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CBT for Voices

CBT for Voices

This module contains answers to frequently asked questions about CBT for voice-hearing and links to relevant articles, as well as information about and resources from an iPad manual for CBT for distressing voices developed by Hearing the Voice.

Frequently Asked Questions

What is cognitive behaviour therapy (CBT)?
CBT refers to a family of therapeutic interventions which target change in cognition and behaviour as a way of reducing the distress caused by mental health problems. It thus differs from other therapeutic methods that use medication such as antipsychotic drugs, or which try directly to influence brain functioning to reduce the distress caused by psychiatric symptoms.
What is CBT for psychosis?
Psychosis refers to unusual experiences that involve a break with reality, such as hallucinations (perceiving things that are not present) and delusions (holding beliefs that most other people would not hold). When these experiences become distressing and affect how an individual functions in their everyday life, a psychotic disorder is often diagnosed.  
Can CBT be tailored specifically for voice-hearing?

Yes. Although psychotic experiences such as hallucinations and delusions are often considered together, there are good reasons to think that they will involve different psychological and brain processes. It therefore follows that they might respond to different therapeutic approaches.

CBT can also be adapted to deal with the varied nature of voice-hearing experiences. Research has shown that voice-hearing experiences take many different forms. For example, it seems useful to distinguish voices that relate to an unusual perception of ordinary inner speech (the ordinary silent conversation that many of report having with ourselves). Other voices seem to have more to do with intrusions from memory, particularly memory for past events. Finally, there is a class of voices that seem to relate to excessive attention to what is happening in the outside world.

Useful Articles

Butler, A.C., Chapman, J.E., Forman, E.M. & Beck, A.T. (2006). The empirical status of cognitive behavioural therapy: a review of meta analysesClinical Psychology Review, 26, 17-31.

Morrison, A. P., & Barratt, S. (2010). What are the components of CBT for psychosis? A Delphi studySchizophrenia Bulletin, 36, 136-142.

Thomas, N. (2015). What’s really wrong with cognitive behavioural therapy for psychosis? Frontiers in Psychology, 6, 323.

National Institute for Health and Clinical Excellence (2009). CG82 Schizophrenia (update): quick reference guide. London, UK: NICE.

McCarthy-Jones, S., Thomas, N., Dodgson, G., Fernyhough, C., Brotherhood, E., Wilson, G., and Dudley, R. (2014). The state of the art: what evidence is there that cognitive behavioural therapy can help voice-hearers? In M. Hayward, C. Strauss and S. McCarthy-Jones (eds.), Psychological approaches to understanding and treating auditory hallucinations: From theory to therapy. London: Routledge.

Thomas, N., et al. (2014). Psychological therapies for auditory hallucinations (voices): Current status and key directions for future research. Schizophrenia Bulletin, 40 (suppl. no. 4), pp. S202–S212.

Smailes, D., Alderson-Day, B., Fernyhough, C., McCarthy-Jones, S., and Dodgson, G. (2015). Tailoring cognitive behavioural therapy to subtypes of voice-hearing. Invited resubmission, Frontiers in Psychology.

CBT for Voice-hearing: An iPad Manual

In collaboration with Dr Guy Dodgson (Northumberland, Tyne and Wear NHS Foundation Trust), Hearing the Voice has developed an iPad manual for Cognitive Behaviour Therapy for distressing voices. The coping strategies and treatment methods outlined in the manual are based on the assumption that voices can be divided into three main types:

(1) Voices that result from misattributed inner speech
(2) Voices that are based on memory (e.g. memories of past trauma)
(3) Voices that result from hypervigilance

The manual is unusual in that client and therapist use an iPad to work collaboratively on the therapy.

Although digital technologies are being used more widely in mental health services, CBT tends to involve paper-based manuals. CBT for voice-hearing was developed for the iPad in order to allow client and therapist to watch multimedia demonstrations of certain psychological phenomena, such as illusions, and of researchers speaking about key topics in the psychology and neuroscience of voice-hearing. The intention is to create a state of collaborative curiosity about what goes on in the mind and brain when someone is hearing a voice. The manual is currently in use with clients in the North-East of England, and its acceptability to both clients and mental health staff is currently being assessed. Advantages of the CBT approach include the fact that it does not involve medication, which is often associated with side effects and can thus be unpopular. It can also be very specifically tailored to different kinds of voice-hearing experience based on a collaborative formulation of the client’s problems. Disadvantages are that psychological interventions seem to be particularly effective for individuals in the early stages of having a mental health problem. CBTp seems less effective for those with established voices.

Voices and Inner Speech

What is inner speech?

Very crudely, inner speech is the inner voice that accompanies thinking as when you say to yourself ‘Remember to buy coffee in the morning’ or re-enact an argument that you had with a friend.

The phrase ‘inner speech’ was used by Russian psychologist Lev Vygotsky to describe a stage in language acquisition and the process of thought. Vygotsky believed that inner speech is irreducibly social in origin.  The “private speech” that children use in order to direct behaviour (for example, while playing by themselves) develops out of a social dialogue with parents and caregivers.  Over time, it is gradually internalised to form verbal thought or inner speech.  Vygotsky proposed that external speech is transformed during the internalisation process, becoming “abbreviated” and “condensed”, so that an individual adult’s inner speech no longer resembles the full sentences he or she may use in dialogue with other people.

One of the consequences of Vygotsky’s view is that very young children are really only able to ‘think out loud’ and pre-linguistic infants don’t have any thoughts at all (at least not where ‘thoughts’ are equated with episodes of inner speech).  However, recent research suggests that a normally functioning adult’s inner speech does in fact have the subjective properties that Vygotsky’s theory would predict for it.  For example, studies involving Russell Hurlburt‘s descriptive experience sampling appear to provide evidence for the compression of sentences that Vygotsky postulated, and recent research by Fernyhough and McCarthy-Jones has found that 60% of people report that their inner speech has an important dialogic property – that is, “the to-and-fro quality of a conversation”.  This is just what might be expected if Vygotsky is correct and inner speech develops from dialogue and other social interactions.  Recent fMRI studies have also revealed links between inner speech and activity in the left interior frontal gyrus, including a region named ‘Broca’s area’, which is known to play a role in speech production.  In other words, both inner and external speech appear to activate similar neural networks, thereby providing further support for Vygotsky’s theory.


What is the relationship between inner speech and hearing voices?

It is plausible that some voice-hearing experiences arise when a person mistakenly attributes an episode of inner speech – i.e. one of their own thoughts – to an external source. Evidence for this view includes fMRI scanning studies, which show that voice hearing activates same part of the brain as voice production. Muscles around the mouth have also been found to move when a person is hearing voices, and this also happens when a person generates inner speech. See, for example, Rapin et al. (2013).

What is the difference between hearing one's own inner voice and hearing a voice in the absence of any speaker?

Unlike instances of our own inner voice which clearly belong to us, most people report that hearing a voice in the absence of any speaker has an ‘alien’ quality to it, so that it doesn’t feel like it comes from the self (see, for example, Hoffman et al., 2008).  In some cases, people may distinguish voices from their own thoughts by means of the content.  For example, if the voices are derogatory, they might say ‘I would never think that’ and attribute the experience to an external source.  Interestingly, it is not the case that voices are always distinguished from thoughts by virtue of their perceived location: whether or not they are experienced as coming from ‘inside’ or ‘outside the head’.  Some people experience voices that sound as if they are coming from the external environment, but many voices are experienced as internal in the same way that our own inner voice is.   (Equally, loudness and clarity are not generally things that people use to distinguish voices from their own thoughts.)

For more information on the criteria people use to distinguish voices from instances of their own inner voice, please see Hoffman, R. E., Varanko, M., Gilmore, J., and Mishara, A. L., ‘Experiential features used by patients with schizophrenia to differentiate ‘voices’ from ordinary verbal thought’ (2008). Psychological Medicine, 38, 1167-1176.

Why would a person not recognise their own inner speech?

Sometimes a person’s inner speech does not sound like them, and when this occurs, it is easier to see how it can be misattributed to an external source. Other reasons why a person might not recognise their own inner speech include:

  • Because they are under stress or strain (e.g. emotional distress, sleep deprivation or substance misuse)
  • Because it is non-effortfully generated or intrusive
  • Because the content is unacceptable to them


How can understanding inner speech help to normalise some voice-hearing experiences?

Hearing our own or someone else’s voice in our heads is a universal experience. The only thing that it is different for people who hear voices is that they do not recognise that experience as self-generated. And we know it is harder to separate our thoughts from external events when we are stressed, sad or anxious or under physical strain such as lack of sleep, intoxication or drug and alcohol withdrawal.

What are some coping strategies for inner speech-based voices?

Practical techniques
Anxiety reduction techniques (e.g. mindfulness, progressive muscle relaxation) and improving sleep hygiene can all help people to cope with inner speech-based voices. Other practical coping strategies include:

  • Blocking the phonological loop (try humming, reading quietly out loud, listening to songs in your head and soothing self-talk)
  • Changing the content of the voice into something positive or neutral (watch this video from Harry Potter)
  • Transforming the accent/sound of the voice (try hearing the voice as Donald Duck)

These techniques often require practice and some people find them easier than others.

Can we challenge the unacceptability of the content of the voice?
Sometimes people misattribute their own thoughts to an external source because their content is unacceptable. But unwanted and disturbing thoughts are common and there is a very real difference between what we think and what we do: just because we think something, doesn’t mean we’re actually going to do it.

Avoid suppressing disturbing thoughts
Suppressing an unwanted thought can sometimes increase its occurrence. For example, if someone asks you not to think about pink elephants with big pink ears and pink trunks, you will inevitably think about pink elephants. Distraction is a much better coping strategy than thought suppression.

Avoid social isolation and rumination
Social isolation can exacerbate distressing voices, as it can make us more likely to ruminate and become preoccupied with our own thoughts. Sensory deprivation, reduced visual and auditory stimulation, can make unusual experiences more likely. For example,if people are blindfolded for more than a day, they have visual hallucinations of faces and shapes (Merabet et al., 2004). Hoffman (2007) has also shown that we have social brain which is set up to process the voices of others. Thus, if no-one talks to us for a long period of time, the brain starts to produce such experiences by itself.



Can you hear your inner speech in the voice of someone else?

Try, for example, hearing your own thoughts in the voice of Donald Duck. (Watch the video above if you need help.) If you have managed to do this, try maintaining it for a few minutes.

Successful? Our inner speech is malleable and it is possible for it to become a habit to hear different voices in our head. Eventually, this does not require conscious effort, as when you ‘hear’ the voice of a character when you are reading a book.



Managing Thoughts

It is possible to change the content of an unpleasant, disturbing thought or voice in much the same way as Neville changes the appearance of the Boggart in this clip from Harry Potter.

Intrusive and Unwanted Thoughts 

In this short video, Regional Clinical Lead for Early Intervention in Psychosis in the North-East and Cumbria, Dr Guy Dodgson, explains the relationship between intrusive thoughts and previous experiences of trauma. He also suggests some ways to cope with disruptive voices and difficult or unpleasant thoughts.