Setting up, running and evaluating a CBT Hearing Voices Group Dr Anna Ruddle & Dr Steven Livingstone (Clinical Psychologists) Psychosis Clinical Academic Group (CAG) South London and Maudsley NHS Trust ISPS UK Conference 2nd & 3rd October 2012

Psychosis Clinical Academic Group (CAG) Overview Background Context Benefits of CBT Hearing Voices Groups Group Description and Roleplay Setting up the Group Recruitment and Assessment Evaluating the Group Overcoming Obstacles and Roleplay AR Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Workshop Task What experience do you have of working with people who hear voices? What experience do you have of running groups? What made you choose this workshop? SL Share with person next to them. Then get group feedback briefly. (If small group, ask each of them what they want to get out of coming?) Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Background to HVGs First groups via Hearing Voices Network, late 1980s Network principles Current Hearing Voices Network groups NHS HVGs – increasing popularity CBT groups AR Network principles – stems from Romme and Escher’s work – Dutch chatshow; discovery that a) more common than we thought and b) many don’t have contact with services. Therefore assumption that hearing voices does not equal psychosis/schizophrenia; one of many normal human experiences; often triggered by traumatic early experiences. Hearing Voices Network still runs many groups nationally, service-user led, no specific structure or goals other than supportive and normalising. NHS HVGs – range of different approaches and models described in literature e.g. unstructured, psychodynamic, skills-training, CBT, mindfulness. Increase in groups since rise of cognitive theory and therapy, alternative to biomedical view. CBT groups the most common within the NHS, sometimes offered as “CBT for psychosis” and sometimes specifically for voice-hearers. Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Benefits of CBT HVGs Evidence base – Ruddle et al., 2011 Increasing access to CBT (NICE recommended) Normalising a stigmatised experience Safe space to try new beliefs and behaviours Decreasing social isolation AR Evidence base – mixed but most studies show some benefits e.g. symptoms, distress, self-esteem, social behaviour. Increasing access – not a substitute for 1:1 but realistically we can’t meet NICE guidelines. In SLAM for instance, not even meeting aim of 10% of people having any dose of CBTp in a 12mth period. Safe space – get feedback and ideas from similar peers that they “hear” more effectively. Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) The group 7-sessions, weekly, 1hr-1hr15mins Closed group 6-8 ideal; bear in mind drop-out Facilitators x2; past experience Manualised; balance of structure/open discussion Group aims – reduce distress, possibly by enhancing coping and challenging negative beliefs about voices SL Seven sessions over seven weeks, each builds on the last. Closed group – we asked people to commit to attending all 7 sessions and it’s not possible to join once the group has started. Numbers vary on the service, bear in mind drop out. Our experience suggests 2 facilitators are necessary. Often a good learning experience for other staff, trainees, or service users (who bring the expertise of lived experience) – although in this case at least one facilitator should have experience of running groups and a CBT background. Manualised approach with different topics each week, but important to find a balance between structure and flexibility. The manual is there to guide discussion but the exact content of each session depend on what participants bring up. There are suggested questions but facilitators shouldn’t feel obliged to ask these verbatim. The content can be flexible to an extent e.g. introduce paired-tasks, encourage alliance between group members if some quieter than others. Each week starts with general catch-up, summary of previous week, review of homework tasks, introducing and carrying out new topic, then summary of what covered. Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) CBT HVG Manual Adapted from Wykes et al.’s (1999) manual: Session 1 – Sharing information about voices Session 2 – Explanations of voices Session 3 – Coping strategies Session 4 – Beliefs about voices Session 5 – Stigma and discrimination Session 6 – Self-esteem Session 7 – Overall model of voices SL - Offer copies of manual - Explain it is an adapted version of Wykes et al’s original manual. - Don’t have time to discuss all sessions in detail – see manual. - Focus on session 1 – look at the manual and session summary sheet. This approach differs from the Hearing Voices Network in terms of being more structured and CBT focussed, but the underlying principle of normalisation is similar and this is emphasised from the first session. The focus of the first session is sharing information about hearing voices. Show video clip to stimulate discussion – easier than asking participants to talk about their own experience straight away. One facilitator writes on the flipchart and the other guides the discussion. The facilitator asks people what they made of the video, and explores in what ways peoples voices are similar and different. The session summary sheet can be used as a guide for the facilitator scribing on the flipchart: they should group people’s comments about voices into different circles, i.e. how many voices are there, when did they start, where do they sound like they are coming from, etc. The main issue the facilitator is trying to draw out is that although everyone’s experiences of hearing voices is unique to them, there are a lot of similarities. This is good for group cohesion and should also help people to feel less alone with the experience. - Set up groups of 4-5 for role-play eliciting discussion of experience of voices. - Imagine you’ve just watched the video clip with different people talking about the experience. The facilitator should try to draw out this discussion. Those playing the group members: most groups have a mix of people who are open and talkative and those who are quiet, so don’t make it too difficult for the facilitator. - Get general feedback and ask them to bear in mind obstacles which we will discuss later. - The final session draws together all of the themes from previous sessions to create a model of hearing voices. It’s important the group feel they own the final model, so the facilitator should use the language the group has used. The facilitator draws it together in a cognitive behavioural model of distress maintenance, making links between how thoughts, feelings and behaviours affect hearing voices. The facilitator also refers back to previous sessions on normalisation, coping strategies, the continuum model of psychosis, stress-vulnerability, famous voice hearers etc., to show how people can reduce the distress caused by hearing voices. This should be an empowering model of voice hearing, as it shows what people can do to reduce the power voices have over them. - Show video if possible Psychosis Clinical Academic Group (CAG)

Service setting and client group Usually community-based teams Other settings/client-groups possible Evidence based on clients with a schizophrenia-spectrum diagnosis Clients who currently report hearing voices that cause distress and/or limit their functioning SL Other settings – usually done in the community, although has also been done in inpatient settings, with adolescent groups. Not necessarily diagnosis specific, but the evidence base comes from clients with and ICD F20-29 diagnosis. Untested in other client groups. We have done the group both in early intervention and with longer-term psychosis clients, both are possible and the benefits were similar, but our experience has been that it was harder to recruit and retain clients in the EI pathway. In terms of inclusion criteria: anyone who currently reports hearing distressing voices is potentially eligible – tempting to open it up more broadly, e.g. to people who used to hear voices, or you think hear voices but don’t acknowledge it, or people no longer really distressed. However, in our experience, it’s good for group cohesion when people are fairly similar, and also ensures all the topics are relevant. Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Setting up the group Plan in advance Practicalities – room; budget (refreshments, stationery, flipchart, name labels etc); DVD player; kettle, mugs etc Time commitment SL Planning and time – plan group 3 months in advance to allow time for preparation, recruitment, assessments, room bookings etc Practicalities – book a room in the CMHT most of them attend; only need a small budget; refreshments often make a big difference Time commitment – one session a week for 7 weeks, need to ensure both facilitators block this out in their diary. There is quite a bit of work involved in recruitment, if you do an assessment, reminding people to attend and following up with non-attenders, planning and debriefing, writing clinical note summaries, session summaries, evaluation, writing and reports … so it is quite a time commitment! Psychosis Clinical Academic Group (CAG)

Recruitment Suggestions Recruit from within your team Rolling recruitment Posters and leaflets Encourage over-inclusiveness Team meetings Discuss each CC caseload It can be very hard!! AR Someone taking ownership of the group within each team – give our recent experience. Also easier when I worked within the team than when I was recruiting for research. Rolling recruitment may help e.g. whenever get psychology referrals, consider HVG and ask CC and client if sounds appropriate? Can then re-assess for 1:1 CBT afterwards if necessary. Over-inclusiveness/caseload – Often many CCs don’t refer for number of reasons, one being that they don’t think any of their clients would come/be interested/get any benefit. Often the least expected clients surprise us so offer hope and encouragement for any client – you can filter them via phone/asst. Psychosis Clinical Academic Group (CAG)

Assessment Suggestions Recommend individual assessments Facilitator/s to conduct Service user co-conduct Aims: engage; normalise; offer information; reassurance; assist informed decision; check suitability; do outcomes 30 mins approx Incorporate into asst for 1:1 therapy AR Justify assessments – unclear how valuable as always done them, subjective view that they are for all reasons listed in aims BUT if resources very limited, could try without and see. Just ideas! Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Evaluation Based on our experience: CORE-OM (self-report questionnaire) PSYRATS (semi-structured interview) 2 self-identified goals for the group (VAS scale 0-10) – see CHOICE Qualitative feedback (semi-structured interview) AR Recent service evaluation tried using other measures e.g. coping strategies, BAVQ, quality of life, CHOICE, but none were sensitive enough to change. Positive outcomes on these three measures, which are arguably the key targets and what trusts are interested in. Psyrats – really needs to be semi-structured but has been given in questionnaire form in some research studies. Self-identified goals – rate self pre and then post. Qualitative – proving very important as often the quantitative measures miss important information/benefits. Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Obstacles? What obstacles could people envisage arising in the setting up, running or evaluation of the group? SL (AR write on flipchart) Group shouting out Summarise themes on flipchart Pick out the valid concerns and reassure on less problematic ones Generate ideas from group for how to overcome, offer our thoughts and experience Psychosis Clinical Academic Group (CAG)

Psychosis Clinical Academic Group (CAG) Roleplay an Obstacle Both facilitate roleplay, ask delegates to be clients Egs: Someone dominating group Not doing homework task Someone not taking part and seem disinterested/distressed Arguments/aggression e.g. different views – religion, medication, Getting angry about other professionals/services/hospital Psychosis Clinical Academic Group (CAG)

Questions? If you decide to run the group in your local service, please do not hesitate to contact us with any queries.

Psychosis Clinical Academic Group (CAG) Key References Romme, M. & Escher, S. (1993). Accepting voices. Dorset, UK: Blackmore Press - Sets out the normalising approach used by the Hearing Voices Network, alternative ways of understanding voices, and interesting first hand accounts from voice-hearers. Ruddle, A., Mason, O., & Wykes, T. (2011). A Review of Hearing Voices Groups: Evidence and Mechanisms of Change. Clinical Psychology Review, 31, 757-766. – Overview of different HVG approaches and their evidence-base. Wykes, T., Parr, A., & Landau, S. (1999). Group treatment of auditory hallucinations: Exploratory study of effectiveness. British Journal of Psychiatry, 175, 180-85. – Developed the original CBT manual we have now adapted. Psychosis Clinical Academic Group (CAG)