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By Aaron T. Beck, MD, and Molly R. Finkel, MSEd

Where do the harsh, persecutory voices experienced by individuals with serious mental illness emanate from? We suggest that the harsh voices and paranoia may be learned from experience as vulnerable individuals monitor the commands and criticisms from one’s family and societal/cultural groups. Alternatively, they may be embedded from our mammalian heritage and re-activated by one’s current circumstances. In order to obtain acceptance from one’s family, as well as group acceptance, the individual needs to conform to family or group norms. Typically group norms such as fairness, cooperation, competency, obedience, and loyalty become ingrained, often through positive reinforcement. However, when individuals go against the norm, they may receive punishment from a single person, group or culture through forms such as devaluation, rejection or isolation. Importantly, individuals also engage in self-punishment, self-criticism, and devaluations which often includes negative appraisals of the self as bad, stupid, inadequate, inferior, or marginalized.

Therapy session

Individuals diagnosed with serious mental illnesses (SMI) have an unusual amount of self-devaluations, put-downs, manipulations, and self-criticisms, leading to hypervigilance. This is often a result of being controlled in the past by a significant person who has dominated the individual, leading to internal compliance, demands, and in some cases, harsh or commanding hallucinations. Additionally, those who hear voices often learn to over-monitor themselves and others, leading to paranoid thinking and behavior.

In thinking about possible interventions that target threatening or harsh voices, research has begun to explore using compassion as a tool that can be enhanced to facilitate recovery. For example, Waite et al. (2015) found significant linkages between compassion and recovery from psychosis. Specifically, these researchers found that self-compassion was associated with growth and empowerment as measures of recovery, whereas self-criticism related to shame was associated with greater levels of distress from psychotic experiences. With this finding in mind, along with others that have shown the associations between compassion and wellbeing, achievement, social connection, etc. (Barnard & Curry, 2011), we have highlighted some clinical techniques that are aimed to help individuals with harsh, critical and/or commanding voices.

Targeted compassion-based programs such as Compassion Focused Therapy (CFT; Gilbert, 2009;2014) and other related interventions with more peripheral connections to compassion (Gestalt/ Emotion Focused Therapy Chair techniques, Mindfulness based skill building, Acceptance and Commitment Therapy activities, etc.) have gained significant traction in the literature and have shown to be effective in treating a range of psychopathology and increasing well-being (Neff, Rude & Kirkpatrick, 2007; Shapiro et al., 2005; and for a review paper, see Barnard & Curry, 2011). Compassion focused interventions may show specific utility with those suffering from serious mental health conditions, especially individuals who experience harsh, threatening and critical voices. Gilbert and colleagues (2019) state that the primary goal for voice hearers in CFT is to learn to be able to switch from a threat-based motivational system, to a safer, self-compassionate motivational and affective state. CFT recommends numerous interventions which aim to facilitate a switch to the compassionate self and explore and strengthen this part of the personality. These interventions include but are not limited to imagery, letter writing and social/behavioral techniques.  

In the imagery techniques, individuals learn to activate and utilize their compassionate self to imagine less-harmful characters as representing their voices and set up imaginary scenarios which feel safer compared to their actual interactions with their harsh voices, so that the individual can explore different aspects and intentions of the voices. Additionally, one can use imagery to modify some of the characteristics of the voice speaking character (for example, lowering the volume or changing tone of the voice) and attempt to engage in an imaginary conversation with the voice from the perspective of the compassionate self.

The letter writing intervention is very similar to the visualization techniques in that that through activation and engagement of the compassionate self, the individuals write letters to their voices and aim to feel compassion and understanding towards their voices, how the voice may have developed based on traumatic experiences, and the “threat-protective” role they may play. This allows the individual to not only understand possible factors that contributed to the voices being harsh or critical, but importantly, the individual gains self-compassion in that they can recognize that the fact that they experience voices is not their fault and they can hold space for themselves to recognize the negative experiences in their life that may have contributed to the voices, as well as the evolutionary aspects of threat and protection that play a part as well.

The in-vivo social experiences that are part of CFT map on quite closely to Recovery Oriented Cognitive Therapy (CT-R) ideologies. These pro-social and meaningful activities in real-world settings serve to foster individuals’ compassion for others as well as gaining comfort in receiving compassion. In addition, these experiences again serve to create a sense of safety and connection that counters the threat-based motivational state and associated threatening or harsh voices. Generally the compassion based interventions overlap with CT-R in that both orientations seek to build on the positive, or adaptive elements of personality and through active interventions, provide important meanings of safety, connection, empowerment, and many other individualized meanings for those with psychological distress and mental illness diagnoses.

References:

Barnard, L. K., & Curry, J. F. (2011). Self-compassion: Conceptualizations, correlates, & interventions. Review of general psychology, 15(4), 289-303.

Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41.

Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in psychiatric treatment, 15(3), 199-208.

Heriot-Maitland, C., McCarthy-Jones, S., Longden, E., & Gilbert, P. (2019). Compassion focused approaches to working with distressing voices. Frontiers in psychology, 10.

Neff, K., Rude, S., & Kirkpatrick, K. (2007). An examination of self-compassion in relation to positive psychological functioning and personality traits. Journal of Research in Personality, 41,908 –916. doi:10.1016/j.jrp.2006.08.002

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mind-fulness-Based Stress Reduction for health care professionals: Resultsfrom a randomized trial. International Journal of Stress Management, 12,164 –176. doi:10.1037/1072-5245.12.2.164

Waite, F., Knight, M. T., and Lee, D. (2015). Self-compassion and self-criticism in recovery in psychosis: an interpretative phenomenological analysis study. J. Clin. Psychol. 71, 1201–1217. doi: 10.1002/jclp.22211