🧠 “The Voice Told Me To…”: Command Hallucinations in Early Psychosis

Imagine being told by a voice in your head to hurt yourself – or someone else. What would you do?

This is the terrifying reality for some young people experiencing psychosis, especially in the early stages of their mental health journey. These kinds of hallucinations, called command hallucinations (CH), can be more common than most of us realise – and they carry serious risks.

In my research with an early intervention psychosis service in the UK, I explored just how widespread these voices are, what they typically say, and who is most at risk. Our ultimate goal is to better protect and support young people facing these experiences.

❓ What Are CH — And Why Do They Matter?

CH are a type of auditory verbal hallucination (AVH) – which means hearing a voice when no one is actually speaking. In the case of CH, the voice instructs the listener to do something. These instructions can be positive (“go help those in need”), innocuous (“stand up”), or harmful (“jump in front of a car”).

We already know from previous studies that people who experience CH are at higher risk of self-harm, violence, or hospitalisation. But little was known about how CH is among people in the early stages of psychosis — a crucial time when timely care can make all the difference.

So, I set out to answer three questions, focusing on people in the early stages of psychosis.

1️⃣ How common are CH among those who hear AVH?

2️⃣ What do these voices typically say?

3️⃣ Can we predict who is more likely to hear them?

⚙️ What Did We Do?

We looked at clinical health records from 740 young people, aged 13 to 37, who were getting support from an early psychosis service in England. All of them had reported hearing AVH. 

1️⃣ For each person, we checked whether their AVH included commands.

2️⃣ If so, we recorded what kinds of things those voices said. We logged key details — like whether the voice told them to hurt themselves or others, and who the commands were aimed at.

3️⃣ Finally, we wanted to see who might be more at risk of hearing CH. We compared different groups of people to see if certain factors made CH more likely. For example:
……Do people who’ve been unwell for longer hear CH more often?
……Does getting help sooner make a difference?
……Are some groups — like younger people or men — more likely to experience these voices?

🔍 Key Findings

1. CH Are Common

• Over half (51%) of participants reported CH.
• That’s 1 in 2 — not a rare occurrence.
  
  

2. Most CH Instruct Harm

• 77% of people who heard CH reported harmful commands — often involving serious self-harm or violence.
  As shown in the graph, harmful commands were by far the most common — a worrying finding that highlights just how serious these experiences can be.

3. The Voice Often Targets the Self — But Not Always

• 90% of CH hearers reported commands that targeted themselves.
  
• Over 25% also heard commands aimed at unspecified others.
  
• More than 1 in 10 reported commands directed at family members.

4. What Makes Someone More Likely to Hear These Voices?

• Longer illness duration: The longer someone had psychosis, the more likely they were to experience CH.
• Delayed treatment: Even a delay of just 11 days in getting help made a person 44% more likely to report CH.

🌎 What Do These Findings Mean?

The fact that CH are so common — and often harmful — means we need to be asking about them early and often. These voices aren’t just a niche issue; they affect a large number of young people and can lead to serious consequences if ignored. 

In some cases, the commands are directed at family members or others, which raises additional concerns about safety and safeguarding. Mental health services need to be prepared not just to support the person hearing voices, but also to consider the wider context of who might be affected. 

We also saw that delays in treatment can increase the risk of hearing these kinds of voices. That makes early detection — even in the first few weeks — incredibly important. A faster response might mean the difference between a manageable experience and a crisis. 

On a more hopeful note, existing therapies like Cognitive Behavioural Therapy and AVATAR therapy already offer tools to help people relate differently to the voices they hear. With some adaptation, these approaches could be used more directly to reduce the distress and risk caused by CH.

❗ What This Research Does Not Tell Us (Yet!)

No research is perfect, and mine is no exception. While the findings are important, here are a few things to keep in mind:

1️⃣ We were looking back at notes and records that had already been written by clinicians. That means we could only work with what had been recorded — and it’s possible that some details were missed or just never written down. 

2️⃣ All the young people in the study were seen by the same mental health service in London. The group was diverse, but we can’t be sure these patterns would look the same in other parts of the UK — or the world.

3️⃣ Some of the patterns we spotted — like how delays in getting help may affect whether someone hears CH — were not part of the original study plan. They’re interesting, but they’ll need to be tested again in future research before we can fully rely on them.

💌 Take-Home Message…

Too often, discussions around psychosis are clouded in mystery or stigma. But with this detailed and specific information about CH, we can create safer, more responsive services – especially for people in the early stages of psychosis.

Whether you’re a mental health worker, a policymaker, or simply someone who cares, here’s the takeaway: CH can be harmful — but they can also be understood and managed with the right help.

📝 Want to Learn More?

About command hallucinations

Why command hallucinations are a public health issue

(973 words; 5 mins read)

References:

American Psychiatric Association. (2000, October 2). Voices In The Head Not To Be Ignored. ScienceDaily. Retrieved May 5, 2025 from www.sciencedaily.com/releases/2000/09/000928071154.htm