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J. Michael McGuire, PharmD, BCPP                                                                                                  Assistant Professor of Pharmacy Practice
Belmont University College of Pharmacy
Nashville, TN

Clinical Pharmacist Psychiatry
Rolling Hills Hospital
Franklin, TN

The use of simulators in pharmacy education has become an increasingly common component of curricula. The Accreditation Council on Pharmacy Education (ACPE) 2016 standards discuss the use of simulations in multiple areas. Notably, in standard 21.2 regarding physical facilities, access to education simulation capabilities is mentioned along with faculty office space, classroom space, classrooms and lab space.1 The use of hallucination simulators has been described in health profession student education including pharmacy students. Skoy and colleagues reported the effect of the Hearing Distressing Voices toolkit on pharmacy student empathy.2,3 The authors found an increase in pharmacy student empathy assessed by a validated empathy scale. In addition, the authors reviewed student reflections and found the students reported an increase in empathy as well as feeling distracted and difficulty with concentration.3 Ness and colleagues reviewed student reflections after utilizing the Hearing Distressing Voices toolkit in a mental health elective class for third year pharmacy students.4 The hallucination exercise increased student awareness of challenges faced by patients who experience auditory hallucinations. Students reported positive outcomes from participating in the simulation such as empathy and a better understanding of psychotic symptoms.4

A number of studies published on the use of hallucination simulations have assessed stigma or social distance. Several studies found that students were able to understand the challenges faced by patients.5-7 Alternatively, some studies have found that the use of hallucination simulations increased stigma or social distance.8,9 Further, Ando and colleagues conducted a review of the effect of hallucination simulators on stigma of schizophrenia and while they found an overall increase in empathy they also found a desire for distance from individuals who were experiencing hallucinations.10 Course faculty and preceptors who utilize hallucination simulators should be aware that increased stigma and/or social distance may result from the exercise and openly discuss these issues with students. 

There are a variety of simulators available for use in the classroom. The Hearing Distressing Voices toolkit is a 45 minute exercise in which students listen to “auditory hallucinations” (voices based on the hallucinations experienced by the creator) while participating in a variety of activities such as a job application, word and number find puzzles, and an origami exercise.2 Janssen Pharmaceuticals developed a hallucination simulation called Mindstorm. Initially, the simulator was developed to utilize a virtual reality device. Most recently, a video has been available through Janssen sales representatives viewable on a tablet device. The audience views a variety of scenes through the eyes of a patient with schizophrenia. During the experience, the patient experiences auditory hallucinations, ideas of reference, as well as paranoid delusions.   

This author has utilized the Hearing Distressing Voices toolkit for multiple years in a mental health elective course for third year pharmacy students. The results from the first use in the classroom have recently been accepted for publication and are summarized above.4 During the Spring of 2017, students watched a TED talk by Elyn Saks prior to the class period.11 During class period, students watched the Janssen Mindstorm video from a tablet device connected to an overhead projector. After the video demonstration, students then participated in the Hearing Distressing Voices exercise. Students listened to the audio file while completing a variety of activities including a word find, number find, mental status examination and origami exercise. Students then completed a guided reflection after the exercises. 

Consistently, students describe an increased sense of understanding what patients with schizophrenia are going through day to day as they experience their symptoms. The exercises increased the students appreciation for the accomplishments of Elyn Saks as well as John Nash in “A Beautiful Mind” and Lori Schiller in “The Quiet Room,” both of which were assigned readings for the class.12,13 Multiple students expressed an understanding for patients with schizophrenia self-medicating or acting on their hallucinations. Several students stated that the auditory hallucination exercise gave them a headache as they tried to concentrate on the activities while listening to the hallucination. Others reported that the Hearing Distressing Voices experience was a more realistic experience of the symptoms of schizophrenia but several also stated that the two exercises complemented each other. Some students reported that the exercises were difficult for them to complete – they felt frustrated or annoyed and just wanted the voices to stop – much like a patient with schizophrenia often feels. One student stated, “I actually believed I was ‘stupid’ and unable to complete [the tasks] because I was being told so by these voices.” Another stated, “The auditory hallucination simulation was a little harder on me than the Janssen video because some of the things the voices were saying were things that I had felt about myself at some points.” The voices in the auditory hallucination exercise vary in their tone throughout the experience – sometimes derogatory, sometimes gentle. 

In summary, the use of hallucination simulation in pharmacy curricula, whether in a mental health elective, a health assessment course or elsewhere, can aid in students’ understanding what psychotic symptoms are really like. Faculty and students should be aware that student experience can vary from increased stigma and social distance to overt mental distress.


  1. American Council for Pharmacy Education Standards 2016.  Available from:
  2. Deegan P.  Hearing Distressing Voices Toolkit.  Available from:
  3. Skoy ET, Eukel HN, Frenzel JE, Werremeyer A, McDaniel B. Use of an Auditory Hallucination Simulation to Increase Student Pharmacist Empathy for Patients with Mental Illness. Am J Pharm Educ. 2016;80(8):142. DOI: 10.5688/ajpe808142. PubMed PMID: 27899838.
  4. Ness GT, McGuire JM, Taylor P.  A Qualitative Analysis of Student Pharmacists’ Response after an Auditory Hallucination Simulation.  Innovations in Pharmacy  In Press.
  5. Smith MK, Tamburrino MB, Naskar I, Lynch DJ, Chen Y. Hearing voices: evaluation of a medical student training experience about psychosis. Acad Psychiatry. 2014;38(4):514-5. DOI: 10.1007/s40596-014-0166-z. PubMed PMID: 24989989.
  6. Hamilton Wilson JE, Azzopardi W, Sager S, Gould B, Conroy S, Deegan P, et al. A Narrative Study of the Experiences of Student Nurses Who Have Participated in the Hearing Voices that are Distressing Simulation. Int J Nurs Educ Scholarsh. 2009;6(1). DOI: 10.2202/1548-923X.1727. PubMed PMID: 19572835.
  7. Mawson K. Use of media technology to enhance the learning of student nurses in regards to auditory hallucinations. Int J Ment Health Nurs. 2014;23(2):135-44. DOI: 10.1111/inm.12031. PubMed PMID: 23755742.
  8. Brown SA. Implementing a brief hallucination simulation as a mental illness stigma reduction strategy. Community Ment Health J. 2010;46(5):500-4. DOI: 10.1007/s10597-009-9229-0. PubMed PMID: 19669675.
  9. Brown SA, Evans Y, Espenschade K, O'Connor M. An examination of two brief stigma reduction strategies: filmed personal contact and hallucination simulations. Community Ment Health J. 2010;46(5):494-9. DOI: 10.1007/s10597-010-9309-1. PubMed PMID: 20414723.
  10. Ando S, Clement S, Barley EA, Thornicroft G. The simulation of hallucinations to reduce the stigma of schizophrenia: a systematic review. Schizophrenia Res. 2011;133(1-3):8-16. DOI: 10.1016/j.schres.2011.09.011. PubMed PMID: 22005017.
  11. Saks, E. (2012, June).  A tale of mental illness - from the inside [Video File].  Available from:
  12. Howard R. A Beautiful Mind. 2001.
  13. Schiller L, Bennett A. The quiet room : a journey out of the torment of madness. New York: Warner Books; 1994.
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