1. CBT for Hearing Voices AOT Dr Rozmin Halari, Natalia Petros & RISE Ealing Assertive Outreach Team

2. 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….

3. 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

4. Setting up the group Team decision Service user/carer involvement (needs assessment) Enables: Ownership Support participation

5. 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

6. 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

7. Why a CBT group Evidence 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

8. Why a CBT group Evidence 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)

9. 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

10. 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

11. 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

12. Exclusion criteria Continued use of illegal substances known to affect symptoms Alcohol misuse

13. 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

14. Participant Demographics CHARACTERISTICCBT GROUP (N=10) CONTRO L GROUP (N=10) TOTAL GROUP GENDERMALE/FEMALE4/65/520 AGEMEAN SD [RANGE] 46.5 (9.76) [33-67] 39.9 (9.07) [27-55] 43.2 (9.77) [27-67] ETHNICITYBLACK AFRICAN10% (1)40% (4)25% (5) BLACK BRITISH20% (2)10% (1)15% (3) BLACK CARRIBEAN0% (0)10% (1)/5% (1) WHITE BRITISH20% (2) 20% (4) SOUTH ASIAN40% (4)10% (1)25% (5) OTHER10% (1) 10% (2)

15. Evaluation Outcome 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

16. Evaluation Outcome 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

17. 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

18. Structure 8-10 participants 2 facilitators Length- 10 weeks Weekly Practical considerations Comfortable, safe environment Tea/coffee and biscuits

19. 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

20. 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

21. 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

22. Results

23. Clinical Characteristics CHARACTERISTICN% OF TOTAL CBT GroupControl Group DIAGNOSISParanoid Schizophrenia8565% Schizoaffective Disorder2430% Bipolar Disorder015% MEDICATIONAtypical Antipsychotics6345% Typical Antipsychotics4755% Both Atypical and Typical Antipsychotics 015% Anti-manic Medication3225% Antidepressants1110% Benzodiazepines105% Side Effect Medication4335% DURATION OF ILLNESS1-10 Years1425% 11-20 Years6450% 21-30 Years2220% 31-40 Years105%

24. Analysis Mixed model repeated measures design Within group: Measures Pre and post group Between group: Intervention (CBT +TAU) vs TAU Significant interactions paired t tests

25. Outcome measures Descriptives CBT GroupTreatment as usual MEASURESPREPOSTPREPOST MEANSDMEANSDMEANSDMEANSD BAVQ BEN8.13.57.13.67.52.17.82.3 BAVQ MAL8.13.16.23.17.72.67.63.1 BAVQ RES11.74.610.63.312.33.112.83.6 BAVQ ENG9.86.27.94.610.44.210.54.3 PSYRATS28.65.623.83.926.26.526.56.9 BCIS SC223.721.34.121.75.821.75.8 BCIS SR11.72.312.12.511.64 4 BCIS composite10.34.969.25.7310.49.19.79.15 BDI22.57.518.87.118.84.9194.5 BCIS - Higher scores on self reflectiveness and BCIS composite reflects better insight Lower scores on self certainty reflects better insight

26. 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)

27. 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)

28. 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)

29. 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

30. 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

31. Discussion II CBT as an adjunct to medication Possible increase in compliance due to group Discussions between ‘experts’ – homogeneity – increases credibility

32. Limitations Small sample size Longer term follow up Other measures: Self esteem, social functioning, coping strategies

33. 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?

34. 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!!