Book Review
Hallucination-focused Integrative Therapy: a specific treatment that hits auditory verbal hallucinations
by Jack A Jenner (Routledge, 2015)
Despite its unprepossessing appearance, this book is full of good ideas to guide work with people with psychosis who are distressed by the voices they hear. The author, a consultant psychiatrist and psychotherapist working with children, adolescents and adults in the Netherlands, is the creator of hallucination-focused integrative treatment (HIT), which integrates techniques from cognitive-behavioural therapy (CBT), systems therapy, psychoeducation, coping training and rehabilitation, and emphasises family involvement. A HIT programme usually lasts for nine to 12 months, with between 11 and 15 sessions, the treatment focusing on the patient “taking back control of his or her head”. Although the protocol is delineated in a manual, it is meant to be tailored to suit each patient.
Although the author clearly supports use of medication and appears to think, to a degree, in terms of designated psychiatric labels, HIT is a creative and respectful approach, with much to remind the reader of psychiatrist Milton Erickson’s idiosyncratic style. For instance, when working with voice hearers with psychosis, the author puts considerable emphasis on what he terms hypercongruent interventions – taking what a person says literally – when congruent approaches such as CBT and direct explanations of how and why voice hearing occurs do not work. ¬In one of his many fascinating case stories, Jenner describes Peter, a 46-year-old learning disabled Presbyterian, who had entrenched delusions about being poisoned and heard voices urging him to destroy his parents’ fridge and kitchen for that reason. A congruent approach had not worked, as Peter passionately held onto his beliefs, so Janner came up with the idea of comparing him with the Pharaoh’s food taster and reframed Peter’s delusion of being poisoned as a kind of talent. This appealed to Peter, who became willing to replace his destructive behaviour with the more constructive stance of protecting his parents from poisoning, and took it on himself to help his mother pick safe food in shops. He became compliant with taking his medication on being helped to see that, if he failed to take it, had one of his angry outbursts and was committed to hospital, his parents would be left unprotected. (This was all achieved through Socratic reasoning, which leads people to own desired conclusions through their responses to questions such as ‘is it possible that …? Have you considered whether…?’, etc.)
The hypercongruence may also take the form of simultaneously endorsing seemingly opposing ideas. Thus Janner might say to someone who is resistant to suggestions that they should get sufficient rest and also that they should vent their aggression through activity. The patient cannot help but acquiesce with one or the other.
As in the human givens approach, communication style is seen as massively important, as is generating hope, positive reframing and focusing on strengths and resources. Jenner goes through all sorts of options for engaging people who are differently motivated. For instance, some people may respond to multiple choices rather than instructions; others may be threatened by choice and prefer ‘and and’ tasks to ‘either or’ ones. If tasks set between sessions are not carried out, or performance of them deteriorates, the HIT way is to extend the time between sessions, rather than make them more frequent. Not only might this help people who need more time, says Jenner, but it will stop over-reinforcement of low self-esteem; people get fewer chances to rehearse self-deprecating excuses for why they couldn’t do the task.
There is an interesting section on how much disability to accept. While ‘manipulative’ behaviour should “be respected as a desperate move made by an individual who sees no better option”, the specific nature of the disability may need to be considered. As he puts it, “a patient with a sore knee may be exempt from carrying heavy loads but it does not prevent him from peeling potatoes”. The parents of six-year-old John accepted his misbehaviour because his voices told him to misbehave. Although, strikingly, the voices only appeared when he didn’t get what he wanted, his parents let him have his way – and also let him get away with stealing his brother’s sweets or even the meat off his plate at meals, when everyone else had their eyes shut, saying grace. Once Jenner’s team got involved, it was agreed that John would try to resist his voices (which he claimed to dislike) as much as he could but was not to worry when he failed and took his brother’s food. If that happened, he simply had to apologise afterwards and buy his brother a replacement from his own pocket money. Within the week, those particular voices had stopped. Others disappeared after a coping programme, and training for the parents in selective reinforcement.
Another creative piece of work described involved a man plagued by bullying voices telling him, among other things, that his neighbours were after him. His personal hygiene was so poor that he smelled highly offensive – the genuinely cause of the neighbours’ disapproval, together with his antisocial behaviour, which led them often to call the police. As the man refused treatment, convinced that his beliefs were real, Jenner took the hypercongruent approach of persuading him (by Socratic reasoning, no doubt) to a plan to confuse the voices by an unexpected act, and thus to reassert control himself. He was to buy some nice-smelling soap, have a shower and tell the voices to look at what was happening to the lather: “the same thing will happen to you if you don’t stop bothering me!” At the next session, the man enthusiastically reported less antipathy from his neighbours, which he attributed to his taking control over his voices. This initial success was built on over the next three months, to the point where the voices reduced, and the neighbours ceased calling the police.
Later in the book, there are illuminating suggestions for working with specific target groups; suicidal patients (as suicide risk is high in patients hearing threatening or demeaning voices); traumatised patients; children; adolescents; and learning disabled people.
Whereas Milton Erickson was a one-off, an inspired maverick, HIT has evidence to back it up. For instance, in a randomised, controlled trial comparing HIT with treatment as usual for 76 patients diagnosed with paranoid schizophrenia, schizoaffective disorder and various forms of psychosis, those given HIT still had significantly reduced burden of voices and distress at the latest follow up 18 months later, and rated their lives significantly better than did those who had treatment as usual. Jenner ends the book by taking a brief glance at other therapies’ success in working with this challenging client group. Surprise, surprise, the studies conclude that psychodynamic and person-centred psychotherapy are both contraindicated.
Reviewed by Mark Cheney