Available online at www.sciencedirect.

com

Cognitive and Behavioral Practice 16 (2009) 73–83

www.elsevier.com/locate/cabp

The Application of Cognitive Therapy for Command Hallucinations

Alisa R. Singer and Donald E. Addington, University of Calgary, Calgary Health Region

It has become increasingly recognized that cognitive therapy (CT) is an effective treatment for the positive symptoms of schizophrenia yet
there are few cognitive therapists in North America who are specialized to work with this patient population. There is a need for further
dissemination of CT for schizophrenia in order to increase its availability. A first step in dissemination is to become familiar with the
cognitive theory and therapy model, as applied to schizophrenia. The purpose of the present paper is to demonstrate the applicability of
CT for psychosis, using the example of command hallucinations. First, we summarize the cognitive theory of command hallucinations
and present the stages of CT, using the example of “Joe,” a 24-year-old male with schizophrenia. The paper concludes with practical
suggestions of how to enhance the effectiveness of CT for command hallucinations.

I T has become increasingly recognized that in com-

parison to routine care alone, the addition of cognitive
behavioral therapy (CBT) results in less positive and
negative symptoms of schizophrenia (Tarrier et al., 1998)
as well as improved social functioning (Startup, Jackson, &
Bendix, 2004). North American clinical practice guide-
lines recommend psychosocial interventions such as CBT
for schizophrenia when the acute symptoms have stabi-
lized (Addington et al., 2005; American Psychiatric
Association [APA], 2004). However, CBT for schizophrenia
is not widely practiced in North America, in part due to the
lack of trained therapists available to provide the therapy.
Much of the research and practice of CBT for
schizophrenia has been conducted in the United King-
dom. There is a growing body of randomized control
trials (RCTs) that have studied cognitive behavioral inter-
ventions for schizophrenia. In one of the largest multi-
centre RCTs, Lewis et al. (2002) randomized 309 patients
with first-episode psychosis to CBT versus a supportive
therapy versus treatment as usual (TAU). They received
5 weeks of intensive CBT in hospital and were followed up
at 18 months. They found that patients with auditory
hallucinations responded best to CBT. Although they
found no differences in overall rate of improvement in
symptoms, there was evidence that both CBT and sup-
portive therapy were better than TAU at reducing positive
and negative symptoms at 18 months. A recent meta-
analysis of 30 papers describing 19 RCTs concluded that
CBT is effective in addition to medication but when
compared to a nonspecific therapy, such as supportive
therapy, the differences are less substantial (Jones,
Cormac, Silveira da Mota Neto, & Campbell, 2004). The
meta-analysis also found limited evidence that CBT can
show lasting effects once the treatment has ended.
Further research is needed to better understand the
effect of CBT for schizophrenia. However, there is also is a
need for dissemination of the treatment, especially within
North America. One method of understanding CBT
interventions for schizophrenia is through the demon-
stration of the therapy using specific case examples
(Byrne, Birchwood, Trower, & Meaden, 2006).
A psychological intervention has been developed for
command hallucinations (CH). This intervention
demonstrates how cognitive theory can be proposed,
studied, and applied for the treatment of schizophrenia.
The therapy is derived from cognitive theory and, thus,
will be referred to as cognitive therapy (CT) because of
the primary emphasis on changing cognition. In the
following paper, we summarize the cognitive theory of
CH and the application of CT within a comprehensive,
multidisciplinary early psychosis program. We describe
the therapy by presenting the case of “Joe,”1 to provide
education in the delivery CT and its potential impact for
psychosis. We will provide examples of CT techniques
and homework assignments.

1077-7229/08/73–83$1.00/0
© 2008 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
; Continuing Education Quiz located on p. 120.
1
Written informed consent was obtained from the patient allowing
the authors to publish the case material and data collected. Aspects of
the case material have been disguised to protect the identity of the
patient and those who know the patient.
74 Singer & Addington
Command Hallucinations
CH are considered among the most disturbing and high-
risk symptoms of schizophrenia, and there is emerging
evidence that CT is an effective adjunct treatment to
medication (Trower et al., 2004). A CH is a subtype of
auditory hallucination in which the voice heard by the
patient commands him or her to perform a particular
action. Many voice hearers report that they experience the
voice as commanding, with evidence that up to 74% report
CH (Braham, Trower, & Birchwood, 2004). Often the CH
will urge the person to perform a violent or dangerous act to
themselves or others (Junginger, 1996; Kasper, Rogers, &
Adams, 1996) but compliance rates vary. Compliance with
the voice refers to the tendency to emit a behavior that
obeys the voice's command. In a review of 11 studies, Hersh
and Borum (1998) found compliance rates of between 39%
to 88%. Retrospective data also show that 4% to 10% of
suicidal behavior in schizophrenia is in response to CH
(Harkavy-Friedman et al., 2003). Individuals experiencing
CH may feel helpless (Rogers et al., 1990), depressed
(Soppitt & Birchwood, 1997; van der Gaag, Hageman, &
Birchwood, 2003), and worried about their CH (MacK-
innon, Copolov, & Trauer, 2004). Research has shown that
patients who comply with CH tend to be on higher doses of
neuroleptic medication compared to those who are able to
resist the voice (MacKinnon, Copolov, & Trauer, 2004).
Given the significant behavioral and emotional conse-
quences associated with CH, it is important that effective
treatments are available.
Cognitive Theory of Command Hallucinations
Why do individual differences exist in rates of CH,
compliance, resistance, and emotional distress associated
with CH? In patients who are hallucinating, the tendency to
misattribute internal events to an external source is the
major information processing bias (Bentall, 1990). The
cognitive theory proposes that CHs are self-generated but
interpreted as being emanated from an external, powerful,
dominant source that has the power to inflict harm if the
command is not carried out (Byrne et al., 2003). The
relationship between the command and emotional and
behavioral consequences (e.g., distress, compliance, resis-
tance) is mediated by the beliefs one holds about the voice's
identity, familiarity, power, and intent (Braham et al., 2004).
The social rank theory (Gilbert, 1992) is a specific
theory of social relationships that has been applied to
understanding the relationship between voice hearer and
hallucinations and why some patients experience hallu-
cinations as commanding (Byrne et al., 2003). Social rank
theory arises from evolutionary psychology and focuses on
dominant hierarchies in animals (human and non-
human) that live in groups. Social hierarchies maintain
order and cohesion in social organizations. Individuals
who possess superior skills are able to threaten, attack, or
intimidate those who are less able. Those who are less able
and in subordinate positions defend themselves through
escaping or fleeing. If the subordinate individuals decide
to stay in the social group, they evoke certain interperso-
nal behaviors, such as submissiveness and appeasement, to
deescalate and cope with threat from the dominant
others. Subordinate characteristics include selective obe-
dience of certain commands or the appeasement of the
dominant when obeying the command is dangerous and
escape is not possible (Byrne et al., 2003). When the voice
is viewed as benevolent, the voice hearer is likely to obey
the voice's command whereas when the voice is perceived
as malevolent, the voice hearer is more likely to carry out
appeasement behaviors. It is proposed that the content of
an individual's beliefs about voices parallels his or her core
schema about the self and relationship to others.
Specifically, individuals who view themselves as inferior
and subordinate to others in their social world also believe
that they are subordinate to the voice, which they view as
coming from a powerful dominant (Byrne et al., 2003).
There is empirical evidence to support this social rank
theory of CH. Several studies have shown that malevolent
voices evoke anxiety and are resisted, while benevolent
voices are engaged (Birchwood & Chadwick, 1997;
Chadwick & Birchwood, 1994). In another study, van
der Gaag et al. (2003) found that beliefs about malevo-
lence were linked to higher depression and anxiety but
the voice's negative content was not associated with
emotional distress. These results support the cognitive
model, which proposes that the appraisal of the voice's
meaning and purpose, not simply the content of the
voice, is linked to emotional consequences. Furthermore,
they found that voices perceived as malevolent were
resisted and not engaged, whereas benevolent voices were
engaged and not resisted. There is also evidence that
individuals with CH also report that they are subordinate
and inferior to other people (Birchwood, Meaden,
Trower, Gilbert, & Plaistow, 2000).
The application of CT for CH evolved out of the
emerging evidence that the way people perceive their
psychotic symptoms can play a role in the emotional and
behavioral consequences of the symptoms. Trower et al.
(2004) conducted a single blind RCT of CT compared to
TAU in a sample of 38 patients who had recently complied
with CH. Compared to TAU, the CT group demonstrated
greater reduction in their beliefs about the power and
omnipotence of voices as well as an increase in their
perceived control over voices. Furthermore, they demon-
strated greater reduction in their compliance with the
voices compared to TAU. This pattern was maintained at a
12-month follow-up. CT resulted in less distress at 6 months
but by 12 months, both groups demonstrated comparable
levels of distress associated with voices. In addition, the CT
group demonstrated significant reductions in positive,
 Cognitive Therapy for Command Hallucinations 75

negative, and general psychopathology, which was main-
tained at a 12-month follow-up. Both groups were
prescribed comparable doses of antipsychotic medication
at baseline. However, during the follow-up period, TAU
demonstrated significant increase in their prescribed
neuroleptics whereas CT demonstrated a small decrease
in their prescribed medication. This study suggests that CT
can make a significant clinical impact on CH.
Cognitive Therapy of CH
Byrne et al. (2003; 2006) have outlined in great detail
a step-by-step procedure for CT of CH, which is pre-
sented in Table 1. The therapy is designed to reduce
distress, dysfunctional beliefs, and compliance behavior
but not the eradication of symptoms per se. The primary
goal of CT is to examine and challenge the patient's
beliefs about voices and their core schema through use of
cognitive and behavioral interventions. The therapy will
be briefly summarized here.
Stage 1: Assessment
The main purpose of the first phase is assessment but
also involves engagement, formulation, promoting control,
and goal setting. Engagement in a therapeutic relationship
can be especially challenging for these patients. They may
fear that the therapist will not understand or will be afraid
of them. They may experience voices telling them that the
therapy is useless and/or that they should harm the
therapist. It is important that the therapist be mindful of
these potential obstacles and implement interventions to
build rapport. The first sessions may begin by discussing
pleasant or more neutral topics. The therapist should
employ the same strategies used to facilitate engagement
with all patients, which include using empathy, listening,
asking clarifying questions, and paraphrasing, to demon-
strate warm positive regard and empathic concern. The
therapist works to identify the relationship between the
voice and the voice hearer. During the assessment phase,
the therapist should elicit the patient's beliefs about voice
identity, power, meaning, and their own control by asking
direct questions about beliefs. The therapist then explains
the CT model, making the distinction between the
activating event (the voice) and the person's interpretation
of it. As a first step in the process, it can be helpful to
provide the patient with information regarding the
prevalence of hallucinations in the general population
(Kingdon & Turkington, 2005). Specifically, there is
evidence that people without psychotic disorders will
experience hallucinations in times of severe trauma or
stress (e.g., torture situations) or during severe deprivation
states (e.g., sensory deprivation rooms). This intervention
is designed to show the patient that hallucinations are part
of human experience but the meaning that is attached to
them maintains their distress.
To promote control and reduce the risk for compliance
with the voice, the therapist then encourages the patient to

Table 1
Summary of Treatment Stages and Interventions

Stage Key Interventions

1. Assessment
• Engage the patient in therapy.
• Identify the hearer–voice power relationship.
• Elicit beliefs about voice identity, power, compliance, resistance, appeasement, and meaning.
• Socialization to the cognitive model: Make a distinction between activating event (the voice) and
the patient's interpretation of it.
• Psychoeducation regarding voices and their prevalence in the general population.
• Identify, enhance, and add to existing coping strategies in order to promote control.
• Set goals for therapy.
2. Intervention
• Challenge beliefs about voices by questioning the evidence for the beliefs.
• Reality testing of beliefs. Encourage patient to reduce appeasement behavior and discover that feared
outcome does not occur.
• Question the voice's command. Say an assertive response to the voice.
• Behavioral experiments to “start” and “stop” the voices and monitor the impact on beliefs and emotions.
• Emphasize resistance of voice commands.
• Identify evidence of their personal mastery and control and increased social rank relative to the voice.
3. Reformulation
• Identify automatic thoughts and their relationship to the content of auditory hallucinations.
• Identify core schema about self, others, and future.
• Identify evidence for and against core schema.
• Develop a rebuttal to automatic thoughts and core schema.
• Assertiveness training to strengthen new beliefs and challenge beliefs regarding subordination in
interpersonal relationships.
76 Singer & Addington
enhance and add to existing coping strategies. This
intervention can be facilitated by offering a menu of choices
and asking the patient to select a strategy that he or she
wishes to try (see Kingdon & Turkington, 2005). These
coping strategies bring some relief and also facilitate
engagement. They are also designed to demonstrate the
person's strength in coping with voices and to begin building
evidence against the voice's power. At the end of this initial
stage, the therapist and patient should set specific goals for
therapy. It is important that the patient understands that the
main goals of therapy are to reduce distress and compliance
behavior. Patients are encouraged to understand that their
distress and behavior have arisen from their beliefs about the
voices and not the automatic product of the voice itself. They
are encouraged to change their beliefs and that beliefs are
hypotheses, not facts. Together, the patient and therapist
devise a list of current and alternative beliefs that can be
tested as part of the therapy process.
Stage 2: Intervention
The next stage involves intervention to challenge
beliefs about voices. There are a number of techniques
that can be used at this stage. Techniques include
questioning evidence, questioning the voice's command,
and behavioral experiments for switching voices on and
off. The beliefs about identity, meaning, and power are
challenged by questioning the evidence using standard
CT, helping the patient to examine their evidence and its
utility. The patient can be asked to say an assertive
response to the voice and to make predictions about their
own and the voice's power and control. After several such
tests of saying an assertive response and discovering that
the voice can not harm, the patient further weakens his or
her beliefs and strengthens alternative beliefs.
Once the patient has developed a detached view of the
voice, behavioral experiments can be devised to stop and
start the voices, in order to promote further control. The
client is encouraged to initiate or increase voice activity for a
short period, then implement a strategy to stop or decrease
the voice. Common triggers to voice activity can be selected
collaboratively with the patient. Patients in our service have
reported triggers such as lack of activity or boredom, focusing
their attention on the voices, news stories, horror movies, and
being around other people. Strategies to stop or decrease the
voice might include saying an assertive response, using a
distraction technique, reading therapy notes, and taking a
temporary retreat from others. These experiments are
designed to demonstrate that the patient has greater control
over the voice and further strengthens adaptive beliefs.
Stage 3: Reformulation
Byrne et al. (2003) refer to this final stage as refor-
mulation of subordination beliefs. In our view, this stage is
an opportunity to identify and challenge subordination
beliefs related to self and others, using standard CT
interventions. Some patients may benefit from seeing the
connection between their own automatic thoughts and
core beliefs about subordination (e.g., “I am inferior”)
and the content of the voice (e.g., “You are inferior”).
Traditional cognitive restructuring interventions, such as
rating the degree of believability of these thoughts and
evidence for/against them, can then be used to examine
and challenge dysfunctional cognitions. Depending on
the cognitive capacity and insight of the patient, the
therapist may be able to collaborate with the patient to
examine the current and historical evidence that main-
tains the patient's core beliefs, helping them to discover
the inaccuracy of their thoughts and to develop more
accurate thinking (e.g., promoting equality in relation-
ships). Behavioral interventions may also be needed, such
as assertiveness training, to strengthen new beliefs
regarding equality to others and to further challenge
beliefs regarding subordination.
Special Considerations in Implementing CT for
Schizophrenia
In working with patients with psychotic disorders, it is
important that the clinician modify CT to accommodate
potential cognitive impairments that are associated with
psychosis. Patients may have difficulty recalling the
lessons learned in therapy and the homework to be
completed in between sessions. Memory aids, such as
keeping detailed notes of therapy sessions and tape
recording sessions, can be used to accommodate cogni-
tive limitations. In our service, many patients have res-
ponded well to the concept of developing their own
“personal self-help book.” Each CT patient is asked to
bring a binder in which to keep therapy notes. The binder
is conceptualized as their personal self-help book devel-
oped specifically for them so that when therapy has
ended, they can remind themselves and use therapy
concepts independently. The purpose of the binder is to
act as a memory aid to assist with the learning and
retention of therapy concepts.
In the following case, we demonstrate how CT can be
applied for the amelioration of distress associated with
CH, using a specific case example. This case was treated in
the Early Psychosis Treatment Service, which provides
case management and CT services. This case is described
to provide a detailed description of how to implement CT
for CH.
Case Example
Presenting Problems
Joe was referred by his psychiatrist (D.A.) for CT. Joe
experienced uncontrollable voices in his head. His most
distressing voice sounded like a male and he named it
 Cognitive Therapy for Command Hallucinations
“Lucifer,” believing that it was the devil. The voice's content
was always hostile, telling him that he was worthless or
useless, that others were worthless or useless, and that he
should kill people. He heard this voice every day and it was
usually triggered by situations involving other people (e.g.,
bus rides, Clubhouse meetings) or when he made a mistake
or error. His reactions were frustration, fear, physiological
arousal (e.g., heart racing), and withdrawal from others. He
became fearful that he was going to do “something violent”
and experienced a “violent urge,” which he described as a
feeling of tension and getting “ready to do something.” He
stated that he imagined how he would perform a violent act
towards others and thought about how his family would be
disappointed. He was unsure if he would be able to
continue resisting the commands and felt compelled to act
on them.
Joe reported that he resisted the voice through prayer.
He also got angry at the voice, saying “shut up” and “leave
me alone.” He never obeyed the severe commands of this
voice; however, he had engaged in appeasement beha-
viors of less severe commands such as ending conversa-
tions or stealing a water glass from a restaurant when
commanded. He believed that these behaviors would
make the voice quiet and prevent future, more violent,
commands. He felt depressed, scoring in the severely
depressed range on the Beck Depression Inventory II
(BDI-II; Beck, Steer, & Brown, 1996). He scored in the
severely anxious range on the Beck Anxiety Inventory
(BAI; Beck & Steer, 1996). On the Beliefs about Voices
Questionnaire (BAVQ; Chadwick & Birchwood, 1995), a
self-report inventory of beliefs about voices, Joe scored
highest on beliefs about malevolence and omnipotence.
He also scored highest on resistance of the commands of
the voice, endorsing both emotional and behavioral
resistance. Joe's baseline scores are presented in Table 2.
History of Presenting Problem
Joe reported that he had experienced CH for as long as
he could remember. In the past 5 years, Joe's voices had
become more frequent and violent but he generally
resisted the commands. He reported that at the age of 19,
he was short-tempered and engaged in physical fights with
his peers, which he believed was commanded by voices.
He stated that he kept the voices hidden from others for
many years. Joe had been taking atypical neuroleptics
since being diagnosed 2 years ago. He was first started on
olanzapine, which was titrated to 25 mg. He continued to
experience residual symptoms and was then tried on
risperidone. The dosage of antipsychotic was gradually
increased to 4 mg but he never achieved full symptom
remission. Joe was also taking 20 mg of the antidepressant
citalopram. His psychiatrist had considered a trial of
clozapine because of the lack of response to other
77
Table 2
Baseline and Posttreatment Scores on Self-Report Measures
Measure Baseline Posttreatment 8-Month
Follow-up
BDI-II 32 5 0
BAI 30 11 9
BAVQ
Malevolence 14 5 2
Omnipotence 11 3 2
Engagement 1 3 3
Resistance 25 21 21
Note. BDI-II = Beck Depression Inventory; BAI = Beck Anxiety
Inventory; BAVQ = Beliefs About Voices Questionnaire.
medications. Joe had recurrent syncope, a cardiovascular
condition marked by a transient loss of consciousness with
an inability to maintain postural tone that is followed by
spontaneous recovery. He had recently been hospitalized
for his heart condition. His psychiatrist was concerned
that Joe may be at higher risk for the cardiovascular side
effects associated with clozapine. Joe was fearful to try
another medication and preferred to try CBT.
Distal History
Joe was the youngest of six siblings. His father was
“mentally abusive” to his mother and the children. Joe was
often called names such as “idiot” and “useless.” He
viewed his father as powerful and he felt helpless relative
to his father. Growing up, Joe stated that he was never
taught how to express anger. When he was angered, he
was afraid that he would become like his father. Joe stated
that he learned to hide his feelings of anger and to
withhold expressing his feelings to others. Joe's parents
divorced when he was age 9 years old.
Joe's academic performance was below average in
school. In elementary and junior school, he was disruptive
in the classroom and had difficulties with teachers and
peers. Over the years, he had continued to feel guilty
about his past behavior in school, recalling that on one
occasion he injured his teacher's hand by slamming it in
his desk. He was placed in a special education classroom
in grade 7, which led to improvements in his learning and
ability to relate to his peers. He completed high school
and graduated from the nonacademic stream. Following
his graduation, he was employed at a department store
where he worked in numerous divisions for 6 years. His
longest relationship, 4 years ago, lasted for 1 month. He
ended the relationship because his siblings did not
approve, but also because the voices commanded him.
Cognitive Therapy Formulation
Joe was the youngest in a sibline of six. Growing up, his
father was verbally abusive, calling him “useless” and
78 Singer & Addington
“idiot”. He reportedly felt powerless and helpless relative
to his father, which may have led to the emergence of a
core schema that he is subordinate to others. Later in life,
he struggled academically and socially, which likely
reinforced this negative self-view. This core schema, that
he is subordinate to and dominated by others, may have
led him to perceive his voices as malevolent and
omnipotent, resulting in depression and anxiety. He has
never obeyed the severely violent commands of the voice,
which he identified as repugnant and socially unaccep-
table. As a child, he was taught that anger was unaccep-
table and to withhold expressing anger, which may have
led him to the development of avoidant strategies to cope
with difficult feelings. Thus, the content of the voices,
marked by violent thoughts directed at others, may serve
as an exacerbation of underlying and normal expressions
of anger, which he has difficulty identifying and expres-
sing. Furthermore, the self-deprecating comments made
by the voice may be a reflection of Joe's core beliefs and
automatic thoughts related to himself. To the extent that
he continues to hold beliefs that he is helpless and the
voices are all powerful, he is possibly at risk for ongoing
distress, depression, and anxiety.
Treatment Interventions
Treatment followed the guideline of Byrne et al.
(2003) for CT for CH. From the onset, the therapist
and Joe set therapy goals collaboratively. Joe's goals for
therapy were to have less fear of the voices, less anxiety
and depression, as well as more control over the voices.
From the onset of therapy, he was provided with
psychoeducation regarding the process of CT. He was
taught that it was unlikely that CT would be able to stop
the hallucinations altogether, but rather, would assist him
in developing more adaptive reactions to the voice.
The first stage of treatment (Sessions 1 to 4)
emphasized the development of a therapeutic relation-
ship and better understanding of Joe's symptoms,
perceptions, and current coping strategies. The therapist
elicited Joe's beliefs about the voices by asking, “What is
your theory about whose voice it is?” Joe believed the voice
was the devil punishing him for past wrongs. He believed
that he had only 10% control and power over his actions
in response to the voice. He was unsure if he could resist
the commands and worried that he would comply with
the voice's wishes by harming another person or himself.
Joe was socialized to the cognitive model and the role of
his own beliefs about voices in maintaining his anxiety,
depression, and social isolation. Joe agreed to examine
and challenge his beliefs about the voice. To increase his
motivation for therapy, he was asked to consider the
advantages and disadvantages to holding on to these
beliefs about the voices. Joe was able to see that the
disadvantages outweighed the advantages, resulting in
more motivation for change.
He was provided with a psychoeducation pamphlet
explaining what voices are, where they come from, and
different ways of coping (obtained from Kingdon &
Turkington, 2005). We discussed the research that
demonstrates that people experience hallucinations
during times of severe stress (e.g., traumatic events) or
deprivation states (e.g., sensory deprivation rooms)
(Kingdon & Turkington, 2005). Joe was able to recognize
that too much stress or lack of stimulation (e.g.,
boredom) often triggered his hallucinations.
Next, CT focused on enhancing his coping repertoire,
to begin to demonstrate that he had power and control
over the voice. He was provided with a list of potential
coping strategies (Kingdon & Turkington, 2005) and he
selected the strategy of saying an assertive response to the
voice: “I am not going to do [something violent]. If you want
something like that to happen, do it yourself [to the voice].”
The following week, Joe was very pleased with the result of
this new coping skill. He was effectively able to say an
assertive response to the voice, resulting in less anxiety
and distress.
In the second stage of therapy (Sessions 5 to 8), we
examined the evidence for his beliefs about the voices
and used evidence from his coping skills to challenge
his beliefs, as demonstrated in the following therapy
excerpt:
THERAPIST: We have been talking about how you can
cope with the voice by trying strategies that other
people have used to cope with voices.
JOE: Yeah, I tried the strategy and it worked! When the
voice told me to kill people, I said to the voice out
loud, “If you want that person killed, I am not going to
do it so why don't you just do it yourself?”
THERAPIST: And what happened?
JOE: The voice quieted down. It didn't say much else
after that.
THERAPIST: What impact did that have on you?
JOE: I felt less anxious and depressed. I decided that I
could leave my room and go spend time with my
family.
THERAPIST: Sounds like a very positive outcome. So you
spoke assertively to the voice and the voice was less
distressing. What was the worst thing you predicted
would happen if you spoke up against the voice?
JOE: Well, I thought the voice would get really angry,
tell me off, and start getting louder and louder. I
 Cognitive Therapy for Command Hallucinations
thought it would start commanding me to kill people
and I would have the urge to do it. And that is not
what happened at all. I think I have more power and
control than I realized.
THERAPIST: Well, it sounds like your experiment
showed that you were able to exert power and control
over the voice. You have mentioned that you believe
that the voice is the devil. If you are able to powerfully
assert yourself, what does that mean about the voice
being the devil?
JOE: Well, maybe it is not the devil…. Maybe it is just my
mind's reaction to stress or lack of stress.
THERAPIST: So what I hear you saying is that your initial
assumptions may have not been entirely true. You now
are wondering if the voice is your mind's reaction to
stress or lack of stress and your experiment showed
you that you have power and control over the voice.
What impact would this have on your life?
JOE: Well, it means that I don't need to worry so much
that I am going to lose control and that I can be with
people, which I really want to do. I don't need to worry
so much that the devil is going to take over me.
Joe revealed that his main coping strategy was prayer,
asking God to “take the devil to the stake.” We discussed
the advantages and disadvantages of maintaining this way
of praying. Joe was able to see that this way of praying was
reinforcing and exacerbating his belief that the voice was
a demon. We discussed how he might develop an
alternative way of praying that would be consistent with
the new belief that the voice was the product of his own
mind and that he had the ability to control his actions and
responses to the voice. Joe was able to develop a prayer in
which he asked God for help in enhancing his own
personal strength and power over the voice.
Figure 1. Behavioral experiment to challenge belief's about voices.
79
Once he had distanced himself further from the voice,
Joe was introduced to the concept of behavioral experi-
ments to test his new and old beliefs about the voice. The
clinician and Joe developed an experiment in which he
would perform a task that would purposefully “start” the
voice followed by a task to “stop” the voice. To provide
further rationale for the intervention, the clinician used
the analogue of learning to ride a bicycle (Byrne et al.,
2003) by saying, “When you are learning to ride a bicycle,
you can not simply learn how to stop the bicycle; you need
to learn how to start it as well.”
Joe agreed to conduct behavioral experiments on
starting and stopping voices, selecting potential triggers of
voices that were of increasing difficulty for him. The
behavioral experiments were designed to test the target
thought, “The voice is the devil and I have no control over
it.” The alternative explanation that he wished to test was,
“The voice is the product of my own mind in reaction to
stress and I have control over how I react to it.” Joe made
predictions about his anxiety, power, and control and
then monitored the outcome following the experiment
(see Fig. 1).
Joe's voices were triggered by lack of activity, spending
time alone, horror movies, and going to the mall. The
experiment was carefully designed with the therapist to be
of moderate yet manageable difficulty. The amount of
time spent involved with the trigger of voices was
calculated and carefully controlled (e.g., watching a
boring television program for 15 minutes) and a way of
stopping the voice was selected (e.g., saying an assertive
response to the voice). Joe performed the experiment for
homework. The outcome of the experiment led to the
discovery that he had more control and power than the
voice, and that he was able to effectively cope.
In the third and final stage of therapy (Sessions 9 to
18), sessions were conducted to evaluate and challenge
the content of Joe's hallucinations, which paralleled his
automatic thoughts and core schema. Joe was able to see
80 Singer & Addington

that the voice's content was similar to his own personal
beliefs about himself (e.g., he believed that he was
worthless and useless) and that these negative beliefs
were activated by disappointments, life stressors, or
perceived failures. Cognitive restructuring was used to
examine and challenge the validity of his negative
thoughts by looking at the historical and current evidence
(see Fig. 2). He was taught how to add a rebuttal to the
evidence that supports his old negative belief by adding
a “but” (Greenberger & Padesky, 1995). Joe identified
the evidence that contradicted these negative thoughts
and developed a more adaptive view of himself. He was
provided with a card with statements to remind him of the
new way of thinking:
Thoughts are not facts. I am working hard to get
better. I have been brave facing my fears. I care about
my family and help out whenever I can. I am gaining
more power and control over my life. I need to forgive
myself for my past mistakes.
To further challenge and strengthen more adaptive
self-views, he was encouraged to “act as if the negative
belief is not true.” Joe decided to become more active by

Figure 2. Cognitive restructuring of core schema.

 Cognitive Therapy for Command Hallucinations
scheduling walks and volunteering at a YMCA. He moni-
tored the impact of these activities on his self-view and
depression. The outcome of these activities was signi-
ficant: Joe lost weight, developed a more positive self-view,
and became more socially active.
In addition, Joe tended to be a “people pleaser” who
lacked assertiveness skills. Motivational enhancement
was used by asking him to think about the advantages
and disadvantages in maintaining this interpersonal
communication style. Joe was able to see that he was
prone to anxiety and depression due to his view that he
was less worthy than others. Through use of Socratic
questioning and examining the evidence, Joe was able to
develop a healthy view that he is equal to others. In the
final sessions, assertiveness training was conducted to
develop a behavioral repertoire to challenge his old view
that he is subordinate and to strengthen his new view
that he is equal to others. He was provided with select
readings on assertiveness (Davis, Robbins-Eshelman, &
McKay, 2000). To challenge his passivity in relationships,
he was taught that he had equal rights to others,
including the right to say no, to change his mind, to
negotiate, to ask for help, and to express how he felt.
These ideas were novel to Joe, and he initially had
difficulty accepting them. Next, he was given instruction
in how to make an assertive response, broken down (in
light of his cognitive limitations) into three simple steps:
I think . . . , I feel . . . , I want. . . . For example, Joe
developed an assertive response to a situation with a
friend who did not return his phone call. He expressed
his feelings (e.g., “I felt hurt when you did not call me
back”) and asked for a specific behavioral change (e.g.,
“I want you to call me back soon so that we can make a
plan to see each other”). Assertive responses were deve-
loped and rehearsed in session and then practiced for
homework in increasingly more difficult situations.
Results
At the end of treatment, Joe reported minimal depres-
sion and mild anxiety, as evidenced by his scores on the BDI-
II and BAI (see Table 2). He also reported a significant
reduction in his beliefs about the voice's malevolence and
omnipotence on the BAVQ. He reported a small decrease
in resistance and a small increase in engagement, which
may have been due to less fear and avoidance of the voices.
He continued to experience hallucinations, but they no
longer had a significant impact on his life. He no longer saw
himself as worthless and useless and had developed a
healthy self-view. He felt more confident in his ability to be
assertive in relationships and reported a decrease in his
belief that he was subordinate to others. He continued to
volunteer and was considering re-education opportunities.
During an 8-month follow-up period, Joe moved
outside of the city and was no longer treated in our
81
service. However, he was contacted to collect follow-up
data. He continued to demonstrate minimal depression
on the BDI-II and mild anxiety on the BAI (see Table 2).
He also continued to score low on beliefs about the voice's
malevolence and omnipotence as well as a tendency to
resist the voice. He reported that during the follow-up
period, he had been hospitalized on one occasion for
suicidal ideation. Following this hospitalization, he was
started on an injectable neuroleptic, Risperidal-Consta, as
well as clonazepam and Ativan for anxiety. His dose of the
antidepressant citalopram was also increased to 40 mg. He
continued to use his therapy notes and therapy techni-
ques. He stated that he was assertive with family and
friends and continued to hold positive beliefs about
himself and his relationship to others.
Joe reported that CT had a profound impact on his life
and described his perspective of the therapy, which was
consistent with the mechanisms of change of CT. He
stated:
“The therapy helped by taking away my fear of the
voices and this happened by realizing that the voices
were just my mind's reaction to stress or lack there of.
I proved this by looking at the evidence which proved
that they were not demons. I always had an under-
lying fear that the voices would take me over and that
I would kill everyone. I tested my control by bringing
on the voices and making them go away with
techniques I learned in therapy. Now that I don't
fear losing control I feel at peace. I used to hide in
the basement all night and most of the day, but now I
hang out with friends and I go out for walks. This is
easier because I now challenge the thoughts that
people are out to get me and that I am out to get
people.”
Discussion
The present report was designed to demonstrate the
application of CT for psychosis, using a case formulation
and theoretically driven treatment. We describe the
effects of CT for CH, a highly distressing and potentially
dangerous symptom of schizophrenia for which few
evidence-based treatments exist. Following 18 CT sessions,
the patient demonstrated a reduction in depression and
anxiety and reduced negative beliefs about voices. These
results were sustained during an 8-month follow-up
period, although he was hospitalized on one occasion in
which several changes were made to his medications.
Qualitatively, he described an improvement in his
functioning.
This case can not speak to the efficacy of CT, which
needs further examination using an RCT. We also do not
know what the active ingredients were in this case, as we
can not control for the nonspecific effects of contact with
82 Singer & Addington
a therapist. Although the follow-up data indicate that the
results were sustained for 8 months, the patient was
hospitalized and had several changes to his medications.
The follow-up data are therefore limited because we can
not distinguish to what extent the results at 8 months were
associated with the effect of CT or his medications.
However, he continued to report reduced negative beliefs
about voices during the follow-up, which is consistent with
the goals of CT and may suggest that CT had a durable
effect. We also do not know if the effect of CT can be
sustained in the longer term. Furthermore, although the
posttreatment and follow-up assessments showed some
changes in symptoms, a more intensive assessment that
included a psychometric assessment of social functioning
and clinical ratings of symptoms would have provided
more thorough information regarding the effect of CT.
Despite these limitations, this case demonstrates the
potential impact of CT in reducing unnecessary distress
and impairment in people with schizophrenia.
This case has implications for therapists who may wish
to practice CT with people with psychotic disorders. Social
connection appears to be important for people with
schizophrenia who typically are isolated (Penn et al.,
2004). The efficacy research shows that even a supportive
therapy results in reductions in symptoms for people with
schizophrenia, which suggests that the relational aspect of
treatment may also be an important active ingredient. In
the present case, we have shown how the patient was
encouraged to focus on social connections (e.g., volun-
teerism, connecting to family, assertiveness) to reduce the
impact of CH on his life. Others have suggested that CBT
for schizophrenia needs to focus not only on symptom
relief, but also emphasize the importance of social
functioning within the context of CBT (Penn et al.). In
this single case, it appeared important that therapy
emphasized social connections.
In addition, it may be necessary to include social skill
interventions for people with CH. The cognitive theory
proposes that these patients believe they are inferior to
others and may engage in appeasement and subordina-
tion behaviors to deescalate the potential “threat” from
others. These patients may benefit from psychoeducation
regarding assertiveness, passivity, and aggressiveness and
how they can communicate their needs effectively to
others. To accommodate for potential cognitive deficits,
assertiveness training should be simplified and broken
down into manageable steps. Concepts may need to be
repeated through role-play exercises and then followed by
in vivo experiments.
Another outstanding issue is related to the conceptua-
lization of an intervention as a behavioral experiment
versus a distraction technique. It seems to be more potent
if the therapist designs a behavioral experiment to test
beliefs rather than simply the implementation of “dis-
traction” or “coping strategies.” We suggest that framing
the intervention as an experiment to directly test beliefs
will make it far more powerful and should lead to further
cognitive changes. It is important that the therapist assist
the patient in analyzing the results from the experiment,
including how these results affect old and new beliefs
about voices. Individuals with psychotic disorders may
hold their beliefs with great conviction. We have found
that directly questioning beliefs using traditional Socratic
questioning results in limited cognitive change and that
the addition of a well-designed behavioral experiment can
lead to more profound cognitive shift. In addition, we
directly intervened at the level of automatic thoughts and
core beliefs related to self and others, which led to further
improvements for the patient. These interventions
included both cognitive (direct questioning of cogni-
tions) and behavioral interventions (e.g., assertiveness
training). It is possible that not all patients with psychosis
will be able to engage in these more sophisticated
interventions. However, if the patient is able to identify
dysfunctional cognitive processes related to self and
others, it may be an important area for intervention.
This paper was designed to provide a detailed
description of CT for CH, with the goal of providing
further dissemination of this much-needed treatment.
Further research is needed to better understand the
active ingredients in CT for CH. An important study
would investigate the effect of CT compared to a less
intensive therapy, such as supportive therapy. Outcomes
could include not only symptom change but hypothesized
mechanisms of change including beliefs about voices,
core beliefs, and automatic thoughts. In addition, social
functioning is an important outcome variable that could
also be measured in a RCT.
References
Addington, D., Bouchard, R., Goldberg, J. O., Honer, B., Malla, A.,
Norman, R., et al. (2005). Canadian clinical practice guidelines
for the treatment of schizophrenia. Canadian Journal of Psychiatry,
50(Suppl. 1), 7–56.
American Psychiatric Association. (2004). Practice guideline for the
treatment of patients with schizophrenia, (2nd ed.). Washington, DC:
Author.
Beck, A. T., & Steer, R. A. (1996). Beck Anxiety Inventory. San Antonio,
CA: The Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory,
(2nd ed.) San Antonio, CA: The Psychological Corporation.
Bentall, R. P. (1990). The illusion of reality: A review and integration of
psychological research on hallucinations. Psychological Bulletin,
107, 82–95.
Birchwood, M., & Chadwick, P. (1997). The omnipotence of voices:
Testing the validity of a cognitive model. Psychological Medicine, 27,
1345–1353.
Birchwood, M., Meaden, A., Trower, P., Gilbert, P., & Plaistow, J. (2000).
The power and omnipotence of voices: Subordination and
entrapment by voices and significant others. Psychological Medicine,
30, 337–344.
Braham, L. G., Trower, P., & Birchwood, M. (2004). Acting on
command hallucinations and dangerous behaviour: A critique of
 Cognitive Therapy for Command Hallucinations
the major findings in the last decade. Clinical Psychology Review, 24,
513–528.
Byrne, S., Birchwood, M., Trower, P. E., & Meaden, A. (2006). A casebook
of cognitive behavioural therapy for command hallucinations: A social
rank theory approach. New York: Routledge.
Byrne, S., Trower, P., Birchwood, M., Meaden, A., & Nelson, A. (2003).
Command hallucinations: Cognitive theory, therapy, and
research. Journal of Cognitive Psychotherapy: An International
Quarterly, 17, 67–84.
Chadwick, P. D., & Birchwood, M. J. (1994). Challenging the
omnipotence of voices: A cognitive approach to auditory
hallucinations. British Journal of Psychiatry, 164, 190–201.
Chadwick, P., & Birchwood, M. (1995). The omnipotence of voices II:
The beliefs about voices questionnaire (BAVQ). British Journal of
Psychiatry, 166, 773–776.
Davis, M., Robbins-Eshelman, E., & McKay, M. (2000). The relaxation
and stress reduction workbook, (5th ed.) Oakland, CA: New
Harbinger.
Gilbert, P. (1992). Depression: The evolution of powerlessness. Hove:
Lawrence Erlbaum.
Greenberger, D., & Padesky, C. A. (1995). Mind over mood. New York:
Guilford Press.
Harkavy-Friedman, J. M., Kimhy, D., Nelson, E. A., Venarde, D. F.,
Malaspina, D., & Mann, J. J. (2003). Suicide attempts in
schizophrenia: The role of command auditory hallucinations for
suicide. Journal of Clinical Psychiatry, 64, 871–874.
Hersh, K., & Borum, R. (1998). Command hallucinations, compliance,
and risk assessment. Journal of the American Academy of Psychiatry &
the Law, 26, 353–359.
Jones, C., Cormac, I., Silveira da Mota Neto, J. I., & Campbell, C.
(2004). Cognitive behavioral therapy for schizophrenia. Cochrane
Database of Systematic Reviews, 4.
Junginger, J. (1996). Command hallucinations and the prediction of
dangerousness. Psychiatric Services, 46, 911–914.
Kasper, M. E., Rogers, R., & Adams, P. A. (1996). Dangerousness and
command hallucinations: An investigation of psychotic inpatients.
Bulletin of the American Academy of Psychiatry and the Law, 24,
219–224.
Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of
schizophrenia. New York: Guilford Press.
83
Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon,
D., et al. (2002). Randomised controlled trial of cognitive-
behavioural therapy in early schizophrenia: Acute-phase out-
comes. British Journal of Psychiatry, 181(Suppl. 43), s91–s97.
MacKinnon, A., Copolov, D. L., & Trauer, T. (2004). Factors associated
with compliance and resistance to command hallucinations.
Journal of Nervous and Mental Disease, 192, 357–362.
Penn, D. L., Mueser, K. T., Tarrier, N., Gloege, A., Cather, C., Serrano,
D., et al. (2004). Supportive therapy for schizophrenia: Possible
mechanisms and implications for adjunctive psychosocial treat-
ments for schizophrenia. Schizophrenia Bulletin, 30, 101–112.
Rogers, R., Gillis, J. R., Turner, R. E., & Frise-Smith, T. (1990). The
clinical presentation of command hallucinations in a forensic
population. American Journal of Psychiatry, 147, 1304–1307.
Soppitt, R. W., & Birchwood, M. (1997). Depression, beliefs, voice
content, and topography: A cross-sectional study of schizophrenic
patients with auditory verbal hallucinations. Journal of Mental
Health, 6, 525–532.
Startup, M., Jackson, M. C., & Bendix, S. (2004). North Wales
randomized controlled trial of cognitive behaviour therapy for
acute schizophrenia spectrum disorders: outcomes at 6 and
12 months. Psychological Medicine, 34, 413–422.
Tarrier, N., Yusupoff, L., Kinney, C., McCarthy, E., Gledhill, A.,
Haddock, G., et al. (1998). Randomized controlled trial of
intensive cognitive behaviour therapy for patients with chronic
schizophrenia. British Medical Journal, 317, 303–307.
Trower, P., Birchwood, M., Meaden, A., Byrne, S., Nelson, A., & Ross, K.
(2004). Cognitivetherapy for command hallucinations: Rando-
mized controlled trial. British Journal of Psychiatry, 184, 312–320.
van der Gaag, M., Hageman, M. C., & Birchwood, M. (2003). Evidence
for a cognitive model of auditory hallucinations. Journal of Nervous
and Mental Disease, 191, 542–545.
Address correspondence to Alisa R. Singer, Early Psychosis Treatment
Service, Foothills Medical Center, 1403-29 Street NW, Calgary, Alberta
T2N 2T9; e-mail: alisa.singer@calgaryhealthregion.ca.
Received: January 11, 2008
Accepted: March 17, 2008
Available online 2 December 2008