Dr Kingdon is professor of mental health care delivery at the University of Southampton and Ms Price is clinical studies officer in the department of psychiatry at the Royal South Hants Hospital in Southampton,Hampshire, United Kingdom. The authors report no conflicts of interest concerning the subject matter of this article.
Treatment
Based on the available information and further discussion with Ellie, a list of problems was formulated and agreed on (Table). Most problematic was the experience of hearing voices. Analysis of the last experience clarified that hearing the voice was an activating event. An emotional reaction to its content (anger, shame, anxiety, and guilt) was the consequence, and avoidance, isolation, and obeying the voice was the behavioral response.
The underpinning beliefs were, “What the voice says is true; it will never stop; it is in control and I have no control over my actions.”We formed the problem statement, “When I hear the voice it makes me angry, then I’m too terrified to go outside because I am frightened I could hurt someone, which affects my quality of life.” A plan was developed to address her psychotic symptoms.
Negative core beliefs linked to past events were identified. Ellie had developed unhelpful automatic thoughts and assumptions (eg, “I’m not good enough”) to manage the negative beliefs. During therapy, differing levels of belief were evoked using thought records completed during sessions and as homework. This gave her a simple yet powerful demonstration of the way thought influences and maintains feelings.
Ellie’s experience of hearing the voice was further clarified through assessing attributions, focusing on specific beliefs, and maintaining a voice diary to clarify connections with daily events. The voice was reminiscent of her grandfather, “an evil man.” Both he and the voice used her full name (Eileen), while no one else did. Relating to the voice was set within her interpersonal history: once the gap between negative perception of herself and overly positive attitudes to significant others decreased, it was easier to challenge the voice. She and her doctor discussed how voices and beliefs about voices can arise from childhood abuse and other precipitating events. A responsibility pie chart helped Ellie reattribute blame for the abuse from herself to the adults responsible. Focusing on the psychological origins and the relationship with her grandfather helped Ellie deconstruct the power beliefs and develop some boundaries with the voice.
Ellie achieved self-identified short-term goals related to the problem statement. These were rated regularly on a progress scale of 0 to 8 and plotted graphically to aid visualization of change. Avoidance decreased despite hearing the voice. As fears were disconfirmed, Ellie’s world expanded.
Behavioral experiments, properly designed and carried out, can modify beliefs and assumptions more powerfully than verbal techniques in the office. Ellie made regular late-night trips to the supermarket, where she would avoid speaking to anyone except the cashier. For the experiment to expand her contacts, she asked an assistant “where are the tomatoes?” The process of planning (designing the experiment), experiencing (the experiment itself), observing (examining what happened), and reflecting (making sense of the experiment) was used to maximize gains from this successful experience, and it was used as a foundation to increase levels of social contact.
Concentrating on Ellie’s experience of voice hearing positively changed the other problems: not getting out, difficulties in sleeping, and hopelessness. Reassessments at 6 months highlighted progress. Ellie had become more insightful regarding hearing voices, and her mood and selfesteem had increased. Ellie had become “her own therapist,” learning from and initiating new experiences. She felt hopeful about implementing positive change.
Recovery is a unique individual journey that may not mean being completely symptom-free. The ability to cope and reengage may be the most appropriate goal. This is illustrated by Ellie’s reflection that:
Life as a whole is no longer black and gray. I have color. Some days are brighter than others. There are times of love, light, and happiness; I can be lost in the moment. My life may not be anything special compared to other peoples’, but it is now my life, and the dark times make the okay times that much more special.
CME Post-Test
