. So, to give you an example, in one particular trial, what the trial focused on was reducing people complying with harmful hallucinations. So people who would hurt themselves or hurt others on the basis of commands that the hallucinations would give them. And the purpose of the trial was to reduce that compliance. And we therefore used a measure which was reducing compliance rather than seeing whether the hallucinations stopped or not. And we found that nearly 50% of people in the therapy group were 50% more likely to not comply with their voices than people in the other group.
But their hallucinations continued. So we didn’t get rid of the voices which wasn’t the aim, but we did reduce the risk that they posed to themselves and others.
And another movement in the evidence base is to just look at one problem at a time. Basically in CBT for psychosis in the clinic whatever the person has on their problem list is what you will do in therapy. So with one person that might be looking at how depressed they feel and like what motivation they have or the despair they feel in not having relationships. With somebody else I’d be dealing with voices. Somebody else with paranoia. And so on and so forth.
So rather than trying to assess all of those things at once, the more recent trials have kind of targeted one area, one particular problem at a time. And then showed that these particular types of therapy for that particular problem was effective. And that literature has shown then much higher effect sizes.
So to cut a long story short, there is a reliable evidence base for CBT for psychosis. And it’s getting stronger all the time.
Lucy: I asked both Chris and Emmanuelle if they had any last remarks for people who are considering CBT for psychosis.
Chris: Just to kind of reiterate, if you are scared, if somebody’s scared about having CBT, try it first of all and then if you don’t like it step away from it.
I think also a good therapist, towards the end of the therapy should have things for their client to do afterwards. They should have places they could recommend for them to go and things they recommend for them to do or ways to get into voluntary work or just things that they’re not left high and dry when it’s finished. That’s what I think’s very important too.
Emmanuelle: People have an idea of CBT in general being very much kind of thought police and it’s very short and it’s just like putting on a sticking plaster. But actually CBT for psychosis is not short. So NICE, the National Institute of Clinical Care and Excellence recommend a minimum of six months. So it’s not a short therapy.
And it’s very collaborative and your therapist will be listening to your point of view and understand your point of view before trying to change anything.
So it is worth thinking about just trying it out.
Lucy: A huge thanks to both Chris and Emmanuelle.
If you’d like more information on CBT for psychosis please check out the show notes.
For more on CBT in general and for our register of accredited therapists, check out BABCP.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems it can help with.
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