Transcript CBT for Hearing Voices

CBT for Hearing
Voices
AOT
Dr Rozmin Halari, Natalia Petros
&
RISE Ealing Assertive Outreach Team
Ealing AOT
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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
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One psychologist in the team
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Increased need/not being able to meet the
demand
Group
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Cost effective
Positive effects of group
Needs assessment
-Care coordinators
-Clients/Carers
44% were identified
Setting up the group
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Team decision
Service user/carer involvement (needs
assessment)
Enables:
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Ownership
Support
participation
Hearing voices
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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
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Non compliance
Persistent residual positive symptoms
Seek other interventions
Existing interventions/groups
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Service user led- support groups
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CMHT’s- CBT for psychosis
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E.g. Hearing Voices Network
Nature of clients
Selected group (In terms of cognitive abilities)
AOT
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Difficult to engage
Non compliant/revolving door
Treatment resistant
No evidence of HVG in AOT
Why a CBT group
Evidence Base I
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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.
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Although positive results - uncontrolled
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Why a CBT group
Evidence Base II
 Group based CBT for AH:
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Improvement Severity of hallucinations
(Wykes et al., 1999; Wykes et al.,
2005; Drury et al., 1996)
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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)
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Better coping (Gledhill et al., 1998, Falloon and Talbot, 1981)
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Positive effects maintained;
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6 months follow up
(Wykes et al., 2005)
Evidence base III
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Penn et al. (2009) CBT vs enhance supportive therapy
Randomly allocated 65 patients
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Group CBT (for HV)
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Chronically ill group with SZ
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Reduce negative beliefs about voices (and severity)
Reduce distress related to HV
Reduce overall symptoms and HV
Increase insight
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Assessment
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Assessment
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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
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Accepting clients
If not reasons explained
Inclusion criteria
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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
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Continued use of illegal substances known to
affect symptoms
Alcohol misuse
Group
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20 participants randomly allocated to either
CBT + TAU or TAU-alone (control).
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Although history of non compliance with
medication
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All compliant
No medication changes were made
95% attendance to group
3/10- CBT and 1/10 – control previous
psychological input
Participant Demographics
CHARACTERISTIC
CBT
GROUP
(N=10)
CONTRO
L GROUP
(N=10)
TOTAL
GROUP
GENDER
MALE/FEMALE
4/6
5/5
20
AGE
MEAN
SD
[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)
WHITE BRITISH
20% (2)
20% (2)
20% (4)
SOUTH ASIAN
40% (4)
10% (1)
25% (5)
OTHER
10% (1)
10% (1)
10% (2)
/5% (1)
Evaluation
Outcome Measures- Primary
Psychotic Symptom Rating Scale
(PSYRATS) for auditory
hallucinations (Haddock et al., 1999)
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11 items assessing severity over past week
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Frequency
Intensity
Distress, disruption
control
Total scores- severity of hallucinations
Beliefs About Voices Questionnaire- revised
(BAVQ-R) (Chadwick et al., 2000)
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35 items beliefs about voices- emotional and behavioural
reactions
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Subscales; malevolence, benevolence, resistance, engagement
Evaluation
Outcome Measures-secondary
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Beck’s Depression Inventory II (BDI-II)(Beck et al., 1996)
 Severity of depression
 21 items
 Self reported depression
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Beck Cognitive Insight Scale (BCIS) Beck et al., 2004)
 2 subscales: self certainty and self reflectiveness
 15 items
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Service user evaluation
Service User Evaluation
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Completed short questionnaire post group
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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
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8-10 participants
2 facilitators
Length- 10 weeks
Weekly
Practical considerations
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Comfortable, safe environment
Tea/coffee and biscuits
Intervention Aims
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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
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Group CBT AH (Wykes et al., 1999)- manualised
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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
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Increased sessions from 7 to 10 sessions
Focussed on engagement, coping, role of
medication
Process
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Initially
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Some structure – reduce anxiety
Explore voice hearing experiences
Normalise and client led
Mindful of the nature of this client group
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Focus on engagement
Team approach
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Attendance to the group- encouraged between
sessions
Session content discussed between sessions
Results
Clinical Characteristics
CHARACTERISTIC
DIAGNOSIS
MEDICATION
DURATION OF ILLNESS
N
% OF TOTAL
CBT Group
Control Group
Paranoid Schizophrenia
8
5
65%
Schizoaffective Disorder
2
4
30%
Bipolar Disorder
0
1
5%
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%
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
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Mixed model repeated measures design
Within group:
 Measures
 Pre and post group
• Between group:
Intervention (CBT +TAU) vs TAU
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Significant interactions
paired t tests
Outcome measures
Descriptives
CBT Group
MEASURES
PRE
MEAN
BCIS -
Treatment as usual
POST
SD
MEAN
PRE
SD
MEAN
POST
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
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
5.6
Higher scores on self reflectiveness and BCIS composite reflects
Lower scores on self certainty reflects better insight
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
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No between group differences at baseline on
these measures (p>0.05)
Results – Secondary
Outcomes
BDI
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Within the group
 Significant time x group interaction (F (1,18) =13.58, p
<0.01)
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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?
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Paired t tests
CBT+TAU group; significant improvement on:
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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
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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
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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
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Small sample size
Longer term follow up
Other measures: Self esteem, social
functioning, coping strategies
Conclusion
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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
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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!!