An Integrative Treatment for Patients With Persistent Auditory Hallucinations

Hallucinations-focused integrative treatment uses multiple modalities to maximize control of persistent auditory hallucinations. The approach is a directive style of single-family therapy that integrates selective motivational interventions, training in coping skills, and cognitive-behavioral therapy with medication, psychoeducation, and rehabilitation. The intervention uses 20 one-hour sessions over nine to 12 months. Crisis intervention is available around the clock.

The intervention

The motivation module includes several components. A focus on disease and on medical institutions is replaced by one on consumer needs and demands. Symptoms and behavior are relabeled positively. Medication noncompliance is recast as a request for medication adjustment. Resistance is no longer explained in psychiatric terms but viewed as consumer complaints for which the adjustments should be made. With use of motivational interviewing, interventions are accommodated to the patient's degree of awareness of the illness. Hallucinations are accepted as a reality for which the patients are responsible.

To enhance patient responsibility the patient selects the timing and order of therapeutic interventions. Compliance is reinforced by adjusting the duration and frequency of sessions according to principles of operant conditioning.

Coping training teaches patients and relatives a repertoire of skills for anxiety management, for distracting the patient's attention from the voices, and for focusing attention on the voices when nececessary. Graduated exercises are followed by practice. Daily monitoring of the characteristics of the voices, contextual aspects, and coping and its effect is pivotal in constructing a coping strategy.

Cognitive-behavioral therapy interventions focus on precipitating events, on emotional, cognitive, and behavioral actions or reactions, and on the reactions of others. False beliefs are challenged. Patients and relatives are encouraged to elicit new ideas and solutions. Psychoeducation focuses on symptoms and on problem solving.

In family treatment, joint sessions with the patient and relatives are preferred. Relatives are given credit for their endurance and sympathy for unsuccessful attempts to work with the patient; feelings of guilt are neutralized. Relatives monitor their feelings, cognitions, and behavior toward the patient, and patients in turn monitor their relatives' reactions. Data from these sessions are used to train relatives in positive labeling and in selectively reinforcing the patient's coping behavior, self-care, and daily activities. Data from continuous monitoring help participants evaluate the effectiveness of their training.

The usual rehabilitation domains are covered, although rehabilitative tasks are reframed as coping strategies for beating the voices. Tasks are divided into small steps. The need for support in accomplishing them is determined, and possible failures are anticipated and countered with coping behavior. Relatives are instructed in selective reinforcement. For each task, participants monitor endeavors, time investment, and the effect of and their satisfaction with activities.

Medication is provided according to guidelines of the Dutch Psychiatric Association, which are similar to those of the American Psychiatric Association.

Evaluations

The effectiveness of hallucinations-focused integrative treatment was tested in two naturalistic studies between 1994 and 1996, one with 40 adults with therapy-refractory hallucinations and the other with 14 adolescents. Diagnoses were made according to DSM-IV; the majority of the patients had schizophrenia. Assessments were conducted with the Auditory Hallucinations Rating Scale for assessing hallucinations; the Groningen Social Disabilities Schedule, which uses a 4-point scale to measure eight social roles of work, social relationships, participation in society, and self-care; and the Positive and Negative Syndrome Scale to measure psychopathology. Satisfaction with therapy was measured on a 5-point scale, with 5 indicating very satisfied.

Half of the adult patients completed treatment. At the end of treatment, 20 percent of the 40 adults, or 40 percent of those who completed treatment, reported continuous freedom from auditory hallucinations for three months. Sixty-four percent of the adolescents reported the same. Two-thirds of the adult group reported that hallucinations neither interfered with daily activities nor caused them anxiety. Among the adolescents, only one reported considerable anxiety. Of 12 adolescents who reported interference with daily activities at baseline and nine who reported interference with thinking, one in each group retained these complaints after treatment.

Forty percent of the adults and 79 percent of the adolescents reported improvements in their daily activities; 57 percent of the adolescents showed substantial improvement in work or study activities, and smaller percentages in both groups reported improvement in contacts and relationships.

Satisfaction with the intervention was high in both groups, with nearly 80 percent rating their satisfaction as 4 or 5 on the 5-point scale. Dropout rates were below 10 percent.

Most patients attributed their improvement to coping training and insight. At a follow-up assessment of the adult group four years later, 60 percent of the adults had retained their gains, and 30 percent showed even further improvement. Ten percent had relapses but were still functioning better than before treatment; nevertheless, social handicaps and anxiety were still severe, requiring further treatment. A follow-up assessment of the adolescents was not conducted. A randomized controlled trial comparing hallucinations-focused integrative treatment with usual care is in progress.

Dr. Jenner is associate professor in the department of psychiatry at University Hospital Groningen, P.O. Box 30.001 9700RB Groningen, The Netherlands (e-mail, [email protected]).