Family and Caregiver Schizophrenia Discussion Forum

Cognitive Behavior Therapy in regards to voices

Ever since I read the possibility that my son’s therapist may be encouraging him to yell at the voices, I have been curious. Online, there are excerpts from “The Massachusetts General Hospital Handbook of Cognitive Behavioral Therapy”. I found this interesting in regards to voices.

“The cognitive model can be applied to voices because it is believed the emotional and behavioral reactions to the voice is mediated by the beliefs about the voice (Beck et al., 2011) It is therefore important to elicit information about the omnipotence , malevolence and benevolence of the voices. Understanding the voices’ identity, purpose, power and perceived consequences of obedience or disobedience is critical in reducing the patient’s distress. The voices are not the problem, but rather the patient’s appraisal of the voices. The distress associated with the inaccurate perceptions lead(s) to vigilance, safety behaviors and avoidance.”

The passage continues talking about how patients are affected by command voices and moves on to voices that call them names.

“Similarly, a patient who hears voices that call him nasty names may disrupt neighbors yelling at them to stop. Therapy can help the patient learn that the voices have no power. Experiments that defy the voices teach the patient that the voices lie and have no power. Experiments that activate stress like running in place, over-breathing or mental calculations can increase the volume of the voices, while anti-anxiety tools can reduce the volume, showing the patient the voices are not the menace he thinks they are. Coping with the voices means the patient no longer feels distress when he knows the voices have no power and do not have to get in the way. Ideally the patient learns that the voice is simply a reaction to stress that in internally generated. Cognitive behavioral therapy for hallucinations and delusions is designed to reduce stress and disability; reducing delusions and hallucinations is only a means to that end.”

If you have made it though this so far, the handbook also talks about confabulations being conclusions that the patients jump to without any thought process being involved. Like -I hear a voice calling me a name, there is a man over there, he just called me a name. Thought projection being the same sort of thing. Patient is waiting to place an order for fast food, person in front of him orders food, patient suddenly believes the other person “has stolen their thoughts”. Has suggestions on how a therapy session is run in which you don’t deny the confabulation, but you lead a conversation around it trying to make them question the confabulation by the conversation you make with them about the confabulation - nothing confrontational just conversational. Its like you lead them to things that could bring about the conclusion that the confabulation is not correct, but just making pleasant conversation.

Its an expensive book, really expensive. Not super textbook expensive, but…


Do they talk about voices, delusions or confabulations that the person finds positive or pleasant?

Try googling it with the name of the book and the subject you want - I was able to pull up different pages. It won’t let you read continuously, probably to help sell the book.

While I don’t necessarily support it - from an intellectual property perspective - there is a website that offers this, and many other books for free download. This may be helpful for families that can’t afford books like this. If you can afford it, I recommend you buy it. This might be a good way for people to see if its worth buying.

For example - here is that book you just mentioned - to download the book, click on the title of the book, then on the large “DOWNLOAD” text at the top of the page (avoid the ads):

The Massachusetts General Hospital Handbook of Cognitive Behavioral Therapy

You can also do a search for any schizophrenia related book at the top level of the web site here:

The same group of people also provide free access to all the world’s research papers too - at

Here is more info on the group and their two main websites:

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Thanks I will buy it, its still easier for me to share references with my husband that I have bookmarked in an actual book, though I do love my kindle. I think it may be quite helpful since my son is actively participating in this form of therapy.

I don’t want to play therapist, I just want to be able to recognize his efforts. Both my husband and I have felt so much more relaxed about the yelling since we realized it may be her attempt to change his thinking about the voices.

Perhaps its a stepping stone to what she hopes for him to achieve.


Thank you for this info. I will check out this book. Ironically, yelling to the voices seems to be the opposite tactic of that used by Dr. John Nash (A Beautiful MInd was written about him). Nash had visual and aural hallucinations of people who did not exist. He was able to look at them and listen to them and say, essentially, “I’m not going to pay attention to them anymore.” I think Nash made a significant contribution to mental health by doing this.

Hi pamina58,

We think the yelling is just a therapy stepping stone to get him to be brave enough to address the voices and move towards taking away the power the voices have over him . CBT really doesn’t seem to condone “excited” behaviors. Jeb has switched to texting the past week instead of yelling. We know he has been in contact with his therapist regularly during these past 4 weeks. I had read an article that said yelling at the voices can be a part of CBT. I would imagine that therapists have to take a route that may differ for some of their patients.

I just was reading recently a good deal about Nash and his son. I knew he didn’t believe in meds. His “not going to pay attention any more” is certainly what his CBT therapist is working towards with Jeb - while at the same time working on what ever it is that Jeb wants addressed.

It sounds like you are on the right track.

Another aspect of Nash’s contribution, imo, is that he demonstrated that each individual may have the keys to their own coping and to some extent understanding what they are experiencing within themself, and helping them tap into that is important.

There is also PTSD therapy, such as that described in Getting Past Your Past, where Shapiro suggests making cartoon characters of any negative voices or chatter.

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My son had a doctor one time who told him to “rebuke” the voices, and his Dad encouraged him to yell at them if it made him feel better. It was frightening to me. I felt it made the voices more real to him and tied in with the idea that they were from the devil. An idea which is considered very logical by a lot of Christians in our area of the world. Once his Dad left I stopped it. Just told our son that because of my anxiety he couldn’t do it. I knew son could stop because he did not yell at voices when he was in residential treatment.

My son’s distress has reached the agonizing point. His screams are those of someone in severe distress. We have contacted our lawyer to find out about starting the procedure for a 90 commitment.

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I’m so sorry hope! It is horrible to listen to your son in that state…I remember it all too well. I’m praying that the process of commitment goes quickly for your sake and his. Keep us up to date ok?

Thanks so much Leiann - here’s what we have to work with in our state. Our lawyer has not yet returned our call. The call to the judge’s office referred us back to the country mental health officer who we have already contacted before. All the county mental health officer did was give us phone numbers for the state resource that requires our son to walk in the door and ask for help.

These are the requirements we have to meet in our request. We don’t want any short measures, we want the 90 day commitment.

For “temporary” (90-day) inpatient commitment, a person must be mentally ill and EITHER:

likely to cause serious harm to self or others; OR
suffering ALL of the following:
severe and abnormal mental, emotional, or physical distress;
substantial deterioration of ability to function independently; AND
(iii) inability to make rational and informed treatment decisions.
For “temporary” (90-day) outpatient commitment, a person must be ALL of the following:

severely and persistently mentally ill;
if untreated, destined to continue to suffer BOTH:
severe and abnormal mental, emotional, or physical distress; AND
deterioration of the ability to function independently, leading to an inability to live
safely in community;
unable to voluntarily and effectively participate in outpatient treatment.

Where we live, we are allowed to file without a lawyer. Your state might be different.

Maybe this time the county mental health officer will be more helpful, if needed.

Does he meet all the requirements for the 90 day Hope?

We think so. His emotional distress is so elevated, so anguished and so violent, it’s painful and frightening to hear. We are trying to get audio of it for court. Not an easy accomplishment. Often by the time we get where we can tape him unseen, he has stopped.

The sexual abuse delusions are causing him severe and abnormal mental and emotional distress.

We believe this deterioration affects his ability to function independently safely in our community.

We know he is unable to voluntarily and effectively participate in outpatient treatment.

His illness has reached a point way beyond anywhere it has been before.

We also believe that if we can get him on audio over the few days, combined with his texts, that may be enough to prove he is likely to cause serious harm to us. Though he has not threatened us, the violence of his rage is off the charts.

You can get a voice-activated USB recorder - like a thumb drive that records - for not very much off Amazon.
I had one until I broke it & it will record for about 12 hours or more.
Then, you just stick it in your computer & find the file you want.

The one I ordered is no longer available, but it cost about $18 - it was a cheap Chinese thing, but it worked fine for a year or two. I didn’t use it a lot, but it got the job done.

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this is a great idea, we think we have one, lets hope it still works

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We did get the the digital recorder working - so far we have recorded some bird songs. Being able to record him seem to have stopped or paused the current episode. All we have is him yelling “Nazi” and “FY” out his door, not nearly at the level of emotional distress he was displaying in past weeks.

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I highly recommend digital voice recorders. As soon as we had it up and going, he went silent.

Sigh, yet good for all of us at the same time. I know we needed the relief, he had to really need it to stop.

We haven’t had anything even slightly at the level of the emotional distress that prompted us to think we finally had grounds for a 90 day commitment. He has been quiet for 7 days. He has communicated calmly and gratefully through texts about some errands I did for him.

I do yard work outside and don’t hear a peep of objection out of him.

Glad he is having better days, glad we are ready to get him recorded when the next severe episode occurs. Though it was a new, ridiculously extreme, level of distress for him, I am pretty sure it will happen again. Always waiting for the next shoe to drop aren’t we?

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Hope–I’m glad you’ve been able to garden in peace🌹

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