Coping skills for hallucinations

Schizophrenia — Signs, symptoms, and coping mechanisms

Mentally Aware Nigeria InitiativeFollow Aug 26, 2018 · 3 min read

Schizophrenia is a chronic and severe mental disorder that affects everything about a person; how they think, feel and even behave. Often, it’ll feel like they’ve lost touch with reality.

Symptoms and Signs of schizophrenia

As individuals differ, so will the symptoms and signs of schizophrenia will vary. We can however classify the symptoms into four:

  • Delusions
  • Hallucinations
  • Speech and Thought disorders (unusual or dysfunctional ways of thinking)
  • Behavioural or cognitive disorders
  • Negative symptoms

1.Delusions — This is when the patient displays having false beliefs. It can take many forms, such as:

  • Delusions of Persecution: They may feel that people are out to get them.
  • Delusions of Grandeur: They may think they have extraordinary powers and abilities.
  • Delusions of Control: They may feel others are attempting to control them remotely.
  • Delusions of Reference: They may feel that something general in the environment was specifically for them.

2.Hallucinations — This is when the patient is sensing things that are not there. However, hearing voices is much more common than seeing, feeling, tasting, or smelling things which are not there. People with schizophrenia may experience some, or all the types of hallucination.

3.Speech/Thought disorder — The person may jump from one subject to another for no logical reason, thus causing their speech to be incoherent and hard to keep up with. The forms include:

  • Loose associations– Shifting from topic to topic, with no correlation between them
  • Neologisms– They might use made up words.
  • Perseveration– Repetition of words and statements; saying the same thing over and over.
  • Clang– Wrong use of rhyming words.

4.Behavioural disorders: For some patients, the overall above forms of symptoms affect the patient, and show signs such as:

  • Poor “executive functioning” (the ability to understand information and use it to make decisions)
  • Trouble focusing or paying attention
  • Problems with “working memory” (the ability to use information immediately after learning it)
  1. Negative symptoms:“Negative” symptoms are associated with disruptions to normal emotions and behaviors. Symptoms include:
  • “Flat affect” (reduced expression of emotions via facial expression or voice tone)
  • Reduced feelings of pleasure in everyday life
  • Difficulty beginning and sustaining activities
  • Reduced speaking

Other symptoms may include:

  • Lack of motivation.
  • Social withdrawal.
  • Unawareness of illness.

Coping Mechanisms

Just like every mental illness, it’s not easy to deal with schizophrenia. The different signs and symptoms make it difficult. However, some coping mechanisms that can make living with schizophrenia easier.

  • Distraction: Some schizophrenic patients may find books, podcasts, music or even tv can be good distractors, painting, or even just listening to someone talk can help too.
  • Writing: journaling their symptoms, can help keep track of progress and also serve as a coping mechanism.
  • Reality test: This involves the assistance of someone trusted and who can be honest no matter what. The person can always tell them if their symptoms are real or imagined.
  • Use their voice to drown out the others: This could mean the person talking to him or herself, talking to others, or singing aloud to a song, thereby distracting them from the other voices.

And as we always say, if you know or love someone who is schizophrenic, caring might be hard, but it’s a necessary sacrifice. Here are some ways you can help them cope:

  • Help them get treatment and encourage them to stay in treatment.
  • Remember that their beliefs or hallucinations seem very real to them.
  • Be respectful, supportive, and empathic without encouraging dangerous or inappropriate behavior.

-Agoha Bertharbella

Contributor, MANI

Psychotic symptoms, functioning and coping in adolescents with mental illness

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Pre-publication history

  1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/14/97/prepub

The support of friends and family plays an integral role in the treatment of schizophrenia. Although it’s natural for caretakers to experience stress, frustration, and feelings of helplessness when caring for someone with schizophrenia, providing support with medical care, coping skills, and life skills can assist with recovery.

It’s essential for caregivers to learn about and understand the illness. Schizophrenia includes a wide range of symptoms and behaviors. Learning about the constellation of symptoms and how those symptoms impact the person with schizophrenia enables caregivers to find appropriate help.

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Concerned about Schizophrenia?

Take our 2-minute Schizophrenia quiz to see if you may benefit from further diagnosis and treatment.

Take Schizophrenia Quiz

Symptoms of schizophrenia

A) Two or more of the following for at least a one-month (or longer) period of time, and at least one of them must be 1, 2, or 3:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior
  • Negative symptoms, such as diminished emotional expression.

B) Impairment in one of the major areas of functioning for a significant period of time since the onset of the disturbance: Work, interpersonal relations, or self-care.

C) Some signs of the disorder must last for a continuous period of at least 6 months. This six-month period must include at least one month of symptoms (or less if treated) that meet criterion A (active-phase symptoms) and may include periods of residual symptoms. During residual periods, only negative symptoms may be present.

D) Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out:

  • No major depressive or manic episodes occurred concurrently with active phase symptoms
  • If mood episodes (depressive or manic) have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual phases of the illness.

E) The disturbance is not caused by the effects of a substance or another medical condition.

F) If there is a history of autism spectrum disorder or a communication disorder (childhood onset), the diagnosis of schizophrenia is only made if prominent delusions or hallucinations, along with other symptoms, are present for at least one month

Additional symptoms that contribute to a diagnosis of schizophrenia include:

  • Inappropriate affect (laughing in the absence of a stimulus)
  • Disturbed sleep pattern
  • Dysphoric mood (can be depression, anxiety, or anger)
  • Anxiety and phobias
  • Depersonalization (detachment or feeling of disconnect from self)
  • Derealization (a feeling that surroundings aren’t real)
  • Cognitive deficits impacting language, processing, executive function, and/or memory
  • Lack of insight into disorder
  • Social cognition deficits
  • Hostility and aggression

Once you understand the disease, you can help your loved one find appropriate treatment options. Keep in mind that your loved one will likely need support scheduling and getting to and from appointments, filling medications, and with medication management.

Provide treatment options

Many people with schizophrenia benefit from medication, but medication alone is not enough to treat schizophrenia. Discuss various treatment options with your loved one to work toward recovery.

  • Medication management
  • Cognitive Behavioral Therapy for stress management
  • Group therapy for support and to build a social network
  • Life skills training to work toward independence and rejoining the workforce
  • Social skills training to help cope with symptoms that impact social interactions and relationship building

Encourage self-help strategies

The daily stress of living with schizophrenia can be challenging. Stress can also exacerbate symptoms of the disease. It is imperative for people with schizophrenia to practice self-help skills to manage symptoms.

  • Relaxation techniques including mindfulness, deep breathing, and progressive muscle relaxation
  • Daily exercise
  • Maintain a healthy, balanced diet
  • Refrain from alcohol and drugs
  • Seek social support other than immediate caregivers

Self-help for caregivers

To support someone with schizophrenia, caregivers need to build their own support networks. Caring for someone with schizophrenia can be emotionally draining and physically exhausting. The more support you have in place, the better the outcome for your loved one.

  • Know your limits – Set realistic expectations about how much support you can provide
  • Seek out resources – Ask your loved one’s doctor or caseworker for referrals for respite services and other sources of local support. Something as simple as rides to and from appointments can provide relief to caregivers.
  • Join a support group to share your emotions and seek support from others who understand what you’re going through.
  • Practice your own self-care strategies: Relaxation strategies, healthy eating, exercise, time spent with friends, and taking care of your own health are all important for caregivers.

Prepare for crisis

Even when treatment is ongoing, there is the potential for relapse. If your loved one’s condition deteriorates rapidly, hospitalization might be necessary. It helps to have an emergency plan for a psychotic episode. When creating your emergency plan, include the following:

  • The name and number of the physician treating the patient
  • The name and number of the therapist treating the patient
  • The name, address, and phone number of the hospital you will go to for psychiatric admission
  • The names and numbers of friends or family members on call to handle child care of any other children in the home in an emergency

Discuss the emergency care plan with your loved one often. A crisis will feel less threatening if the person with schizophrenia knows what to expect.

Create a predictable environment

Creating a routine is helpful to both the caregiver and the person living with schizophrenia. With consistent support and predictable and realistic routines in place, both the caregivers and the patients know what to expect and how to seek additional help when necessary.

Article Sources Last Updated: Feb 13, 2018

10 Strategies for Coping With Hallucinations and Delusions in Schizophrenia

If you have schizophrenia, you may experience psychotic episodes like hallucinations and delusions, both of which can cause distress and disorientation. These symptoms can make it hard to hold a job, maintain relationships, or handle everyday tasks, according to the National Institute of Mental Health (NIMH).

The first line of treatment for the symptoms of schizophrenia are antipsychotic medications. But a 2015 study in the journal Neuropsychiatric Disease and Treatment found that using positive coping strategies to deal with your symptoms can also improve your quality of life.

Strategies for Hallucinations

Hallucinations — seeing, hearing, or smelling something that isn’t there — are a common symptom for people with schizophrenia; oftentimes, people will “hear voices,” which can sometimes be threatening. If you recognize that you’re experiencing a hallucination, use these strategies to cope with one:

  • Distract yourself. A 2007 study published in the journal Psychiatry and Clinical Neurosciences found that many people with schizophrenia cope with hallucinations by listening to music or watching TV. The study authors noted, however, that listening to music tended to be more effective.
  • Practice acceptance. Accepting that the voices are part of life for a person with schizophrenia may have positive emotional effects, according to a 2007 study in the journal Clinical Psychological Review. But some researchers suggest that the danger of acceptance is that the hallucinations may start to consume your life.
  • Try mindfulness. This means paying attention to the present; in this case, increasing your awareness of your schizophrenia symptoms and learning how to accept or disengage from them, according to the study in Clinical Psychological Review. An example of this is called Acceptance and Commitment. With this philosophy, the person agrees to acknowledge the voices but does not agree to accept guidance from them.
  • Start a conversation with someone. Similar to the strategy of distracting yourself, talking to another person can be an effective way to cope with a hallucination, according to the study in Psychiatry and Clinical Neurosciences.
  • Use avatar therapy. Those with schizophrenia may be able to control the hallucinations by creating a computer-generated avatar representing the negative voices, according to a 2017 study in the journal The Lancet. The study authors found that people who participated in the avatar therapy experienced fewer hallucinations and distress than those who participated in supportive counseling sessions.

Strategies for Delusions

Delusions, or irrational and false beliefs, are another common symptom of schizophrenia. People who are experiencing delusions may believe that their lives are in danger or that someone is trying to harm them, for example, says the NIMH. Here are some techniques that may help:

  • Ask for help. Some people with schizophrenia seek out the company of friends and family when they are experiencing delusions. Friends and family can help by providing a distracting activity, or even just a listening ear. People may also seek professional help, and research has found cognitive therapy can help many people cope with schizophrenia symptoms.
  • Control your surroundings. Certain environments, situations, or other stimuli may increase delusional thoughts, such as persecutory delusions (feeling you are being followed, harassed, or otherwise persecuted) and grandiose delusions (believing you are very powerful or important).
  • Practice religion, meditation, or other mind-body activities. People who are religious believers report using prayer or meditation to help deal with their active schizophrenia symptoms. A 2012 study in the International Journal of Yoga found that yoga therapy could may reduce psychotic symptoms, lower depression, and boost quality of life in people with schizophrenia.

Schizophrenia Symptoms: Family Reaction

While hallucinations and delusions may not always upset the person with schizophrenia, they are always very real. So how loved ones react to these symptoms is important. Without meaning to, loved ones can cause distress by betraying fear or worry, or by dismissing the person’s experience.

Family therapy can help the loved ones of a person with schizophrenia know how to react when schizophrenia symptoms manifest themselves, according to the NIMH. It can also teach families about warning signs that their loved one may be using damaging coping mechanisms, like self-medicating with illicit drugs or alcohol.

No matter how you or your loved one with schizophrenia chooses to handle these distressing symptoms, don’t be afraid to talk to your doctor or another healthcare provider for help. There are resources available and effective ways to cope with this often difficult disease.

10 Things You Should Do With Someone Who Suffers Delusions

Photo Credit: Allne B

Do you know someone who struggles with delusional thoughts? A delusion is defined as a belief, that is strongly held to be true, despite evidence to the contrary. It is a fixed and pervasive way of thinking that is not easily derailed by logic. For many people attempting to cope with loved ones who have delusional thoughts, it can be extremely difficult to communicate with the person or live peaceably with them. Another component that results in much stress in families is that the person with delusions does not always seem to be ill. In other words, the individual may go in and out of “consciousness” and show moments of insight, emotional awareness, and engagement. However, this only lasts for a short duration. Are you experiencing a situation like this or know someone who is? If so, this article is for you. This article will discuss the things we can do to make communication slightly better with those who struggle with delusional thoughts.

Living with a loved one (spouse, child, adult child, extended family, or parent) who is suffering from delusional thought patterns can literally flip a life upside down. Everything that was once very logical to the person becomes questionable and the delusions begin to take over. When delusions take over, there is nothing or no one who can stop it. Delusional disorder or other mental illnesses where delusional thoughts may be present (i.e., schizophrenia, psychotic disorder, major depression with psychotic features, etc), results in the individual becoming suspicious, hypervigilant, angry or hostile, confused, and paranoid. For many individuals suffering from delusions, it can be very easy for the person to become confused and paranoid which often leads them to make accusations, easily lose perspective, and maybe even change in temperament. For example, a wife who is struggling with delusional thoughts may believe that her husband is out everyday after work taking his female co-worker to dinner (i.e., paranoia), although there may be no proof of this, and that their marriage should end immediately (i.e., confusion and hostility). Many of my client’s have reported the challenge and deep seeded fear that can result from having a parent with delusional thoughts and paranoia. Delusions, paranoid thoughts, and other psychotic symptoms that are not being managed with medication and therapy can continue to cause deterioration in the suffering person.

As a result, it is important that we learn how to cope with someone who is suffering. A few tips I often provide to clients struggling with family members is that we must

  1. Pay attention to the emotions of the person: Delusions and paranoia can be very difficult to understand. What is logical to us may not be logical to the person suffering from paranoia or firmly help, yet inaccurate thoughts. Because of this, you want to train yourself to avoid arguing your point or arguing over the reality of a situation. You want to pay attention to the emotions of the person and how the person is feeling in regards to their inaccurate beliefs. If you try to argue facts or logic, the person will shut down. Try to stay focused on consoling the person, offering support in ways that you can, or just listening in a nonjudgmental fashion.
  2. Discuss the way you see the delusion: Although you do not want to argue facts and logical, you can express that you see the situation in a particular way and while you want to understand the situation to the best of your ability, you cannot. Sometimes it might be wise to say something like “I understand this is hard for you. I would feel the same way. I’m sorry I cannot understand this 100%, but I certainly get why you feel the way you do.” You are not trying to be correct. You are not trying to be right. You are trying to be understanding while also expressing how you see the situation.
  3. Express that you are concerned about the person: There may come a time when you simply have to tell the person that you are concerned about them. You certainly do not want to express this in a condescending manner. You want the person to believe that you care and are concerned about how their thoughts and feelings are affecting them. You can say something like “it is obvious that you are stressed and overwhelmed. Have you thought about seeking a therapist, someone who can hear you out and provide unbiased support?”
  4. Offer to pursue therapy together but be strategic: You can offer to attend a few therapy sessions or to receive therapy with different therapists on the same day. This strategy gives the impression that you are not only supporting the person in their own recovery but also seeking insight into your own needs. You can also truly benefit from therapy if you find a good therapist to see. A good therapist will teach you how to respond, interact with, and cope with the person who is suffering from delusions or paranoia. Seeking therapy together also helps the individual see that you too are in need of support in some way.
  5. Ask the person why they believe as they do and be open-minded: It is okay to ask the person why they believe as they do. You can also ask the person to explain when their beliefs began and why. The person may try to explain it but will often seem unable to. The persona may also become suspicious and paranoid as to why you are asking about their beliefs. But some people will simply explain their side of things. Either way, you don’t want to make the person feel defensive. You just want to get “inside their head” and see how far into their beliefs/paranoia they are. This can be helpful information for when/if the person seeks therapeutic intervention.
  6. Avoid getting frustrated and expressing that to the person: It is important to remember that the person is ill and in need of compassion. This can be extremely difficult, especially if the individual suffering begins to attack loved ones or a spouse. When you are the target and trigger of the suffering person, you may not feel as if you can avoid getting frustrated or defensive. That is understandable. But it is well worth it to try. You want to learn how to derail inaccurate thoughts and beliefs by downplaying them with your own responses. If you get frustrated or angry in response to a paranoid belief, you will likely inflame the situation more.
  7. Learn about Cognitive Distortions or Thinking Errors: We all engage in thinking errors at some point in our lives. We can exaggerate details, we can look at only the negatives in a situation, we can be judgmental without appreciating imperfection, we can become defensive if things don’t go our way, etc. We all struggle with thinking errors. It’s inevitable. I encourage you to learn more about cognitive distortions and how they may influence your reactions to the sufferer.
  8. Do model engaging in reality testing: Weigh the evidence for or against the delusions can be helpful not only to you but the person suffering from delusions/paranoia. The person may argue with you or find ways to defend their point of view, but it may be helpful to model weighing the evidence for a belief. When you show that you are able to consider various points of view and question things, you are modeling normal thought processes. This may or may not be helpful but it is worth a try.

As difficult as it may be, there are some situations in which separation or divorce is the only way to cope with a loved one who is suffering from delusional thoughts and beliefs. If the individual is refusing to seek psychiatric treatment (medication or therapy), it will be important to determine what is worth salvaging in the relationship and what is not. Safety is important. Emotional health is important. If both safety and emotional health is in jeopardy, you may have to make some very tough decisions, especially if the person refuses help.

Feel free to post your thoughts below.

As always, I wish you well

10 Things You Should Do With Someone Who Suffers Delusions

5 ways to quiet auditory hallucinations

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
  • exercise
  • 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.

Psychosocial coping strategies for auditory hallucinations

This article considers ways of treating the potential distress arising from experiencing auditory hallucinations without the use of pharmacology. A brief discussion of the prevalence of auditory hallucinations is followed by an overview of different perspectives of treating mental illness and the potential need for treatment using non-pharmacological interventions. It is highlighted that many voice hearers are not in contact with formal psychiatric services and the author examines potential methods of managing distress caused by hallucinations. A review of research in this area is presented with the aim of identifying common themes of such coping so that they may be taught to others. While several themes are identified, no unifying method of coping is noted. Recommendations for voice hearers, clinicians and researchers are presented.

Mental Health Practice. doi: 10.7748/mhp.2018.e1273

Citation

Barlow T (2018) Psychosocial coping strategies for auditory hallucinations. Mental Health Practice. doi: 10.7748/mhp.2018.e1273

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Correspondence

[email protected]

Conflict of interest

None declared

Published online: 24 July 2018

Schizophrenia: Coping with Delusions and Hallucinations

Source:

The symptoms of schizophrenia are manifold, and present in such a variety of combinations and severities that it is impossible to describe a ‘typical case’ of schizophrenia.

Positive symptoms

The so-called ‘positive symptoms’ of schizophrenia consist of psychotic phenomena (hallucinations and delusions), which are usually as real to the schizophrenia sufferer as they are unreal to everybody else. Positive symptoms are usually considered to be the hallmark of schizophrenia, and are often most prominent in the early stages of the illness. They can be provoked or aggravated by stressful situations, such as succumbing to a physical illness, breaking off a relationship, or leaving home to go to university.

Hallucinations

Psychiatrists define a hallucination as ‘a sense perception that arises in the absence of a stimulus’. Hallucinations involve hearing, seeing, smelling, tasting, or feeling things that are not actually there. The most common hallucinations in schizophrenia are auditory hallucinations—hallucinations of sounds and voices. Voices can either speak to the schizophrenia sufferer (second-person, ‘you’ voices) or about him (third-person, ‘he’ voices). Voices can be highly distressing, especially if they involve threats or abuse, or if they are loud and incessant. (Carers might begin to experience something of the distress of hearing voices by turning on both the radio and the television at the same time, both at full volume, and then trying to hold a normal conversation.) On the other hand, some voices—such as the voices of old acquaintances, dead ancestors, or ‘guardian angels’—can be a source of comfort and reassurance rather than of distress.

Delusions

Delusions are defined as ‘strongly held beliefs that are not amenable to logic or persuasion and that are out of keeping with their holder’s background’. Although delusions need not necessarily be false, the process by which they are arrived at is usually bizarre and illogical. In schizophrenia, delusions are most often of being persecuted or controlled, although they can also follow a number of other themes.

Positive symptoms correspond to the general public’s idea of ‘madness’, and people with prominent hallucinations or delusions may evoke fear and anxiety in others. Such feelings are often reinforced by selective reporting by the media of the rare headline tragedies involving people with (usually untreated) mental illness. The reality is that the vast majority of schizophrenia sufferers are no more likely than the average person to pose a risk to others, but far more likely than the average person to pose a risk to themselves. For example, they may neglect their safety and personal care, or they may leave themselves open to emotional, physical, or financial exploitation.

How can the schizophrenia sufferer best deal with positive symptoms?

For obvious reasons, there is little that a schizophrenia sufferer can do to address his or her delusions (other than engaging with mental healthcare services in general and with therapy in particular). However, there are a number of measures that he or she can take to reduce or altogether eliminate voices. These measures include,

• Keeping a diary of the voices to help identify and avoid the situations in which they arise

• Finding a trusted person with whom to discuss the voices

• Focussing attention on a distraction activity such as reading, gardening, singing, or listening to music

• Talking back at the voices: challenging them and asking them to go away. If out in public, the schizophrenia sufferer can avoid attracting attention to him- or herself by talking into a mobile phone

• Managing levels of stress and anxiety

• Taking medication as prescribed, especially antipsychotic medication

• Avoiding drugs and alcohol

How can carers best deal with positive symptoms?

Positive symptoms can be very distressing, both to the schizophrenia sufferer and to his or her carers. Carers often find themselves challenging the schizophrenia sufferer’s hallucinations and delusions, partly out of a desire to relieve his or her suffering, and partly out of understandable feelings of fear and helplessness. Unfortunately this can be counterproductive, because it can alienate the schizophrenia sufferer from his or her carers at the very time that he or she needs them most. Difficult though this may be, carers should not lose sight of the fact that positive symptoms are as real to the schizophrenia sufferer as they are unreal to everybody else.

A more helpful course of action for carers is to recognize that the schizophrenia sufferer’s hallucinations and delusions are real and important to him or her, whilst making it clear that they do not personally share in them. For example,

Person: The aliens are telling me that they are going to abduct me tonight.

Carer: That sounds terribly frightening.

P: I’ve never felt so frightened in all my life.

C: I can understand that you feel frightened, although I myself can’t hear the aliens you speak of.

P: You mean, you can’t hear them?

C: No, not at all. Have you tried ignoring them?

P: If I listen to my iPod they don’t seem so loud, and I feel a bit more calm.

C: What about when we talk together, like now?

P: That’s very helpful too.

Neel Burton is author of Living with Schizophrenia, The Meaning of Madness, and other books.

Find Neel on Twitter and Facebook

Coping with Voices

Many people with schizophrenia experience hearing voices or auditory hallucinations as psychiatrists call them. These voices are usually nasty or persecutory and can cause the sufferer enormous distress. Often the voices will be in the third person and will constantly criticise the sufferer but sometimes they may also give the person direct instructions in which case they are known as command hallucinations. (See our information sheet on Understanding Voices for more about voice hearing).

It would be wonderful if we could give some hot tips that people could use to help deal with their voices but unfortunately voices aren’t like that. As anyone who has suffered with persecutory (nasty) voices will testify, voices can often be difficult to get rid of. But it is possible to learn how to cope with the voices better or manage them so that they do not dominate your life as much.

Effects of antipsychotic medication on voice hearing

The first and most important defence you have against nasty voices is antipsychotic medication (also called neuroleptics). Modern antipsychotics are 70 % effective in relieving the voices and will often make them disappear altogether. This is about the same effectiveness as penicillin has in treating an infectious illness such as pneumonia.2

Modern atypical antipsychotic medicines for schizophrenia like risperidone do not have the unpleasant side effects of the earlier ones. (Photo: Creative Commons Attribution on Wikimedia Commons)

Antipsychotic medication can help in a number of ways. First of all it will tend to reduce the amount that you hear your voices. In addition it will reduce the compulsion that you have to engage with the voices. That is to say that you will still hear the voices but you will not feel the overwhelming need to obey them that you used to feel. Similarly with voices that are critical of you, you may feel more detached from the voices and although you will still hear what they are saying about you, you will not feel so badly affected by their criticisms.1

The third way that antipsychotics help is by reducing the anxiety that the voices cause. This is because many antipsychotics also have a mild tranquillising effect.

However one of the biggest problems that doctors face when prescribing antipsychotics is that different medicines work differently on different people. A drug that works well for one person may have little or no effect on another. For this reason it is important to cooperate with the doctor in the prescribing process and to be pro-active in monitoring your condition.

It would help the doctor if you keep a diary of how your voices are from day to day. You should note how frequent they have been during the day and also how nasty or nice they have been. It will also help if you note how strongly you have felt compelled to engage with the voices: that is to do what the voices have been telling you to do.

Keeping a diary of how your voices have been can help the doctor prescribe the best medicine for you (Image:LoloStock/)

You can take this diary along with you when you see your GP or psychiatrist but also try to sum up briefly how the voices have been recently and whether you think the medication you are on is working well or not. If you do not think it is working well do not be afraid to suggest to the doctor that they try an alternative medication or change the dose. However, do give your current medication a chance to work. Sometimes people with voices will show a marked improvement within a few weeks of starting on an antipsychotic whereas for others it may take a little longer.1

Your aim is to work with the doctor to find the medication that works best for you in relieving your symptoms and to take that medication at the minimum effective dose.

Most psychiatrists now have first hand experience of cases where two or three different drugs have been tried without beneficial effect before finding the right one that has brought about a dramatic improvement in the sufferer’s symptoms.6

Of course like all medications antipsychotics have side effects and managing the side effects is something that everyone living with schizophrenia has to learn about (see our information sheet on Managing Side Effects).

Can talking therapy help with voice hearing?

There are three types of talking therapy that can be useful in helping you to cope with your voices: counselling, support groups and cognitive behavioural therapy.

Counselling

Talking therapy like counseling is a vital supplement to medication (Image:Photographee.eu/)

One-to-one counselling with a professionally trained counsellor can be extremely helpful. Sometimes it is easier to talk about strange or bizarre thoughts or experiences with a stranger than it is with your carer or one of your relatives. Counselling is available from the National Health Service in some areas and at some other health care providers at low cost or no cost. You can find out about these services from your family doctor, the local library, or your local Mind or Rethink centre. Typically these services are easier to access in cities than in rural areas.

There are also professional counsellors who operate in private practice but they will charge for their services. They are listed in Yellow Pages and can be found on the internet. Charges are usually around £30 to £50 for an hour session. If you have difficulty funding this yourself think about applying for the Personal Independence Payment (which has recently replaced Disabled Living Allowance) from the Department of Work and Pensions. Try to use a counsellor who is a member of the British Association for Counselling and Psychotherapy which is the UK professional body for counselling. Their website includes a useful directory of counsellors across the UK.

Support groups

In some areas support groups for voice hearers are provided by the NHS or by the local branches of organisations like Mind or Rethink. They can be an extremely valuable resource for someone who hears voices but bear in mind that there are no national standards for such groups and their membership may vary from week to week meaning that some may be more useful than others.

That said a support group will give you the chance to meet with and talk about your voices and other experiences with other people who have experienced the same kinds of things. And by meeting other people with the same kinds of problems you will learn that you are not alone and that your struggle is one that others have gone through before you. You will also be able to pick up helpful tips in coping with the voices.

In addition to sharing about the voices a support group will give you the chance to discuss other sorts of problems that people living with schizophrenia face from day to day: problems with medication and side effects, problems with doctors and nurses, problems with friends and neighbours, problems with claiming benefits and with housing. All those things that can make life more complicated for someone with this condition.1

Cognitive behavioural therapy (CBT)

The other type of talking therapy that is useful is cognitive behavioural therapy which is a form of psychotherapy. Cognitive behavioural therapy cannot make your voices disappear but some people find that it is successful in helping them to control or manage their voices. CBT has been used for some years in the UK to treat a variety of mental health problems with varying results. Some studies have found very good improvements whereas others have not been as convincing. It may be that CBT is more effective with delusions than hallucinations like hearing voices.

One method involves encouraging the person to analyse the voice to try to work out whether it is coming from inside or outside their head. Another method involves the use of distraction techniques to encourage the person to resist the compulsion to engage with the voices. There is no evidence that CBT alone can cure schizophrenia but some people find it beneficial when used in conjunction with medication. There is modest evidence that CBT can help patients to manage their hallucinations and delusions when used in conjunction with antipsychotic medication.3 CBT tends to work best in people who have had their voices for a long time and find them distressing. It will have little effect in people who lack insight into their condition.

In the UK standards of care provided by doctors are laid down by the National Institute for Health and Care Excellence commonly known as NICE. From 2002 it has been part of the NICE guidelines to doctors that all people with persistent symptoms of schizophrenia should be offered CBT.

Self help for voice hearing

Distraction and occupation

Some voice hearers use headphones to distract themselves from the voices. Listening in one ear only may be even more effective (Image:Giampiero Bisceglia/)

Many people who are troubled by voices find that distraction is an effective way of managing them. Some use personal stereos or I Pods to try to drown out the voices. Some people have found that this is even more effective if they listen in only one ear at a time.

However others find that some occupation that helps to focus their mind on other things can also help. In the early stages of recovery from a psychotic episode it may be difficult to find something that you can concentrate on. Reading or watching TV may not help as those activities often feed the delusions or hallucinations, however something simple like jigsaw puzzles or a little light gardening may be a good start.

Vocalisation

Many people find that voices are less troublesome when they themselves are talking. It is thought that the act of talking somehow prevents the voices in the head being heard. So any activity that involves using the voice such as singing, humming or reading out loud can sometimes help to control the voices.10

Reality testing

This is a technique that Gwen Howe describes in her book and which was developed by one of her patients. It consist of agreeing with your carer or partner that you will tell them about the voices when you hear them and ask them if it is true. For instance if you heard a voice say: “he stinks today” you could tell your carer what the voice had said and ask them if it was true. The carer would then respond that it wasn’t true and that in any case you had showered that morning and that all your clothes were clean.

It is important in this technique that the carer is completely honest and gives the person sufficient time to discuss it. By getting constant feedback in this way about what the voices are saying you gradually over time reinforce those natural doubts that you have about the voices and begin to distrust them.

This technique is to be much preferred to the alternatives of either humouring the person with schizophrenia and not challenging their mad thoughts at all or alternatively criticising and ridiculing these ideas.4

Keeping a diary

This is an important tool in your coping tool box. Being able to assess how your voices have been each day and then at the end of the week to reflect on their effect on you will help you to understand the voices and understanding them is the essential first step in coping with them. You can discuss your diary when you meet your doctor or try to find some trusted friend or counsellor to discuss it with.7 The things you should record in your diary include:1

· How active have the voices been? Have you heard them a lot or just occasionally?
· Have the voices been critical or have they given you instructions?
· How have you felt because of the voices?
· Did anything appear to trigger particular episodes of voices e.g. stress?
· How anxious did the voices make you feel (on a scale of one to ten)?
· How compelled have you felt to carry out the voices’ instructions?
· Have you done anything risky because the voices told you to do it?
· What have you done to cope with the voices and how much did it help?

Drugs and alcohol

Using street drugs or alcohol to cope with voices doesn’t work. It may give temporary relief but it will make them worse in the long run (Image: )

We have known for some time that people living with schizophrenia will experience worse symptoms when they use street drugs. Unfortunately many people living with schizophrenia and for whom their voices are still a painful part of their life despite their medication, may resort to using alcohol or street drugs in an attempt to blunt the symptoms. This relief is only temporary and in the long term people with schizophrenia who use alcohol and particularly street drugs like cannabis will experience more relapses and will spend more time in hospital.9 You can read more about schizophrenia and drugs on our page about Schizophrenia and Street Drugs.

Relaxation

Like most of the other psychotic symptoms, voices will often get worse when the sufferer is under stress. Relaxation techniques sometimes help the sufferer by not only reducing the voices but also helping them to cope with the anxiety that goes with them.

Distrust the voices

Some therapists like to advise their clients to make friends with their voices. In our view such advice is unproductive for someone hearing persistent persecutory (nasty) voices and won’t help them to cope with their experience. It may be that some people experience voices that are benign or friendly but for someone with schizophrenia who is plagued by persecutory voices they can make their life hell. It is far better to develop a strategy of continuously questioning and distrusting the voices in order to eventually be in a position where you are controlling the voices and not the other way around.

This process of constantly questioning the voices can be surprisingly successful. Here is what Vera said about her voices: “after a while I found that the voices didn’t know the answers to the questions that I also didn’t have answers to and then I realised that they must be coming from within me. So I realised that they were only auditory hallucinations. You can also ask them a word in Chinese or the solution to a math problem that you don’t know the answer to. If the voices don’t know the answer then they must be halucinatiions.”

How effective Are these techniques?

It has to be said that although some of these techniques will be effective in the short term, voices are very skilful at “moving the goal posts” and the techniques may become less effective over time. It is therefore necessary to keep up the counter-attack against the voices by trying new techniques when this happens.

How can carers help with voices?

Talking about delusional thoughts

For a long time many people working in the field of mental health held the view that trying to challenge tenaciously held psychotic thinking was pointless. However, modern research has shown that it is in fact very productive to talk to people about their mad thoughts.5 This will enable the carer to better understand what the person with schizophrenia is experiencing and give them the opportunity to gently challenge that thinking. It is vital that carers do not collude with psychotic thinking by just humouring their loved one when they express psychotic thoughts.

Some New Developments

Repetitive Transcranial Magnetic Stimulation (RTMS)

In this method of treatment which was developed in the 1990s electromagnets are attached to the outside of the patient’s skull and thus a weak magnetic field is induced in the brain. It is painless and non-invasive and does not require sedation nor does it appear to have any significant side effects. This treatment should not be confused with electro convulsive therapy. Research work into the efficacy of this therapy for auditory hallucinations continues with some but not all studies indicating that it may be useful in reducing both the intensity and the frequency of voices. A recent study at the University of Caen in France and reported in the Daily Telegraph newspaper in the UK in 2017 11 indicated very favourable results in reducing voices albeit in a fairly small number of participants.

The American psychiatrist Edwin Fuller Torrey estimates that one RTMS treatment may be effective in reducing voices for up to three months following treatment 12 however other studies have found that the effect may be much shorter-lived. This is another treatment that is currently showing some promise but requires much more extensive research before we can be sure about it.

Avatars

One new development in the field of treating voices was made in the UK in 2017 by a team of researchers from Kings College and University College in London17 and involved the use of Avatar therapy for people who still hear voices despite their medication. In this method computer technology was used to enable the study participants to create a visual representation of the entity represented by their voices. This entity could be human or non-human. Using feedback from the patient the technology is able to mimic fairly closely the gender, tone and accent of the person’s voices. The participant can then use this image on the screen to practice interacting with the voice and with the aid of a therapist develop ways of resisting them; ultimately if possible gaining the upper hand.

A number of the patients in this study found that after this therapy their voices became less frequent and they experienced less distress caused by their voices. This was a fairly small study of only 142 participants but the research team included eminent scientists in this field and it did indicate that further work to explore this method would be justified.

1. Author’s personal experiences.

2. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial p181.

3. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial. p207.

4. Howe G, 1986, Schizophrenia a Fresh Approach, David and Charles, P90.

5. Warner R, 2000, The Environment of Schizophrenia, Brunner Routledge, P32.

6. Cutting J and Charlish A, 1995, Schizophrenia, Thorsons, P168.

7. Burton N, 2012, Living with Schizophrenia, Acheron Press, P78.

8. Reveley A, 2006, Your Guide to Schizophrenia, Hodder Arnold, P66.

9. Burton N, 2012, Living with Schizophrenia, Acheron Press, P18

11. Scientists identify part of the brain that makes schizophrenia sufferers hear ‘voices’, Daily Telegraph 5th September 2017, viewed on line 3rd August 2018 at https://www.telegraph.co.uk/news/2017/09/05/scientists-identify-part-brain-makes-schizophrenia-sufferers/.

12. 2013, Edwin Fuller Torrey, Surviving Schizophrenia, p204

17. Craig T, Rus-Calafel M, Ward T, Leff J, Howarth E, Emsley H, Garety P. AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial, published in Lancet Psychiatry January 2018.

©Living with Schizophrenia, August 2018.

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Coping Skills For Delusions

In my previous article, I discussed coping strategies for hallucinations. In this article, I will describe the coping skills used to handle the delusions with Schizophrenia.

Distraction

According to www.everydayhealth.com, distraction is the first coping skill to handle delusions with Schizophrenia. Like experiencing hallucinations, when you are experiencing delusions distract yourself from the delusions. Do not fixate on them. Distract yourself from them. Focus on something else. Watch a television show or listen to music. In simple terms, gear your attention away from the delusions.

Ask For Help

In addition to distracting yourself from the delusions, according to www.everydayhealth.com ask for help if you are experiencing delusions. Sometimes talking to a friend or family member about your delusions can be helpful. In addition, according to www.everydayhealth.com , if you seek help from a licensed provider consider cognitive therapy.

Control Your Surroundings

In addition to distracting yourself from the delusions and asking for help from a friend or family member or even a licensed provider, according to www.everydayhealth.com consider controlling your surroundings when you experience delusions. If you experience delusions all the time in a certain area of your home, consider changing rooms. In addition, if you continue to experience delusions in the same public place all the time, avoid that public place. Experiment. Try going to another public place until you do not experience delusions.

Exercise

In addition to distracting yourself from the delusions, asking for help, and controlling your surroundings, according to www.everydayhealth.com consider exercising when you are experiencing delusions. You do not have to do strenuous activity like a marathon. However, start slow. Go for a 20 minute walk outside to distract yourself from the delusions. If you do not want to exercise outside, consider stretching or doing yoga in your room or living room. Either way distract yourself from the delusions. And more importantly, keep moving.

To end this article, four coping strategies have been mentioned for individuals with Schizophrenia. They include distracting oneself from the delusions, asking for help from family or friends or a licensed professional, controlling your surroundings, in addition to exercising. On an important note, if you have Schizophrenia and are experiencing delusions always keep moving. If that is exercising great. You can engage in any form of exercise that keeps you moving. Better yet, do your chores around the house. This will keep you distracted and focused away from the delusions and on your task.n

Coping Skills For Delusions

Simple coping strategies for people who hear voices

Abstract

VOL: 99, ISSUE: 47, PAGE NO: 38

Charlie Place, RMN, is community mental health nurse, South Leeds Intensive Home Treatment Team, Leeds Mental Health Trust

Many mental health nurses find themselves caring for people troubled by voices. Research has found high levels of distress among people who have limited control over the voices and few coping strategies (Nayani and David, 1996). It is the role of professionals to help them (Knudson and Coyle, 1999).

There is a range of simple psychological interventions that can be used to help people who hear voices, yet somehow such techniques seem to be rarely used by mental health nurses. The strategies described in this article are practical and effective, and can be used even in a chaotic acute environment.

Psychological treatments

According to the National Institute for Clinical Excellence (NICE), psychological treatments for psychosis ‘should be an indispensable part of the treatment options available for service-users’ (NICE, 2002). The most common form of psychological treatment is cognitive behavioural therapy (CBT) (British Psychological Society, 2000), and NICE has recently decreed that anyone with persistent psychotic symptoms should be offered CBT (NICE, 2002). There is a clear evidence-base in psychological therapy for using symptom-specific interventions, as they routinely form part of CBT (Nelson, 1997), humanistic counselling (Knudson and Coyle, 1999) and approaches that are based on social psychiatry (Romme and Escher, 2000).

If these simple coping strategies provide such a good opportunity to introduce people who hear voices to psychological treatment, why do mental health professionals not encourage the use of them? There may be two particular reasons. One is that nurses are still afraid to talk openly to people about hearing voices; it is as if they feel that doing so will open a Pandora’s box. A second reason may be that nurses do not know about the strategies that could be used. A recent report highlighted that many mental health workers are unaware of the advances that have been made in understanding psychosis, and that training in psychological approaches is needed (British Psychological Society, 2000).

Coping strategies for people who hear voices do not appear to be routinely taught to nursing students, and the emphasis of postgraduate training in psychosocial interventions lies elsewhere. Moreover, the literature that describes these techniques can be complex, written in an academic style and hard to access.

Symptom-specific interventions

Recent research has shown that voices are heard by many people who do not have mental health problems, and that hallucinations are considered normal experiences (Romme and Escher, 2000, Johns et al, 2002). Hearing voices can be triggered by bereavement, trauma, depression and sexual abuse. The view that voice-hearing is associated with a diagnosis of schizophrenia is becoming outdated, and a symptom-specific approach represents a profound change in mental health care. Many mental health nurses will welcome this shift of emphasis from diagnosis-led treatment to a system of problem-solving for the individual patient.

It is important to note that these simple techniques to help people cope do not represent a comprehensive therapeutic programme for people troubled by voices. Research suggests that people’s beliefs about the voices they hear and the power of those voices may be the most important factor in the degree of distress they experience (Chadwick and Birchwood, 1994). The simple techniques outlined in this article do not address such fundamental issues directly. Rather, they can be classed as ‘distraction techniques’, as opposed to techniques that focus on the voices (Haddock et al, 1998).

Focusing on the voices, listening to what they say, and engaging with them are probably necessary if those who hear them are to be able to address their difficulties (Davies et al, 1999). But research also shows that they become increasingly distressed if they feel they cannot control the voices (Johns et al, 2002). However, Nayani and David (1996) showed that increased control over the voices, coping with the experience, gaining insight into the problem and reduced distress tend to go together.

The interventions described here are straightforward, easy to understand and explain, and can be used by people outside of structured therapy. They are therefore suitable in any nursing environment and with people who are experiencing severe distress. Importantly, the techniques do not directly challenge a person’s own beliefs about the origin of the voices. For example, if a person believes that the voices come from existing independent beings of some kind, for example, God, devils, evil spirits, ghosts, invisible people or dead relatives, the techniques can be suggested without threatening those beliefs. Thus, the interventions are therapeutically safe.

Some of the coping strategies described may appear ridiculously simple; one of them, for example, involves simply talking to people. However, it is important that both the nurse and the person hearing the voices understand and acknowledge even the most basic coping strategy. The aim should be that those who hear voices develop a range of techniques that they can consciously employ to manage them.

All people have coping strategies, but the more understanding they have of them the more effectively they can be used. The role of professionals who work with people who hear voices is to help them gain more control over their voices (Knudson and Coyle, 1999).

Not all people who hear voices will find a particular technique effective. For example, some may find that wearing an earplug makes no difference whatsoever, while others will find it useful. It is important to emphasise this when explaining the interventions. Therefore, rather than making promises, such as saying: ‘Wearing an earplug will stop your voices,’ the nurse should say that it may help: ‘Some people find that wearing an earplug can help them cope with their voices.’

Many individuals find that the effectiveness of a particular technique wears off over time as the voices ‘shift the goal posts’. Finally, the nurse should remember that the voices may command the person to stop using a particular technique or forbid them to try it.

The strategies suggested below can be included in care plans for ward-based or community work.

Some simple interventions

Social contact

For most people who hear voices, talking to others reduces the intrusiveness or even stops the voices. Being around friendly faces and spending time with people can be very effective at pushing voices into the background. Thus when people troubled by voices seek out nurses or fellow patients to talk to, this may be a coping strategy. If a person is clearly distressed by voices and unable to discuss this, a nurses could try approaching the individual and talking to him/her. The reasons why social contact helps a person hearing voices may be complex, but many factors are involved, including distraction, vocalisation and reassurance from the presence of others. Some particular interventions that involve social contact are shown in Box 1.

Vocalisation

Research shows that ‘sub-vocalisation’ accompanies auditory hallucinations (Bick and Kinsbourne, 1987). By this the authors mean that people use their own vocal cords when they hear voices. There is associated evidence that the physical act of talking – or using the vocal cords in other ways, such as singing – interferes with the process that creates voices, thus reducing the intensity of the hallucinations. Any vocal activity may therefore help. This could be singing, humming, counting, talking, reading out loud or sub-vocal speech. The latter involves talking quietly so that others cannot hear. Simply holding open the mouth can stop the sub-vocalisation and therefore stop the voices.

Singing under the breath is also possible, and for some people who hear voices this may be easier to sustain than talking sub-vocally. The key point is that different strategies will be suitable for different people in different situations; for example, reading out loud can be used in the privacy of a quiet room, while humming will be more appropriate when other people are around. People with religious faith often use prayer effectively. Examples of vocalisation interventions are shown in Box 1.

Listening to music

Listening on personal stereos to music or to the spoken word on the radio is a well-established way of reducing the frequency of auditory hallucinations. Almost all people who hear voices gain some respite using this technique. This may be because they switch attention from the voices they are hearing in their head to the music on the stereo or to the voices on the radio, or it may be because listening to music reduces stress. The more relaxing or pleasant the listener finds the music (or the more interesting the speaker/s), the greater the benefit should be to the individual. There is some evidence that aggressive music or violent lyrics can lead to increased levels of agitation (Nelson, 1997).

Wearing earplugs

Wearing an earplug in one ear (monaural occlusion) has been shown to be helpful to many people who hear voices. On initial use, it can reduce voice activity by nearly 50 per cent. The nurse may suggest experimenting to see which ear is the more effective. By wearing one earplug rather than two, the person is able to continue with normal social activities such as being able to hear other people, or the telephone, for example.

Some individuals find that the earplug seems to become less effective as a technique after some time. Another difficulty is that the earplugs may be uncomfortable, or the person feels self-conscious using one in public. However, earplugs work well for people whose voices are particularly troublesome at night.

Concentration

Concentrating on something other than the voices will often help to obscure them. The focus can be on whatever is convenient or appropriate. The vital factor is the degree of the person’s interest or enjoyment in the activity. Puzzles or games can be effective, particularly word games, such as Scrabble, or puzzle books.

Craft activities can also be introduced as coping strategies. Computer games can be very useful, and have the additional advantage of being part of the culture of younger people. If these types of activities are available in an inpatient environment, people can try them out for themselves.

Some people use household tasks, such as doing the washing-up or the laundry, as coping strategies.

One strategy involving concentration is called ‘Stop and name’: the voice-hearer says ‘Stop’, looks around the immediate environment then names the objects that can be seen, for example ‘chair’, ‘television’.

Relaxation

Listening to a relaxation tape involves auditory stimulation and distraction, and encourages the person to concentrate on carrying out the exercises, thereby reducing anxiety and contributing to a reduction in the intensity of the auditory hallucinations.

Many people who hear voices find them particularly problematic at night; therefore playing relaxing music or a relaxation tape at bedtime can be helpful.

Aromatherapy, massage and other relaxation techniques such as having a long soak in the bath can also help, as can exercise.

Identifying appropriate strategies

People who hear voices can usually identify particular situations, or times, when they find it most difficult to cope with them. These may be at night, in the afternoon, in a busy public place or when alone at home. Different coping strategies may be appropriate on different occasions. For example, some people who use an earplug at home or sing to themselves may feel self-conscious about doing this in public. Furthermore, talking to others may not be useful if the voices are troublesome at three o’clock in the morning, when potential conversation partners are asleep.

However, people can be helped to identify interventions that they can use on different occasions when the voices are distressing. An individualised ‘menu’ of interventions can be devised, built around the person’s most effective coping strategies. The interventions can be written on a card that can be carried in a pocket so that when the voices are difficult the person tries an intervention from the menu. The suggested interventions will often be very simple (Box 2). This method can address specific problems, such as voices that wake the person at night, voices occurring in a specific situation or the onset of a particularly distressing voice.

The discussion of coping strategies must be on an individual basis, and identifying the antecedents of voices is a vital factor in helping the individual cope effectively (Knudson and Coyle, 1999).

The nurse’s role

The simple strategies outlined here can also be used by nurses with very acutely distressed people who are not able to discuss their experiences; those in psychiatric intensive care for example. Of course, many of the interventions will already form part of good nursing care.

There are many ways in which this approach to working with voices is valuable. Most importantly, the patient takes the lead in deciding which techniques to try, and which work. The professional’s role is to encourage and support, taking the person’s experiences at face value and helping him/her along the path to becoming the expert in managing the voices.

This approach does not require the mental health nurse to subscribe to any particular set of beliefs about voices, or to any particular theoretical framework. It is irrelevant whether the nurse accepts the medical orthodoxy on auditory hallucinations, rejects it, or has no opinion at all. What matters is that there are simple interventions available that can help people to manage their own symptoms and to gain in understanding and confidence. The process involves open discussion and acceptance of the experience of voice-hearing. It is an excellent example of the pragmatic person-centred care that is at the core of good mental health nursing.

Conclusion

It is acknowledged that people who hear voices have high levels of distress. However, many could be helped to manage these by being made aware of some simple psychological interventions that can be used at any time and anywhere. They are therapeutically safe because they do not challenge the person’s beliefs about the origin of the voices. Furthermore, they do not require that mental health nurses subscribe to any particular beliefs about them. Because the strategies are introduced on an individual basis they are a means of offering person-centred care.

FURTHER INFORMATION

The Hearing Voices Network

91 Oldham Street

Manchester M4 1LW

Telephone 0161 834 5768.

The British Psychological Society report, Recent Advances in Understanding Mental Illness and Psychotic Experiences. It is available at www.understandingpsychosis.com

– This article has been double-blind peer-reviewed.

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