Neil Thomas
Psychological interventions for voices: Key developments and research
priorities
[email protected] Satellite meeting of the International Consortium for Hallucinations Research, Trondheim, Norway, Sep 2014
ICHR Psychological Therapies Workgroup
- CBT for psychosis as the dominant paradigm and the recent debate about effect sizes
- The need for a more specific research agenda for voices
- Two key areas of development
- Acceptance and mindfulness based therapies
- Going beyond the expert psychotherapy model
Outline
- Hallucinations can be a source of distress and interference with functioning
- Limitations of medication
- Consumer perspectives:
- Importance of personal recovery:
- Taking charge of self-managing mental health
- Pursuing a meaningful and satisfying life alongside the presence of ongoing symptoms
- An experience which is often personally meaningful yet hard to make sense of
Why are we interested in psychological interventions?
“CBT for psychosis”
The development of CBT for psychosis (CBTp)
Clinical practice guideline recommendations
Acute treatment
“Offer cognitive behavioural therapy (CBT) to all people with schizophrenia… either during the acute phase or later” (para. 1.3.4.1)
Recovery phase
“Offer CBT to assist in promoting recovery in people with persisting positive and negative symptoms and for people in remission” (para. 1.4.3.1)
CBT for psychosis
Therapeutic framework emphasising
• Adapting to psychotic experiences
• Normalising perspective
• Building up an adaptive shared formulation of
psychosis, highlighting roles of
– Appraisals of psychotic experiences
– Cognitive processes (biases, attention, etc)
– Maintaining cycles
– Developmental origins
• Testing out specific appraisals of experiences
and broader schemas impacting upon distress or
disability
CBT for psychosis: specific methods for voices
Key target appraisals of voice experience
• Voice power, e.g. “the voices can make bad
things happen to my loved ones”
• Omniscience, e.g. “the voices can predict the
future”
• Hearer control over experience
• Voice identity and explanatory beliefs for
origin of voices
• Related delusions, e.g. “they are telling
everybody what I am thinking”
• Specific voice content
Randomised controlled trials of CBT for psychosis
Wykes et al. Schizophr Bull 2008
Swinburne
The ongoing focus on CBTp RCTs in 2014
Battle of the meta-analyses
Lynch et al. Psychol Med 2010
Battle of the meta-analyses
Jauhar et al. Br J Psychiatry 2014
Battle of the meta-analyses
Overall symptoms: d = 0.33 * Positive symptoms: d = 0.23 * Negative symptoms: d = 0.13 Hallucinations: d = 0.34 * But significant heterogeneity of effect sizes between studies
Jauhar et al. Br J Psychiatry 2014
Battle of the meta-analyses: persisting symptoms
Burns et al. Psychiatr Serv 2014
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Battle of the meta-analyses: effects on hallucinations
Van der Gaag et al. Schizophr Res 2014
For people with a diagnosis of schizophrenia and current experiences of psychosis, seeing a therapist for a series of
sessions focused on adapting to psychotic experiences seems to be, on average:
(1) more helpful in reducing the impact of voices than not seeing a therapist (TAU)
(2) probably more helpful in reducing the impact of voices than meeting with a therapist to talk about other things (control
therapy).
Battle of the meta-analyses: the result
Limitations of CBTp trial design
Broad participant
group eg voices or
delusions
Individualised intervention
eg CBTp
Broad outcome
measures
eg PANSS
Specific
outcome
eg PSYRATS
• CBTp is no more than a broad framework
• Hence few meaningful conclusions from most trials about: • Specific therapy methods • The magnitude of specific outcomes
• Which specific methods are useful for hallucinations
• Applicability to hallucinations in people with non-schizophrenia diagnoses
• What types of voice experiences different methods are most useful for, e.g. commanding/threatening vs critical voices
• Methods for working with hallucinations which are not in the form of voices
What CBTp trials don’t tell us
Thomas et al. Schizophr Bull 2014
- 2 RCTs of CBT targeting power beliefs for people with harmful command hallucinations vs TAU:
- Trower et al, 2004 N=38
- COMMAND Trial - Birchwood et al, 2014, N=197
- Reduction in compliance with harmful commands
- Mediated by changes in perceived voice power
- However, not a consistent effect on voice-related distress
Trials of focused individual CBT for voices
Trower et al. Br J Psychiatry 2004; Birchwood et al. Lancet Psychiatry 2014
1. Beyond broad outcomes and therapy approaches to specific therapeutic targets and methods
2. Developing therapies to target identified mechanisms in voices
3. Improved outcome measurement
4. Understand individual differences between voice hearers
5. Beyond “auditory” and “schizophrenia”
6. Addressing limitations of the reach of CBTp
A more focused research agenda for interventions
Thomas et al. Schizophr Bull 2014
1. Beyond broad outcomes and therapy approaches to specific therapeutic targets and methods
2. Developing therapies to target identified mechanisms in voices
3. Improved outcome measurement
4. Understand individual differences between voice hearers
5. Beyond “auditory” and “schizophrenia”
6. Addressing limitations of the reach of CBTp
A more focused research agenda for interventions
Thomas et al. Schizophr Bull 2014
Targets of therapies for voices in current literature
Therapy target Examples
Range/effectiveness of coping strategies Element of CBTp, eg Tarrier et al 1993, 1998
Discussion of coping in voices groups
Seeing voices as a mental phenomenon Element of CBTp
Perceived power of voices/subjective
control over experience
Key element of CBTp, esp. command hallucinations,
Chadwick & Birchwood 1994
Ability to disengage and decentre from
voice experience
Mindfulness training, eg Chadwick 2003;
Acceptance and commitment, eg Thomas et al 2013;
Element of CBTp, eg Hutton et al 2014.
Understanding voices in context of past
experiences and self/other representations
Longden et al 2012, Corstens et al 2011
Element of CBTp
Self-esteem and self-compassion COMET, eg van der Gaag et al 2012
Compassionate Mind, eg Mayhew & Gilbert 2008
Specific traumatic memories/imagery Imagery rescripting , eg Ison et al 2014
Prolonged exposure, eg de Bont et al 2013
EMDR, eg van der Berg et al 2012
Relating between hearer and voices Hayward et al 2009; Leff et al, 2013.
Thomas et al. Schizophr Bull 2014
Targets of therapies for voices in current literature
Therapy target Examples
Range/effectiveness of coping strategies Element of CBTp, eg Tarrier et al 1993, 1998
Discussion of coping in voices groups
Seeing voices as a mental phenomenon Element of CBTp
Perceived power of voices/subjective
control over experience
Key element of CBTp, esp. command hallucinations,
Chadwick & Birchwood 1994
Ability to disengage and decentre from
voice experience
Mindfulness training, eg Chadwick 2003;
Acceptance and commitment, eg Thomas et al 2013;
Element of CBTp, eg Hutton et al 2014.
Understanding voices in context of past
experiences and self/other representations
Longden et al 2012, Corstens et al 2011
Element of CBTp
Self-esteem and self-compassion COMET, eg van der Gaag et al 2012
Compassionate Mind, eg Mayhew & Gilbert 2008
Specific traumatic memories/imagery Imagery rescripting , eg Ison et al 2014
Prolonged exposure, eg de Bont et al 2013
EMDR, eg van der Berg et al 2012
Relating between hearer and voices Hayward et al 2009; Leff et al, 2013.
Thomas et al. Schizophr Bull 2014
Targets of therapies for voices in current literature
Therapy target Examples
Range/effectiveness of coping strategies Element of CBTp, eg Tarrier et al 1993, 1998
Discussion of coping in voices groups
Seeing voices as a mental phenomenon Element of CBTp
Perceived power of voices/subjective
control over experience
Key element of CBTp, esp. command hallucinations,
Chadwick & Birchwood 1994
Ability to disengage and decentre from
voice experience
Mindfulness training, eg Chadwick 2003;
Acceptance and commitment, eg Thomas et al 2013;
Element of CBTp, eg Hutton et al 2014.
Understanding voices in context of past
experiences and self/other representations
Longden et al 2012, Corstens et al 2011
Element of CBTp
Self-esteem and self-compassion COMET, eg van der Gaag et al 2012
Compassionate Mind, eg Mayhew & Gilbert 2008
Specific traumatic memories/imagery Imagery rescripting , eg Ison et al 2014
Prolonged exposure, eg de Bont et al 2013
EMDR, eg van der Berg et al 2012
Relating between hearer and voices Hayward et al 2009; Leff et al, 2013.
Thomas et al. Schizophr Bull 2014
- Mindfulness groups/Person based cognitive therapy
- Group format including training in meditation skills
- Integrated with broader peer discussion of experiences
- Acceptance and commitment therapy
- Range of components facilitating the person letting go of unproductive struggle with internal experiences and focus on living in line with values alongside their presence
- Includes mindfulness skills training plus other experiential exercises, such as clarifying personal values, defusing specific thought/voice content
Acceptance and mindfulness based interventions
Social
Verbal
Intrusive
• Has characteristics of human addressing or talking about the hearer
• Meaningful verbal content related to the hearer’s ongoing activity, thoughts, memories, etc.
• Audible, real seeming, loud, inescapbale stimulus
Layers of salience of voices as a stimulus
Thomas et al. In Morris et al (Ed) ACT and mindfulness for psychosis . Wiley, 2013
Acceptance and mindfulness based interventions
Khoury et al. Schizophr Res 2014
- N = 96 schizophrenia related disorders and persisting medication-refractory voices or delusions
- Randomised to receive:
- 8 sessions ACT
- 8 sessions manualised befriending intervention
- Four experienced therapists, supervised by Steven Hayes, validation of fidelity
- Blind assessment at pre, post and 6 months post, incl:
- PANSS
- PSYRATS-AH
- Voices Acceptance and Action Scale
Lifengage Trial of ACT for psychosis
Thomas et al. BMC Psychiatry 2014
Client self-report feedback
Did discussion make psychosis problems better, worse or no different?
Mann-Whitney U test p=.02
Lifengage Trial
Between-group post intervention effects on PSYRATS voices scales controlling for voice frequency
1. Belief voices are real ns
2. Distress p < .01
3. Interference with functioning p < .05
Lifengage trial
Shaywer et al, in prep
1. Usefulness of therapy
- General endorsement as useful
- Acceptance, defusion, mindfulness, values/goals
2. Symptomatic and behavioural changes attributed to ACT processes
3. Variation in understanding and connecting with therapy
- Not all clients connected with metaphors and exercises as intended
- Mindfulness and defusion sometimes led to transient increase in experiences
Thematic analysis of participant experiences of ACT
Bacon et al, Behav Cogn Psychother 2014
- First full RCT of an acceptance and mindfulness-based intervention for persisting psychosis
- Promising impacts on voice-related distress and disability
- Findings not definitive - does need further trialling
- However a danger of “ACTp” as another “CBTp”
- Need to examine and refine specific application to voices
- Impact of discrete elements such as mindfulness training
- Further adaptations of intervention to context of psychosis
Acceptance and mindfulness for voices: next steps
1. Beyond broad outcomes and therapy approaches to specific therapeutic targets and methods
2. Developing therapies to target identified mechanisms in voices
3. Improved outcome measurement
4. Understand individual differences between voice hearers
5. Beyond “auditory” and “schizophrenia”
6. Addressing limitations of the reach of CBTp
A more focused research agenda for interventions
Thomas et al. Schizophr Bull 2014
- Primarily tailored to work of clinical psychologists
- Requires training and experience in both psychological therapies and work with psychosis
- Workforce availability issues
- Dissemination efforts (eg THORN) were not particularly successful
- Variable client demand for formal therapies
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Can we address limitations of the reach of CBTp?
Farhall & Thomas. Aus NZ J Psychiatry 2014
- Need interventions which can be delivered by a broader workforce
- Capitalising on growth of
- Graduate level mental health workers
- Peer workforce
- Potential use of technology to aid delivery
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The need to go beyond expert psychotherapy
Walker & Bryant (2013) meta-synthesis of qualitative studies on peer support: experiences of people in recovery include
- Peers as positive role models
- Increased hope and motivation
- Extend social network
- Facilitate building rapport
What do people get from peer contact?
Walker & Bryant (2013). Psychiatr Rehab J, 36, 28-34.
Online resources for severe mental illness Can we promote personal recovery?
Example: MI Recovery
Thomas, Nunan, Leitan, Anderson, Porter & Farhall, in prep.
- 8 session peer-facilitated course on personal recovery
- Significant improvements relative to a stable 3 month baseline on measures of:
- Empowerment p < .001
- Social connectedness p < .001
- Internalised stigma p < .001
- In both completer and intention-to-treat analyses
- Maintained at 3 month follow-up
• Contact with peers advocated within the Hearing Voices Movement as helpful in promote recovery in voice hearers (Corstens et al, 2014)
– Mainly in form of hearing voices groups
– One-to-one peer support has evolved in places where peer expertise is well developed
• However:
– No clear framework for integrating one-to-one peer support with work on voices
– Outcome research on one-to-one peer support has involved targeting recovery broadly, rather than with a specific focus such as hearing voices (Lloyd-Evans et al, 2014)
Peer work for voices
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Changing the relationship
with voices
Making sense of voices
Telling the story
Promote empowered and accepting relationship with voices
Development of a deeper understanding of voice characteristics, phenomenology, content, identities
Discussing life history, establishing a context for emergence of voices
Sh
are
d liv
ed
exp
erie
nce
Peer work for voices
• Collaborative research with Hearing Voices Network in Victoria (Voices Vic)
• Intervention framework – 12 x 1 hour weekly sessions with one of two peer workers – Peer workers had lived experience of hearing voices – Manualised, regular group supervision
• Pilot randomised controlled trial:
– Random allocation: peer work vs waiting list – Blind assessments of subjective experience of voices and personal
recovery pre- and post-intervention
• Feasibile to deliver
• Results in analysis
Voice Exchange project
Potentials for online provision
• Peer stories
http://www.ted.com/talks/eleanor_longden_the_voices_in_my_head
Potentials of online format
Use of video:
- Positive recovery stories
- Illustrating and modelling skills
Use of forums/commenting:
- Promote connection with others with shared experiences
- Able to use lived experience to give to others
Overall aim: to examine the therapeutic use of Internet-based technology in mental health services
Development and trialling of:
- Single online portal for mental health workers to use with clients and consumers and carers to access directly
- Therapeutic materials on mental health self-management and personal recovery
- Videos featuring peers discussing lived experience
- Designed for tablet use by mental health staff across clinical and CMMH sectors
SMART Research Program
1. A focus overall outcomes of CBTp obscures understanding the specifics of interventions for voices
2. We need to establish a research base on methods for working with the range of voice experiences beyond reducing targeting voice power - Interventions which promote people disengaging and decentring from voices offer one possible path of investigation
3. We need to develop interventions that are not reliant upon expert psychotherapy - Methods which can be used by the broader mental health workforce are a key area for ongoing development
Conclusions