Cognitive-behavioral therapy (CBT) can help patients cope with auditory hallucinations and reshape delusional beliefs to make the voices less frequent.1 Use the following CBT methods alone or with medication.
1. Engage the patient by showing interest in the voices. Ask: “When did the voices start? Where are they coming from? Can you bring them on or stop them? Do they tell you to do things? What happens when you ignore them?”
2. Normalize the hallucination. List scientifically plausible “reasons for hearing voices,”2 including sleep deprivation, isolation, dehydration and/or starvation, extreme stress, strong thoughts or emotions, fever and illness, and drug/alcohol use.
Ask which reasons might apply. Patients often agree with several explanations and begin questioning their delusional interpretations. Your list should include the possibility that the voices are real, but only if the patient initially believes this.
3. Suggest coping strategies, such as:
- humming or singing a song several times
- listening to music
- reading (forwards and backwards)
- talking with others
- ignoring the voices
- medication (important to include).
Ask which methods worked previously and have patients build on that list, if possible.
If a patient hears command hallucinations, assess their acuity and decide whether he or she is likely to act on them before starting CBT.
4. Use in-session voices to teach coping strategies. Ask the patient to hum a song with you (“Happy Birthday” works well). If unsuccessful, try reading a paragraph together forwards or backwards. If the voices stop—even for 2 minutes—tell the patient that he or she has begun to control them.3 Have the patient practice these exercises at home and notice if the voices stop for longer periods.
5. Briefly explain the neurology behind the voices. PET scans have shown that auditory hallucinations activate brain areas that regulate hearing and speaking,4 suggesting that people talk or think to themselves while hearing voices.
When patients ask why they hear strange voices, explain that many voices are buried inside our memory. When people hear voices, the brain’s speech, hearing, and memory centers interact.5
That said, calling auditory hallucinations “voice-thoughts,” rather than “voices,” reduces stigma and reinforces an alternate explanation behind the delusion. As the patient begins to understand that hallucinations are related to dysfunctional thoughts, we can help correct them.