When Doug Turkington, a UK psychiatrist, first announced to his colleagues that he wanted to help people with psychotic experiences by talking to them, he was told by some that this would just make them worse, and by others that this would be a risk to his own mental health, and would probably cause him to become psychotic! Fortunately, he didn’t believe either group, and in the following decades he went on to be a leading researcher and educator about talking to people within the method called CBT for psychosis.
I’m writing about Turkington because I just spent a week learning more about CBT from him at a training in California. This training was part of a bigger effort to bring this psychological approach into wider use in the western US. Attending this training and seeing the interest and passion in those who attended got me reflecting on what the role of CBT might be in changing our mental health system overall.
A key question related to that, it seems to me, is the question of how CBT can improve its relationship to another key change effort in the field of psychosis, that of the Hearing Voices Movement (HVN). I have a lot of interest in the possible improvement in that relationship between CBT and HVN, because for quite a while I have had my “feet in both worlds.” My first involvement with the mental health system was as an activist for change and increased choice, then I became a mental health professional so I could work to provide some of the alternatives I believed should exist.
The first alternative approach to voices I heard about was the CBT methods of Paul Chadwick, so I started with that, and went on to become a CBT practitioner and educator. Then, when I heard about the HVN, I adopted many of its ideas as well, arranged for Ron Coleman to come to my town of Eugene Oregon to do some trainings, and got an HVN group going here. While I have always interpreted CBT for psychosis in a flexible way, integrating it with HVN ideas, I have sometimes been unsure how well that would fit with the approach of the CBT for psychosis establishment. So it was really interesting to spend a week with Turkington, and to have a chance to explore his views in depth.
According to Turkington, the very most important part of cognitive therapy for psychosis is “normalizing” which means framing psychotic experiences as understandable and as just a fairly common variation of normal human experience and issues. This includes talking with people about how to get past fearing or “catastrophizing” such experiences, and even how to see them as possibly valuable; for example by seeing how such experiences can be part of a creative process or of a shamanic journey, etc. I have always been open to talking about this positive, somewhat shamanic side of psychotic experiences, and discussion of such views is common within HVN, but it was nice to see Turkington teaching this approach as part of standard CBT for psychosis!
Probably most of you recognize just how uncommon such views are within traditional psychiatry. Karl Jaspers, for example, stated that the psychotic symptoms of schizophrenia are “un-understandable: not reflecting a person’s personality or experiences.” Turkington mentioned that quote and others like it, and then confronted such views sharply, stating that “everything I know about psychosis tells me that such statements are delusional.” (In a previous MIA post, Olga Runciman faulted CBT for never confronting standard psychiatry. Turkington may not confront everything that needs to be confronted, but he definitely was willing to strongly critique many existing approaches, and I was amused and impressed by his story of how he measures progress in psychiatry in the US – that is, by the gradual reduction in booing he receives when he speaks about his ideas at the American Psychiatric Association!)
CBT has often been criticized for lacking an interest in people’s stories, but Turkington taught the opposite: that it is essential to hear people’s stories and to help people clarify them. He told a story himself about how he and his fellow professionals came to realize this was important. In some of the earlier research on CBT for psychosis, a control group was arranged of people who were supposed to receive only a “befriending” sort of therapy, where people could just chat about whatever they wanted.
It turned out that many of the people in this control group chose to tell their stories, and these stories were typically about traumas that had happened to them. At the time, Turkington did not conceptualize psychosis as being particularly related to trauma, but this view quickly changed as a result of what was heard. Turkington does still sees some psychosis, in particular those which start with a lot of “negative symptoms” and problems in thinking, and where “positive symptoms” develop only later, to be likely mostly genetic or biological rather than a result trauma or life stress.
I was skeptical of his conclusion about this, though he did present a fair amount of research indicating that there may be very different explanations for why some people become psychotic compared to others. The key thing I believe is that we continue to listen and learn, so we can really understand people’s stories even when they vary from our preconceptions, and such listening is very consistent with good CBT. It may be true that some people are more vulnerable or “sensitive” due to genetic or biological factors, but even in that case, they still may be able to learn to live well with that sensitivity, as when a person genetically vulnerable to sunburn learns how to protect themselves while continuing to be active outdoors, etc.
Developing a “formulation” or story of what has and is going on with a person’s experience and life situation is what Turkington described as the second most important part of CBT for psychosis. At times in the training, we focused on developing understandings of the story of what was going on “right now” with people – and this is what people more commonly think of as CBT – but at other times, the focus more clearly on understanding the bigger stories of how people’s experience and beliefs had emerged over time, in a meaningful way in response to life events.
The third most important component of CBT was described as being “reality testing.” This component is usually not emphasized as part of the HVN approach, and may even seem to clash with its “tolerance of all points of view” perspective. I find, though, that important elements of reality testing can be found in individual stories of HVN members. Eleanor Longden for example described starting to question the voices herself, then being told by the voices that she would either have to cut off a toe that evening, or they would come that night and kill her entire family. It was when she was able to stand up to this threat, and stand guard all night over her family instead (with a plastic fork, her only available “weapon”) that she was able to really demonstrate to herself that the voices were not actual beings outside of herself, but something more personal. This was a key event in her recovery.
Still, it’s easy to imagine “reality testing” being taken to mean the imposition of the therapist’s ideas about reality onto the client, and this is often believed to be the CBT approach. Turkington argued against this, and suggested it was impossible to do good work unless the therapist could keep an open mind about what might possibly be real. During the training, he shared stories of apparently supernatural and ghostly events that he had personally experienced, and emphasized that therapists should talk about such experiences with clients and with other therapists, in order to acknowledge our basic uncertainty about the nature of reality.
At the same time, he described CBT as often being often helpful in getting people to notice the ways their experiences might be personal rather than part of the reality being experienced by others, so that they could deal with them more effectively. In the film “Voices Matter“ and in an earlier MIA blog post, Rufus May suggested that we need to go beyond “just CBT” and appreciate the value of experiences like voices for their role as messengers about emotions and issues that need to be dealt with. I think Rufus is correct, but also, it seemed to me that Turkington was often saying the same thing in different words.
Turkington talked about the importance of discovering people’s underlying affect, and then of helping them find ways to deal with it. He told stories of how working with psychotic experiences often led to disclosures of abuse or other kinds of key life issues, which could then be addressed in therapy. And Turkington was happy to talk about approaches that went past standard CBT. He taught about integrating psychoanalytic approaches that see psychotic experiences as metaphors for emotional issues, a line of thinking that parallels the HVN understanding that the message of voices is often metaphorical.
We discussed Compassion Focused Therapy which addresses people’s need for love and acceptance in a very direct way. And Turkington advocated for, and demonstrated, Voice Dialogue, a method that Rufus and others in the HVN have been teaching as a good way to explore and possibly change relationships with voices.
CBT practitioners have been critiqued in the past for being too slow to criticize things like forced treatment and excesses around medication. While Turkington was not perfect in my opinion on these issues, he was definitely willing to be critical of existing practices. A fair amount of time was spent talking about how forced treatment can induce trauma, creating future mental health problems. He pointed out how neuroleptics can shrink brains, and even identified a problem I hadn’t heard about, which involves atypical neuroleptics making command voices worse.
He explained that what happens is that the atypicals block serotonin, but then such blockage can aggravate OCD like brain processes, and since command voices are OCD like, they can be increased by the drugs. He also shared the recent study on how CBT can be helpful for people who don’t want medications, and clearly advocated for choice in treatment options. On the flip side, Turkington also talked about using CBT to get people to be more consistent with taking medications.
Using psychological approaches to get people even more hooked on drugs that are likely to hurt them can be a terrible approach, but some of what Turkington was talking about didn’t seem to be entirely a bad idea – I think sometimes people have a better chance of getting off drugs if they take them consistently while learning skills and weaning down gradually, rather than bouncing on and off drugs in a chaotic manner. So though I think while CBT could be used in a destructive way to push for “compliance” it can also be used in better ways, as part of thoughtful decision making.
But, some of you might be asking, shouldn’t we aim to just liberate everyone from the mental health system, and get rid of all the professionals? I would argue that while some may be ready to move away from getting support from anyone who is paid to help them, many others are not, and so we continue to require some kind of paid or professional system to help these people. I believe we should be exploring a variety of options, from Open Dialogue to Soteria Houses, peer run respite, and CBT. One reason I am interested in CBT specifically is that it can be started with just a few individuals here and there, rather than waiting for a whole system to endorse a method like Open Dialogue.
But what about the key fact that HVN is an emancipatory approach, a social movement that aims to help people realize that experiences like hearing voices can be just a human variation, and in so doing aims to liberate people rather than to “treat” them? Does this mean there is a fundamental difference in aim between HVN and CBT? In a blog post I mentioned previously, Olga faulted Alison Brabban, a CBT psychologist, for suggesting that HVN do research to show that its methods are effective in helping people. Why, Olga asks, should an emancipatory approach be asked to do research? Quoting her, “can you imagine women fighting for women’s rights saying yes to presenting models of emancipation to men so that they can be researched and tested to see if they work?”
Thinking about this question, I reflected on the role of research in social movements. Research can be really helpful in getting past social myths. As a participant in the movement toward LGBT rights, I’m very aware of the research of Evelyn Hooker, who demonstrated that gay people were on average just as happy and healthy as heteros, which shocked people at the time and helped to sharply question the psychiatric oppression of gay people. The research with voice hearers is quite different however – voice hearers on average tend to be psychologically troubled. So how can we interpret that, within an emancipatory framework?
HVN and CBT practitioners like Turkington agree that voices often emerge after distressing life events, and are signs of unresolved issues around those events. Then, depending on how the person relates to them, those voices can lead to further, more severe problems, or they can actually be helpful indicators and communicators about the nature of the underlying problem, that helps get it resolved. But people often need assistance in changing that relationship, so things can go in a good way.
LGBT people can usually do fine if just left alone by “helpers” but voice hearers often need some kind of help to get to that good relationship. So I think we need both the emancipatory approach, and sensitivity to the fact that many people are deeply distressed by voice hearing experiences and do need help, which won’t always be accomplished by voluntary networks. It is not surprising that those paying the bill for services provided will want to see evidence that the money will be spent effectively, so it is really important we have methods like CBT for psychosis that are both researched and progressive and humanistic.
At the same time, I think it is essential that people continue to organize outside of any professional community, challenging that community with the kind of new ideas that groups like HVN and other peer communities are capable of developing. This is essential for expanding our ideas about the ways it is possible to be healthy, and of the very diverse ways people can go about finding the kind of life that will work for them.
So, how can approaches like CBT and HVN best work together? I would suggest ongoing dialogue and exchange of ideas about that, along with openness to appreciating the strengths and weaknesses of each. I think HVN groups, done entirely without professionals, are much more liberating (and also cheaper!) which makes them the best choice whenever they are sufficient to meet people’s needs. Professionals, including CBT professionals, should be asked to do what they can to support such groups and to widely refer people to them.
But the HVN model doesn’t fit everyone, or address all the issues, and many people simply refuse to go to any kind of group. So I think it’s also going to be important to develop competent professional approaches like CBT. Friendly relations and integration between the CBT and HVN movements will help insure that we can provide the right kind of help, something that fits each person, to more of the people who might need it.
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Note: The online conference, “Therapy on the Wild Side – Depathologizing and Working with “Psychosis” and Extreme States of Consciousness,” which offers 6 CE credits for professionals, is still currently available. It touches a bit on CBT, has a lot more on methods developed in the HVN, like Voice Dialogue, and also approaches that come out of working with hypnosis and other voluntary altered states. In the future, I hope to arrange online education specifically in CBT for Psychosis. Click here if you want to be notified of when those trainings become available. And/or consider filling out this survey about what other kinds of online education about psychosis you might be interested in.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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Interesting piece. I’m in the UK and we do seem a little further along the CBT road than you are in the US but the road is steep, narrow, full of potholes due to lack of funding, and hidden by a dense undergrowth of neuroleptics.
You brought up something my observations have absolutely convinced me of but for which I haven’t been able to find an explanation – atypical neuroleptics making voices worse, or creating them where there were none.
My son had suffered some confusion, delusions and paranoia, but no voices (that anyone was aware of or that he reported) until he was dropped from his third neuroleptic and started on a fourth – despite being entirely symptom-free at the time. (Feel free to wonder why someone who is symptom-free is given a neuroleptic.) Within ten days he was arguing with at least two different voices at high volume.
Did Doug Turkington give you any references to papers identifying the issue? I would like to beat the perpetrator around the head with them.
Forgive me for not linking it immediately, but I can likely search my research, and find a couple journal articles stating that neuroleptics are known to cause psychosis in people, when there was none prior. I remember one article was written by a doctor who experienced this neuroleptic side effect. And there was another from 1964, which discussed this possible neuroleptic side effect – 50 years ago!
I, too, had this happen to me. And I think it’s much more common than doctors are willing to confess. But I know with 100% certainty that neuroleptics, in my case the atypicals, can cause psychosis and “voices” in a person with no prior personal or family history of mental health issues.
And, Ron, as someone who suffered from both drug induced “psychosis” and drug induced “voices,” I will say it’s “lacking in insight” to believe they have no relevance to the person experiencing the “voices” or “psychosis.” They are relevant, you are correct.
In my case, I suffered from a brief “psychosis” exactly two weeks after being put on Risperdal (given to “cure” the common withdrawal symptoms of a “safe smoking cessation med,” Wellbutrin). The psychosis was terrifying at the time, and Risperdal “cure” was recorded in my medical records as a “Foul up.” I left that psychiatrist because he felt doubling the med was the answer. But, one of the rationales for drugging me was my disgust at 9.11.2001. And the terrifying psychosis did relate to the terror that was occurring in our country in late 2001.
Next, I was taken off the Rispedal, put on lithium and Seroquel; then the Risperdal was added back two weeks later. The night it was added back, I got “voices.” Now, according to my medical records, I was actually railroaded into seeing the initial psychiatrist based upon a written list of lies and gossip from the people who abused my children (my son was sexually abused at a school board member’s house, then that was covered up by a pastor – who is best friends with this school board member – who denied my daughter a baptism, at the exact moment the second plane hit the second World Trade Center building on 9.11.2001.). The “voices” I got in my head were those of the pastor and the couple at whose home my child was sexually abused. I never confused the inane “voices” with the real people, but my neurologist did.
I did also suffer a drug withdrawal induced super sensitivity psychosis, about 6 months after I’d been weaned off all the drugs. That psychosis took the form of an awakening to the story of my dreams. And it’s interesting, because I’d been painting the story of my dreams for decades, but never realized where the inspiration for my artwork came from; and I didn’t even understand the meaning of some of my paintings, until I had this awakening to my dreams / super sensitivity manic psychosis.
“Psychosis” and “voices” aren’t contagious, I’m quite certain. But at least in my case, they are relevant to a person’s real life traumatic experiences, and perhaps shamanistic in nature (the story of my dreams is of a religious nature).
If Turkington did give a reference for the atypicals aggravating command voices, I didn’t get it written down. Sorry about that. His point though was that such voices are on a continuum with basic OCD, and the reason they sometimes increase such voices is the same reason they can induce more OCD. I found at least a bit of documentation of the latter effect when doing a quick Google search, for example look at http://ajp.psychiatryonline.org/article.aspx?articleid=172890
Interesting piece Ron. I could see how the traditional notion of CBT could clash with the HVN persepctive in that CBT generally involves confronting preconceived notions and self-limiting narratives, while HVN often involves engaging with the “psychotic” experience of hearing voices without judgement or agenda, but as a way to explore the deeper meaning of the voices.
Turkintgton sounds very open minded in his practice of CBT and I wonder if that differs from the usual practice of CBT. He is open to normalizing these extreme states, not “catastrophizing them”, perhaps seeing them from a spiritual dimension…but he also discussed “reality testing”…a key component of CBT. You go on to say that that can actually be a key part of the healing process for some who hear voices- to see them as metaphorical, expressing true emotional experience, such as being based in trauma, but perhaps lacking in external reality.
CBT often encourages an individual to examine and then reframe narratives. I think HVN also looks for ways to normalize and “un-catastrophize” experiecnes like hearing voices. I think the main problem is that many CBT therapists still function within the framework of a DSM psychiatric model where extreme states are pathologized and seen as permanent markers of illness. Though Turkington sounds very progressive, I wonder how many of his colleagues share his views.
I dfefinitely see how CBT and HVN could blend and I appreciate your exploration of this interesting topic.
Thanks Jonathan, for your comments and feedback. Regarding Turkington and how different he might be from “mainstream” CBT for psychosis – I think it is harder to be more central to CBT for psychosis overall than Turkington has been, so I think he is a very representative face of that approach.
At the same time, there is still the problem of less well trained CBT therapists (especially ones who have some CBT training but not really in CBT for psychosis) who as you say “still function within the framework of a DSM psychiatric model where extreme states are pathologized and seen as permanent markers of illness.” Turkington did complain that even when he trains people to do things like inquire into stories of possible trauma, he checks back and often finds out they aren’t doing it. So there is a big problem with people slipping back into the psychiatric mainstream approach, of just explaining away everything as “illness.” That however is not what CBT for psychosis is really about.
Ron, The information that comes out of this whole project with HVN, almost purely a good will effort, is doubtless a source of encouragement and ideas for sufferers and professionals. Something more has to light a fire under even such helpful and “liberated” doctors as Dr. T., though, I think.
What his colleagues tended to say about his interests in alternatives is appalling, is weird, is offensive.
Thank you Ron for this thoughtful article. It’s validating to hear evidence for my daughter’s claim that she never heard voices until AFTER she had been involuntarily committed and forcibly drugged with neurleptics. I believed her at the time, but I felt powerless to fight the system on her behalf when she was in an altered state and unable to shield herself against psychiatric harm. We parents need an alternative to NAMI to find out the range of alternatives and become better advocates for our loved ones. NAMI has completely sold our children out. This information needs to get out to parents.
Yes, I think it is important to understand that psychiatric drugs often have effects opposite of what is intended and also often opposite to what is the most usual effect of that particular class of drug.
I would say that neuroleptic or “antipsychotic” drugs in general do tend to reduce hallucinations overall, yet I know one young woman whose only experience of clear cut hallucinatory experience happened while taking antipsychotics. And it wasn’t just moderate hallucinations either – instead she was hearing, seeing, and feeling the touch of dead people.
With Karen Taylor’s permission, I am reposting a conversation between her and I that started on facebook in regards to the post above. It touches on some very important issues. (For those of you who don’t know, Karen Taylor is very active in the hearing voices network and hearing voices training, and she is also the wife of Ron Coleman, who is even more active in that field.)
Karen Taylor: Hi Ron It may interest you to know, that most of the early CBT in psychosis learning was done by psychologists who regularly went to the manchester hearing voices groups when Ron C was there and took the self help techniques and turned them into a therapy. This is why there is similarities but also why there is animosity as lately there is a feeling that you have to be a psychologist to do this work with voice hearers which is bullshit as it originated as self help in the voices movement. People have always gently challenged each other over their belief systems the respect is in accepting the persons answer if they dont want to think about it from another view point, but most ideas are not fixed but fluid dependant on what is happening in the persons life. One researcher who used Ron’s working with voices book came to the conclusion that his workbook was based on CBT, in fact it was the other way around the book predates the CBT in psychosis papers, also voice dialoguing was a natural part of the hearing voices groups and something some voice hearers have always done. Keeping alive the history of the HVN movement is important and necessary to make sure it is not colonised and sanitised by professionals which is what has happened to every other consumer movement breakthrough. This is not to say that professionals who work in this way are not needed or wanted but that they must not own this stuff as their own work and then exclude self help and peers from using these techniques themselves.
Ron Unger: Hi Karen, Thanks for this important note, including the historical bit! I share your outrage at the idea of professionals taking ideas that come from places like hearing voices groups and then claiming them as their own and saying others shouldn’t try them! As far as what I heard in the Turkington training, he didn’t say much about where ideas he shared came from, and he also didn’t suggest anyone needed any particular training to try the various ideas, other than of course an understanding of the ideas and the methods themselves.
Karen Taylor: Psychologists like Richard Bentall & people like Doug Turkington will be the first to acknowledge how important the groups and voice hearers were to their learning, in person. Richard is a great supporter of HVN and Ron C has shared the platform with Doug at many events. It is the professionals who have read the CBT books and done some of the training who sometimes pontificate on who can and cannot then use these techniques. I remember Ron talking about being at a psychosocial intervention conference where a professional was talking on running hearing voices groups -and the training needed to run it-he didn’t know Ron C who got up to ask him if he would be able to run a hearing voices group -the guy said “have you done our training” to which Ron replied no he hadnt the person then went on to say no he wouldnt be able to do it, at which point Ron told him who he was and how many groups he had run with out training and why he was entitled to run a group -his lived experience . This is the danger as the spread of CBT grows peers will be told they dont have the skills to engage in this work.
Ron Unger: Thanks Karen, for the added information. I think you are right about the tendency of many professionals to want to claim that things can’t be done without professional training, even though they were started by people who didn’t have such training. I have seen this reaction for example when I taught about voice dialogue – some professionals in the class expressed a belief that only highly trained professionals should attempt such things, even though I let them know about how the method has been used successfully by non-professionals. I would say though that this isn’t really a CBT kind of perspective – one of the merits of CBT is that it is usually taught as something anyone can do, it is put in self help books and such, professionals may be trained in applying the methods and helping people with them but the ideal is that people learn to do any methods themselves and make the professional obsolete. Maybe one thing we need is a guide for how professionals can work cooperatively and without arrogance or “colonization and sanitization” of practices that come out of the consumer/self help movement.
Thanks Ron for this informative post.
I also appreciate this approach’s emphasis on collaboratively creating and hearing of people’s stories of what’s happened to them. So much more meaningful and empowering than a diagnostic label.
I find myself feeling very ambivalent about the over-riding focus on evidence based practices. On the one hand, they can help explain and teach a method or technique. On the other, they can tend to squelch the flexibility, creativity and humanity out of trying to be helpful.
Then. someone comes along to “professionalize” what may have been an organic, healing practice – (and then sell it).
I completely agree with your ambivalence about evidence based practice. Dr. Scott Miller does a great job of debunking evidence based claims ( See his website at http://www.centerforclinicalexcellence.com/). I recently heard an expert in corporate leadership studies say “There is no perfect structure. Structure is lubricated by relationship.”
Dr. Miller likes to say “It’s the relationship stupid!” God help us if we become nothing more than technicians.