Client is a 54 years old with a bachelor degree on physics, but for him is to difficult to accept his mental condition. He attributes high value of what his voices tell him. He is able to cope with his voices. He is maintain himself functional and sociable. He is on Clozaril.
Dear Dr Farfan,
There is not one unique way to deal and help psychotic patients to realize their hallucinations are not real. First of all, you should realize that they are real to them. For example, in the case you mention, the patient really listen the voices talking to him. And your patient is functional and sociable. So, I suggest not to discuss with him if the hallucinations are real or not. Probably this discussion will not get any useful result. I suggest to target a strong good therapeutic alliance. A good patient-therapeutic relationship is the main key for keeping his quality of life. And also it will keep him taking the medicines that are probably helping him not to deteriorate from the psychosis. The therapeutic approach in the long term could also help him to discuss about the hallucinations and realize some aspects of it. Some other antipsychotics and their associations could also help him to decrease the frequency of hallucinations and you could talk to his psychiatric about other possibilities drugs. For exemple, the old or typical antipsychotics are still the most efficacious one, although the medical literature does not always agree with that. In conclusion, do not discuss if hallucinations are real or not, keep a good therapeutic alliance, emphasize the importance of the medication and psychotherapeutic support. The rest will come with time.
Warm regards,
Antonio
This is a great question and also has relevance for delusions. If the patient is capable of some reality testing, you might point out that under various circumstances, virtually anyone can experience psychotic symptoms ( high fever, ingestions, temporal lobe epilepsy , etc) and that as Dr Nardi points out, these phenomena are "real" in that there is a process going on in the brain that is triggering this and it can seem very real or true. This matter-of-fact approach tends to lessen shame and may make the patient more open to questioning the psychotic symptoms.
With regard to delusions, the convention wisdom of my training was that they are unshakeable beliefs that are immune to logic. However, there is now a literature on using CBT techniques to challenge unrealistic ideas. The same techniques might be applied to voices , eg pointing out that voices of nurses making negative comments about them in the hallway was not likely to be real for a variety of reasons.
Of course, patients are more likely to listen to your counter-arguments if they have begun to experience effects from antipsychotic meds...
Michael Casher
Dear Dr. Farfan,
When a friend with schizophrenia complained about being troubled by auditory hallucinations, to better understand what she was experiencing, I asked if the voices she was hearing were her internal voice or a radio voice. She replied, radio voice. These, perceived as external sounds, were critical, hostile voices incessantly demanding that she do harmful things. She felt pressured to act on these authoritative instructions. I told her: Get a second opinion.
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