# Situation: A 29-year-old man with schizophrenia was admitted voluntarily to the psychiatric ward of a provincial hospital 3 days ago. He hears voices, stays in his room most of the day, and speaks a regional language at home; he is also fluent in Filipino and English. A nursing student is assigned to him and writes a process recording of each interaction. At noon he stops in the hallway, covers his ears and says, "The voices keep calling me useless." This morning he denied any voices telling him to harm himself or others. Which response by the nurse is MOST therapeutic?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 29-year-old man with schizophrenia was admitted voluntarily to the psychiatric ward of a provincial hospital 3 days ago. He hears voices, stays in his room most of the day, and speaks a regional language at home; he is also fluent in Filipino and English. A nursing student is assigned to him and writes a process recording of each interaction.

At noon he stops in the hallway, covers his ears and says, "The voices keep calling me useless." This morning he denied any voices telling him to harm himself or others. Which response by the nurse is MOST therapeutic?

## 보기

1. "That sounds upsetting. I don't hear the voices, though." **✔ 정답**
2. "You sound upset. Tell me what the voices sound like."
3. "I don't hear any voices, and you are not useless at all."
4. "What else are the voices telling you about yourself?"

**정답: 1**

## 해설

With hallucinations, the nurse first responds to the feeling behind the experience, then presents reality briefly without arguing, and does not dwell on the content of the voices. Command content matters for safety, but he denied command voices this morning, so probing further details only focuses his attention on the hallucination.

## 심화 해설

Therapeutic communication in auditory hallucinations

The priority in this interaction is to acknowledge the emotional distress the voice is causing, then offer a brief, non-argumentative statement of reality, and avoid exploring the hallucination’s content in detail. Option 1 does exactly that: it names the feeling (“That sounds upsetting”), states the nurse’s own perception without challenging the patient (“I don’t hear the voices, though”), and does not ask for more details about what the voices are saying.

Auditory verbal hallucinations (AVH) are reported by 60–80% of people with schizophrenia, and they frequently generate significant distress [2][4]. The distress is not only about the words themselves but about the experience of being intruded upon by a voice that feels real and uncontrollable. When a patient says, “The voices keep calling me useless,” the immediate clinical need is to validate that this is upsetting and to ground the patient in the shared, observable environment.

Key point! The nurse’s statement “I don’t hear the voices” is not an argument. It is a brief reality presentation that helps the patient distinguish between internal experience and external world, without saying “you are wrong” or “it is not real.” This aligns with the principle that nurses should respond to the feeling first, then present reality briefly, and avoid dwelling on hallucination content [3].

The other options are less therapeutic because they focus attention on the hallucination itself. Option 2 (“Tell me what the voices sound like”) and option 4 (“What else are the voices telling you about yourself?”) invite the patient to elaborate on the sensory details and content of the voices. While understanding the phenomenology of AVH is important for assessment, doing so during an acute moment of distress can intensify the patient’s engagement with the hallucination and increase anxiety [1]. Option 3 (“you are not useless at all”) argues with the content of the voice and offers false reassurance, which can make the patient feel misunderstood because the nurse is debating a voice the patient perceives as real [3].

Watch out! Command hallucinations are a safety priority. However, this morning the patient denied any voices telling him to harm himself or others. Therefore, the immediate safety concern is not the focus of this interaction, and probing for more content is not indicated at this moment. The nurse should still continue to monitor for any change in command content, but the most therapeutic response now is to acknowledge distress and gently reorient to reality.

| Response approach | Example | Why it is or is not therapeutic |
| --- | --- | --- |
| Validate feeling + brief reality statement | “That sounds upsetting. I don’t hear the voices, though.” | Acknowledges distress, presents reality without arguing, avoids content exploration |
| Explore sensory details | “Tell me what the voices sound like.” | Focuses attention on the hallucination, may increase distress |
| Argue with content | “You are not useless at all.” | Debates the voice, risks invalidating the patient’s experience |
| Probe further content | “What else are the voices telling you?” | Encourages elaboration on hallucination content without immediate safety need |

In summary, the most therapeutic response is the one that names the underlying feeling, briefly states the nurse’s own perception, and redirects away from the hallucination’s content [1][3]. This approach supports the patient’s distress without reinforcing the voice as a topic of extended conversation.References (research sources)

- [1]The phenomenology of auditory verbal hallucinations among clients with schizophrenia: The association with acceptance and autonomous action responses.Research articleEl-Ashry AM, Abd Elhay ES, El-Sayed MM (2023) · DOI: 10.1016/j.apnu.2023.04.025

- [2]Can You Hear What I Hear: Exploring ability and perspective when matching loudness of auditory verbal hallucinations to audio volumeResearch articleHeap J, Stephenson RB, Beasley CL. (2026) · DOI: 10.64898/2026.07.27.26359058

- [3]Hallucinations: insights and supportive first care.Research articlePrice B (2016) · DOI: 10.7748/ns.30.21.49.s45

- [4]Patient perspectives on modified virtual reality-assisted therapy for persistent auditory verbal hallucinations: A qualitative substudy of the CHALLENGE randomized clinical trial.RCT/clinical trialRasmussen K, Vernal DL, Mariegaard LS, Jørgensen G, Zeka F, Smith LC, Nordentoft M, Midtgaard J, Glenthøj LB. (2026) · DOI: 10.1177/20552076251411033

## 임상 시나리오

Responding to Auditory HallucinationsFeelings first, then brief reality
When a patient reports distressing voices, first acknowledge the emotion behind the experience, then offer a brief, non-argumentative statement of reality.

Say "That sounds upsetting. I don't hear the voices, though." This validates the feeling without arguing or reinforcing the hallucination.

CautionDo not ask for details about the voice content unless command hallucinations are suspected. Probing content focuses attention on the hallucination and can increase distress.

## 핵심 개념

- **Auditory Verbal Hallucination** — A false perception of sound, often voices, experienced by 60-80% of individuals with schizophrenia.
- **Therapeutic Communication** — Verbal and nonverbal techniques that focus on the patient's needs and promote a safe, trusting nurse-patient relationship.
- **Reality Presentation** — Briefly and non-argumentatively stating the nurse's own perception to help the patient differentiate internal experience from external reality.
- **Command Hallucination** — An auditory hallucination that instructs the patient to perform specific acts, requiring immediate safety assessment.
- **Process Recording** — A written record of a nurse-patient interaction used to analyze communication techniques and therapeutic effectiveness.

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