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A Treatment for Command Hallucinations

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Length: 30 minutes

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Louis Tinnin, MD

People sometimes obey the commands of their hallucinated voices and this fact makes it urgent to do something about command hallucinations.  Many common attempts to do something are simply futile. One cannot close one’s ears to the voices. Medications dull consciousness long before affecting the voice. Auditory hallucinations often persist even after electroshock treatment. Such treatment efforts are protracted and demoralizing to the patient and the end point is usually an uncertain claim that the voices are “gone.” I recommend an entirely different approach to dealing with voices.

The patient’s inner voice seems too close, too unmanageable, and even mystical with a commanding power. Obedience to the commands of the voice seems obligatory. A clinician can demystify the voice and reduce automatic obedience in the first interview. The clinician announces to the patient. “I will now ask the voice some questions and you tell me what you hear.” Then proceed with authority, “Voice, I have three questions for you to answer. Question number one: Are you listening?” The patient may report hearing “Hell no,” or some other words, or silence. Now say “Voice, question number two: Will you help the treatment?” After that answer, be it yes or no, the clinician might say, “Voice, can you learn new things? The content of the answers that the patient reports doesn’t matter. It is the patient’s experience of the voice responding to another person that exposes that it as not God or demon. The presumed power of the voice has been reduced to simply that of another mortal.

The next step is for the patient to talk with the voice. This requires externalizing the voice, which is best done by video recording but can be done by writing a message to the voice, addressing it as “you.” This will be the first of a series of taking turns, each addressing the other as “you” or by name. Now it is the turn for “Voice” to speak. The patient may have to write for the voice at first but before long Voice will speak for itself, the writing hand moving by its will.

The rules for the externalized dialogue are three: 1. Take turns. 2. Don’t interrupt. 3. Write complete sentences. The dialogue with commanding voices can begin with an exploration of their roles and their origins. Usually the roles began as attempts to help the person. Unfortunately, according to their logic even suicide might be regarded as a helpful solution for the need to escape. A successful negotiation with the suicidal part can substitute less extreme solutions.

The external dialogue is easily mastered by the patient and becomes a self-help tool. The voices can be recruited “onto the team” and participate positively in the patient’s life.


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