Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 8, 136147 (2001)

Practitioner Cognitive Therapy

Report
for Auditory
Hallucinations as an
Alternative to
Antipsychotic
Medication: A Case
Series
Anthony P. Morrison1,2 *
1
2

Psychology Services, Mental Health Services of Salford, Manchester, UK

Department of Psychology, University of Manchester, UK

Antipsychotic medication is the main focus of current treatment

approaches to schizophrenia and psychotic symptoms. However,
there are some disadvantages to such treatments including sideeffects, non-response and non-compliance. Cognitive behavioural
interventions have been employed successfully as an adjunct to
medication, and two case studies suggest that such interventions can
be of benefit to patients as an alternative to antipsychotic medication.
Four patients received cognitive therapy for auditory hallucinations
as an alternative to antipsychotic medication and were assessed
weekly used a semi-structured interview that quantifies dimensions
of psychotic symptoms. Measurements occurred over a two week
baseline period, during intervention and at follow-up. Three of the
four patients seemed to find the treatment acceptable. Two patients
achieved significant decreases in conviction, distress and frequency.
Cognitive therapy may be a useful alternative to medication for
auditory hallucinations. A more controlled evaluation is required.
Copyright 2001 John Wiley & Sons, Ltd.

INTRODUCTION
Antipsychotic drugs continue to be the treatment
of choice for schizophrenia, although they have
certain difficulties associated with their use. A proportion of patients will continue to experience

* Correspondence to: Dr. Tony Morrison, Psychology Services, Mental Health Services of Salford, Bury New Road,
Manchester M25 1BL, UK.
E-mail: tmorrison@psychology.mhss-tr.nwest.nhs.uk

Copyright 2001 John Wiley & Sons, Ltd.

DOI: 10.1002/cpp.269

symptoms despite drug therapy, and 6070%

will relapse within two years (Ram et al., 1992).
In addition, distressing side-effects are common.
There are also significant difficulties associated
with patients compliance with such antipsychotic medication (possibly as a result of the
combination of unpleasant side-effects and ineffectiveness for some individuals, see Hoge et al.,
1990).
Recent studies examining cognitive behaviour
therapy (CBT) with this client group have shown

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Cognitive Therapy for Auditory Hallucinations

it to be effective in reducing residual positive
symptoms on an outpatient basis, and maintaining
these gains at follow-up (Tarrier et al., 1993; Garety
et al., 1994; Chadwick and Birchwood, 1994; Kingdon and Turkington, 1991). CBT has been shown
to be superior to other psychological treatments
such as supportive counselling (Tarrier et al., 1998)
and to treatment as usual involving case management and antipsychotic medication (Kuipers et al.,
1997) and routine psychiatric care (Tarrier et al.,
1998). A reduced stay in hospital (by 54% in comparison with control group) has also been shown
for CBT of acute schizophrenic patients (Drury
et al., 1996) and recovery time for symptom reduction was also improved, suggesting that CBT is
of benefit for in-patients as well as outpatients.
Therefore, it appears that CBT methods can be
used to promote symptom reduction and reduce
time spent in hospital, as well as promoting relapse
prevention.
Whilst CBT has been shown to be superior
to standard psychiatric care, the specific benefits
that it yields are less clear; this is particularly
the case for patients experiencing auditory hallucinations. Kuipers et al. (1998) found that global
symptomatology was significantly better at end of
treatment, but that hallucinations and delusions
did not become significantly better until 18 month
follow-up. Tarrier et al. (1993) found that hallucinations did not improve significantly whereas
delusions did, and this is consistent with the difficulties found in another study examining CBT
for hallucinations (Haddock et al., 1998). However, Chadwick and Birchwood (1994) reported
encouraging findings using cognitive therapy for
voices and Tarrier (1999) reported that CBT produced a greater change in hallucinations than
delusions in comparison with supportive counselling.
Given the difficulties outlined in relation to
antipsychotic medication, it may be important to
assess the effectiveness of cognitive behavioural
interventions for psychotic symptoms in the minority of patients who are unable to tolerate such
medications, who do not benefit from such medications or who are non-compliant with such medications. In addition, the delivery of such services and
approaches to psychosis is consistent with service
users views as identified by Hansson et al. (1995)
and current healthcare policy regarding promotion
of choice for service users.
There is some evidence to suggest that cognitive
therapy for auditory hallucinations can produce
clinically significant benefits in patients who are
Copyright 2001 John Wiley & Sons, Ltd.

not currently receiving antipsychotic medication.

Morrison (1994) reported a single case study in
which a 38 year old patient with a diagnosis
of schizophrenia, not currently on any medication (because of past unpleasant side-effects and
ineffectiveness), received cognitive therapy for her
auditory hallucinations. Significant decreases in
conviction, frequency and distress associated with
the voices were achieved and these gains were
maintained at follow-up. Chadwick and Birchwood
(1994) reported a case of a 34 year old woman with a
diagnosis of schizoaffective disorder who received
cognitive therapy for her voices in the absence of
any medication. Conviction in her beliefs about the
voices was considerably weakened, and her psychiatrist also noted improvements in mood, confidence
and self-initiated behaviour. This study aims to further investigate the acceptability and effectiveness
of cognitive therapy for auditory hallucinations
as an alternative to antipsychotic medication in
patients who are unable or unwilling to take such
medication or patients for whom such medication
is ineffective.

METHOD
Subjects
Four patients were referred for cognitive therapy
for their auditory hallucinations. Details regarding
the patients age, source of referral, diagnosis
(using DSM-IV criteria, APA, 1994), length of
illness, reasons for not being on any antipsychotic
medication, antipsychotic medication history and
current medications are given in Table 1.

Measures
PSYRATS AH Subscale (Haddock et al., 1999)
A clinician administered a semi-structured interview consisting of 11 items assessing dimensions
of auditory hallucinations. All items are scored 0
to 4, with higher scores indicating more severe
phenomena. The items assess frequency, preoccupation, location, loudness, conviction, amount of
unpleasant content, severity of unpleasant content,
amount of distress, intensity of distress, degree of
impairment and control. All 11 items have good
inter-rater reliability (coefficients were all greater
than 0.78) and the scale total was significantly
associated with the hallucination item from a commonly used psychiatric assessment, demonstrating
Clin. Psychol. Psychother. 8, 136147 (2001)

138

A. P. Morrison

Table 1. Descriptive information regarding patients

Patient Age

Referral
Source

DSM-IV
Diagnosis

Length of
Illness

58

consultant
psychiatrist

schizophrenia

21 years

38

S. R. in
psychiatry

schizoaffective

16 years

75

consultant
psychiatrist

schizophrenia

55 years

57

general
practitioner

schizophrenia

9 months

some validity (Haddock et al., 1999). Whilst the

scale has empirically derived subscales consisting
of emotional characteristics, physical characteristics
and cognitive interpretations, it was decided to
present the results using composite measures for
some dimensions of the patients voices: the distress
and disability composite measure was created by
summing the scores for amount of distress, intensity of distress and amount of impairment, and the
frequency composite was created by summing the
frequency and duration scores. These provide data
that are clinically more meaningful at the level of
individual cases.

Procedure
All patients were assessed over the first two weeks
using the PSYRATS AH subscale and a cognitivebehavioural interview. The baseline measures were taken during this period. Active intervention commenced at session three. Patients were
offered time limited contracts which were renewed
or not as a result of negotiation between therapist
and patient (patient A was offered ten sessions,
patient B was given two six session contracts,
patient C was offered six sessions but decided that
he did not want any further involvement after
only five sessions and patient D was offered two
ten session contracts). All patients were offered
booster sessions, which were used to consolidate
treatment gains and to collect follow-up data at two
weeks and six weeks after termination of therapy.
In addition, patient D was followed up at 12 weeks
Copyright 2001 John Wiley & Sons, Ltd.

Reason for
no Current
Antipsychotic
Medication
failure to respond
to all typical
and atypical
antipsychotics
tried
adverse reaction
to antipsychotic
medication
adverse reaction
to antipsychotic
medication
refusal to take
antipsychotic
medication

History of
Antipsychotic
Medication

Current
Medication

5 oral typicals, 2
depot, 2
atypicals (inc.
clozapine)

none

3 oral typicals,
sulpiride

lithium

trifluoperazine

none

none

none

post-therapy. All ratings were made by the therapist who has been trained specifically in the use of
the PSYRATS scales.
The choice of intervention strategies was determined by an individual formulation of the patients
voices and the responses to their voices that was
based on the cognitive approach to auditory hallucinations outlined by Morrison et al. (1995) and
Morrison (1998a). The intervention is based on
the assumption that a combination of the interpretations of voices and the content of voices
cause the majority of the distress and disability associated with voices and that metacognitive beliefs (beliefs that people hold about their
mental processes) are implicated in the development of hallucinations. This approach also assumes
that mood, physiology, safety behaviours, selective attention and other cognitive and behavioural
responses are involved in the maintenance of hallucinatory experiences. Common strategies included
examining the interpretations of voices, challenging the content of voices and modifying focus of
attention. The intervention was based on the general principles of cognitive therapy (Beck, 1976;
e.g. problem orientated, time-limited, educational,
use of the Socratic method). Each session followed the recommended structure of cognitive
therapy (e.g. setting an agenda, reviewing homework, specific session targets, eliciting feedback and
collaboratively setting new homework in relation
to the session content). A more detailed description of the clinical strategies used and the overall
structure of therapy can be found in the work
Clin. Psychol. Psychother. 8, 136147 (2001)

Cognitive Therapy for Auditory Hallucinations

of Morrison (1998b), but a brief description of
the elements of therapy for each of the cases
follows.

Case A
A believed that his voices were coming from outer
space and that he was able to hear them because
of a receiving device that had been planted in his
neck. The content of the voices was insulting (often
calling him a bastard and racially abusing him).
The voices also commented on world affairs (particularly when he was reading a newspaper). He
also experienced delusions of reference, believing
that people were talking about him and that people could read his mind. Largely because of these
psychotic symptoms, he had considerable levels
of anxiety and depression. At initial assessment,
he identified these concerns on his problem list,
and he prioritized the voices as being the most
important (he also put a number of physical aches
and pains on this list). The goals that were set
in relation to his voices were to reduce the distress associated with them and/or the frequency
of them and/or the degree of conviction that he
had in them being externally generated. Formulation was based on the cognitive models of auditory
hallucinationhe interpreted his voices as being
of malicious intent, believing that the aliens were
trying to torture him. This interpretation, in combination with the unpleasant content (that at times he
agreed with), appeared to account for the majority
of his distress. On this basis, intervention consisted
of attempting to challenge his interpretation by
reviewing evidence, attempting to generate alternative explanations (such as stress), manipulating
his responses to the voices as behavioural experiments to test different predictions and helping him
to challenge the content of the voices. The intervention was unsuccessfulthis could be related to
his hopelessness and pessimism, which interfered
with homework compliance and it also appeared
that the chronicity of his difficulties and their past
consequences also interfered (he had lost his job,
his relationship and contact with his family because
of thisit could be speculated that this would be
difficult to accept if he were to become symptom
free).
Case B
B believed that his voices were from his father.
They were often very critical in content, frequently
challenging decisions that he made and suggesting
the opposite course of action. At assessment, he
reported his concerns to be largely related to the
Copyright 2001 John Wiley & Sons, Ltd.

139
experience of these auditory hallucinations, viewing them as causing much distress. He also believed
that he was able to read minds at times, and occasionally experienced ideas of reference concerning
messages from the television. He identified the
voices as his number one priority on his problem
list and goals were set in relation to this in a similar
manner as for case A. A review of his life history indicated that the onset of his psychosis had
been in a period when he experienced several life
events within one month of each other and also
had severe sleep disturbances. He typically interpreted his voices as being his father, although he
sometimes thought they might be aliens or related
to his thoughts. He viewed them as unfriendly,
and this appraisal had consequences emotionally
(annoyed, irritable, angry), physically (muscle tension, sleep difficulties), behaviourally (talking back,
trying to shut them up by suppressing) and cognitively (poor concentration, pre-occupation and
confusion). This information was collaboratively
developed into a formulation, and it was hypothesized that these reactions could contribute to the
maintenance. He agreed that the distress resulted
from his interpretation of the voices, and therefore
the initial target for intervention should be this.
Alternative explanations for the voices were generated within session and the evidence for and against
each were reviewed (including the content of the
voices from the weeks diaries and how compatible
modulators were with each explanation) and belief
ratings were taken for each. Education about normal thought processes and intrusive thoughts were
used to facilitate reattribution to an internal source,
as was exploration of the links between his previous experiences and the content of the voices, and
his relationship with his dad and how this might
be connected with the critical nature of the voices.

Case C
C identified three major concerns at assessment.
These were his voices (which he believed to be
a young Irish woman who was sexually attracted
to him), touching sensations in his genital region
(which he believed to be the woman touching
him intimately) and anxiety regarding a forthcoming operation for cancer. The sessions with him
were used to gather information about the voices
from diary measures and to begin to examine the
nature of his interpretations of his voices (alternative explanations that were generated following
psychoeducation included them being caused by a
knock on the head some 55 years ago, his imagination, his thoughts, sleep deprivation and stress).
Clin. Psychol. Psychother. 8, 136147 (2001)

140
Diary measures indicated that attempts at suppression of the voices proved counter-productive,
so he was encouraged to experiment with this,
alternating focusing (see Haddock et al., 1998) with
suppression. The diaries also indicated that the
voices were exacerbated by low mood, so activity
scheduling was also encouraged. He was also asked
to identify worries about his operation so that these
could be dealt with, but he denied having any.
However, at this point he cancelled a couple of
appointments and then requested that no further
appointments be sent.

Case D
D had been hearing two abusive and persecutory
male voices for the past year. He had associated
delusions of persecution, believing that the voices
were real people intent on causing him harm. D
avoided going out of the house as he feared being
assaulted, but sometimes did escape from the house
if he feared an imminent attack from the voices
(usually based on what they were saying). When
he did go out he was extremely wary (and often
drank alcohol in an attempt to remain calm). He
also reported panic attacks when concerned about
being attackedthis appeared to be linked to his
alternative interpretation of the voices, which was
that he is losing his marbles. This information
was incorporated into a formulation for a recent
specific incident and then used to generate a
more general formulation. Intervention with D
was based upon such a cognitive formulation.
Alternative explanations were generated for the
appraisal of his voices; thus, in addition to them
being real persecutors or a sign that he was going
mad, the possibilities that they were stress related,
related to a traumatic road accident in which
he had been involved or related to strong pain
relieving medication he had taken in the past were
considered. The evidence for and against each of
these possibilities was also considered. Clearly,
when generating alternatives and examining the
evidence, it was important to provide education
regarding the frequency of voice hearing, the fact
that certain stressors can induce hallucinations
and the fact that hearing voices is not always
associated with mental illness. The content of the
voices was monitored using shadowing in sessions
and diaries between sessions, and this content was
examined with regard to its consistency with each
of the explanations. It was agreed that it would
be useful to provide a test of the most distressing
appraisal, which was that there were real people
attempting to persecute him. He decided that an
Copyright 2001 John Wiley & Sons, Ltd.

A. P. Morrison
appropriate experiment would be to cease all of his
safety behaviours that were designed to prevent
him being attacked (such as sitting near the door
and checking in the attic or under floorboards
for the potential assailants), and to sit still in his
house and wait for one hour to see if they did
come to attack him; it was particularly important
to stop the safety behaviours as they appeared
to have prevented cognitive change in the past.
In other words, he attributed the fact that he
had not yet been attacked to having performed
these behaviours in the past. It seemed that
modifying the interpretation of the voices reduced
the distress associated with the experience. Another
method that was employed to reduce distress and
conviction was using a modified DTR to challenge
the content of the voices on an ongoing basis; Mr
D was encouraged to examine the evidence for
and against what the voices said, and to record his
associated mood (this appeared to be particularly
effective in altering his emotional response when
the voices were being abusive and insulting about
him as a person). These rational responses to his
voices were practised in session using role-play
(with the therapist modelling appropriate verbal
challenges initially). He was also helped to work
with some of the other problems he identified
on his problem listthese included relationship
difficulties, low mood and alcohol abuse (the latter
was also targeted as a safety behaviour in relation
to his interpretation of the voices as meaning he
was about to go madhe drank to stay calm and
avoid this possibility.

Factors Specific to Cognitive Therapy with

Unmedicated Patients
There are actually surprisingly few adaptations
or differences for using cognitive therapy with
patients who are not receiving antipsychotic medication. Pessimism and hopelessness can be a factor
because of the failure of medical approaches in
the past; however, this is not uncommon in all
people with serious mental illness (see Birchwood
et al., 1993). Thus, some increased emphasis on
the assessment and treatment of such factors is
useful in working with unmedicated patients, but
this should possibly be stressed more for all psychotic patients receiving cognitive therapy. With
these four cases described above, only for case A
did hopelessness interfere significantlythis could
have been addressed explicitly, assessed using the
Beck Hopelessness Scale (Beck et al., 1974), and the
evidence for such beliefs examined closely. Alternative explanations for previous lack of change
Clin. Psychol. Psychother. 8, 136147 (2001)

141

Cognitive Therapy for Auditory Hallucinations

could be generated, behavioural experiments targeting very small improvements could be used and
the importance of early success in therapy could
have meant focusing on more easily achievable
goals initially. Engagement can also be a difficult
issue with people experiencing psychotic symptoms, but, again, this is not specific to unmedicated
patients. This was problematic with case C only,
and it is unlikely that this was related to his
being unmedicated; rather, he probably had more
pressing concerns that he did not see as being
amenable to psychological intervention (his cancer). Therefore, the lack of a shared agreement
about problems and goals may have accounted for
his decision to terminate therapy. In general, cognitive therapys focus on shared problems and goal
lists, collaboration, guided discovery and a shared
understanding of the development and maintenance of problems seemed to help engage the other
patients.
Working with patients who are not receiving
medication can in some ways be easier. There
is no possibility of medication being used as
a safety behaviour (e.g. If I hadnt taken extra
tablets I would have been possessed by the devil),
there are no side-effects to contend with (some of
which can interfere with therapeutic progress, e.g.
poor memory or concentration) and there is no
possibility of patients attributing their own success
experiences to medication (therefore facilitating an
increased perception of control).

RESULTS
In analysing the data, composite measures were
used for some dimensions of the patients voices;
the distress and disability composite measure was
created by summing the scores for amount of
distress, intensity of distress and amount of impairment, and the frequency composite was created by
summing the frequency and duration scores. The
ratings concerning the distress and disability, frequency, conviction and control in relation to the
patients voices are shown in Figure 1.
The total PSYRATS (AH Subscale) scores for each
patient at baseline, end of treatment and six weeks
follow-up are shown in Table 2.
An attempt to assess the clinical significance of the
changes observed was also made. The proportions
of patients scoring within a range that would
seem to represent minimal frequency, distress and
impairment pre- and post-treatment are shown in
Table 3.
Copyright 2001 John Wiley & Sons, Ltd.

CONCLUSIONS
It would appear that cognitive therapy for voices
is an acceptable treatment as an alternative to antipsychotic medication (only one of the four patients
dropped out, and that appeared to be because
he was extremely preoccupied by major surgery
that was due to be performed in the near future).
In addition to being acceptable, it appears that a
proportion of patients receiving cognitive therapy
as an alternative to antipsychotic medication can
achieve clinically significant gains. In particular,
two of the four patients achieved significant
reductions in frequency of voices, the distress and
disability associated with the voices and conviction
in the belief that their voices were real (indeed,
one of the patients was free of voices for the
last four weeks of therapy and at all follow-up
appointments). Such findings are consistent with
those from the case studies reported by Chadwick
and Birchwood (1994) and Morrison (1994). It
appears that cognitive therapy can increase the
perception of control over voices for some patients
not on antipsychotic medication. An increase in
perceived control over illness could be important
clinically as it has been found to be associated with
depression and suicidal ideation (Birchwood et al.,
1993). It is also worth noting that cognitive therapy
did not appear to produce any significant increases
in any of the patients symptomatology.
This data is clearly only a preliminary step
towards evaluating the efficacy of cognitive therapy
as an alternative to antipsychotic medication, and
more thorough investigations are clearly required
as a number of possible factors could account for
some of these results (for example, spontaneous
recovery or non-specific factors such as contact
time). The baseline period was short (only two
weeks) and future research should incorporate
longer baselines to control for some of these factors
and would also allow the application of appropriate statistical techniques (such as interrupted
time series analysis; Crosbie, 1993). In addition,
ratings were conducted by the therapist and therefore were not blind or independent. However, it
is also worth noting that the two patients who
showed no response to CT had chronic histories
and one of them had been tried on a huge variety
of medications (none of which had any effect) and
had also received previous CBT with no response;
therefore it is possible that CT as an alternative to
medication may be more effective in a less chronic,
drug-resistant population. The small number of
patients within this study also makes the findings
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A. P. Morrison

Figure 1. PSYRATS AH ratings for each patient

Copyright 2001 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 8, 136147 (2001)

Cognitive Therapy for Auditory Hallucinations

143

Figure 1. (continued)

Copyright 2001 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 8, 136147 (2001)

144

A. P. Morrison

Figure 1. (continued)

Copyright 2001 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 8, 136147 (2001)

Cognitive Therapy for Auditory Hallucinations

145

Figure 1. (continued)

Copyright 2001 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 8, 136147 (2001)

146

A. P. Morrison

Table 2. Total PSYRATS (AH) scores

Total PSYRATS
(AH) scores
CaseA CaseB CaseC CaseD
Pre
Post
Follow-up

31
32
32

33
22
17

32
33

34
0
0

Table 3. Percentage of patients meeting criteria for

minimal pathology status
Criteria for minimal N (%) of patients N (%) of patients
pathology status
pre-treatment post-treatment
Voices occur once
a week or less
Voices cause mild
distress or less
Voices cause
minimal
impairment or
less

0 (0)

2 (50)

0 (0)

2 (50)

1 (25)

3 (75)

difficult to interpret; larger numbers of unmedicated or neuroleptic-naive patients would have

improved this study but there are very few such
patients in routine psychiatric services. Despite
these methodological weaknesses, these initial findings are mildly encouraging and could be used to
justify a more controlled evaluation of cognitive
therapy as an alternative to antipsychotic medication (particularly given some of the difficulties
associated with traditional antipsychotics such as
non-compliance, unpleasant side-effects and nonresponse).

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