cognitive therapy for reducing distress and harmful compliance with powerful voices dr. alan meaden...

Cognitive Therapy for Reducing Distress and Harmful Compliance with Powerful Voices

Dr. Alan MeadenDr. Alan MeadenConsultant Clinical PsychologistConsultant Clinical Psychologist

COMMAND TrialCOMMAND Trial

Why get distressed Why get distressed and act on voices?and act on voices?

DO AS I SAY OR ELSE!

““All things are subject All things are subject to interpretation to interpretation whichever whichever interpretation interpretation prevails at a given prevails at a given time is a function of time is a function of power and not power and not truth.”truth.”

Friedrich Nietzsche Friedrich Nietzsche 1844–19001844–1900

CTCH: CTCH: The TheoryThe Theory in in BriefBrief

A Cognitive Model of Distress A Cognitive Model of Distress and Behaviour within an and Behaviour within an

Interpersonal RelationshipInterpersonal Relationship

The Cognitive Model of VoicesThe Cognitive Model of Voices

► In CTCH we view the voice as an In CTCH we view the voice as an activating event (A)activating event (A)

►The significance of which is interpreted The significance of which is interpreted by the individual in terms of their by the individual in terms of their belief belief system (B);system (B); the voice hearer develops the voice hearer develops further beliefs as part of an on-going further beliefs as part of an on-going process to make sense of this process to make sense of this experienceexperience

►Distress and behaviour are the Distress and behaviour are the consequences (C) consequences (C) which follow from which follow from these beliefsthese beliefs

The Cognitive Model of The Cognitive Model of VoicesVoices

►This belief system is underpinned by This belief system is underpinned by the development of a quasi-the development of a quasi-interpersonal relationshipinterpersonal relationship

►The voice hearer is often subordinate The voice hearer is often subordinate in this relationshipin this relationship

►Compliance with this powerful ‘other’ Compliance with this powerful ‘other’ means that the validity of the voices means that the validity of the voices commands is never tested outcommands is never tested out

►This constitutes a type of ‘safety This constitutes a type of ‘safety behaviour’behaviour’

BELIEFSBELIEFS[Power; intent][Power; intent]

EVIDENCEEVIDENCEBehavioural Behavioural

ConsequencesConsequences

((Safety Behaviours)Safety Behaviours)

Emotional Emotional Consequences:Consequences:Fear, guilt, elation,Fear, guilt, elation,

depressiondepression

VoiceVoice

ActivityActivity

Omniscience:shame; predictions

Control

Threat Mitigation Full CompliancePartial (appeasement)

Subordination to others

and Core Beliefs

Power and authority are summarised Power and authority are summarised and evidenced by 4 core beliefs about and evidenced by 4 core beliefs about voices:voices:

IDENTITY IDENTITY (devil)(devil)

MEANING / PURPOSE MEANING / PURPOSE (punish or (punish or destroy)destroy)

COMPLIANCE COMPLIANCE (disastrous (disastrous consequences)consequences)

CONTROL CONTROL (inescapable)(inescapable)

The VOICE Power The VOICE Power SchemaSchema

Power & IntentionPower & Intention

►Malevolence/Benevolence = Malevolence/Benevolence = the intention of the voicethe intention of the voice

►Power = the perceived ability Power = the perceived ability of the voice to carry out this of the voice to carry out this intention and is the driver of intention and is the driver of distress and behaviourdistress and behaviour

Compliance BeliefsCompliance Beliefs

►If I don't do what my voices say...If I don't do what my voices say... Others I care about will be harmedOthers I care about will be harmed I will be harmedI will be harmed The voices will go on and on at me The voices will go on and on at me They will reveal bad things about me They will reveal bad things about me

to others: publicly shame and to others: publicly shame and humiliate mehumiliate me

Safety Behaviours Safety Behaviours Prevent Prevent

Disconfirmation of Disconfirmation of The Voices Ability to The Voices Ability to Carry Out the ThreatCarry Out the Threat

CTCH CTCH aims to reduce aims to reduce motivation to comply or motivation to comply or

appease by:appease by:

►Undermining the power of the voice Undermining the power of the voice especially its perceived ability to especially its perceived ability to harm or shameharm or shame

► Increasing the power of the voice Increasing the power of the voice hearerhearer

► Improving interpersonal Improving interpersonal effectivenesseffectiveness

Overview of the TherapyOverview of the Therapy

►8 Levels8 Levels►Offered flexibly – need adaptedOffered flexibly – need adapted►(current trial up to 42 sessions – (current trial up to 42 sessions –

average of 24)average of 24)►May spend more time on some levelsMay spend more time on some levels►May not work on all levels – led by the May not work on all levels – led by the

personperson

Aim is to Reduce Aim is to Reduce Distress & Harmful Distress & Harmful

ComplianceComplianceVs Vs

Reducing or Removing Reducing or Removing VoicesVoices

CTCH CTCH Level 1Level 1

Assessment & Assessment & Engagement Engagement

Engagement Issues Engagement Issues

►Focus on development of a sound Focus on development of a sound therapeutic alliance: empathy, trust, therapeutic alliance: empathy, trust, genuineness, non-judgemental, flexibility, genuineness, non-judgemental, flexibility,

►Anticipating problems:Anticipating problems: Pace of therapyPace of therapy Worsening of symptomsWorsening of symptoms Further restrictions being applied when Further restrictions being applied when

disclosing information about symptomsdisclosing information about symptoms

Level 1 StrategiesLevel 1 Strategies

►The “panic button” gives the voice The “panic button” gives the voice hearer control over the therapy and hearer control over the therapy and models taking control back and models taking control back and promoting the hearers own powerpromoting the hearers own power

►Inoculating the voice hearer against Inoculating the voice hearer against the voices commenting negatively the voices commenting negatively about the therapy and therapistabout the therapy and therapist


►Keep focused on the purpose: Keep focused on the purpose: reduction of harmful reduction of harmful behaviours and distressbehaviours and distress

►Carefully listen to and eliciting Carefully listen to and eliciting the hearers story and the hearers story and experience of voicesexperience of voices

CTCH: Level 2CTCH: Level 2

Promoting ControlPromoting Control

Promoting Control AimsPromoting Control Aims

►Bolster the person’s strengths in coping with Bolster the person’s strengths in coping with their voices and ability to have some control their voices and ability to have some control

►Start to build evidence against their Start to build evidence against their powerlessness and against the voice’s powerpowerlessness and against the voice’s power

►Develop an understanding of factors Develop an understanding of factors that increase/ decrease the presence of that increase/ decrease the presence of voicesvoices

►Bring some immediate relief and Bring some immediate relief and thereby underpin engagementthereby underpin engagement

Promoting ControlPromoting Control

►The process of promoting control involves The process of promoting control involves developing or reinforcing a coping repertoire developing or reinforcing a coping repertoire for reducing the distress associated with for reducing the distress associated with their voicestheir voices

► Introduce novel ideas that have been tried Introduce novel ideas that have been tried successfully by other voice hearers, such as successfully by other voice hearers, such as humminghumming

Common Strategies for Voice Common Strategies for Voice ControlControl

► TV/Radio/ReadingTV/Radio/Reading► HeadphonesHeadphones► Humming/GarglingHumming/Gargling► Following lyrics to favourite songs in ones Following lyrics to favourite songs in ones

headhead► Ear plugsEar plugs► Time-limiting contactTime-limiting contact► Only speaking to benevolent voicesOnly speaking to benevolent voices► Assertively addressing the voiceAssertively addressing the voice► Negotiating with voicesNegotiating with voices

Developing Initial BoundariesDeveloping Initial Boundaries

►We view the voice-hearer as being in a We view the voice-hearer as being in a relationship in with their voices over which relationship in with their voices over which they can develop boundariesthey can develop boundaries

►The nosy neighbour and other analogies are The nosy neighbour and other analogies are used to along with coping strategies to:used to along with coping strategies to: help the hearer have their own time (turn the help the hearer have their own time (turn the

voice off)voice off) make their own decisions, rather than always make their own decisions, rather than always

listening to and waiting for the voice to make listening to and waiting for the voice to make themthem

Naomi Naomi (from our first trial)(from our first trial)► The therapist supported Naomi to develop a variety The therapist supported Naomi to develop a variety

of ways of coping with the voices, enabling her to of ways of coping with the voices, enabling her to have more control over them:have more control over them:

► Distraction techniques included: Distraction techniques included: keeping occupied (regularly attending college, keeping occupied (regularly attending college,

going out for a walk, shopping, tidying her room, going out for a walk, shopping, tidying her room, cooking)cooking)

talking with or being in the company of trusted talking with or being in the company of trusted othersothers

reading a good bookreading a good book listening/dancing to musiclistening/dancing to music

NaomiNaomi

►By learning to By learning to ignore the voices as much ignore the voices as much as possible, and get on with other things, as possible, and get on with other things, rather than engage in conversation with rather than engage in conversation with themthem

►Naomi found that she was able to have Naomi found that she was able to have more control over the voices and gain more control over the voices and gain respite from them respite from them

►This further reinforced her use of such This further reinforced her use of such coping strategiescoping strategies

CTCH: Level 3CTCH: Level 3Developing a Shared Developing a Shared

UnderstandingUnderstanding

Building Optimism for Building Optimism for ChangeChange


►Here we introduce the ABC model Here we introduce the ABC model formally and offer it as an alterative formally and offer it as an alterative way to look at the experience of voices way to look at the experience of voices and why they can be so distressing and why they can be so distressing and lead to unwanted actionsand lead to unwanted actions

►Voice activity is a fact Voice activity is a fact (A)(A) but it’s but it’s power and the need to act on it is not power and the need to act on it is not (B)(B)

Introducing the ABC ModelIntroducing the ABC Model

Scenario a)Scenario a)► Tom hears a voice Tom hears a voice

say “you are on say “you are on your way.” He your way.” He thinks that the thinks that the voice is going to voice is going to kill him. kill him.

► How does he feel?How does he feel?► What does he do?What does he do?

Scenario b)Scenario b)► Tom hears a voice Tom hears a voice

say “you are on say “you are on your way.” He your way.” He thinks that he is on thinks that he is on the way to great the way to great things. things.

► How does he feel?How does he feel?► What does he do?What does he do?

Consider the advantages and disadvantages of the beliefs being true or false

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 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

So There are benefits So There are benefits to Resisting!to Resisting!

Training the Inner DetectiveTraining the Inner Detective

►As part of teaching the ABC model the As part of teaching the ABC model the therapist might suggest adopting the therapist might suggest adopting the persona of a fictional detective. persona of a fictional detective.

► In collaboration with the therapist, the In collaboration with the therapist, the voice hearer is invited to collect voice hearer is invited to collect evidence in support of the voice and evidence in support of the voice and alternative (less distressing) beliefsalternative (less distressing) beliefs

CTCH Level 4:CTCH Level 4:

Reframing and Reframing and Disputing Beliefs About Disputing Beliefs About

VoicesVoices

Redressing the Power ImbalanceRedressing the Power Imbalance

►The overall aim is to address the power The overall aim is to address the power imbalance which underpins compliance imbalance which underpins compliance and distress by:and distress by: Questioning the power of the voiceQuestioning the power of the voice Weakening the conviction that the voice Weakening the conviction that the voice

hearer is being and will be punished or hearer is being and will be punished or harmedharmed

Revealing its fallibilityRevealing its fallibility

CTCH StrategiesCTCH Strategies

►The therapist draws upon the voice The therapist draws upon the voice hearers:hearers: Own doubt, past or presentOwn doubt, past or present Own contradictory evidence and Own contradictory evidence and

behaviourbehaviour Own concerns about the possibility that Own concerns about the possibility that

their beliefs about the voices may be their beliefs about the voices may be wrongwrong


►Explore the origin or source of the Explore the origin or source of the beliefbelief

►List and critically examine reasons and List and critically examine reasons and evidence for the belief: evidence for the belief: I can’t start or stop it (control)I can’t start or stop it (control) It is all seeing and knowing (omniscience)It is all seeing and knowing (omniscience)


►Develop and critically examine the Develop and critically examine the implications and consequences of the belief: implications and consequences of the belief: “so you believe that you have to do what it “so you believe that you have to do what it says otherwise you will be punished?”says otherwise you will be punished?”

►Seek and fairly examine conflicting views Seek and fairly examine conflicting views (alternative points of view): (alternative points of view):

““so sometimes you can stop it or ignore it so sometimes you can stop it or ignore it then (disputing control)?”then (disputing control)?”


►Disconfirming evidence can be built up Disconfirming evidence can be built up from anything the voice hearer has from anything the voice hearer has noticed in the past that seemed to be noticed in the past that seemed to be inconsistent with what the voices saidinconsistent with what the voices said

►By subsequently following a line of By subsequently following a line of logical reasoning further logical reasoning further inconsistencies can be exposedinconsistencies can be exposed

DavidDavid

►David and his therapist carefully explored, David and his therapist carefully explored, and was unable to find, any evidence that and was unable to find, any evidence that the voice had ever harmed him, or indeed the voice had ever harmed him, or indeed as a ‘spirit’ could possibly physically do soas a ‘spirit’ could possibly physically do so

►He slowly came to realise there was no He slowly came to realise there was no basis for his belief that the voice could basis for his belief that the voice could physically harm him and he could physically harm him and he could therefore ignore its commands without therefore ignore its commands without fear of punishmentfear of punishment

Challenging Claims Made by the Challenging Claims Made by the VoicesVoices

►We further try to discredit the voices by We further try to discredit the voices by pointing out mistakes or lack of pointing out mistakes or lack of evidence – to reveal the fallibility of the evidence – to reveal the fallibility of the voices (thereby down-ranking them)voices (thereby down-ranking them) JCJC whose voices told him that the end of whose voices told him that the end of

the world was coming in the world was coming in the year 2000the year 2000

SS SS whose voice told him shave your head whose voice told him shave your head and you will get respect and you will get respect

from othersfrom others

So – Voices make lots So – Voices make lots of claims but cannot of claims but cannot

back them up!back them up! So... if they lie about So... if they lie about

this………?this………?

Kevin Kevin

► Kevin believed that he had to comply with the Kevin believed that he had to comply with the voices’ commands because hevoices’ commands because he feared that the feared that the voices might harm him or someone he cared voices might harm him or someone he cared about if he resisted about if he resisted

► This belief was challenged in therapy:This belief was challenged in therapy: It was proposed that only something physical, like a It was proposed that only something physical, like a

knife or a bullet, can harm the physical bodyknife or a bullet, can harm the physical body Gradually Kevin began to develop the belief that the Gradually Kevin began to develop the belief that the

voices were not physical objects, thus concluding voices were not physical objects, thus concluding that they cannot do him any physical harmthat they cannot do him any physical harm

KevinKevin

► It was observed that the voices seemed to It was observed that the voices seemed to rely on Kevin to do what they saidrely on Kevin to do what they said

► The therapist explored what happened when The therapist explored what happened when Kevin chose Kevin chose notnot to act to act

► Kevin began to realise that he had resisted Kevin began to realise that he had resisted the voices’ commands many times without the voices’ commands many times without him or his family coming to any harmhim or his family coming to any harm

► He concluded that the voices could not He concluded that the voices could not physically make him comply and that they physically make him comply and that they were powerless to act themselveswere powerless to act themselves

So So They cannot do any harm .. They cannot do any harm .. Therefore they cannot carry Therefore they cannot carry

out their threatsout their threatsandand

They have not done anything They have not done anything when resisted – when resisted – Kevin did not Kevin did not use a safety behaviour with use a safety behaviour with

no feared consequencesno feared consequences


Reducing Safety Reducing Safety Behaviours & Behaviours & Compliance Compliance

Testing Compliance BeliefsTesting Compliance Beliefs

►Once the voice hearer canOnce the voice hearer can Challenge the truth of what the Challenge the truth of what the

voices sayvoices say Challenge their omniscienceChallenge their omniscience Recognising their true capacity to Recognising their true capacity to

carry out their threatscarry out their threats Have more controlHave more control

►They can then consider dropping They can then consider dropping their safety behaviourstheir safety behaviours

Using Stories: Using Stories: The Elephant on the TracksThe Elephant on the Tracks

John is taking his usual train trip to John is taking his usual train trip to work and notices that another man on work and notices that another man on the train is throwing small pieces of the train is throwing small pieces of paper out of the window. paper out of the window.

He watches the man for a few minutes He watches the man for a few minutes and switches his attention back to his and switches his attention back to his book. They both get off at the same book. They both get off at the same stop and nothing is said. stop and nothing is said.

The Elephant on the TracksThe Elephant on the Tracks

The next day John notices that the man The next day John notices that the man from the previous day is doing the same from the previous day is doing the same thing again. He becomes fascinated by thing again. He becomes fascinated by the man throwing paper out of window the man throwing paper out of window and decides to ask him what he is doing. and decides to ask him what he is doing.

The man says that he’s throwing paper The man says that he’s throwing paper out of the window to keep elephants off out of the window to keep elephants off the tracks. John states that there are no the tracks. John states that there are no elephants on the track.elephants on the track.

The Elephant on the TracksThe Elephant on the Tracks

►The man responds by saying - ‘well, it The man responds by saying - ‘well, it must be working then!’must be working then!’

►The voice hearer is asked to assess The voice hearer is asked to assess the story:the story: ““What are the reasons the people in the What are the reasons the people in the

story are behaving as they are? “story are behaving as they are? “ ““What would the person in the story need What would the person in the story need

to do to test out their beliefs?” to do to test out their beliefs?”

Behavioural ExperimentsBehavioural Experiments

►Behavioural experiments are then Behavioural experiments are then devised to test the voice hearers devised to test the voice hearers belief:belief: Carrying out or withholding a Carrying out or withholding a

behaviour in order to test a prediction behaviour in order to test a prediction that something bad will happen that something bad will happen

The person is encouraged to reduce The person is encouraged to reduce the use of the safety behaviour and the use of the safety behaviour and note that the feared outcome does note that the feared outcome does not occur, hence weakening the not occur, hence weakening the beliefbelief

DavidDavid

►Having doubted his belief that the Having doubted his belief that the voice could harm him David put this to voice could harm him David put this to the test by ignoring the commandsthe test by ignoring the commands

►After several such tests, he discovered After several such tests, he discovered there were in fact no consequencesthere were in fact no consequences


Raising the Power of the Raising the Power of the IndividualIndividual

Questioning the Voice’s CommandQuestioning the Voice’s Command ►Questioning the voice’s command directly Questioning the voice’s command directly

is an extension of the behavioural test is an extension of the behavioural test and builds upon earlier boundary setting and builds upon earlier boundary setting workwork

►At this stage the voice may be challenged At this stage the voice may be challenged more assertively: more assertively: ““Why should I do that?” Why should I do that?” ““Why don’t you do it yourself?” Why don’t you do it yourself?”

►Ray told his voices: “YOU go in walk in Ray told his voices: “YOU go in walk in the road if you want to!”the road if you want to!”

Raising Awareness of the Power Raising Awareness of the Power ShiftShift

►Most of the preceding interventions Most of the preceding interventions are aimed at challenging beliefs are aimed at challenging beliefs about the power of the voiceabout the power of the voice

►These will simultaneously and These will simultaneously and necessarily be proving that necessarily be proving that the the voice hearer now has mastery and voice hearer now has mastery and control, not the voice control, not the voice

►By careful questioning, the voice By careful questioning, the voice hearer can be made aware of thishearer can be made aware of this

Developing Powerful Self Developing Powerful Self BeliefsBeliefs

Powerful Voice beliefsPowerful Voice beliefs► I must comply (at least I must comply (at least

partially) to prevent the partially) to prevent the voice harming mevoice harming me

► I have no control over my I have no control over my voicevoice

► My voice is powerful and My voice is powerful and therefore should be therefore should be obeyedobeyed

Powerful Self beliefsPowerful Self beliefs► The voice cannot harm The voice cannot harm

me, therefore, I can me, therefore, I can choose to resist or ignore choose to resist or ignore its commandsits commands

► I have learnt to have I have learnt to have control over my voice by control over my voice by using the following coping using the following coping strategiesstrategies………………

► My voice is not powerful, My voice is not powerful, and so I do not have to and so I do not have to obey itobey it

Advanced CTCHAdvanced CTCH

CTCH Levels 7 & 8CTCH Levels 7 & 8

Working with Personal Working with Personal Meaning and Core Meaning and Core

Beliefs Beliefs

Why Advanced CTCH?Why Advanced CTCH?

►Voice Hearers may not respond to Voice Hearers may not respond to interventions aimed just at power interventions aimed just at power beliefs - work at the core belief level beliefs - work at the core belief level may be needed to effect longer term may be needed to effect longer term changechange

►Advanced CTCH builds on progress Advanced CTCH builds on progress made at earlier levels and attempts to made at earlier levels and attempts to inoculate the person against future inoculate the person against future relapsesrelapses

Level 7 and 8 WorkLevel 7 and 8 Work►Examines the possible personal meaning Examines the possible personal meaning

of voices: of voices: Why this voiceWhy this voice Why nowWhy now Why this contentWhy this content

►Sometimes it is possible to explain voices Sometimes it is possible to explain voices in terms of their psychological originsin terms of their psychological origins

►This work if carefully handled and timed, This work if carefully handled and timed, can be a powerful move to finally can be a powerful move to finally deconstruct power beliefsdeconstruct power beliefs

Level 7 and 8 WorkLevel 7 and 8 Work

►REBT theory and ABC model suggest REBT theory and ABC model suggest that core beliefs and beliefs about that core beliefs and beliefs about voices may be connected and reflect voices may be connected and reflect early adverse experiences and other early adverse experiences and other traumastraumas

►Negative core belief work may be Negative core belief work may be needed: person evaluationsneeded: person evaluations

►May also need to work on trauma May also need to work on trauma issuesissues

Does it Work?Does it Work?

Service Hearers Accounts: JService Hearers Accounts: J

►I was doing some really stupid I was doing some really stupid things before I started to work things before I started to work with the therapist. with the therapist.

►I was walking in front of cars and I was walking in front of cars and cutting myself. cutting myself.

►I was doing lots of stuff that the I was doing lots of stuff that the voices wanted me to do. voices wanted me to do.

J’s StoryJ’s Story

►I remember thinking that if I did I remember thinking that if I did what they wanted things would what they wanted things would get better – but they didn’t. They get better – but they didn’t. They just kept going on. When I just kept going on. When I harmed myself this upset me, my harmed myself this upset me, my family and my CPN was worried as family and my CPN was worried as well. well.


►When I went to the next appointment When I went to the next appointment on my own this was really difficult for on my own this was really difficult for me. The voices wanted me to harm me. The voices wanted me to harm the therapist. They kept swearing at the therapist. They kept swearing at me and kept going on. me and kept going on.

►Once therapy got going .... the Once therapy got going .... the therapist encouraged me to use some therapist encouraged me to use some strategies to distract myself from the strategies to distract myself from the voices. voices.


► I noticed that when I did art work I I noticed that when I did art work I didn’t hear the voices so much. They didn’t hear the voices so much. They went into the background. I also found went into the background. I also found the same thing when I went to my the same thing when I went to my support group.support group.


► I came to realise that the voices only new I came to realise that the voices only new the things I did. They didn’t know anything the things I did. They didn’t know anything else. else.

► I can’t express how powerful this was. I I can’t express how powerful this was. I felt so good. The voices weren’t felt so good. The voices weren’t magical ...they weren’t as powerful as I magical ...they weren’t as powerful as I had thought they were. This is something I had thought they were. This is something I still remember and it makes me realise still remember and it makes me realise that they are normal like me. They are not that they are normal like me. They are not specialspecial..


► In my past quite a few different things In my past quite a few different things have happened .... I learned from the have happened .... I learned from the therapist that when I had flashbacks, therapist that when I had flashbacks, nightmares or thought about all these bad nightmares or thought about all these bad things it would be very upsetting. This things it would be very upsetting. This meant I tried not to think about these meant I tried not to think about these things. Over time I have sorted out what things. Over time I have sorted out what the voices bring up about my past and the voices bring up about my past and have sorted and filed them away. This have sorted and filed them away. This means I am upset less of the time. means I am upset less of the time.


► I have now stopped cutting myself. I realise I I have now stopped cutting myself. I realise I don’t need to do what the voices tell me to don’t need to do what the voices tell me to do .... even if I did .... they wouldn’t stop do .... even if I did .... they wouldn’t stop going on – they never did. going on – they never did.

► I also recognise that I can resist them and I also recognise that I can resist them and when I go against them nothing bad happens. when I go against them nothing bad happens.

► I remind myself of the value of not doing I remind myself of the value of not doing what they want: I stay in control and I don’t what they want: I stay in control and I don’t upset any of my family – this is really upset any of my family – this is really important to me.important to me.


► It was difficult to stand up to them the first It was difficult to stand up to them the first time. I guess I had listened to them for so time. I guess I had listened to them for so long. I was very nervous. But I began to long. I was very nervous. But I began to question them and challenge them. question them and challenge them.

► I won, I had control and I had the power – I won, I had control and I had the power – they didn’t! They lost their power when I they didn’t! They lost their power when I realised that they only new what I did. realised that they only new what I did. This was such an important moment for This was such an important moment for me.me.


► I think I am a braver person now and I think I am a braver person now and more confident. I do have some days more confident. I do have some days when I don’t do so well, I lose when I don’t do so well, I lose confidence a little and can get low. But confidence a little and can get low. But I am able to stay positive. Things don’t I am able to stay positive. Things don’t seem to affect me so much. What they seem to affect me so much. What they say to me doesn’t take hold as much. say to me doesn’t take hold as much.


► It was a good job the project came It was a good job the project came along when it did. I was very nervous along when it did. I was very nervous doing it but it was worth it. It really paid doing it but it was worth it. It really paid off. Without it I might be six foot under.off. Without it I might be six foot under.

► I now accept the voices. I don’t know I now accept the voices. I don’t know whether they will stop or not. I can still whether they will stop or not. I can still live my life and have a positive future. I live my life and have a positive future. I am confident about things now and this am confident about things now and this will help me get the most from my life. will help me get the most from my life.

Angel’s StoryAngel’s Story►Therapy involved concentrating on the Therapy involved concentrating on the

voices which I had actively avoided doing voices which I had actively avoided doing for fear of them overpowering me. for fear of them overpowering me.

► I kept diaries of when I experienced the I kept diaries of when I experienced the voices, times when they were more voices, times when they were more distressing and times when they were less distressing and times when they were less distressing. distressing.

►We also looked at what was going on in We also looked at what was going on in my life and how this had an impact on the my life and how this had an impact on the severity of the voices. severity of the voices.

Angel’s StoryAngel’s Story

►This gave me an awareness that there This gave me an awareness that there were times when I did not actually were times when I did not actually hear the voices ..... how I could use hear the voices ..... how I could use various coping strategiesvarious coping strategies

►Challenging the voices by not Challenging the voices by not complying .... was a frightening complying .... was a frightening thought but in practise was very thought but in practise was very powerful. powerful.

Angel’s StoryAngel’s Story

►By using the resistance diaries I could By using the resistance diaries I could see at a glance how non-compliance see at a glance how non-compliance over a period reduced the frequency of over a period reduced the frequency of the commands and tested the voices the commands and tested the voices threats and questioned their power threats and questioned their power and transferred power to me. and transferred power to me.

cognitive therapy for reducing distress and harmful compliance with powerful voices dr. alan meaden...

Documents

threat slide

person slide

voice power schema slide

assessment engagement

voices ability

type of safety behaviour

compliance beliefs

powerful voices