In recent years, people in mental health circles in the UK and Ireland have highlighted the role of Compassion Focused Therapy (CFT) in helping voice-hearers.
1. What is Compassion-Focused Therapy?
Compassion Focused Therapy aims to help voice-hearers better relate to themselves, their voices, and other people in their lives from the position of a more compassionate self. Advocates of CFT believe that we, as voice-hearers, can develop more compassion for ourselves and others, including for our aggressive or negative voices. As a result, we will feel safer, more protected, happier, and healthier.
The hope is that the resulting therapeutic change will also result in permanent positive changes with our voices. Negative voices may be transformed into positive, supportive voices. Or we may find a neutral ground where we can live and thrive with our voices.
How does Compassion Focused Therapy differ from traditional psychiatric approaches?
Traditional psychiatry largely treats hearing voices from a pathological standpoint (in other words, as the symptom of an illness). It does not generally encourage the voice-hearer to engage with their voices. For example, my own psychiatrist has never asked me about the content of my voices, what I think about them, how I relate to them and them to me, or whether I connect the voices, their onset, duration and content to any type of trauma or specific events in my life.
In contrast, those who advocate for CFT believe that engaging our voices is the best way to resolve the hidden trauma or dramatic life events behind them. Proponents of CFT see the brain as a social mechanism that has evolved over the millennia to represent social relationships in a very specific way.
2. Why did inner voices evolve?
All mammals have evolved to be able to monitor each other socially so that they can understand who is a threat, who is friendly, who is dominant or subordinate, and who would like to engage in reproduction.
Human beings, in addition to the typical mammalian type of social monitoring just mentioned, have also evolved to be able to recreate in our brains, through language, the way we perceive how someone else might theoretically relate to us. We often imagine in our heads the conversations that someone else might have about us or with us as a result of some action we are thinking of taking.
Inner voices as mental simulations of social encounters
According to the proponents of CFT, there is a clear evolutionary advantage to doing this, because we can consider all of the possible options that might result from a given behaviour on our part. If we take X action, how will the other person react, think or reply to us? It is like running a mental simulation in our head and adjusting our behaviour according to a prediction of the best possible outcome. In the process, we are also monitoring the other individual for threatening behaviours with the goal of avoiding the threat and responding appropriately to any other behaviours.
3. Hearing voices: inner voices gone awry
The idea is that with voice-hearers, this mental process of representing our own inner voice and the voices of others through the mental simulations that we all engage in might have become impaired as a response to extreme, extended stress or trauma.
One significant example is childhood trauma, wherein the voice-hearer might have experienced subordination to a dominant other. This may have been an abusive parent or relative, a bully at school, or some other more dominant person who threatened, shamed and traumatised the voice-hearer.
Furthermore, any other lifetime traumas where there is a dominant-subordinate, controlling or threatening relationship may also play a role in voice-hearing. Such traumas often result in feelings of shame and lack of self-esteem.
Under attack – trauma, stress and hostile voices
This is important because so many voice-hearers are attacked by their negative voices in a way that treats them as if they are undesirable, unattractive or disgusting in some way. In other words, they are “shamed” or taunted by their voices in the way that they might have been by an abuser, a bully or some other controlling person in their past or in their present lives.
Most negative voices also behave like typical hostile, dominant bullies or abusers found in real life, often commanding and threatening the voice-hearer. The proponents of CFT believe that voice-hearing, rather than being the result of abnormal brain chemistry, might in fact have more to do with the functions for social threat monitoring that have evolved within the human race over time.
Hearing voices: a way of monitoring social threat?
For voice-hearers who have experienced threats from dominant others, their social threat detection systems are more easily activated and can create invasive fears. In other words, there is a part of the personality that is focused on daily life and functioning, and another part that is constantly looking for threats and becomes laser focused on survival tactics like fight, flight or submit.
Putting voices into context
Instead of understanding the brain as a computer with a chemical flaw, advocates of CFT see mental processes as the product of social interactions and influences. In this context, voice-hearing is seen as a different state of consciousness that reflects the different dissociated or disconnected and traumatised aspects of the self.
By seeing voices as a representation of the self, proponents of CFT believe that engaging our voices can promote more peaceful and productive interactions between the voice and the voice-hearer. Engagement with voices can reduce the disconnect, and lead to the resolution of unresolved emotional conflicts.
Obviously, this is a very different approach to that of traditional psychiatry, which advocates for non-engagement of our voices out of a fear that engaging them would encourage false delusions, fantasies or fantastical beliefs, thus sending us deeper down the rabbit hole.
4. CFT: Moving away from threat towards compassion
Compassion Focused Therapy aims to help the voice-hearer understand that the social competition represented by the dominant-subordinate human relationship is only one of a number of social motivational systems that human beings engage in. Another, very important one, is caring and supportive behaviour, which organises attention, behaviour, thoughts and bodily processes in a very different way.
The main focus of CFT is an attempt to help voice-hearers to make a transition from a threat-based, dominant-subordinate motivational system, where their consciousness may be currently trapped, to a caring, nurturing one so that they can learn different emotion regulation skills that will help them to feel safe, and to feel compassion for themselves, others and their voices.
The argument is that developing compassion for ourselves and for others stimulates different neurophysiological systems and also has a very acute effect on threat processing.
The focus of the therapy is not to prevent voice hearing, but to help the voice hearer transform and change the motivational threat-based system from which the voices are arising.
Strategies used in Compassion Focused Therapy
The goal of CFT is to help the voice-hearer engage with, understand and integrate their threat-based emotions and experiences. This is done through strategies that help the voice-hearer learn to feel safe, by
- adopting calm and composed body postures
- learning mindful breathing and mentalising practices
- completing other physical, awareness and memory exercises to learn to remain calm and soothed.
Other goals of Compassion Focused Therapy
The compassionate self
Another goal is to cultivate a new self-identify that is called “the compassionate self”. This new idea of the self is focused on developing skills that will bring compassion to one’s own self and to other relationships.
Compassionate engagement with voices and emotions
The final goal is to achieve compassionate engagement with our voices and any other threat-based emotion or distressful conflicts that comes up in a voice-hearer’s life. During this process, the voice-hearer is encouraged to work with the therapist to engage their voices by initiating dialogues between their compassionate self and their voices.
The calm, compassionate self uses respect to validate the voice’s protective role, but also identifies the links between the voice and the emotions it represents.
Chair work
This can be done through role-playing with our voices using different chairs. For example, the compassionate self begins by using one chair and then moving to another chair when it is the voice’s turn to speak. The main goal behind such a dialogue with our voices is to understand the emotion behind the voice and to express compassion for that anger, fear, insecurity, need to dominate, etc.
In addition to chair work, other techniques such as creative imagery work and letter writing are also used.
Creative imagery work
Imagery work might include creating imagined characters or drawings to represent the voices and adjusting them over time as the relationship with them changes.
Letter writing
Compassionate letter writing involves writing a letter to a voice from the perspective of the compassionate self, generating empathy and understanding for the voice and its protective role.
Compassionate real world interactions
Finally, CFT also focuses on creating compassionate actions out in the real world of social interactions and interpersonal relationships helping the voice-hearer to learn to be compassionate with other people and also to receive compassion from others. In this way, CFT is also compatible with the Hearing Voices Network approach and other social network approaches to psychosis.
5. The bottom line
In conclusion, CFT is another tool in the tool box for voice-hearers to help manage their voices, strengthen their emotional intelligence, and deal with the underlying trauma that might be the source of their voices and their stressful, critical and threatening content.
The end goal is to transform the way that we perceive our voices and the way that we respond to them, ending the cycle of fear, anger, shame and distress that often accompanies the experience of hearing voices.
About the author
The author is a writer, teacher, voice hearer and mental health survivor. The article above is based on an article entitled Compassion Focused Approaches to Working with Distressing Voices by Charles Heriot-Maitland, Simon McCarthy-Jones, Eleanor Longden and Paul Gilbert. Here you will find more details about CFT, its theoretical underpinnings, and its context within the larger domain of approaches to dealing with voices.