CBT for Hearing Voices

AOT

Dr Rozmin Halari, Natalia Petros

&

RISE Ealing Assertive Outreach Team

Ealing AOT Caseload 100 London Borough of Ealing Multi cultural and ethnic backgrounds Team approach

……Unified & Proactive: All team members are involved in supporting all AOT service users. The approach helps with engagement….provides intensive support ….. High frequency of contact with the team strengthens engagement process….

Why a CBT group?Service needs

One psychologist in the team Increased need/not being able to meet the

demand Group

Cost effective Positive effects of group

Needs assessment -Care coordinators -Clients/Carers 44% were identified

Setting up the group

Team decision Service user/carer involvement (needs

assessment) Enables:

Ownership Support participation

Hearing voices Common symptom of psychosis (also present

in non clinical populations) Over 60% experience hearing voices Anti psychotics- front line treatment 25% to 50% continue to hear voices Limitations

Non compliance Persistent residual positive symptoms Seek other interventions

Existing interventions/groups Service user led- support groups

E.g. Hearing Voices Network CMHT’s- CBT for psychosis

Nature of clients Selected group (In terms of cognitive abilities)

AOT Difficult to engage Non compliant/revolving door Treatment resistant No evidence of HVG in AOT

Why a CBT groupEvidence Base I

Individual CBT- effective positive and negative symptoms (Wykes et al., 2005)

Not widely accessible for schizophrenia Group approach – efficient, cost effective way

of delivering this intervention Few formal evaluations of a group approach. Although positive results - uncontrolled

Why a CBT groupEvidence Base II

Group based CBT for AH: Improvement Severity of hallucinations (Wykes et al., 1999; Wykes et al.,

2005; Drury et al., 1996)

Improvement Social functioning (Wykes et al., 2005)

Increase Insight (Wykes et al., 1999) Lower depression (Gledhill et al., 1998) Reduce negative beliefs about hearing voices (Pinkham et al., 2004) Reduce distress related to hearing voices (Perlman and Hubbard, 2000;

Newton et al. 2005) Better coping (Gledhill et al., 1998, Falloon and Talbot, 1981)

Positive effects maintained; 6 months follow up (Wykes et al., 2005)

Evidence base III Penn et al. (2009) CBT vs enhance supportive therapy Randomly allocated 65 patients

Group CBT (for HV) Chronically ill group with SZ

Reduce negative beliefs about voices (and severity) Reduce distress related to HV Reduce overall symptoms and HV Increase insight

Assessment Assessment

Brief history Experience of groups Assessment of voices Neuropsychological impairments Positive and negative syndrome scale (PANSS, Kay et al.,

1989) Previous psychology input

Letter sent with care-coordinator Accepting clients If not reasons explained

Inclusion criteria ICD-10 criteria for schizophrenia, schizoaffective

disorder and bipolar disorder Persistent and distressing AH (score 3 or above

on hallucination item of PANSS; Kay et al., 1989) Over 18 years No substance misuse or medical disorder

contributing to symptoms No medication change planned

Exclusion criteria

Continued use of illegal substances known to affect symptoms

Alcohol misuse

Group

20 participants randomly allocated to either CBT + TAU or TAU-alone (control).

Although history of non compliance with medication All compliant No medication changes were made 95% attendance to group 3/10- CBT and 1/10 – control previous psychological

input

Participant DemographicsCHARACTERISTIC CBT

GROUP(N=10)

CONTROL GROUP

(N=10)

TOTAL GROUP

GENDER MALE/FEMALE 4/6 5/5 20

AGE MEANSD

[RANGE]

46.5 (9.76)

[33-67]

39.9(9.07)

[27-55]

43.2(9.77)

[27-67]

ETHNICITY BLACK AFRICAN 10% (1) 40% (4) 25% (5)

BLACK BRITISH 20% (2) 10% (1) 15% (3)

BLACK CARRIBEAN 0% (0) 10% (1) /5% (1)

WHITE BRITISH 20% (2) 20% (2) 20% (4)

SOUTH ASIAN 40% (4) 10% (1) 25% (5)

OTHER 10% (1) 10% (1) 10% (2)

EvaluationOutcome Measures- Primary

Psychotic Symptom Rating Scale (PSYRATS) for auditory hallucinations (Haddock et al., 1999)

11 items assessing severity over past week Frequency Intensity Distress, disruption control Total scores- severity of hallucinations

Beliefs About Voices Questionnaire- revised (BAVQ-R) (Chadwick et al., 2000)

35 items beliefs about voices- emotional and behavioural reactions Subscales; malevolence, benevolence, resistance, engagement

EvaluationOutcome Measures-secondary Beck’s Depression Inventory II (BDI-II)(Beck et al., 1996)

Severity of depression 21 items Self reported depression

Beck Cognitive Insight Scale (BCIS) Beck et al., 2004) 2 subscales: self certainty and self reflectiveness 15 items

Service user evaluation

Service User Evaluation

Completed short questionnaire post group Better understanding of the different areas

covered (e.g. role of medication, importance of coping, psychological model of AH)

Most and least useful Presentation of sessions Future improvements

Structure 8-10 participants 2 facilitators Length- 10 weeks Weekly Practical considerations

Comfortable, safe environment Tea/coffee and biscuits

Intervention Aims Triggers, behaviours and consequences Develop and share cognitive and behavioural

coping strategies to help deal with the voices Share experiences reflect similarities and

differences aid restructuring of beliefs Accept the voices Self esteem Increase social support Reduce Isolation Share the experience Learn from one another Erase the stigma of voice hearing

Intervention

Group CBT AH (Wykes et al., 1999)- manualised Engagement and sharing of information- voices Psychoeducation; Exploring models of psychosis Content of AH (e.g. malevolent, benevolent) Behavioural analyses of voices Exploring beliefs about hallucinations/cognitive restructuring Developing effective coping strategies Improving self esteem Modified Manual

Increased sessions from 7 to 10 sessions Focussed on engagement, coping, role of

medication

Process Initially

Some structure – reduce anxiety Explore voice hearing experiences Normalise and client led

Mindful of the nature of this client group Focus on engagement Team approach

Attendance to the group- encouraged between sessions

Session content discussed between sessions

Results

Clinical CharacteristicsCHARACTERISTIC N % OF TOTAL

CBT Group Control Group

DIAGNOSIS Paranoid Schizophrenia 8 5 65%

Schizoaffective Disorder 2 4 30%

Bipolar Disorder 0 1 5%

MEDICATION Atypical Antipsychotics 6 3 45%

Typical Antipsychotics 4 7 55%

Both Atypical and Typical Antipsychotics

0 1 5%

Anti-manic Medication 3 2 25%

Antidepressants 1 1 10%

Benzodiazepines 1 0 5%

Side Effect Medication 4 3 35%

DURATION OF ILLNESS 1-10 Years 1 4 25%

11-20 Years 6 4 50%

21-30 Years 2 2 20%

31-40 Years 1 0 5%

Analysis Mixed model repeated measures design

Within group: Measures Pre and post group• Between group: Intervention (CBT +TAU) vs TAU

Significant interactionspaired t tests

Outcome measuresDescriptives

CBT Group Treatment as usual

MEASURES PRE POST PRE POST

MEAN SD MEAN SD MEAN SD MEAN SD

BAVQ BEN 8.1 3.5 7.1 3.6 7.5 2.1 7.8 2.3

BAVQ MAL 8.1 3.1 6.2 3.1 7.7 2.6 7.6 3.1

BAVQ RES 11.7 4.6 10.6 3.3 12.3 3.1 12.8 3.6

BAVQ ENG 9.8 6.2 7.9 4.6 10.4 4.2 10.5 4.3

PSYRATS 28.6 5.6 23.8 3.9 26.2 6.5 26.5 6.9

BCIS SC 22 3.7 21.3 4.1 21.7 5.8 21.7 5.8

BCIS SR 11.7 2.3 12.1 2.5 11.6 4 11.6 4

BCIS composite 10.3 4.96 9.2 5.73 10.4 9.1 9.7 9.15

BDI 22.5 7.5 18.8 7.1 18.8 4.9 19 4.5

BCIS - Higher scores on self reflectiveness and BCIS composite reflects better insight

Lower scores on self certainty reflects better insight

Results –Primary Outcome

BAVQ Within the group

Significant time x measure x group interaction (F (3,16) =5.34, p <0.01)

PSYRATS Significant time x group interaction (F (1,18) =16.29, p

<0.01)

Differences pre and post in CBT+TAU group only

No between group differences at baseline on these measures (p>0.05)

Results – Secondary Outcomes

BDI Within the group

Significant time x group interaction (F (1,18) =13.58, p <0.01)

Differences pre and post in CBT+TAU group only

BCIS

No significant main effects or interactions (p>0.05) No between group differences at baseline on

these measures (p>0.05)

Where are the differences? Paired t tests CBT+TAU group; significant improvement on:

PSYRATS (p<0.01) BDI (p<0.01) BAVQ-Malevolent (p<0.01) No improvement on the BCIS (p>0.05)

TAU-alone – no significant improvement on any of the primary or secondary outcome measures (p’s>0.05)

Service user satisfaction

High levels of satisfaction reported Better understanding of psychological model

of voices Increased repertoire of coping strategies Better able to talk about about their

experiences Requested recovery focussed group -future

Discussion I Positive effect of CBT for AH Consistent with previous studies (e.g. Wykes et

al., 2005, Penn et al, 2009) Factors contributing to these significant findings:

Intellectual Ability Cultural differences Sharing experiences allows for reflection and

can consequently aid in the restructuring of beliefs

Team approach

Discussion II

CBT as an adjunct to medication

Possible increase in compliance due to group

Discussions between ‘experts’ – homogeneity – increases credibility

Limitations

Small sample size Longer term follow up Other measures: Self esteem, social

functioning, coping strategies

Conclusion

Short course of group CBT effective in improving severity of voices and reducing self-reported depression (scores on the BDI)

Long term follow up needed - effects maintained?

Acknowledgements

• Prof. Veena Kumari Institute of Psychiatry,• Prof. Til Wykes– Institute of Psychiatry,

Kings College London

Guidance, support and collaboration.

• AOT for continual support without whom the group would not have been possible!!