Nama: Muhammad Iskandar

NPM: 1B519815

Kelas: 3PA05

Psikologi Abnormal

TUGAS: Analisis Kasus, dan Intervensi

Kasus: New Mexico man dead after breaking into YouTube stars Gavin Free and Megan Turney's home

It's unclear if the man, Christopher Giles, died from a self-inflicted wound or was fatally shot by police.
Feb. 15, 2018, 2:18 AM +07 / Updated Feb. 15, 2018, 2:18 AM +07
By Kalhan Rosenblatt and The Associated Press
Two YouTube stars hid in the closet of their Austin, Texas, home last month after an obsessive fan broke
into their home with a shotgun, according to local reports.
Christopher Giles kept hundreds of notes on his phone about YouTube personalities Gavin Free and
Megan Turney, according to court records obtained by the Albuquerque Journal.
In the early hours of Jan. 26, Giles shot through a glass door and entered the couple's home. As Turney
and Giles hid inside their closet, they dialed 911.
When Austin police arrived, they had a brief altercation with Giles in the driveway. When Giles shot his
gun, an officer returned fire. Giles died from injuries, but the medical examiner has not officially
determined whether he died from police gunfire or a self-inflicted wound.
Austin Police Department and the Travis County Medical Examiner's Office did not immediately respond
to NBC News' request for comment.
"Thank y’all so, so much for each and every kind message today and a special thank you to the
@Austin_Police for their quick response that night and their ongoing support during this difficult time.
Heart you guys so much," Turney wrote on Twitter to her 425,000 followers.
Free, who has more than 819,000 followers, thanked the police and his fans for their support on Twitter.
Giles was one of millions of people who became familiar with Turney and Free through YouTube, and is
part of what appears to be a rising trend of internet celebrities who have come in close proximity to
dangerously obsessive fans.
Related: Teen YouTuber Shoots and Kills Boyfriend in Video Stunt, Police Say
Free is creator of "The Slow Mo Guys" channel on YouTube, which has over 10 million subscribers and
millions more in views. Turney, who is also a cosplayer, has more than 341,000 subscribers on her
personal YouTube channel.
Both Turney and Free have been involved with content creator "Rooster Teeth," which has created
numerous YouTube channels with millions of subscribers and boasts more than 9 million subscribers on
it's eponymous main channel.
"These are real people who have reason to fear that they will be the next person in a headlock," said
YouTuber Philip DeFranco, who has more than 6 million subscribers, in a video about the break-in.
DeFranco himself also has come face-to-face with overzealous fans who have broken into his studio.
"I've had issues in the past where people found our studio, actually walked into my room while I was
filming and since then we've upped security," he said.
Other prominent YouTubers, who are often able to make a living off of the views of loyal fan bases by
utilizing the site's monetization feature, have made videos asking viewers not to come and find them.
Giles, who was described as "single, lonely and disturbed," in an affidavit cited by the Statesman, wrote
that he wanted "Gavin Free to die alone, with no children,” according to the documents, which NBC
News has not seen.
“Based upon these notations, it was apparent that Giles developed a fondness of Turney yet resented
Free for his lifestyle and success,” the Statesman reported the affidavit saying.
Although Free and Turney were unharmed, other YouTubers have died at the hands of obsessive fans.
In June of 2016, YouTuber and "The Voice" contestant Christina Grimmie was shot and killed by an
obsessive fan while signing autographs in Orlando, Florida.
Police later said that the gunman, Kevin James Loibl, traveled to Orlando for the specific reason of
harming Grimmie.
"If there's anything we can accomplish with this story it's to remind people that the people you are
watching online, on your phone, on TV, they are just people," DeFranco said. "Having their privacy and
security breached shouldn't just be something that is cast off as something that just comes with the job."

Analisis

Kasus diatas memberitakan peristiwa yang terjadi pada tanggal 26 Januari, 2018, dimana seseorang
mendobrak masuk rumah dua pasang orang, masing-masing Youtuber yang terkenal, dengan maksud
untuk membunuh si pria dan mengambil si wanita.

Subjek, yang bernama G, melakukan perjalanan selama sepuluh jam dari tempat tinggal nya ke rumah F
dan T, pasangan E-celeb tersebut. Pada saat G tiba, ia menembak kaca rumah F dan T, dimana kedua
pasangan langsung bersembunyi di lemari mereka, serta menelepon polisi local. Responnya datang
dalam jangka waktu beberapa menit, dimana terjadi sebuah alterkasi antara G dan polisi, diakhiri
dengan kematiannya G. Link diatas menyatakan bahwa adanya kekurangan informasi mengenai apakah
G membunuh diri atau diberhentikan oleh polisi, tetapi artikel-artikel yang lain menyatakan bahwa G
berhasil ditangani oleh polisi.
Kasus ini, selain memberitakan rencana G, juga menyingkapi tanggapan bahwa banyak sekali orang
terkenal yang dapat menjadi korban oleh seorang penggemar, dan mengingati kebahayaan nyawa
mereka.

Banyak dokumen G yang terkumpul, dimana G menceritakan hendaknya untuk mengambil T sebagai
kekasihnya, dan suatu kedengkian dan kebencian terhadap F karena gaya hidup dan kesuksesan yang ia
miliki, termasuk rencananya untuk membuh F, agar “F mati sendiri tanpa anak”.

Kasus tersebut menunjukkan bahwa G adalah seseorang yang, berdasarkan DSM-V, memiliki gejala-
gejala yang termasuk Schizophrenia Spectrum. Secara lebih spesifik, G memenuhi kriteria Delusional
Disorder, dengan subtype Erotomanic type, berdasarkan kefokusannya terhadap T dan keinginan G
untuk membunuh F. Kefokusannya terhadap T, dan anggapan bahwa T itu akan membalas perasaan G
itu menunjukkan ketidak mungkinan karena T itu sudah dalam hubungan yang erat dengan F, apalagi
karena G telah mendobrak rumah mereka.

Adanya kurang informasi mengenai perasaan G serta recananya selain apa yang pihak polisi menyatakan
berdasarkan investigasi mereka. Akan tetapi, G menunjukkan seberapa kerasnya delusi dia, karena G
rela membuat dan melaksanakan recananya, yang terdiri dari berjalan selama sepuluh jam ke rumah
kediaman F dan T, menyerang mereka, beralterkasi dengan polisi, dan berakhir dengan kematiannya.

Intervensi yang dapat dilakukan adalah dengan menahan G sebelum ia dapat melukan recananya,
karena rencana tersebut itu berbahaya bagi dirinya dan orang lain. Berdasarkan review yang
dikendakkan oleh Haddock, G et al (1998) menemukan bahwa, walaupun berbagai macam obat itu
kurang efektif untuk menangani halusinasi, delusi, dan berbagai macam psikopatologi kognitif,
Cognitive-Behavior Therapy (CBT) itu merupakan salah satu terapi yang efektif untuk menjadi suatu
treatment bagi yang mengalami halusinasi dan delusi, walaupun terapi tersebut masih perlu
perkembangan di area lain.

Kemungkinan, jika G itu dapat ditemui dan ditangani sebelum semua ini terjadi, nasibnya tidak menjadi
se mendadak seperti yang di beritakan.

Source:

Haddock, G. et al. (1998). Individual Cognitive-Behavior Therapy in the Treatment of Hallucinations and
Delusions: a Review. Clinical Psychology Review, 18(7), 821-838. 10.1016/s0272-7358(98)00007-5
Clinical Psychology Review, Vol. 18, No. 7, pp. 821–838, 1998
Copyright © 1998 Elsevier Science Ltd
Printed in the USA. All rights reserved
0272-7358/98 $19.00 1 .00
PII S0272-7358(98)00007-5
821
INDIVIDUAL COGNITIVE-BEHAVIOR
THERAPY IN THE TREATMENT OF
HALLUCINATIONS AND DELUSIONS:
A REVIEW
Gillian Haddock
University of Manchester, Tameside General Hospital
Nicholas Tarrier
University of Manchester, Withington Hospital
William Spaulding
University of Nebraska
Lawrence Yusupoff, Caroline Kinney, and Eilis McCarthy
University of Manchester, Withington Hospital
ABSTRACT. The limitations of biochemical treatments in reducing the severity of hallucinations and
delusions has led to an increased interest in the investigation of psychological treatments for these
symptoms. These investigations have spanned the last 4 decades and have covered a range of
psychological approaches from psychoanalytically oriented psychotherapy to behavioral approaches.
More recently, findings that some psychotherapies are not effective treatments for psychosis and that
cognitive-behavior therapy can be an effective treatment for neurotic disorders have led to increasing
interest in the investigation of the effectiveness of cognitive-behavior therapy for psychosis. This review
describes and evaluates the research on the cognitive-behavioral treatment of hallucinations and delusions
and describes the cognitive models from which the treatments have developed. The conclusion is that, on
the whole, the literature provides fairly strong evidence for the efficacy of cognitive-behavioral
approaches in the management of chronic Correspondence should be addressed to Gillian Haddock,
Academic Department of Clinical Psychology, Tameside General Hospital, Ashton-Under-Lyne, OL6
9RW, United Kingdom.822 G. Haddock et al. psychotic disorders and associated symptoms, although
there are a number of areas where further development is necessary. © 1998 Elsevier Science Ltd
THE USUAL FIRST-LINE TREATMENT for patients with psychotic symptoms such as hallucinations
and delusions is neuroleptic medication. The finding that this type of medication was effective in the
treatment of psychosis during the 1950s (Delay, Deniker, & Harl, 1952) brought about important
developments in the care and management of people with schizophrenia (e.g., by reducing positive
symptoms during acute crises and preventing subsequent relapse rates). Despite this, neuroleptic
medication has some limitations with regard to its efficacy on psychotic symptoms. For example, a
substantial number of patients will continue to experience persistent and distressing hallucinations and
delusions or will be subject to periodic relapse of these symptoms despite appropriate doses of neuroleptic
medication. Although the introduction of atypical neuroleptics has gone some way to improve outcome
for neuroleptic nonresponders, medication still does not provide full remission for large numbers of
patients. The discovery of drug therapies that will completely eradicate the occurrence or relapse of
psychotic symptoms has remained elusive since the 1950s when chlorpromazine (a drug still in use in the
United Kingdom today) was first introduced as a possible treatment for psychosis.
PSYCHOTHERAPY AND SCHIZOPHRENIA
As a result of the limitations in drug treatments, many clinicians and researchers have seen the need for
development of complementary treatment approaches that can enhance the effectiveness of medication
and improve patient outcome. The main areas investigated are those that have involved some form of
psychotherapy, although, by the mid-1980s most researchers and clinicians interested in schizophrenia
were familiar with large-scale studies showing little or no efficacy of supportive or psychodynamic
psychotherapy in the treatment of the disorder and its symptoms (Gunderson et al., 1984; May, 1968;
Mosher & Keith, 1980; Stanton et al., 1984).
In contrast, the research on cognitive-behavioral therapy for the positive symptoms of schizophrenia,
which spanned the same historical period and continues today, is less universally familiar. However,
studies of cognitively oriented behavioral approaches to treating schizophrenia go back at least to
Meichenbaum’s work (Meichenbaum & Cameron, 1973), and less cognitively oriented behavioral
approaches were being widely studied at least a decade before that (see Curran, Monti, & Corriveau,
1982; Paul & Lentz, 1977). Historically, cognitive-behavior therapy was developed for the treatment of
neurotic disorders, such as anxiety or depression. Its efficacy in the treatment of these disorders is now
well established. The assumption behind cognitive-behavior therapy, as applied to any disorder, is that the
occurrence and maintenance of a symptom or problem are mediated by cognitive and environmental
processes that may be modified by teaching more adaptive cognitive and behavioral skills. The cognitive-
behavioral models driving the application of treatment are more developed in some disorders than others.
For example, Clark (1988) described a comprehensive cognitive model of panic that explains its
development and maintenance and that provides a formulation for guiding specific interventions that are
intended to modify the processes that are contributing to symptom occurrence.
Cognitive models of psychosis that similarly underpin intervention are less developed and are more
problematic due to the lack of consensus of theoretical explanations of schizophrenia. This problem can
be resolved to a certain extent by attempting to explain the occurrence and maintenance of psychotic
symptoms rather than to account for the development of the syndrome of schizophrenia. This is consistent
with behavioral and cognitive-behavioral approaches to treatment that have a long history of
accommodating indi-vidual differences (e.g., Bandura, 1969) into their theoretical accounts from which to
derive interventions and thus optimize outcome.
COGNITIVE-BEHAVIOR THERAPY AND SCHIZOPHRENIA
Early research into psychological methods of treating schizophrenia emerged predominantly from the
behavioral school and focused on modifying symptoms and the behavioral sequelae associated with the
disorder. These approaches particularly focused on using external reinforcers to modify observed
psychotic behaviors such as talking to oneself. Most reports were in the form of individual case studies or
small case series, and they usually modified social interaction to reinforce nonpsychotic behavior or
speech (e.g., Ayllon & Haughton, 1964; Bulow, Oei, & Pinkey, 1979; Liberman, Teigen, Patterson, &
Baker, 1973; Nydegger, 1972). Although in general the results relating to operant procedures appeared
promising, their use in the treatment of positive psychotic symptoms has never been exposed to a larger
controlled evaluation of their effectiveness, and a major criticism of this type of approach is that the
results do not generalize outside the inpatient setting where contingent reinforcement can be consistently
delivered. This latter failing has been particularly exposed with the widespread adoption of community
treatment for people with severe mental illnesses such as schizophrenia where consistent reinforcement
schedules are difficult to deliver. In addition, most studies evaluating the efficacy of operant approaches
have studied chronic psychotic patients with long histories of psychosis. An exception to this is an early
case series by Kennedy (1964) who treated three inpatient schizophrenics of which two had only a short
inpatient admission and psychiatric history. The author reinforced nondelusional speech using social
approval and punished delusional speech verbally. Delusional speech significantly decreased, and the
results generalized outside treatment sessions and were maintained. It is possible that operant procedures
are more generalizable and sustained if delivered to patients with a recent onset psychosis. Despite this
one finding, the results of operant conditioning approaches suggest that clinical improvements are
unlikely to generalize or be sustained over time, and, with the current advent of community treatment, the
opportunity to deliver this approach systematically is limited.
Over the last decade, as behavioral approaches and cognitive approaches became established as viable
treatments for neurotic disorders, there has been a growing interest in their effectiveness with the
psychotic disorders. The main foci of this have been (a) cognitive-behavioral treatment of specific
psychotic symptoms (e.g., hallucinations and delusions) and (b) remediation of underlying cognitive
processes. Although these two types of cognitive-behavioral therapy have common characteristics, the
latter is primarily directed toward the cognitive deficits that may underlie schizophrenia, whereas the
former has more commonly been applied to the symptoms that result from schizophrenia. As a result, this
review focuses on cognitive-behavior therapy as applied to specific psychotic symptoms.824 G. Haddock
et al.
COGNITIVE-BEHAVIORAL TREATMENT OF DELUSIONS AND HALLUCINATIONS
Delusions
Several behavioral and cognitive-behavioral approaches have been used to modify or change patients’
delusional beliefs. There is no consensus model to explain the occurrence and maintenance of delusions,
although many authors have noted the similarity in delusional beliefs with ordinary belief processes in
normal subjects. Maher (1988) suggested that delusions are the result of normal reasoning processes
being applied to unusual or abnormal perceptual experiences (e.g., secondary to an abnormal perception),
whereas Bentall, Kinderman, and Kaney (1994) suggested that although delusional beliefs may share
important characteristics with “normal” beliefs, deluded patients exhibit biases in their reasoning
processes about the world that contribute to the formation of “abnormal” beliefs that are not shared by the
majority of the population. Nevertheless, this lack of agreement does not preclude the application of
cognitive-behavior therapy, as both perspectives suggest that therapeutic interventions designed to modify
reasoning processes and strategies that enhance cognitive or other coping strategies will be effective at
reducing the severity of delusional beliefs.
Belief Modification
Systematic attempts to modify individuals’ delusional beliefs have been reported by a number of authors
(B. A. Alford, 1986; B. A. Alford & Beck, 1994; Beck, 1952; Chadwick & Lowe, 1994; Hartman &
Cashman, 1983; Milton, Patwa, & Hafner, 1978; Watts, Powell, & Austin, 1973). The approach involves
careful examination of the nature of a delusional belief and associated factors that contribute to its
occurrence. In addition, sensitive questioning of individuals about the evidence underlying their belief is
used to reduce patients’ convictions. This intervention has shown to be effective at reducing the severity
of delusional beliefs in a number of studies. Watts et al. (1973) showed belief modification to be superior
to relaxation training in a small study carried out with delusional patients. Milton et al. (1978) showed
belief modification to be superior to confrontation in a small study with 14 patients. In the latter study,
both treatments resulted in a reduction in self-reported conviction in the delusion following treatment, but
only belief modification resulted in a sustained reduction in conviction at 6-week follow-up.
Confrontation resulted in an increase in conviction levels at 6-week follow-up that exceeded pretreatment
levels.
More recently, B. A. Alford (1986) reported a single case study of a chronic paranoid schizophrenic man
who was experiencing delusional beliefs and a visual hallucination. Treatment involved belief
modification in the form of instructions to monitor the frequency of the beliefs, the strength of their
conviction, and to generate alternative explanations for the delusional experiences. There was a reduction
in the frequency and conviction of delusional beliefs and in the patient’s requests for prn medication. At
3-month follow-up, the benefits were partially maintained. The patient had no conviction in his previous
belief that a witch was following him and believed that his previous beliefs were solely a product of his
imagination, although he occasionally experienced voices about which he was uncertain of their origin.
Similarly, Chadwick and Lowe (1990, 1994) reported successful interventions with patients experiencing
delusions using a form of verbal questioning, belief modification, and experimental reality testing. They
reported on 12 outpatients who had been experiencing delusions of at least 2 years’ duration (Chadwick
& Lowe, 1994). The intervention took place over a number of weeks and consisted of identifying the
nature of the delusions, helping the individual to question the evidence underlying the belief, and
developing behavioral experiments designed to test out the reality of this evidence. Following treatment,
the results showed that, of the 12 patients, 5 had rejected their beliefs completely and 5 others reported a
reduction in the conviction with which they held their belief. For those patients whose belief conviction
decreased, there was an accompanying decrease in depression following treatment. These findings
generalized outside therapy sessions as observed by another professional or relative. Chadwick and Lowe
also attempted to examine whether particular components of their treatment were more effective than
others. Reality testing was less effective than verbal challenge when delivered alone but enhanced the
benefits when it followed verbal challenge.
Conclusions
Although promising, these studies have involved small numbers, and the treatments have not been subject
to large-scale evaluation. Despite this, there appears to be a consistent trend suggesting that treatment
approaches that have focused on cognitions and beliefs associated with the symptom, including self-
monitoring, have produced benefits that have generalized outside the treatment session, to other
symptoms, and over time. Further research is needed to explore this tentative conclusion. The role of
coping-skill enhancement in the treatment of delusions is discussed later.
Hallucinations
Cognitive-behavioral treatments of hallucinations have generally focused on auditory hallucinations,
perhaps because these are the symptoms most frequently reported by patients who have a diagnosis of
schizophrenia (Sims, 1988). In comparison, visual, olfactory, and tactile hallucinations have received
little attention. The treatment of auditory hallucinations has developed from a number of different
theoretical backgrounds, based partly on cognitive explanations of auditory hallucinations and partly on
cognitive theory in general as applied to emotional disorders. As with delusions, there is no consensus on
a cognitive model for auditory hallucinations, although most assume that auditory hallucinations are
associated with speech processing in some way (e.g., that some sort of misattribution of inner speech is
implicated). The accounts for the type of deficit or bias that may bring about a misattribution of inner
speech vary considerably. For example, Hoffman (1986) assumed that auditory hallucinations occur as a
result of random firing of speech processing mechanisms that result in “parasitic memories” being
brought into consciousness. As these are unexpected and unplanned, the experiencer perceives them as
being alien and attributes them to an external source. David (1994) also accounted for auditory
hallucinations in terms of a deficit in the speech-processing mechanisms where a deficit in a particular
part of the speech-processing pathway results in different types of auditory experiences such as
hallucinations, thought echo, and the like. Frith (1992) proposed that the actual inner speech of
hallucinators is normal but that an internal monitor of inner speech is faulty, resulting in unexpected alien
speech that is perceived as originating from an external source. Finally, Bentall (1990) suggested that the
speech-processing pathways are performing normally in hallucinators but that their specific beliefs and
attitudes produce biases that determine their interpretation of inner speech. He proposed that826 G.
Haddock et al. this explains why cultural differences occur in the experience of hallucinations
(Bourgignon, 1970) and why hallucinators are more susceptible to suggestions than nonhallucinators
(Haddock, Slade, & Bentall, 1995). Although there is not enough evidence to account for auditory
hallucinations totally by any of these accounts alone, there is evidence to support all of them to some
degree. It is possible that a combination of these accounts may be correct, such that there may be an
underlying neuropsychological deficit (e.g., Hoffman, David, Frith) but that cognitive factors such as
monitoring, beliefs, and attributions (e.g., Frith, Bentall) determine their occurrence, interpretation, and
effect on the individual. Further research is required to elucidate the actual mechanisms involved and the
relative contribution of each. Nevertheless, the models all have implications for cognitive-behavioral
treatment, and there is considerable overlap between these accounts and the cognitive-behavioral
treatments that would remedy them. For example, the models of Hoffman, David, and Frith suggest that
some form of compensatory coping for dealing with the underlying deficits that produce the hallucination
may be effective. The observations that hallucinations tend to worsen under conditions of increased
arousal suggest that cognitive treatments that aim to reduce arousal may also be effective. Bentall’s model
and the observation that hallucinators may be more susceptible to the influence of suggestions indicate
that an intervention designed to modify beliefs and attributions may also play an important part in
modifying hallucinatory experience. Finally, as with delusions, all of the previously noted models suggest
that some form of coping skills enhancement would improve patient functioning.
Compensation Approaches
Distraction. Implicit in some distraction approaches is the reasoning that the impact of experiencing
hallucinations will decrease if attentional resources are redirected through the introduction of competing
stimuli. This is hypothesized to occur as a result of the person’s effortful ability to direct attention away
from the hallucination.
This reasoning has developed from knowledge of behavioral principles, but counterstimulation or
distraction approaches have also been implemented on the basis that they interfere with processes thought
to be involved in the production of hallucinations. For example, as it has been suggested that
hallucinations are a form of inner speech that is associated with subvocalization similar to that observed
in normal participants during internal speech (Gould, 1950; P. Green & Preston, 1981; Inouye & Shimizu,
1970; McGuigan, 1966), there is an assumption that individuals mistakenly attribute their own inner
speech to external sources resulting in the experience of an auditory hallucination. Although the findings
relating to inner speech and auditory hallucinations are equivocal, nevertheless, it has been argued that if
auditory hallucinations are a form of inner speech (which is mistakenly attributed to an external source)
then tasks that interfere with subvocalization should also inhibit hallucinations (Bentall, Haddock, &
Slade, 1994; Frith, 1992; Hemsley, 1993). There is some support for this. For example, Nelson, Thrasher,
and Barnes (1991), in an uncontrolled group study, encouraged 20 patients experiencing auditory
hallucinations to use personal stereos and engage in subvocal counting or earplug use whenever they
experienced hallucinations. The patients rated personal stereo use to be the most helpful technique,
although only six patients continued to use these methods long term. The authors did not describe how
effective the techniques were at reducing the severity of the hallucinations. Similar positive results
relating to a variety of attention directing strategies have been found, for example, using a personal stereo
(Feder, 1982; Hustig, Tran, Hafner, & Miller, 1990; Morley, 1987) or occupational therapy diversion
(Allen, Halperin, & Friend, 1985). Heilbrun, Diller, Fleming, and Slade (1986) suggested that the type of
distraction strategy that patients are able to utilize may vary between different subtypes of patients with a
diagnosis of schizophrenia. In a study of 46 hallucinating schizophrenics and 18 nonhallucinating
schizophrenics, Heilbrun et al. (1986) evaluated patients’ ability to utilize two different types of attention-
diverting strategies. Process schizophrenics and reactive schizophrenics differed in their ability to use the
techniques, although there was no indication whether there was a similar differential effect on the severity
of hallucinations.
In a small case series of seven subjects, Margo, Hemsley, and Slade (1981) examined the effects of nine
types of environmental stimulation on the severity of auditory hallucinations in a small case series of
schizophrenic patients. These included patients reading out loud, listening to an interesting passage,
listening to a boring passage, listening to a passage in Afrikaans (which none of the patients understood),
listening to pop music, listening to regular and irregular electronic blips, listening to white noise, a
sensory deprivation condition where the patients ears were blocked, and finally a control condition with
no distraction material. All except white noise and sensory deprivation were more effective than the
control condition at reducing the patients’ concurrent selfreports of the frequency, clarity, and loudness of
their hallucinations. White noise and sensory deprivation produced increases in the frequency, clarity, and
loudness of the hallucinations compared with the control condition. Asking patients to listen to verbal
material or read out loud (those that most involved subvocalization) had the greatest effect in reducing the
frequency, clarity, and loudness of the hallucinations. These results have recently been replicated in
another small case series of seven patients (Gallagher, Dinan, & Baker, 1994), and the finding that white
noise is associated with an increase in hallucinating has also been reported by Feder (1982). Similar
studies with individual cases involving activities that utilize the muscles associated with subvocalization
have found consistent results (G. S. Alford, Fleece, & Rothblum, 1982; Bick & Kinsbourne, 1987;
Erickson & Gustafson, 1968; M. F. Green & Kinsbourne, 1989). For example, Bick and Kinsbourne
(1987) examined the effects of a mouth-opening procedure on the self-reports of hallucination severity in
patients experiencing auditory hallucinations and in normal participants trained to simulate auditory
hallucinations. They found that the procedure was effective in both groups of participants, although Levitt
and Waldo (1991) were not able to replicate Bick and Kinsbourne’s findings in relation to hypnotically
induced hallucinations in normal participants.
Monaural occlusion. An alternative compensation strategy emerged as a result of P. Green’s (1978)
proposal that hallucinations arise as a result of faulty interhemispheric transmissions of speech material
originating from the nondominant hemisphere in hallucinating patients that makes it more difficult for
them to determine whether the speech material originates from an internal or external source. Green
suggested that reducing the auditory input to the nondominant hemisphere and engaging in speech (a
strategy thought to be incompatible with the implicated processes) encouraged whenever hallucinations
occurred would result in a reduction or disruption in their severity. Wearing an earplug in the left ear (or
right depending on dominance, which should be predetermined) and engaging in incompatible speech
such as naming objects were proposed as suitable techniques to achieve this. M. F. Green, Glass, and
O’Callaghan (1980) supported this hypothesis in their description a single case study828 G. Haddock et
al. using these techniques. Further support for the hypothesis came from a more recent case study by
Birchwood (1986). A schizophrenic patient with drug resistant auditory hallucinations was instructed to
use an earplug in the left ear and to employ an object naming exercise at onset of voices. The techniques
resulted in a substantial drop in hallucinatory activity that was maintained over time but that increased
following removal of the plug. Despite this, contradictory results were found by James (1983) who
reported on two schizophrenic patients treated using these approaches. The approaches were effective in
reducing hallucination severity, but the effect was evident even when the earplug was switched to the
opposite ear. A similar inconsistent result was shown by Morley (1987), suggesting that further research
is necessary to clarify Green’s hypothesis. The corollary of monaural occlusion, that wearing a hearing
aid should increase hallucinations, has never been tested.
Thought stopping. Thought stopping, which has been used successfully to treat intrusive thoughts
(Wolpe, 1973), has also been shown to have positive effects in the treatment of auditory and visual
hallucinations (Johnson, Gilmore, & Shenoy, 1983; Samaan, 1975), although a controlled study
comparing thought stopping plus medication to medication alone in 20 chronic schizophrenic patients
found no significant benefits of thought stopping for hallucinations, although the patients reported
significantly less persecutory thoughts in the thought-stopping group following treatment (Lamontagne,
Audet, & Elie, 1983).
Generalization of compensation approaches. In spite of the obvious benefits of the previously noted
approaches, they do not always appear to generalize across situations or result in enduring benefit,
although a recent study suggested that some distraction approaches can produce generalizable benefits.
Haddock et al. (1996) randomly allocated 19 schizophrenic patients into either a focusing (discussed
later) or distraction treatment. Those receiving the distraction treatment and focusing treatment showed
treatment gains beyond the therapy sessions. In the distraction approach, attention was given to
maximizing the opportunity for patients to use techniques that could be easily integrated into their normal
daily lives and involved a form of activity scheduling that encouraged the patients to use distraction
techniques in many different settings attempting to maximize generalization. The results indicated that
employing distraction techniques in this way could decrease both the frequency of episodes and the
disruption to life resulting from the hallucinations and that this was maintained for the majority of
patients at a short follow-up of 6 months. This suggests that treatment generalization across settings may
well occur if it is programmed into the treatment plan. Thus, distraction will be more effective and
generalizable if it is self-directed by the patient across a range of settings and when the patient can control
the cues to generate external competing stimuli.
Modification of Anxiety-Provoking Correlates of Auditory Hallucinations
Some authors have explored managing auditory hallucinations by focusing on the antecedent or
concurrent phenomena that are associated with the occurrence or worsening of hallucinations. In a single
case study, Slade (1972) observed that one patient’s auditory hallucinations became worse either in the
presence of or when thinking unpleasant thoughts about his father. Slade applied graded imaginal
exposure to the patient’s thoughts about his father, which resulted in a reduction of the patient’s reports
on the severity of his hallucinations. Similar results were obtained in another single case study, in which a
woman whose auditory hallucinations were identified as being associated with smoking and drinking a lot
of coffee, using a form of systematic desensitization (Alumbaugh, 1971). Alumbaugh desensitized the
woman to the situations in which she felt compelled to smoke and drink coffee. Smoking and coffee
drinking decreased, and this was associated with a subsequent reduction in the severity of her
hallucinations. Positive results have also been found in relation to treating delusional avoidance using
systematic desensitization (Cowden & Ford, 1962; Weidner, 1970). However, the use of systematic
desensitization to treat phobic symptoms in schizophrenia has been less successful. A contemporary study
reported on the ineffectiveness of systematic desensitization and assertiveness training in 24 hospitalized
schizophrenic patients, although the aim of this study was fear reduction and improved social skills rather
than reduction of psychotic symptoms (Serber & Nelson, 1971).
Exposure and Anxiety Reduction
The use of focused attention on hallucinations themselves rather than their antecedent stimuli as described
before has also been shown to increase patients’ perceived control over their experience, which may in
turn reduce anxiety or other negative emotional reactions. Focused attention using a self-monitoring
procedure was described by Rutner and Bugle (1969). They encouraged a 47-year-old chronic
schizophrenic female inpatient to record the frequency of her hallucinations privately and subsequently to
display those recordings publicly. The frequency reduced when employing both approaches and was
maintained at 6-month follow-up. It was not possible to determine whether the public or private
monitoring was most effective.
Glaister (1985) treated the persistent hallucinations of a male inpatient with chronic treatment-resistant
hallucinations using satiation, which has also previously been shown to be effective in the treatment of
obsessional thoughts. Satiation therapy involved 85 half-hour homework sessions in which the patient
recorded the time of the voice, the content, and the demandingness of the voice. There was a large
decrease in the frequency of hallucinations, in the fear associated with hearing a voice, and in the
subjective ratings of the demandingness of the voice. The benefits were reported to be maintained at a
follow-up 5 years after the end of therapy. The approach has also been used successfully to reduce the
rate of delusional speech (Wolff, 1971).
In another approach, Liberman, Wallace, Teigen, and Davis (1974) encouraged two patients to focus their
attention on tape recordings that mimicked their voices. Reductions in voice frequency occurred that were
maintained in the two patients studied. A similar approach was noted by Persaud and Marks (1995) who
described a pilot study with five patients who took part in an exposure program that required patients to
direct their attention on the form of their hallucinations rather than their content while concurrently
employing anxiety reduction techniques. Patients were also asked to evoke their hallucinations and to
consider the differences between their hallucinations and externally generated sounds. The results
indicated that patients increased their perceived control over their hallucinations and experienced a
reduction in anxiety and improvement in social behavior following treatment. During treatment, there was
an increase in mean time spent hallucinating, which declined only moderately below pretreatment levels
at the end of treatment. In a slightly different exposure approach, Fowler and Morley (1989) reported a
study in which five patients who were experiencing chronic persistent auditory hallucinations were
encouraged to elicit and then dismiss their hallucinations830 G. Haddock et al. to facilitate their
reattribution from external to internal sources (i.e., to demonstrate that the hallucinations were under their
own internal control rather than resulting from an uncontrollable and external source). The use of
distraction strategies and discussions regarding the origin of the hallucinations was also encouraged. Only
one participant showed a significant reduction in hallucination frequency, but four of the five reported an
increase in the amount of control they perceived they had over their experiences.
These three studies highlight the multidimensional nature of hallucinations and suggest that dimensions
may vary (at least partially) independently and respond differently to cognitive-behavioral treatment. For
example, an increase in perceived control of hallucinations or a reduction in distress associated with them
may have an enormous impact on the quality of life of a patient even if the frequency of occurrence of the
hallucinations remains unchanged. In addition, these studies also indicate that this type of approach may
lead to generalization of benefits over time.
Exposure and Modification of Beliefs Secondary to Hallucinations
Exposure and modification of the content and beliefs underlying an individual’s auditory hallucinations
have been described in detail by Haddock and colleagues (Bentall, Haddock, & Slade, 1994; Haddock,
Bentall, & Slade, 1993; Haddock et al., 1996). The treatment (called “focusing”) involved a within- and
between-session gradual exposure to the content of hallucinations, a between-session daily monitoring of
their frequency and other characteristics, and discussion of the meaning and beliefs surrounding them.
The aim was, through exposure to hallucination content and its relationship to current thoughts, for
individuals to recognize that their experiences were internally generated and potentially amenable to
modification. Thoughts and beliefs relating to the hallucinations were then modified using standard
cognitive-behavioral methods to modify the impact of the content. The approach was successful not only
in reducing the amount of time spent hallucinating but also in the disruption they caused to the person’s
life. In addition, there was a trend toward a decrease in the distress associated with the hallucinations. The
authors evaluated this approach in comparison with the distraction treatment described earlier (Haddock
et al., 1996) and found that the two approaches did not differ in their effect on hallucination frequency
and disruption caused by them. No further differences in effectiveness were found between the two
approaches, although there was a trend toward the focusing treatment resulting in an improvement in self-
esteem whereas distraction tended to result in a reduction in self-esteem, as measured by the Rosenberg
self-esteem questionnaire (Rosenberg, 1965). The benefits were maintained outside the treatment session
but not at 2-year follow-up (Haddock et al., in press).
Modification of Beliefs Alone
Although modification of the patients’ beliefs about their hallucinations have been included in some of
the studies already described, other studies have concentrated solely on this aspect. G. S. Alford et al.
(1982), in a case study evaluating the effect of a number of different approaches on severity on one
chronic schizophrenic patient’s hallucinations, found that cognitive modification of the patient’s beliefs
was most effective at reducing the duration and frequency of hallucinations. The cognitive intervention
involved helping the patient to examine her beliefs regarding the origin of the voices and their meaning
(before treatment she considered her voices to be originating from a positive source). The intervention
focused on helping her to consider the possibility that her voices were originating from a negative source.
The emphasis was on helping the patient to reach her own conclusions rather than those of the therapist.
The patient changed her beliefs about her voices, and her hallucinations reduced in severity. In a small
case series of four patients, Chadwick and Birchwood (1994) identified patients’ core beliefs about their
hallucinations and elicited the evidence used to support them. Standard belief modification techniques
were then used to dispute the veracity of the belief (see the previous section on delusions). Large
reductions in belief conviction relating to the hallucinations were observed together with reduced distress
and a reduction in hallucination activity. These improvements were maintained at follow-up.
Conclusions
It is clear that the psychological treatment of hallucinations has been addressed from different
perspectives, partly due to differences in conceptualization of the origins of hallucinations and partly due
to practical and clinical considerations. Some treatments have been derived from general psychological
theories that have then been applied to the experience of hallucinations whereas others have originated
from specific theoretical explanations of hallucinations. As a result, there is also considerable blurring
and overlap about the putative psychological processes and treatment procedures involved, which has led
some research groups to combine effective elements of treatment into comprehensive intervention
programs designed to address both hallucinations and delusions similarly. Examples of these treatments
are described next.
Coping skills enhancement. Several authors have observed that patients with enduring and persistent
psychotic symptoms develop their own coping strategies to deal with these symptoms (Breier & Strauss,
1983; Falloon & Talbot, 1981; Tarrier, 1987). For example, patients may independently use distraction
techniques to control their persistent auditory hallucinations and develop strategies aimed to reduce
arousal associated with these symptoms. These techniques are consistent with those that have been
demonstrated to be effective experimentally. On the basis of these observations, Tarrier and colleagues
(Tarrier, Harwood, Yusupoff, Beckett, & Baker, 1990; Tarrier, Beckett, et al., 1993) developed a
treatment strategy (coping strategy enhancement; CSE) that aimed to enhance and refine patients’ own
effective naturally occurring coping strategies. A range of coping strategies was identified and classified
as involving cognitive actions (e.g., attention narrowing, distraction, self-instruction, reattribution),
involving behavioral actions (e.g., increasing activity levels, initiating social engagement, social
disengagement, reality testing), modification of sensory input (e.g., listening to the radio), and modifying
physiological state (e.g., breathing and relaxation exercises). Patients were taught to identify the
antecedents to their symptoms and to use a range of coping strategies as alternative responses to reduce
the severity and emotional consequences resulting from their symptoms.
Tarrier, Beckett, et al. (1993) described a randomized controlled trial comparing the effectiveness of CSE
with a cognitive-behavioral approach, not directly targeted at symptoms (problem-solving training), and a
waiting list control group in 27 schizophrenic patients who were experiencing chronic persistent
hallucinations or delusions that had been present for at least 6 months without improvement despite
neuroleptic medication. The CSE group was taught to monitor symptoms, and effective832 G. Haddock et
al. coping strategies were targeted and refined to encourage optimum use for the patient. Problem solving
involved teaching strategies for patients to resolve problems or difficulties effectively, but these
techniques were not directed toward their psychotic symptoms. Four therapists were used and
counterbalanced across treatments so as to control for any therapist effect.
The authors found both experimental approaches to be successful at reducing some symptoms compared
with the waiting list group, particularly anxiety and delusions. CSE was superior to problem solving
particularly for delusions at the end of the treatment period. Sixty percent of patients who received CSE
showed at least a 50% reduction in their hallucinations and delusions posttreatment as measured by the
appropriate subscales of the Brief Psychiatric Rating Scale (Lukoff, Nuechterlein, & Ventura, 1986)
compared with 25% of the patients who received problem solving. Neither treatment resulted in any
significant change in negative symptoms or social functioning. No follow-up data were collected.
Patients improved in the respective skills they had been taught, but only improvements in coping skills
were significantly correlated with symptom improvement (Tarrier, Sharpe, et al., 1993). It was further
hypothesized that a positive response to cognitive-behavioral treatments, such as CSE, may be influenced
by the presence and magnitude of negative symptoms experienced by the patient. To examine this
question, patients were assessed with the Scale for Assessment of Negative Symptoms (Andreasen, 1981)
prior to treatment, and these results were correlated with the changes in positive symptoms achieved
through treatment. It was found that affective flattening and alogia (impoverished thinking and cognition),
but not avolition, anhedonia, or attention, were significantly correlated with symptom change scores, so
that high initial scores on these negative symptoms were associated with a poor response to treatment
(Tarrier, 1996). Hence, there is a suggestion that patients who show negative symptoms, characterized by
a poverty of emotion and thought that are probably indicative of cognitive deficits, appear to respond
poorly to cognitive-behavioral approaches. This is a finding that needs further study. A further evaluation
of the effectiveness of CSE has recently been completed. CSE was extended to 18 sessions (plus 6
booster sessions) and was combined with problem solving and relapse prevention (6 sessions of each
element). CSE was compared with supportive counseling (of equal therapy contact time) and routine
treatment in a randomized controlled trial with 79 chronic schizophrenic patients experiencing persistent
hallucinations and delusions. CSE was significantly superior to supportive counseling and routine
treatment in terms of overall severity of psychotic symptomatology (Tarrier et al., in press). Followup
data have not yet been collected.
Comprehensive cognitive-behavioral approaches. In response to the range of problems, which spans a
number of domains, experienced by schizophrenic patients, many authors have combined cognitive-
behavioral approaches aimed at reducing the distress and occurrence of psychotic experiences and
combined them with a range of techniques aimed at resolving other psychological problems associated
with psychosis (e.g., strategies aimed to reduce anxiety and increase self-worth, medication compliance,
and negative symptoms).
Kingdon and colleagues (Kingdon & Turkington, 1991, 1994; Kingdon, Turkington, & John, 1994)
described a cognitive-behavioral approach in the management of individuals with a diagnosis of
schizophrenia in a large case series. Over a 5-year period, they treated 64 patients who demonstrated a
marked reduction in psychoticCognitive-Behavior Therapy 833 symptoms. Chronic patients and those
experiencing an acute episode were included, and both outpatients and inpatients were treated. Patients
were given a “normalizing rationale” to reduce the stigma of mental illness and fears and anxiety evoked
by their symptoms. Comparisons were made between psychotic symptoms and phenomena that occurred
in the normal population in extreme circumstances, such as under conditions of sensory deprivation or
high levels of stress. The normalizing strategy also included teaching individuals anxiety management
techniques, promoting a comprehensive approach from all staff involved, homework assignments such as
monitoring of symptoms, cognitive strategies directed toward symptoms such as those described before,
promotion of methods aimed at early intervention to reduce the severity or onset of relapse (cf.
Birchwood et al., 1989), plus techniques designed to increase selfesteem and reduce depression. Kingdon
and Turkington’s approach is clearly multifaceted, and a controlled evaluation has yet to be carried out,
but they anecdotally report symptomatic improvements and reduced rehospitalization rates in most of the
patients treated (Kingdon & Turkington, 1994, pp. 119–123). It should be emphasized that their approach
also involved a well-organized community psychiatric service with an infrastructure to manage patient
care.
Fowler and colleagues (Fowler, 1992; Garety, Kuipers, Fowler, Chamberlain, & Dunn, 1994) also
described a comprehensive approach to the treatment of long-term psychosis. They emphasized a
cognitive approach aimed to maximize engagement, to be flexible in the length and timing of sessions, to
provide information regarding the nature of the individual’s condition and medication, to short- and long-
term goal setting, and to strategies to avoid future relapse. In a trial involving 19 patients, Fowler (1992)
found clear improvements among those with residual positive symptoms and those with accompanying
affective problems, although very little change was observed for patients with negative symptoms alone.
Fowler and his colleagues (Garety et al., 1994) have continued to develop this approach. Techniques they
used during therapy included some of those already mentioned as well as strategies to overcome
hopelessness and modification of dysfunctional beliefs and assumptions about the self. In a trial designed
to test the efficacy of their approach compared with a waiting list control group, 11 patients completed
therapy and 7 were used as controls. Patients received an average of 16 sessions over approximately 6
months. There were significant reductions in total psychopathology scores, depression, and a range of
measures relating to delusions, such as, conviction, distress, and interference to daily life for those
patients in the active treatment compared with controls, although there was little impact in relation to
improvements in negative symptoms. This approach was further evaluated in a recent randomized
controlled trial comparing cognitive-behavior therapy with treatment as usual (case management and
medication). Over 9 months, significant benefits on BPRS symptom scores were found only for those
receiving cognitive-behavior therapy (Kuipers et al., 1997).
CONCLUSIONS
The range of cognitive-behavioral approaches used in the treatment of psychosis is diverse, and there
have been changes in the emphasis and type of interventions over time, with development from solely
behavioral approaches to a recent emphasis on modifying cognitive processes. Whether these changes
have led to greater improvements in treatment outcome is, as yet, unclear although more contemporary
cognitive834 G. Haddock et al. behavioral treatments appear to have greater generalization over time.
Nevertheless, as many researchers have evaluated comprehensive combination treatment packages, the
single essential elements of cognitive-behavioral treatments have not been evaluated, and much research
is necessary to indicate what are the effective elements of treatment and which strategies are most
effective at remedying particular symptoms.
In addition, there are few large controlled studies demonstrating their efficacy in relation to a comparable
control group, although several funded trials are ongoing in the United Kingdom. Further research is also
necessary to establish cognitive-behavioral techniques as an effective management strategy either as a
stand-alone treatment or in conjunction with traditional medical approaches to management. In addition,
most of the cognitive-behavior and behavior therapy research on schizophrenia has been performed with
patients in a residual phase of the disorder, in conjunction with a stabilizing antipsychotic drug regimen
rather than newly diagnosed or acute patients. However, rigorous procedures to determine stability in the
residual phase are often not performed or not reported. In many cases, a psychosocial treatment is
indicated because drugs have failed to resolve symptoms or other problems adequately. Positive
symptoms (hallucinations, delusions, thought disorder, etc.) usually show the most definitive response to
antipsychotic drugs and are in that sense more associated with the acute phase. However, sometimes they
persist despite pharmacological treatment.
This suggests that the meaning of “residual phase” and “optimal medication” is different for different
patients. As a result, the implications for the probable success of cognitive-behavior therapy, given the
variability in individual differences in symptom stability, duration, configuration, and response to
medication, are as yet unclear.
Despite the predominance of research on drug-refractory patients in the residual state, there is some
evidence that cognitive-behavioral interventions may also facilitate recovery from acute psychosis. Drury,
Birchwood, Cochrane, and Macmillan (1996a, 1996b) targeted acutely ill hospitalized psychotic patients,
some of whom were experiencing their first episode of psychosis. In this study, cognitive-behavior
therapy was used to improve and speed time to recovery. Patients allocated to the cognitive-behavior
therapy condition received intensive individual sessions plus family support and education sessions. This
was compared with a nonspecific control group that received recreational activity and a group that
received routine hospital care. Sixty-five percent of the cognitive-behavior therapy group achieved full
symptomatic recovery by 12 weeks compared with 40% of the controls. The mean time to recovery and
time in hospital were reduced by 48% and 54%, respectively, for the cognitive-behavior therapy group
compared with the recreational control group, which showed no advantage over routine care.
The first two authors are currently carrying out a similar but much larger multicenter study designed to
target acutely psychotic patients during an early episode of their illness. This study (the SOCRATES
study) will assess the effectiveness of providing intensive cognitive-behavior therapy plus routine hospital
care compared with hospital care alone in terms of levels of psychopathology, distress, and time to
recovery from the index episode and will examine whether this treatment provides any protection against
subsequent relapse (Lewis, Tarrier, Haddock, Bentall, & Kinderman, 1995).
There are several conflicts to resolve if these promising beginnings are to fulfill their therapeutic
potential. It is clear that pragmatic trials of sufficient size are required to demonstrate what treatment
works best with which patient and under which conditions, but it is also necessary to agree on a common
currency in terms of outcome. For example, what are the most important outcomes by which it is
necessary to demonstrate a treatment effect in any trial involving schizophrenia. This lack of agreement is
highlighted by the debate on whether to concentrate on individual symptoms alone, on a range of
symptoms and dysfunctions, or on the putative underlying mechanisms. This in turn reflects different
explanatory models held by researchers in the area, and communication among researchers is needed to
yield an integrated model of psychosis. A related issue is the investigation of the processes involved in
therapeutic change. Rigorously designed studies are needed to elucidate which therapeutic processes are
responsible for which therapeutic changes and whether these are changes in cognitive deficits, actual
changes in the phenomenology of symptoms, changes in beliefs, or arousal reduction. A greater
integration of theory and practice is required to further develop psychological treatment in psychosis.
Finally, keeping independent assessors of outcome blind to the treatment condition can be problematic,
especially when comparing cognitive-behavior therapy to routine care, because patients may disclose
information regarding the treatment they are receiving. It is less of a problem when comparing different
types of cognitivebehavior therapy or a placebo intervention, but care is required to ensure that
assessments are carried out with the same rigor that would be expected in a pharmacological study. The
use of “active” psychological treatments also raises issues of treatment quality and fidelity. There are
practical difficulties involved in delivering the required “dose” of treatment of a required quality with
appropriate patient adherence. Differing priorities of therapist and patient may mean that a patient may
view his or her positive symptoms as low priority compared with other symptoms, medication side
effects, disabilities, and social deprivations. Similarly, a congenial interaction with a therapist may be a
more attractive aspect of a therapeutic contact than the active therapy itself, with a resulting decrease in
time spent on actual therapy. These may all signify that the amount and quality of therapeutic input of
cognitive-behavior therapy may vary considerably within a treatment group with a corresponding effect
on outcome. Future trials will need to assess treatment credibility and what was actually done in therapy
and relate this to outcome.