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Challenging the omnipotence of voices: group cognitive behavior therapy for voices
Behaviour Research and Therapy 38 (2000) 993±1003
www.elsevier.com/locate/brat
Challenging the omnipotence of voices: group cognitive behavior therapy for voices Paul Chadwick a,*, Suzanne Sambrooke b, Sarah Rasch c, Ellie Davies d a
Royal South Hants Hospital & Department of Psychology, University of Southampton, High®eld, Southampton, SO17 1BJ, UK b DClinPsych, Winchester NHS Trust, Winchester, UK c DClinPsych, Newham Community Health Services NHS Trust, Newham, UK d DClinPsych, Royal South Hants Hospital, Southampton, UK Accepted 28 June 1999
Abstract The present study examines the impact of group based cognitive behavior therapy (CBT) for drug resistant auditory hallucinations, or voices. In particular it assesses treatment eect on beliefs in a voice's omnipotence and control. Twenty-two participants entered one of ®ve 8-session CBT groups. Measures of omnipotence, control, process measures, and symptoms of anxiety and depression were completed at assessment, and ®rst and last group sessions. The groups achieved a signi®cant reduction in conviction in beliefs about omnipotence (df 2, P = 0.002) and control (df 2, P = 0.001). There were no aective changes. Certain participants showed important spontaneous changes in behavior. Process measures suggested that participants valued the groups and bene®ted from them. These results are promising and the treatment may prove a useful addition to existing psychological interventions. 7 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Approximately 4.6% of the population experience hallucinations in one or other modality (Tien, 1991). Research on a combined clinical and community sample of people experiencing auditory hallucinations Ð hearing voices Ð revealed diverse emotional and behavioral reactions (Romme & Escher, 1989). In part this re¯ects dierences in content, for example, * Corresponding author. 0005-7967/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 9 ) 0 0 1 2 6 - 6
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being abused and criticized vs being ¯attered and wooed. Chadwick and Birchwood (1994) used a cognitive behavior therapy (CBT) conceptual framework to propose that people's beliefs about voices would also shape how they felt and coped. Four empirical papers (Birchwood & Chadwick, 1997; Chadwick & Birchwood, 1994, 1995; Close & Garety, 1998) provide empirical support for this cognitive formulation of voices. These studies show ®rst, that people who hear voices do indeed construct meaning from the experience. Speci®cally, four beliefs appear to be of particular importance. That is, identity (who is the voice?); purpose (why is the voice talking to me, not someone else?); omnipotence (how powerful is the voice?); and control. Second, there is evidence to suggest that beliefs play a mediating role. Voices believed to be malevolent are associated with resistance and high distress, in contrast to those believed to be benevolent, which are associated with engagement and lower distress or pleasure. Also, voices believed to be omnipotent are associated with more common and severe symptoms of depression (Chadwick & Birchwood, 1996). This conceptualization has three advantages. First, it shows that voices are a psychological problem when, and only when, they are associated with emotional or behavioral problems. Second, it yields a new treatment option for drug resistant voices. CBT may be used alongside medication to try to weaken beliefs associated with distress, self-harm, etc. Outcome research on voices shows CBT can be eective for certain people in reducing distress, and increasing control, though not in reducing voice frequency (Bouchard, Vallieres, Roy & Maziade, 1996) Ð though the only RCT yielded modest results (Haddock, Slade, Bentall, Reid & Faragher, 1998). There are no published studies evaluating group based CBT for voices. Yet groups have for many years been the centerpiece of certain international voluntary organizations for voice hearers (Romme & Escher, 1989). Also, a recent study using CBT for people with a diagnosis of schizophrenia (though not necessarily hearing voices) reported signi®cant symptomatic change (Gledhill, Lobban & Selwood, 1998). For many voice hearers, voices are imbued with a `terrifying and compelling quality' and people `feel caught in their power' (Bauer, 1970). A fundamental challenge in CBT for voices is to challenge voices' omnipotence (Chadwick, Birchwood & Trower, 1996). In the present study we report data from ®ve CBT groups, each lasting eight sessions. The principal object of the group format was to weaken disabling beliefs about omnipotence and increase a sense of personal control over voices. 2. Method 2.1. Participants Five groups were run (three in Southampton, one in both London and Winchester) as part of clinical psychology services. Ethical approval was provided in each center. Participants were all receiving standard psychiatric care, and medication was provided throughout the study. Referral was made by a consultant psychiatrist or another clinician. Inclusion criteria were that the person had been experiencing drug resistant and subjectively distressing voices for at least the preceding two years. Membership was set at four or ®ve people to each group, at the request of voice hearers themselves. All people referred had an ICD 10 diagnosis of
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schizophrenia or schizo-aective disorder. The exclusion criteria were evidence of an organic psychosis or disabling use of illicit drugs. Table 1 shows what happened to the 35 people who were referred. Five did not complete assessment; their possible suitability is unknown. Two people did not meet the inclusion criteria (one heard no voices, one found his voices pleasant). Three people asked for and received individual CBT. Three people chose to have no therapy. One person entered a group without a prior assessment. At the time of assessment 8 of the 22 were in hospital: 20 had been hospitalized at least once because of problems coping with voices within the preceding year. Seventeen of the 22 heard voices commanding self-harm, and well over half commanding suicide or homicide (most commonly children or family). Distress levels on the Hospital Anxiety and Depression Scale were high prior to therapy. One woman stopped attending because she was moved temporarily away from Southampton (she joined a subsequent group not included in this paper). Three people dropped out after attending 1, 2 and 3 sessions, respectively. No reasons were provided and all three declined follow-up contact. After complete description of the study to the participants, written informed consent was obtained. It was written that attendance of the group was not dependent on completing measures, and that participants were free to withdraw at any point without penalty. One person chose to complete only one measure (therapeutic factors), and one not to complete conviction ratings. 2.2. Measures 2.2.1. Hospital anxiety and depression scale (HADS) Symptoms of anxiety and depression were monitored using the HADS (Zigmund & Snaith, 1983). The HADS was completed at assessment and at the close of the group. 2.2.2. Belief conviction: omnipotence, control, and personal meaning Participants rated their conviction in three beliefs Ð power, control and personal meaning Ð at assessment and ®rst and last group sessions. Individuals indicated their conviction by marking a 10 cm visual analogue line, anchored at either end as 0 or 100%. So for omnipotence, the line was anchored on the left `0%, not at all powerful' and the right `100%, totally powerful'. For the question `How much control does your voice have over you?' the Table 1 Participants involvement in study Initial referrals Did not complete an assessment Unsuitable for therapy Declined therapy Began individual therapy Completed individual therapy Began group therapy Completed group (i.e. attended >4 sessions)
35 5 2 3 3 3 22 18
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anchors were `0%, none at all' and on the right `100%, total control over me'. Each person rated in the same way conviction in an idiosyncratic belief about personal meaning (a composite of identity and purpose: e.g. the voice is my step-father who hates me and wants me dead). 2.2.3. Hustig and Hafner topography of voices rating scale This is a ®ve item self-report scale designed to measure the frequency, volume, clarity and intrusiveness of voices, as well as the distress associated with them (Hustig & Hafner, 1990). It was developed for use with people who have persistent auditory hallucinations. This scale was completed at assessment and at the ®rst and last group sessions. 2.2.4. Independent assessment Within 2 weeks of the groups ending, participants met an independent clinician to discuss their experience of the group. Speci®c prompts were used to draw out what people had found most and least helpful in the groups. Individuals were assured that their responses were anonymous and were encouraged to be honest as this would bene®t voice hearers attending future groups. 2.2.5. Therapeutic factors At the independent assessment individuals were asked to rank two sets of statements relating to the same eight therapeutic factors: altruism, group cohesiveness, universality, interpersonal learning, guidance, catharsis, self-understanding and instillation of hope (Yalom, 1995). These categories have been used elsewhere to assess the bene®ts of non-speci®c therapeutic factors in group therapy (e.g. Bloch, Reibstein, Crouch, Holroyd & Themen, 1979). 2.2.6. Satisfaction After a gap of at least 1 month, all members were sent a standard satisfaction questionnaire. The letter, from a departmental secretary, stated that this was an anonymous questionnaire sent to all service users and encouraged them to be as honest as possible as this was their opportunity to bene®t future service users. It listed seven statements, concerned with dierent aspects of therapy. Each statement was worded armatively (e.g. my therapist treated me with respect) and rated on the scale, disagree strongly, disagree slightly, unsure, agree slightly, agree strongly. Total scores ranged from 0 to 28. 2.3. Procedure 2.3.1. Phase 1: assessment All participants were assessed over 2±4 sessions. The assessment covered a cognitive analysis of voice onset, form, content, and triggers; the behavioral and emotional impact of the voices; and the beliefs held about the voices (identity, purpose, power and control). Assessment also covered background psychological assessment. People were told that the group would not get rid of their voices, but would oer an opportunity to share experience of hearing voices. People discussed any concerns about joining a group. The mean time interval between end of assessment and start of group meetings was 5 weeks.
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2.3.2. Phase 2: group cognitive behavior therapy The group was a closed group and treatment consisted of eight weekly sessions of 1 h duration. All ®ve groups were facilitated by two therapists. The authors adhered to a manual (available from the ®rst author on request), which they had developed collaboratively, and adhered to through peer supervision. Two groups were asked if sessions might be audio or video taped, to enable adherence to manuals to be assessed, but both groups declined. The process was open, collaborative and dialogue was free ¯owing. Therapists avoided controlling discussion through the use of turn taking or lecturing. Guided discovery was preferred to direct challenge. The ®rst 3 sessions contained no challenging or disputing. Session 1 began with an exploration of feelings leading up to the group, and how this impacted on voices. Therapists encouraged the groups to establish ground rules, oering the rationale that this was a good way of reducing anxiety within the group. A brief rationale for the group was oered. Therapists explored if members had discussed their voices with other people (this is rare) and drew out the beliefs and aect which went with any avoidance. The remainder of session 1 and all session 2 were spent exploring three themes: when the voices ®rst began; people's own ideas about why they heard voices; and the impact of hearing voices on their lives. In session 3, content, distress and coping were explored. From session 4 onwards, socratic dialogue, or guided discovery, was used to explore and weaken the two core beliefs about omnipotence and control. Beliefs were also subject to empirical testing, for example, by teaching a participant to try to increase and decrease voice activity to test the belief about control. Over the last two sessions the therapists explored beliefs about personal meaning. The therapists introduced the idea that voices might originate from the mind perhaps being similar to intrusive thoughts (Haddock et al., 1998). The group explored advantages and disadvantages of two possible views Ð voice as internally generated, or as coming from someone else. Participants discussed termination and any wishes for further support. A handout was produced after each session, summarizing the main discussion points, and was distributed at the start of the next session. 2.3.3. Phase 3: independent assessment After the ®nal group session an independent clinician met with all participants to explore their re¯ections on the group and to complete the measure of therapeutic factors. These sessions lasted 1 h.
Table 2 Mean conviction scores and standard deviations in the three beliefs (omnipotence, control and personal meaning) for the 17 participants who completed ratings at assessment, and ®rst (Pre) and last (Post) sessions
Omnipotence Control Personal meaning
Assessment
Pre
Post
91.9 (18.2) 91.1 (12.6) 95.5 (6.3)
85.4 (20) 86.9 (13.6) 94.7 (8.7)
65.9 (23.2) 59.9 (20.6) 78.5 (23.4)
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3. Results 3.1. Belief conviction The mean scores, with standard deviations, for all three beliefs at assessment and ®rst and last group sessions are shown in Table 2. Of the 22 people who began the ®ve groups, 18 completed ratings at assessment; one person had no assessment (she subsequently dropped out of the group), and three declined to complete ratings at this point. Eighteen people completed ratings at the close of the ®rst session (again, two declined and two were absent). Sixteen of the 18 people who completed the groups rated conviction at the end of the ®nal session (two who had declined thus far, again declined). An initial Friedman's analysis revealed a signi®cant group by time eect for power (df 2, P = 0.002), control (df 2, P = 0.001), and not for personal meaning (df 2, P = 0.057). Subsequent Wilkinson pair wise analysis revealed a signi®cant dierence for power between time 1 and time 3 (P = 0.015) and time 2 and time 3 (P = 0.004) and not for time 1 and time 2 (P = 0.330). Similarly, for conviction in the belief about control, Wilkinson pair wise analysis revealed a signi®cant dierence between time 1 and time 3 (P = 0.004) and time 2 and time 3 (P = 0.004) and not for time 1 and time 2 (P = 0.309). Thus, the group therapy appeared to have a signi®cant eect on conviction in the two target beliefs about power and control, and not in personal meaning Ð although data here suggested a trend. The overall eect on the two target beliefs is encouraging, but it blurs many individual dierences. We therefore calculated the degree of change for each person by taking whichever conviction score was lower from either assessment or pre group (to give a conservative calculation of change), and compared this with the post-group score. For power, four people showed a fall in conviction of 30% or more, seven showed a fall of 10±29%, ®ve showed a fall of 0±10%, and one showed an increase of 14%. For control, seven people reported a fall of 30% or more, ®ve of 11±29%, ®ve of 0±10%, and one showed an increase of 20%. 3.2. Dimensions of voice hearing: the topography of voices Five aspects of voice topography were assessed using the Hustig and Hafner rating scale. Visual inspection revealed that there were no dierences in scores from assessment, ®rst session and last session. Mean scores respectively were 20.8 (SD 2.2), 18.7 (SD 5.1) and 19.7 (SD 6.4). Table 3 Numbers of people scoring in the four severity ranges on the HADS for anxiety (A) and depression (D) pre and post therapy Severity
Pre group (n = 16)
Post group (n = 17)
Normal (0±7) Mild (8±10) Moderate (11±14) Severe (15±21)
1A 3A 3A 9A
2A 3A 3A 9A
3D 0D 7D 6D
2D 5D 4D 6D
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3.3. HADS: depressive and anxious symptoms As is shown in Table 3, at assessment 16 individuals completed the HADS, 12 of whom showed moderate or severe levels of anxiety, and 13 of depression. Seventeen individuals completed the HADS post-groups. There was no fall in anxiety or depression scores following the groups. 3.4. Therapeutic factors An identical rank order of factors emerged for each list, suggesting that the lists reliably assess the eight constructs. The mean rankings of helpfulness, with standard deviations in parenthesis, were: universality, 2.7 (1.6); catharsis, 3.3 (2.1); instillation of hope, 4.3 (2.2); selfunderstanding, 4.7 (1.8); altruism, 5 (2); group cohesiveness, 5 (2.2); interpersonal learning, 5.4 (2.2); guidance, 5.7 (2.1). (Lower numbers indicate factors were rated as more helpful.) 3.5. Independent assessment All but one person reported having found the group very helpful. The exception was a man who said it had not helped because he still heard the voices. No-one found it harmful or unhelpful. Analysis of participants responses to the `what was helpful about the groups?' fell into seven categories. Eight people gave examples of belief change due to being in the group (e.g. `I realize that maybe the voice is from me'). For example, one woman reported having heard a voice racially abusing her during a session. She believed the comment was said by a therapist. At the subsequent session she felt able to express this belief. The other group members assured her they had heard nothing and one of them asked if she thought it might have been a voice. This incident provoked an important shift in her thinking. Seven members expressed how they had found it helpful to be able to discuss their voices without fear of being criticized, judged, misunderstood, or even hospitalized. Seven members described ways in which they now coped better with their voices (e.g. `I've learned ways of how to control the voices'). Six members gave examples of universality (e.g. `it helps to know that other people are going through the same thing'). Three members talked of the value of forming relationships with other group members. Two people mentioned the value of the written summaries of sessions, and two mentioned the therapists. When asked `Was there anything about the group that you found unhelpful?' nine members replied `nothing'. Four members identi®ed aspects of other's behavior. For example, one man judged a woman in his group to be too ill to contribute. Someone from a dierent group was upset when others' behavior reminded her of how unwell she had been in the past. Two members said the groups were too short, and two members, both from the same group, disliked aspects of the location where the group was based. One member found it dicult when attendance varied week by week. 3.6. Satisfaction Questionnaires were sent to the 18 people who attended at least half the sessions. Fourteen
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replied (77.7%). The mean total satisfaction score was 21.2 (range 0±28). Each item was rated on a ®ve point scale and scored 0±4. The seven items in descending rank order, with mean scores in parenthesis, were: `my therapist treated me with respect' (3.6), `therapy helped me deal more eectively with my problems' (3.2), `how would you rate the quality of the service you received?'(3.1), `my problems were assessed thoroughly' (2.9), `my therapist understood my problems' (2.9), `therapy has given me strategies/ideas to help me cope in the future (2.8), `my therapist and I agreed clear aims for therapy' (2.7).
4. Discussion The intention behind the present study was to evaluate a new group CBT for voice hearers. The groups achieved their speci®c objectives Ð that is, to weaken a voice's apparent omnipotence, and increase perceived control over voices. All participants were taking antipsychotic medication throughout the study. All eects need to be attributed to the combined treatments of medication and CBT. Initial refusal and subsequent drop-out are common in CBT research with psychosis (Tarrier, Yusupo, Kinney & Wittkoski, 1998). In the present study ®ve people (14%) did not complete an assessment and three (8%) were assessed as suitable and declined therapy. It is important not to assume that this indicates `resistance'. Certain people may have been hoping that CBT would eliminate voices; this possibility was ruled out at assessment. Also, voices commonly command people not to attend sessions Ð indeed, this was true for most of those who completed groups. With this in mind, it is encouraging that only three people dropped out of the groups (one person was moved away from Southampton). Of the three who dropped out, two might have been predicted. One woman failed to attend her assessment appointments but nonetheless requested and was given a place in a group Ð she attended one session only and was extremely anxious. Another man told the group at the ®rst two sessions that he would not last the eight sessions, and was as good as his word. One member dropped out unexpectedly. The group had been conceived and the manual constructed primarily to weaken beliefs in omnipotence and control, rather than a personal meaning. Whilst there were group eects for conviction in both omnipotence and control, individuals varied considerably. For omnipotence, four individuals showed a fall in conviction of 30% or more; for control, seven reported this reduction. For omnipotence, seven individuals reported a fall in conviction of 10±29%; ®ve did likewise for control. For both omnipotence and control ®ve people reported a fall of 0±10%. One man scored higher at the close of the group on both beliefs. Thus, 37% of people showed little or no change in conviction in target beliefs. Overall, data suggest that the groups were more successful at increasing perceived control than diminishing a voice's imputed omnipotence. The possibility that voices originated from the person's own mind was introduced only at sessions 7 and 8. It was therefore somewhat surprising to ®nd a trend (P = 0.057) towards a fall in conviction for this belief too. This ®nding perhaps indicates that future groups might be extended and more time devoted to beliefs about personal meaning. No measures of behavioral change were taken in this study, but important spontaneous behavioral changes occurred for certain individuals. Most strikingly, one woman had been an
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in-patient for almost a year at the beginning of the group. She heard voices commanding her to kill her children, and fears of her complying prompted the admission. By session 6 of the group she was able to have her children on her knee for the ®rst time since admission, and by the close of the group was allowed home on overnight leave. Her psychiatrist spoke of a remarkable change. A further woman heard a voice telling her that she would be harmed by her son Ð she spontaneously talked to her son about this. For two members, psychiatrists documented a marked improvement in coping and sense of mastery over voices. Again, one man was able to attend a rock concert, in spite of his voices telling him he would be attacked. Yet for all participants, living with voices remained a struggle: the man referred to still found it very dicult to go outdoors after the rock concert. Assessment scores on the HADS showed the sample of voice hearers to experience considerable distress prior to therapy. The study found no change in depressive or anxious symptoms on the HADS. This ®nding is perhaps unsurprising, bearing in mind the severity of symptoms and the brevity of the group. Indeed, a randomized control trial (RCT) on individual CBT for voices also found no reduction in depression scores following 16 sessions of individual therapy (Haddock et al., 1998). Also, in neither the RCT (ibid.) or the present study, was there a fall in distress occasioned by voices. Indeed, the present study found no change in topography of voices as measured by the Hustig and Hafner scale. This indicates points for future clinical research. First, is for therapists to continue to search for therapeutic procedures for easing distress occasioned by beliefs about voices, as well as wider emotional problems. Second, it may be important to measure not only how distressing the hallucinatory experience is, but how people react to this distress. Acquisition of compensatory strategies which limit distress and behavioral disturbance is thought to be the most likely mechanism of change in all forms of CBT (Barber & deRubeis, 1989). In addition to outcome measures, we used three measures of process; ranking of Yalom's therapeutic factors, content analysis of comments at a post-group interview, and subjective satisfaction. Data are therefore relative Ð that is to say, a factor ranked as eighth most helpful may still have been viewed as helpful by that person, merely less so than the other seven. Universality Ð the recognition that others experience similar problems Ð was ranked as most helpful of the eight therapeutic factors assessed on each of the two lists of statements used in the study. Overall, data conform to an expected pattern for a group of this brevity (Yalom, 1995). Factors which concern `personal' gains (universality, catharsis, and instillation of hope) were consistently ranked as most helpful. Factors concerned more with how members relate with one another (cohesion, interpersonal learning, guidance) were consistently ranked least helpful. Qualitative data from the independent assessment cast further light on the process. Participants comments reinforced processes of cognitive shift (e.g. `I realize that maybe the voice is from me') and improved coping (`I've learned ways of how to control the voices'). What the independent assessments added, and the quantitative data did not reveal, was just how crucial participants found it to break their silence over their voices. All voice hearers spoke of the immense diculty of talking about voices. With family or friends, for example, individuals kept quiet for fear of being misunderstood, judged, criticized, or viewed as dangerous. Similarly, members rarely talked openly to professionals for fear of being given impossible advice (`just ignore them') or risking increased medication or an enforced return to
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hospital. One group member described how he had once told a community worker how his voices commanded him to harm others; henceforth the professional visited accompanied by another male colleague. Added to this, voices very commonly warn hearers against discussing them. This is more than catharsis (expression of emotion accompanied by cognitive change), this is breaking a long-held silence. The present study has clear limitations. Measurement was kept to a minimum because of a concern of over burdening participants, and the groups were started at the earliest point rather than following a controlled baseline period. Also, as noted, formal measurement of behavior change would be desirable in future. Again, whilst a repeated measures design of this type is appropriate for developing new treatments, it lacks control. The results are perhaps suciently encouraging to warrant a randomized control trial. The strengths of the study are ®rst, its presentation of an original, manual based, group CBT for voices, and second, that the study reports on ®ve such groups. A further strength is the clear, theoretically driven focus on two disabling beliefs about voices Ð namely, omnipotence and control. Prior research and clinical practice indicate the merits of challenging these beliefs prior to those about personal meaning. Moreover, the study reports data relating to outcome and process. Finally, the study has clear clinical applicability. In conclusion, the present study reports on a CBT group format which is valued by service users. In only eight sessions the group achieves a high degree of engagement and a reduction in voices' perceived power and control. As such it may prove to be a useful addition to the emerging range of psychological interventions for people with psychotic problems.
Acknowledgements Thanks mostly to the participants, and also to Professor David Kingdom, David Dayson, MD, Tom Schlick, MD, Anne Marie Korner, Sarah Elgie and Claire Corbridge for their invaluable assistance.
References Barber, J. P., & DeRubeis, R. J. (1989). On second thought: where the action is in cognitive therapy for depression. Cognitive Therapy and Research, 13, 441±447. Bauer, S. (1970). The function of hallucinations. In W. Keup, Origin and mechanisms of hallucinations. New York: Plenum. Birchwood, M. J., & Chadwick, P. D. J. (1997). The omnipotence of voices: testing the validity of the cognitive model. Psychological Medicine, 27, 1345±1353. Bloch, S., Reibstein, J., Crouch, E., Holroyd, P., & Themen, J. (1979). A method for the study of therapeutic factors in group psychotherapy. British Journal of Psychiatry, 134, 257±263. Bouchard, S., Vallieres, A., Roy, M., & Maziade, M. (1996). Cognitive restructuring in the treatment of psychotic symptoms: a critical analysis. Behavior Therapy, 27, 257±277. Chadwick, P. D. J., & Birchwood, M. J. (1994). The omnipotence of voices. A cognitive approach to auditory hallucinations. British Journal of Psychiatry, 164, 190±201. Chadwick, P. D. J., & Birchwood, M. J. (1995). The omnipotence of voices II. The beliefs about voices questionnaire (BAVQ). British Journal of Psychiatry, 166, 773±776.
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Chadwick, P. D. J., & Birchwood, M. (1996). Cognitive therapy for voices. In G. Haddock, & P. D. Slade, Cognitive±behavioral interventions with psychotic disorders. London: Routledge. Chadwick, P. D. J., Birchwood, M. J., & Trower, P. (1996). Cognitive therapy for delusions, voices and paranoia. Chichester: Wiley. Close, H., & Garety, P. (1998). Cognitive assessments of voices: further developments in understanding the emotional impact of voices. British Journal of Clinical Psychology, 37, 189±197. Gledhill, A., Lobban, F., & Selwood, W. (1998). Group CBT for schizophrenia. Behavioral and Cognitive Psychotherapy, 26, 63±77. Haddock, G., Slade, P., Bentall, R., Reid, D., & Faragher, E. B. (1998). A comparison of the long term eectiveness of distraction and focusing in the treatment of auditory hallucinations. British Journal of Medical Psychology, 71(3), 339±349. Hustig, H. H., & Hafner, R. J. (1990). Persistent auditory hallucinations and their relationship to delusions of mood. Journal of Nervous and Mental Diseases, 178, 264±267. Romme, M., & Escher, S. (1989). Accepting voices. London: Mind Publications. Tarrier, N., Yusupo, L., Kinney, C., & Wittkoski, A. (1998). Some reasons why patients suering from chronic schizophrenia fail to continue in psychological treatment. Behavioral and Cognitive Psychotherapy, 26, 177±181. Tien, A. Y. (1991). Distributions of hallucinations in the population. Social Psychiatry and Psychiatric Epidemiology, 26, 287±292. Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books. Zigmund, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361±370.
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Challenging the omnipotence of voices: group cognitive behavior therapy for voices Paul Chadwick a,*, Suzanne Sambrooke b, Sarah Rasch c, Ellie Davies d a
Royal South Hants Hospital & Department of Psychology, University of Southampton, High®eld, Southampton, SO17 1BJ, UK b DClinPsych, Winchester NHS Trust, Winchester, UK c DClinPsych, Newham Community Health Services NHS Trust, Newham, UK d DClinPsych, Royal South Hants Hospital, Southampton, UK Accepted 28 June 1999
Abstract The present study examines the impact of group based cognitive behavior therapy (CBT) for drug resistant auditory hallucinations, or voices. In particular it assesses treatment eect on beliefs in a voice's omnipotence and control. Twenty-two participants entered one of ®ve 8-session CBT groups. Measures of omnipotence, control, process measures, and symptoms of anxiety and depression were completed at assessment, and ®rst and last group sessions. The groups achieved a signi®cant reduction in conviction in beliefs about omnipotence (df 2, P = 0.002) and control (df 2, P = 0.001). There were no aective changes. Certain participants showed important spontaneous changes in behavior. Process measures suggested that participants valued the groups and bene®ted from them. These results are promising and the treatment may prove a useful addition to existing psychological interventions. 7 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Approximately 4.6% of the population experience hallucinations in one or other modality (Tien, 1991). Research on a combined clinical and community sample of people experiencing auditory hallucinations Ð hearing voices Ð revealed diverse emotional and behavioral reactions (Romme & Escher, 1989). In part this re¯ects dierences in content, for example, * Corresponding author. 0005-7967/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 9 9 ) 0 0 1 2 6 - 6
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being abused and criticized vs being ¯attered and wooed. Chadwick and Birchwood (1994) used a cognitive behavior therapy (CBT) conceptual framework to propose that people's beliefs about voices would also shape how they felt and coped. Four empirical papers (Birchwood & Chadwick, 1997; Chadwick & Birchwood, 1994, 1995; Close & Garety, 1998) provide empirical support for this cognitive formulation of voices. These studies show ®rst, that people who hear voices do indeed construct meaning from the experience. Speci®cally, four beliefs appear to be of particular importance. That is, identity (who is the voice?); purpose (why is the voice talking to me, not someone else?); omnipotence (how powerful is the voice?); and control. Second, there is evidence to suggest that beliefs play a mediating role. Voices believed to be malevolent are associated with resistance and high distress, in contrast to those believed to be benevolent, which are associated with engagement and lower distress or pleasure. Also, voices believed to be omnipotent are associated with more common and severe symptoms of depression (Chadwick & Birchwood, 1996). This conceptualization has three advantages. First, it shows that voices are a psychological problem when, and only when, they are associated with emotional or behavioral problems. Second, it yields a new treatment option for drug resistant voices. CBT may be used alongside medication to try to weaken beliefs associated with distress, self-harm, etc. Outcome research on voices shows CBT can be eective for certain people in reducing distress, and increasing control, though not in reducing voice frequency (Bouchard, Vallieres, Roy & Maziade, 1996) Ð though the only RCT yielded modest results (Haddock, Slade, Bentall, Reid & Faragher, 1998). There are no published studies evaluating group based CBT for voices. Yet groups have for many years been the centerpiece of certain international voluntary organizations for voice hearers (Romme & Escher, 1989). Also, a recent study using CBT for people with a diagnosis of schizophrenia (though not necessarily hearing voices) reported signi®cant symptomatic change (Gledhill, Lobban & Selwood, 1998). For many voice hearers, voices are imbued with a `terrifying and compelling quality' and people `feel caught in their power' (Bauer, 1970). A fundamental challenge in CBT for voices is to challenge voices' omnipotence (Chadwick, Birchwood & Trower, 1996). In the present study we report data from ®ve CBT groups, each lasting eight sessions. The principal object of the group format was to weaken disabling beliefs about omnipotence and increase a sense of personal control over voices. 2. Method 2.1. Participants Five groups were run (three in Southampton, one in both London and Winchester) as part of clinical psychology services. Ethical approval was provided in each center. Participants were all receiving standard psychiatric care, and medication was provided throughout the study. Referral was made by a consultant psychiatrist or another clinician. Inclusion criteria were that the person had been experiencing drug resistant and subjectively distressing voices for at least the preceding two years. Membership was set at four or ®ve people to each group, at the request of voice hearers themselves. All people referred had an ICD 10 diagnosis of
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schizophrenia or schizo-aective disorder. The exclusion criteria were evidence of an organic psychosis or disabling use of illicit drugs. Table 1 shows what happened to the 35 people who were referred. Five did not complete assessment; their possible suitability is unknown. Two people did not meet the inclusion criteria (one heard no voices, one found his voices pleasant). Three people asked for and received individual CBT. Three people chose to have no therapy. One person entered a group without a prior assessment. At the time of assessment 8 of the 22 were in hospital: 20 had been hospitalized at least once because of problems coping with voices within the preceding year. Seventeen of the 22 heard voices commanding self-harm, and well over half commanding suicide or homicide (most commonly children or family). Distress levels on the Hospital Anxiety and Depression Scale were high prior to therapy. One woman stopped attending because she was moved temporarily away from Southampton (she joined a subsequent group not included in this paper). Three people dropped out after attending 1, 2 and 3 sessions, respectively. No reasons were provided and all three declined follow-up contact. After complete description of the study to the participants, written informed consent was obtained. It was written that attendance of the group was not dependent on completing measures, and that participants were free to withdraw at any point without penalty. One person chose to complete only one measure (therapeutic factors), and one not to complete conviction ratings. 2.2. Measures 2.2.1. Hospital anxiety and depression scale (HADS) Symptoms of anxiety and depression were monitored using the HADS (Zigmund & Snaith, 1983). The HADS was completed at assessment and at the close of the group. 2.2.2. Belief conviction: omnipotence, control, and personal meaning Participants rated their conviction in three beliefs Ð power, control and personal meaning Ð at assessment and ®rst and last group sessions. Individuals indicated their conviction by marking a 10 cm visual analogue line, anchored at either end as 0 or 100%. So for omnipotence, the line was anchored on the left `0%, not at all powerful' and the right `100%, totally powerful'. For the question `How much control does your voice have over you?' the Table 1 Participants involvement in study Initial referrals Did not complete an assessment Unsuitable for therapy Declined therapy Began individual therapy Completed individual therapy Began group therapy Completed group (i.e. attended >4 sessions)
35 5 2 3 3 3 22 18
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anchors were `0%, none at all' and on the right `100%, total control over me'. Each person rated in the same way conviction in an idiosyncratic belief about personal meaning (a composite of identity and purpose: e.g. the voice is my step-father who hates me and wants me dead). 2.2.3. Hustig and Hafner topography of voices rating scale This is a ®ve item self-report scale designed to measure the frequency, volume, clarity and intrusiveness of voices, as well as the distress associated with them (Hustig & Hafner, 1990). It was developed for use with people who have persistent auditory hallucinations. This scale was completed at assessment and at the ®rst and last group sessions. 2.2.4. Independent assessment Within 2 weeks of the groups ending, participants met an independent clinician to discuss their experience of the group. Speci®c prompts were used to draw out what people had found most and least helpful in the groups. Individuals were assured that their responses were anonymous and were encouraged to be honest as this would bene®t voice hearers attending future groups. 2.2.5. Therapeutic factors At the independent assessment individuals were asked to rank two sets of statements relating to the same eight therapeutic factors: altruism, group cohesiveness, universality, interpersonal learning, guidance, catharsis, self-understanding and instillation of hope (Yalom, 1995). These categories have been used elsewhere to assess the bene®ts of non-speci®c therapeutic factors in group therapy (e.g. Bloch, Reibstein, Crouch, Holroyd & Themen, 1979). 2.2.6. Satisfaction After a gap of at least 1 month, all members were sent a standard satisfaction questionnaire. The letter, from a departmental secretary, stated that this was an anonymous questionnaire sent to all service users and encouraged them to be as honest as possible as this was their opportunity to bene®t future service users. It listed seven statements, concerned with dierent aspects of therapy. Each statement was worded armatively (e.g. my therapist treated me with respect) and rated on the scale, disagree strongly, disagree slightly, unsure, agree slightly, agree strongly. Total scores ranged from 0 to 28. 2.3. Procedure 2.3.1. Phase 1: assessment All participants were assessed over 2±4 sessions. The assessment covered a cognitive analysis of voice onset, form, content, and triggers; the behavioral and emotional impact of the voices; and the beliefs held about the voices (identity, purpose, power and control). Assessment also covered background psychological assessment. People were told that the group would not get rid of their voices, but would oer an opportunity to share experience of hearing voices. People discussed any concerns about joining a group. The mean time interval between end of assessment and start of group meetings was 5 weeks.
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2.3.2. Phase 2: group cognitive behavior therapy The group was a closed group and treatment consisted of eight weekly sessions of 1 h duration. All ®ve groups were facilitated by two therapists. The authors adhered to a manual (available from the ®rst author on request), which they had developed collaboratively, and adhered to through peer supervision. Two groups were asked if sessions might be audio or video taped, to enable adherence to manuals to be assessed, but both groups declined. The process was open, collaborative and dialogue was free ¯owing. Therapists avoided controlling discussion through the use of turn taking or lecturing. Guided discovery was preferred to direct challenge. The ®rst 3 sessions contained no challenging or disputing. Session 1 began with an exploration of feelings leading up to the group, and how this impacted on voices. Therapists encouraged the groups to establish ground rules, oering the rationale that this was a good way of reducing anxiety within the group. A brief rationale for the group was oered. Therapists explored if members had discussed their voices with other people (this is rare) and drew out the beliefs and aect which went with any avoidance. The remainder of session 1 and all session 2 were spent exploring three themes: when the voices ®rst began; people's own ideas about why they heard voices; and the impact of hearing voices on their lives. In session 3, content, distress and coping were explored. From session 4 onwards, socratic dialogue, or guided discovery, was used to explore and weaken the two core beliefs about omnipotence and control. Beliefs were also subject to empirical testing, for example, by teaching a participant to try to increase and decrease voice activity to test the belief about control. Over the last two sessions the therapists explored beliefs about personal meaning. The therapists introduced the idea that voices might originate from the mind perhaps being similar to intrusive thoughts (Haddock et al., 1998). The group explored advantages and disadvantages of two possible views Ð voice as internally generated, or as coming from someone else. Participants discussed termination and any wishes for further support. A handout was produced after each session, summarizing the main discussion points, and was distributed at the start of the next session. 2.3.3. Phase 3: independent assessment After the ®nal group session an independent clinician met with all participants to explore their re¯ections on the group and to complete the measure of therapeutic factors. These sessions lasted 1 h.
Table 2 Mean conviction scores and standard deviations in the three beliefs (omnipotence, control and personal meaning) for the 17 participants who completed ratings at assessment, and ®rst (Pre) and last (Post) sessions
Omnipotence Control Personal meaning
Assessment
Pre
Post
91.9 (18.2) 91.1 (12.6) 95.5 (6.3)
85.4 (20) 86.9 (13.6) 94.7 (8.7)
65.9 (23.2) 59.9 (20.6) 78.5 (23.4)
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3. Results 3.1. Belief conviction The mean scores, with standard deviations, for all three beliefs at assessment and ®rst and last group sessions are shown in Table 2. Of the 22 people who began the ®ve groups, 18 completed ratings at assessment; one person had no assessment (she subsequently dropped out of the group), and three declined to complete ratings at this point. Eighteen people completed ratings at the close of the ®rst session (again, two declined and two were absent). Sixteen of the 18 people who completed the groups rated conviction at the end of the ®nal session (two who had declined thus far, again declined). An initial Friedman's analysis revealed a signi®cant group by time eect for power (df 2, P = 0.002), control (df 2, P = 0.001), and not for personal meaning (df 2, P = 0.057). Subsequent Wilkinson pair wise analysis revealed a signi®cant dierence for power between time 1 and time 3 (P = 0.015) and time 2 and time 3 (P = 0.004) and not for time 1 and time 2 (P = 0.330). Similarly, for conviction in the belief about control, Wilkinson pair wise analysis revealed a signi®cant dierence between time 1 and time 3 (P = 0.004) and time 2 and time 3 (P = 0.004) and not for time 1 and time 2 (P = 0.309). Thus, the group therapy appeared to have a signi®cant eect on conviction in the two target beliefs about power and control, and not in personal meaning Ð although data here suggested a trend. The overall eect on the two target beliefs is encouraging, but it blurs many individual dierences. We therefore calculated the degree of change for each person by taking whichever conviction score was lower from either assessment or pre group (to give a conservative calculation of change), and compared this with the post-group score. For power, four people showed a fall in conviction of 30% or more, seven showed a fall of 10±29%, ®ve showed a fall of 0±10%, and one showed an increase of 14%. For control, seven people reported a fall of 30% or more, ®ve of 11±29%, ®ve of 0±10%, and one showed an increase of 20%. 3.2. Dimensions of voice hearing: the topography of voices Five aspects of voice topography were assessed using the Hustig and Hafner rating scale. Visual inspection revealed that there were no dierences in scores from assessment, ®rst session and last session. Mean scores respectively were 20.8 (SD 2.2), 18.7 (SD 5.1) and 19.7 (SD 6.4). Table 3 Numbers of people scoring in the four severity ranges on the HADS for anxiety (A) and depression (D) pre and post therapy Severity
Pre group (n = 16)
Post group (n = 17)
Normal (0±7) Mild (8±10) Moderate (11±14) Severe (15±21)
1A 3A 3A 9A
2A 3A 3A 9A
3D 0D 7D 6D
2D 5D 4D 6D
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3.3. HADS: depressive and anxious symptoms As is shown in Table 3, at assessment 16 individuals completed the HADS, 12 of whom showed moderate or severe levels of anxiety, and 13 of depression. Seventeen individuals completed the HADS post-groups. There was no fall in anxiety or depression scores following the groups. 3.4. Therapeutic factors An identical rank order of factors emerged for each list, suggesting that the lists reliably assess the eight constructs. The mean rankings of helpfulness, with standard deviations in parenthesis, were: universality, 2.7 (1.6); catharsis, 3.3 (2.1); instillation of hope, 4.3 (2.2); selfunderstanding, 4.7 (1.8); altruism, 5 (2); group cohesiveness, 5 (2.2); interpersonal learning, 5.4 (2.2); guidance, 5.7 (2.1). (Lower numbers indicate factors were rated as more helpful.) 3.5. Independent assessment All but one person reported having found the group very helpful. The exception was a man who said it had not helped because he still heard the voices. No-one found it harmful or unhelpful. Analysis of participants responses to the `what was helpful about the groups?' fell into seven categories. Eight people gave examples of belief change due to being in the group (e.g. `I realize that maybe the voice is from me'). For example, one woman reported having heard a voice racially abusing her during a session. She believed the comment was said by a therapist. At the subsequent session she felt able to express this belief. The other group members assured her they had heard nothing and one of them asked if she thought it might have been a voice. This incident provoked an important shift in her thinking. Seven members expressed how they had found it helpful to be able to discuss their voices without fear of being criticized, judged, misunderstood, or even hospitalized. Seven members described ways in which they now coped better with their voices (e.g. `I've learned ways of how to control the voices'). Six members gave examples of universality (e.g. `it helps to know that other people are going through the same thing'). Three members talked of the value of forming relationships with other group members. Two people mentioned the value of the written summaries of sessions, and two mentioned the therapists. When asked `Was there anything about the group that you found unhelpful?' nine members replied `nothing'. Four members identi®ed aspects of other's behavior. For example, one man judged a woman in his group to be too ill to contribute. Someone from a dierent group was upset when others' behavior reminded her of how unwell she had been in the past. Two members said the groups were too short, and two members, both from the same group, disliked aspects of the location where the group was based. One member found it dicult when attendance varied week by week. 3.6. Satisfaction Questionnaires were sent to the 18 people who attended at least half the sessions. Fourteen
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replied (77.7%). The mean total satisfaction score was 21.2 (range 0±28). Each item was rated on a ®ve point scale and scored 0±4. The seven items in descending rank order, with mean scores in parenthesis, were: `my therapist treated me with respect' (3.6), `therapy helped me deal more eectively with my problems' (3.2), `how would you rate the quality of the service you received?'(3.1), `my problems were assessed thoroughly' (2.9), `my therapist understood my problems' (2.9), `therapy has given me strategies/ideas to help me cope in the future (2.8), `my therapist and I agreed clear aims for therapy' (2.7).
4. Discussion The intention behind the present study was to evaluate a new group CBT for voice hearers. The groups achieved their speci®c objectives Ð that is, to weaken a voice's apparent omnipotence, and increase perceived control over voices. All participants were taking antipsychotic medication throughout the study. All eects need to be attributed to the combined treatments of medication and CBT. Initial refusal and subsequent drop-out are common in CBT research with psychosis (Tarrier, Yusupo, Kinney & Wittkoski, 1998). In the present study ®ve people (14%) did not complete an assessment and three (8%) were assessed as suitable and declined therapy. It is important not to assume that this indicates `resistance'. Certain people may have been hoping that CBT would eliminate voices; this possibility was ruled out at assessment. Also, voices commonly command people not to attend sessions Ð indeed, this was true for most of those who completed groups. With this in mind, it is encouraging that only three people dropped out of the groups (one person was moved away from Southampton). Of the three who dropped out, two might have been predicted. One woman failed to attend her assessment appointments but nonetheless requested and was given a place in a group Ð she attended one session only and was extremely anxious. Another man told the group at the ®rst two sessions that he would not last the eight sessions, and was as good as his word. One member dropped out unexpectedly. The group had been conceived and the manual constructed primarily to weaken beliefs in omnipotence and control, rather than a personal meaning. Whilst there were group eects for conviction in both omnipotence and control, individuals varied considerably. For omnipotence, four individuals showed a fall in conviction of 30% or more; for control, seven reported this reduction. For omnipotence, seven individuals reported a fall in conviction of 10±29%; ®ve did likewise for control. For both omnipotence and control ®ve people reported a fall of 0±10%. One man scored higher at the close of the group on both beliefs. Thus, 37% of people showed little or no change in conviction in target beliefs. Overall, data suggest that the groups were more successful at increasing perceived control than diminishing a voice's imputed omnipotence. The possibility that voices originated from the person's own mind was introduced only at sessions 7 and 8. It was therefore somewhat surprising to ®nd a trend (P = 0.057) towards a fall in conviction for this belief too. This ®nding perhaps indicates that future groups might be extended and more time devoted to beliefs about personal meaning. No measures of behavioral change were taken in this study, but important spontaneous behavioral changes occurred for certain individuals. Most strikingly, one woman had been an
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in-patient for almost a year at the beginning of the group. She heard voices commanding her to kill her children, and fears of her complying prompted the admission. By session 6 of the group she was able to have her children on her knee for the ®rst time since admission, and by the close of the group was allowed home on overnight leave. Her psychiatrist spoke of a remarkable change. A further woman heard a voice telling her that she would be harmed by her son Ð she spontaneously talked to her son about this. For two members, psychiatrists documented a marked improvement in coping and sense of mastery over voices. Again, one man was able to attend a rock concert, in spite of his voices telling him he would be attacked. Yet for all participants, living with voices remained a struggle: the man referred to still found it very dicult to go outdoors after the rock concert. Assessment scores on the HADS showed the sample of voice hearers to experience considerable distress prior to therapy. The study found no change in depressive or anxious symptoms on the HADS. This ®nding is perhaps unsurprising, bearing in mind the severity of symptoms and the brevity of the group. Indeed, a randomized control trial (RCT) on individual CBT for voices also found no reduction in depression scores following 16 sessions of individual therapy (Haddock et al., 1998). Also, in neither the RCT (ibid.) or the present study, was there a fall in distress occasioned by voices. Indeed, the present study found no change in topography of voices as measured by the Hustig and Hafner scale. This indicates points for future clinical research. First, is for therapists to continue to search for therapeutic procedures for easing distress occasioned by beliefs about voices, as well as wider emotional problems. Second, it may be important to measure not only how distressing the hallucinatory experience is, but how people react to this distress. Acquisition of compensatory strategies which limit distress and behavioral disturbance is thought to be the most likely mechanism of change in all forms of CBT (Barber & deRubeis, 1989). In addition to outcome measures, we used three measures of process; ranking of Yalom's therapeutic factors, content analysis of comments at a post-group interview, and subjective satisfaction. Data are therefore relative Ð that is to say, a factor ranked as eighth most helpful may still have been viewed as helpful by that person, merely less so than the other seven. Universality Ð the recognition that others experience similar problems Ð was ranked as most helpful of the eight therapeutic factors assessed on each of the two lists of statements used in the study. Overall, data conform to an expected pattern for a group of this brevity (Yalom, 1995). Factors which concern `personal' gains (universality, catharsis, and instillation of hope) were consistently ranked as most helpful. Factors concerned more with how members relate with one another (cohesion, interpersonal learning, guidance) were consistently ranked least helpful. Qualitative data from the independent assessment cast further light on the process. Participants comments reinforced processes of cognitive shift (e.g. `I realize that maybe the voice is from me') and improved coping (`I've learned ways of how to control the voices'). What the independent assessments added, and the quantitative data did not reveal, was just how crucial participants found it to break their silence over their voices. All voice hearers spoke of the immense diculty of talking about voices. With family or friends, for example, individuals kept quiet for fear of being misunderstood, judged, criticized, or viewed as dangerous. Similarly, members rarely talked openly to professionals for fear of being given impossible advice (`just ignore them') or risking increased medication or an enforced return to
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hospital. One group member described how he had once told a community worker how his voices commanded him to harm others; henceforth the professional visited accompanied by another male colleague. Added to this, voices very commonly warn hearers against discussing them. This is more than catharsis (expression of emotion accompanied by cognitive change), this is breaking a long-held silence. The present study has clear limitations. Measurement was kept to a minimum because of a concern of over burdening participants, and the groups were started at the earliest point rather than following a controlled baseline period. Also, as noted, formal measurement of behavior change would be desirable in future. Again, whilst a repeated measures design of this type is appropriate for developing new treatments, it lacks control. The results are perhaps suciently encouraging to warrant a randomized control trial. The strengths of the study are ®rst, its presentation of an original, manual based, group CBT for voices, and second, that the study reports on ®ve such groups. A further strength is the clear, theoretically driven focus on two disabling beliefs about voices Ð namely, omnipotence and control. Prior research and clinical practice indicate the merits of challenging these beliefs prior to those about personal meaning. Moreover, the study reports data relating to outcome and process. Finally, the study has clear clinical applicability. In conclusion, the present study reports on a CBT group format which is valued by service users. In only eight sessions the group achieves a high degree of engagement and a reduction in voices' perceived power and control. As such it may prove to be a useful addition to the emerging range of psychological interventions for people with psychotic problems.
Acknowledgements Thanks mostly to the participants, and also to Professor David Kingdom, David Dayson, MD, Tom Schlick, MD, Anne Marie Korner, Sarah Elgie and Claire Corbridge for their invaluable assistance.
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