Helping patients with schizophrenia control those threatening voices

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Auditory hallucinations, delusions, and command hallucinations are common symptoms in schizophrenic patients. These often persist even with the use of antipsychotic medications.

How can you respond when a patient is expressing command hallucinations with voices that are threatening and distressful? I have found that the following psychological interventions help:

Acknowledge that these experiences are quite real to the patient, but that as a therapist, you have not had any similar experiences. This allows the patient to retain the sense of the validity of these experiences without fostering them.

Display a sense of understanding. Empathize with the schizophrenic patient’s experience of being overwhelmed by hallucinations and delusions. Acknowledging the distress that these hallucinations create in the patient’s mind will help build a therapeutic alliance.1 It may help to make a comment such as, “You must be exhausted considering what you’ve been through,” without actually agreeing that every hallucination and delusion is real.

Urge the patient to try to ignore or reduce the intensity of the voices and hallucinations. I strive to help the patient "discount" these experiences with the knowledge that the voices will most likely continue. I often use the analogy of a radio that can be turned down; similarly, the patient can attempt to reduce the volume of the voices so that they may become less troubling.

Several methods exist for helping patients reduce the intensity of the voices or hallucinations. I suggest that the patients focus on something that is positive, such as art, music, or reading. I have found that this distraction often works.

Remind the patient that he or she is in charge. Despite what the voice is commanding, remind the patient that he or she has the final authority to follow or not follow the commands. This tends to empower the patient to regain control of his or her actions and behavior despite the commands. This is difficult for some patients.

For example, I might say to the patient, “If a negative voice is telling you to harm yourself, you can control your actions.” As part of treatment I praise and encourage healthy behavior. Then together as doctor and patient with some time, effort, support, and medication, we work toward finding a positive outcome and to ensure the patient’s safety.

I have found that these interventions tend to reduce the severity of the hallucinations in certain patients, used in the context of a trusting and supportive doctor-patient relationship and in conjunction with the use of antipsychotic medication.

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