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Group person-based cognitive therapy for distressing voices: Pilot data from nine groups
J. Behav. Ther. & Exp. Psychiat. 42 (2011) 111e116
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Group person-based cognitive therapy for distressing voices: Pilot data from nine groups Laura Dannahy a, Mark Hayward c, d, *, Clara Strauss c, d, Wendy Turton e, Emma Harding f, Paul Chadwick b a
Hampshire Partnership NHS Foundation Trust, Andover CMHT, 68b Junction Road, Andover, Hampshire SP10 3QX, UK King’s College London, Institute of Psychiatry, Department of Psychology, PO77 Henry Wellcome Building, De Crespigny Park, London SE5 8AF, UK Sussex Partnership NHS Foundation Trust, Sussex Education Centre, Millview, Nevill Avenue, Hove, East Sussex BN3 7HZ, UK d Psychology Department, University of Surrey, Guildford, Surrey GU2 7HX, UK e Psychosocial Interventions for Psychosis Service, Osborn Centre, Osborn Road, Fareham PO16 7ES, UK f South London and Maudsley NHS Foundation Trust, Support and Recovery 1, St Giles House, St Giles Road, London SE5 7UD, UK b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 June 2009 Received in revised form 24 July 2010 Accepted 29 July 2010
The present study examines the impact of group Person-Based Cognitive Therapy (PBCT) for distressing voices within an uncontrolled evaluation. In particular it utilizes a framework of acceptance of voices and self to enhance well-being and reduce distress and perceived voice-control. Sixty-two participants entered one of nine PBCT groups conducted over 8e12 sessions. Fifty participants completed therapy. Measures of well-being, distress, control and relating characteristics were completed pre- and posttherapy and at brief follow-up. Data were subjected to an intention-to-treat analysis. The groups achieved significant benefits in terms of well-being, distress, control and dependence upon the voice. The present study is the first to report significant improvement in both distress and control. Consequently, Group PBCT for distressing voices may prove a useful addition to existing psychological interventions and is worthy of further investigation. The findings are discussed in relation to clinical implications and limitations. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Schizophrenia & psychotic states Cognitive therapy Group therapy & treatment outcome
1. Introduction In cognitive-behaviour therapy (CBT) for psychosis the majority of outcome research has focussed on individual therapy. Uncontrolled studies of group CBT found improvements on measures of psychotic symptoms (Gledhill, Lobban, & Sellwood, 1998; Wykes, Parr, & Landau, 1999), and on perceived voice-control and power (Chadwick, Sambrooke, Rasch, & Davies, 2000). Two subsequent well-controlled randomised studies of group CBT versus treatment as usual found no significant treatment effect in severity of voices in a sample of 85 voice hearers (Wykes et al., 2005) or positive symptom improvement in a sample of 113 people with persistent distressing positive symptoms (Barrowclough et al., 2006). However, it might be argued that the primary aim of CBT for psychosis is to reduce distress and disturbance in response to psychotic experience, rather than to reduce or eliminate psychotic experience (Chadwick, Birchwood, & Trower, 1996). With this in
* Corresponding author. Tel.: þ44 1483 689441. E-mail address: [email protected] (M. Hayward). 0005-7916/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2010.07.006
mind the randomised trials of group CBT for psychosis look more encouraging. Barrowclough et al. (2006) found that people attending a CBT for psychosis group reported significant improvements on measures of self-esteem and hopelessness in comparison to people receiving their usual care e two important psychosocial outcomes. Similarly, Wykes et al. (2005) found that CBT group participants, in comparison to control participants, reported significant improvements in social functioning. However, the Barrowclough study did not find improvement on a measure of anxiety and depression or on a measure of global functioning. One way in which the effectiveness of CBT for psychosis may be enhanced is through inclusion of so called ‘third wave’ acceptancebased theory and practice (Hayes, 2004). Whilst traditional CBT for psychosis focussed primarily on identifying and changing thoughts and beliefs about psychotic experiences, third wave approaches focus primarily on how people relate with and respond to these and other experiences (e.g. through mindfulness practice). There is emerging evidence supporting individual and group third wave CBT approaches for psychosis. Bach and Hayes (2002), in a randomised study, found that rehospitalisation rates over a four month period were halved for participants receiving four individual sessions of Acceptance and Commitment Therapy (ACT), in
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comparison to participants receiving their usual treatment. A replication by Gaudiano and Herbert (2006) found affective and symptom improvement at discharge, though did not find a significant reduction in rehospitalisation. Two small studies of mindfulness groups for people with treatment-resistant positive symptoms of psychosis both found significant pre-post group improvement in general well-being (Chadwick, Hughes, Russell, Russell, & Dagnan, 2009; Chadwick, Newman-Taylor, & Abba, 2005). Person-Based Cognitive Therapy (PBCT: Chadwick, 2006) integrates traditional CBT for psychosis and mindfulness practice, with its explicit emphasis on acceptance of voice hearing. Whilst PBCT retains the central ABC formulation (Chadwick et al., 1996) of the voice hearing experience, it builds upon it in three main ways. First, there is an explicit emphasis on acceptance of the voice hearing experience. Whilst this was implicit within an ABC formulation of voices (where a voice experienced at point A is not controllable) the development of therapies such as Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999) has brought the importance of acceptance to the fore. In PBCT this is established mainly through Socratic dialogue and 10 minute mindfulness practice. Second, there is greater emphasis on identifying and testing out positive self-schema and self-acceptance. Third, there is an even greater focus on relationship with voices (e.g. Chadwick & Birchwood, 1994; Hayward, 2003). The present study represents a first phase of evaluation of PBCT groups for distressing voices to determine effectiveness and feasibility of a larger-scale, randomised controlled trial. Baseline, outcome and one month follow-up data are reported. Consistent with both the ABC model and an acceptance-based approach, it is hypothesised that, following the group, participants will report significant improvements in general well-being, voice-distress, perceived voice-control and relationship with voices. 2. Method 2.1. Participants Nine groups were run across two neighbouring NHS Trusts in the South of England. Ethical approval was obtained in both Trusts. Participants were all receiving standard psychiatric care, including medication. Inclusion criteria were that: the individual had been experiencing treatment-resistant and subjectively distressing voices for at least the preceding two years, with voice-distress rated at 3 or greater on at least one of the two PSYRATS voice-distress items (Haddock, McCarron, Tarrier, & Faragher, 1999). The exclusion criteria were evidence of an organic psychosis or disabling use of alcohol or illicit substances. Diagnosis was not an exclusion criterion as a symptom model was adopted. Power analysis suggested that 52 participants would be needed to obtain 80% power, assuming a medium effect size on the COREOM (based on d ¼ .53 from Chadwick et al., 2005). Seventy-nine people were referred and all were offered an assessment. Seventeen of these were not invited to attend a group; seven people did not hear distressing voices, eight declined to participate and two had attended a previous CBT group. Thus, 62 people (22 men and 40 women) were invited to attend a PBCT group (78% of those referred). Mean age was 41.1 years (sd ¼ 9.2 years). Fifty-five of these had an ICD 10 diagnosis of schizophrenia or schizoaffective disorder. The remaining seven people had a diagnosis of ‘psychosis’ (N ¼ 5), a non-specified personality disorder (N ¼ 1) or PTSD (N ¼ 1) (Fig. 1). Of the 62 people invited to a PBCT group 50 people (81% of those invited) were considered ‘completers’ in that they attended six or more sessions, with the remaining 12 attending fewer than six sessions. Reasons for not attending six or more sessions were:
moving out of the region (N ¼ 2), reporting early recovery or improvement (N ¼ 2), physical ill health (N ¼ 2), requesting individual therapy (N ¼ 2), major life events (N ¼ 1), sporadic attendance (N ¼ 2) and an inpatient admission (N ¼ 1). When research is based in a symptom model, rather than a syndrome model, it is important to describe the symptomatic experience as fully as possible. To achieve this in the present study, prior to therapy participants completed the PSYRATS Auditory Hallucinations Rating Scale (Haddock et al., 1999). The mean total PSYRATS voices score was 30.90 (sd ¼ 3.34) out of a possible 44. Individual item mean scores were rated as follows (range 1e4): frequency ¼ 2.94, duration ¼ 3.03, location ¼ 2.41, loudness ¼ 2.74, origin ¼ 3.00, amount of negative content ¼ 3.63, degree of negative content ¼ 3.71, amount of distress ¼ 3.50, intensity of distress ¼ 3.49, disruption to life ¼ 2.14 and controllability of voices ¼ 3.36. Participants had heard voices for an average of 14.3 years (sd ¼ 9.7 years). 2.2. Measures Given the focus on psychosocial outcome measures, the primary outcome measure was general psychosocial well-being (COREOM), and secondary measures were used of voice-distress, voicecontrol and relationship with voice. As the focus was not on symptom reduction PSYRATS was not used as an outcome measure. 2.2.1. Clinical outcomes in routine evaluation-outcome measure (CORE-OM) The CORE-OM is a 34-item scale of mental health which includes subscales of well-being, problems, functioning and risk. Item scores range from 0 to 4, with higher scores indicating deteriorating mental health and responders are asked to consider the past week only in giving their responses. The CORE-OM was developed for use in routine clinical practice, where it has established psychometric properties and is particularly valuable as an outcome measure due to its sensitivity to change (Evans et al., 2000). 2.2.2. Voice-control Analogue rating scales of subjective experience are well established in the clinical literature and have been shown to be sensitive to change when rating distress and control in relation to voices (Chadwick et al., 2000). In this study participants were asked to rate the perceived control voices had over them on an analogue scale in response to the question: ‘How much control does your voice have over you?’ Ratings were given on a 10 cm analogue scale ranging from 0 (‘none at all’) to 100 (‘total control over me’). 2.2.3. Voice-distress Participants were asked to rate their voice-distress on a 5-point, analogue scale ranging from 1 (‘not at all distressed’) to 5 (‘very distressed indeed’). 2.2.4. Voice and You (VAY: Hayward, Denney, Vaughan, & Fowler, 2008) The VAY is a 28-item measure of interrelating between the hearer and his/her predominant voice. Relating is measured across four scales: two concerning the hearer’s perception of the relating of the voice e voice dominance and voice intrusiveness; and two concerning the relating of the hearer e hearer distance and hearer dependence. Each item is measured on a four-point Likert scale (0e3), generating the following range of scores for each scale: Voice Dominance, 0e21; Voice Intrusiveness, 0e15; Hearer Distance, 0e21; and Hearer Dependence, 0e27. The VAY has good internal consistency (a > .75 for all scales) and acceptable test-retest reliability (r > .7 for all scales).
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Initial referrals by care coordinators and psychiatrists (n = 79)
Excluded (n=17)
Assessed for the study (n = 79)
Not meeting inclusion criteria (n=10) Not willing to participate (n=7)
Allocated to PBCT group (n = 62)
Group intervention (n = 62)
Non-completers (fewer than 6 sessions) (n = 12) Moving away (n=2) Early recovery (n=2) Physical ill health (n=2) Requesting individual therapy (n=2) Major life events (n=1) Sporadic attendance (n=2) Inpatient admission (n=1)
Post-group assessment (n = 53)
One-month follow-up assessment (n = 50)
Data analysis (intention to treat analyses) (n = 62)
Fig. 1. Flowchart illustrating pathways through study.
2.3. Procedure 2.3.1. Assessment All participants were assessed by a research assistant at three time points: prior to therapy (Time 1), within a week of therapy ending (Time 2), and one month after the therapy (Time 3). Due to differences in recruitment strategy, the first 24 participants were additionally assessed one month before Time 1 (Time 0) in order to ascertain stability of baseline. At first contact, inclusion and exclusion criteria were verified. Participants were encouraged to discuss any concerns about attending the group before being asked to complete the PSYRATS screening measures and four outcome measures. 2.3.2. Group person-based cognitive therapy (PBCT) Groups were closed with each session lasting 90 min, including a 10 min break. The first six groups ran for up to nine weekly
sessions. Following participant feedback the final three groups ran for up to 12 weekly sessions to allow more time to deliver the protocol (the content of the protocol was constant across all groups). The groups were facilitated by two clinical psychologists experienced in CBT for psychosis. Measures of therapy adherence were not taken due to participant concerns about audio recording sessions. In order to establish adherence a detailed, session-bysession protocol was produced. A handout was produced and distributed after each session, summarising the main discussion points and allowing adherence to the protocol to be checked. If required, telephone contact with the research assistant was available for participants between sessions. Following Chadwick et al.’s (2000) study of group CBT for voices, the therapeutic relationship was characterised by free flowing dialogue, guided discovery and Rogerian principles of acceptance and empathy for the client. PBCT builds upon traditional CBT for psychosis. The PBCT groups thus retained the three central
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elements from Chadwick et al. (2000). These are, first a commitment to understanding people’s current experience of voice hearing. The first two sessions were spent exploring people’s thoughts and feelings about coming to the group, and how this impacted on voices, establishing ground rules, and exploring three themes: when the voices first began; participant’s own ideas about why they hear voices; and the impact of hearing voices on their lives. The second central element of traditional group based CBT is organising people’s experience within a cognitive framework. At session 3 the ABC framework was introduced, together with the concept of learning to live with voices in a way that reduced distress and disturbance and allowed maximum self-acceptance and quality of life. Participants’ current relationship with voices, characterised by omnipotence and fear, emerged as a major obstacle to this. The third central element from traditional CBT then began e that of using Socratic dialogue and behavioural experiments to explore change in current relationship with voices, and especially perceived omnipotence. In addition to these traditional elements, the PBCT groups included further key ingredients. First, a primary aim of the group was to promote acceptance of voices. In this context, acceptance of voices means accepting that trying to avoid and control them is not possible and self-defeating, and therefore consciously choosing to find a way of living more peacefully with them. Second, acceptance was supported through formal 10-min mindfulness meditation practice developed specifically for people with psychosis (Chadwick, 2006, chap. 5) plus reflection. All participants experienced psychotic experience during meditation practice. During meditation, participants are guided to bring full awareness to difficult voices, feelings, thoughts and images, and also to become aware of habitual coping reactions and their effects emotionally and in the body. Participants practice letting go of these reactions and learn to allow voices and other difficult cognitions and feelings to come into awareness and fade or pass without getting caught up in habitual reacting. Meditation and discussion lead to insight that struggling, judging and ruminating on psychotic experience creates distress, while mindful observation and acceptance of psychotic experience is empowering and calming. Third, PBCT seeks to delineate negative self-schema, by challenging experientially the idea that the whole self is bad, flawed, inadequate, and to facilitate people to express and then embody in their everyday lives positive schematic experience. This broadening of the sense of self further supports acceptance of psychotic experience as simply one part of the self. The final sessions focussed on consolidation of skills, reflections on the group, and ending. 2.4. Strategy for statistical analysis Intention-to-treat analyses are reported for all 62 participants using the last observation carried forward method (e.g. Time 1 data will be substituted for Time 2 data and Time 2 data for Time 3 data).
This method provides a conservative estimate of outcome as it assumes no change for people who drop out. After assessing if data met assumptions for parametric analysis means were compared for each outcome measure across the three time points using either repeated measures ANOVA with post-hoc Bonferroni-adjusted pairwise comparisons or, for non-parametric data, Freidman analyses with post-hoc Wilcoxen tests. As this study evaluated therapy groups, in order to take account of the potential violation of the assumption of independence of observations data were also analysed using a random effects model to identify and correct for any differences in outcome in comparison to the main analyses. 3. Results Sixty-two people were invited to attend one of the nine PBCT groups. Fifty people attended at least six group therapy sessions (81% of participants). All 62 people completed the measures at Time 1, 53 completed them at Time 2 and 50 completed measures at all time points. The last observation carried forward method was used to replace missing data, with 15 percent and 19 percent of data replaced using this method at Time 2 and Time 3 respectively. It can be assumed that data met assumptions for parametric analyses unless otherwise stated. Due to differences in recruitment strategy, the first 24 participants completed the assessment measures at two pregroup time points one month apart (Time 0 and Time 1) e all subsequent participants completed only one pre-group assessment. Table 1 shows means and standard deviations on the measures at Time 0 and Time 1. It can be seen that, using paired t-tests, the differences on the measures between the two time points were all non-significant. There is a statistical trend for CORE-OM scores to worsen between the two time points, though the difference in means are small and multiple comparisons were conducted. 3.1. Primary outcome: CORE-OM Table 2 shows means and standard deviations of CORE-OM scores at the three time points. An intention-to-treat analysis using repeated measures ANOVA of CORE-OM scores across the three time points revealed a significant main effect of time (F(2,122) ¼ 12.17, p < .001). Bonferroni-adjusted post-hoc pairwise comparisons revealed significant differences in CORE-OM score from pre-group to post-group (mean difference ¼ .34, p < .001) and from pre-group to follow-up (mean difference ¼ .38, p < .001). There were no significant differences in CORE-OM score from post-group to follow-up (mean difference ¼ .42, p ¼ 1.0). The percentage of participants showing a reliable pre-group to post-group change on the CORE-OM (i.e. a change unlikely to be due to measurement error) was calculated using the method described by Jacobson and Truax (1991). At post-group, of those participants who
Table 1 Mean baseline scores on outcome measures taken one month apart (Time 0 and Time 1) prior to the intervention (N ¼ 24). CORE-OM total/4
VAY dominance/21
VAY intrusiveness/15
VAY Hearer dependence/27
VAY distance/21
Voice-control/100
Voice-distress/5
Time 0 Mean (sd)
2.09 (.61)
16.50 (3.73)
10.50 (3.59)
9.08 (5.11)
14.00 (4.23)
71.76 (20.39)
3.92 (.50)
Time 1 Mean (sd)
2.24 (.71)
16.08 (5.40)
10.46 (4.05)
9.00 (5.44)
13.88 (4.48)
70.92 (17.29)
4.04 (.15)
P
.082
.560
.929
.910
.838
.858
.524
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Table 2 Intention-to-treat pre-group, post-group and one month follow-up means and standard deviations on all outcome scales (N ¼ 62). Scale (min possibleemax possible)
CORE-OM total (0e4) Voice-distress (1e5) Voice-control (0e100) VAY Voice Intrusiveness (0e15) VAY Voice Dominance (0e21) VAY Hearer Distance (0e21) VAY Hearer Dependence (0e27)
Time 1
Time 2
Time 3
Pre-group
Post-group
One month follow-up
Mean (sd)
Mean (sd) [d]
Mean (sd) [d]
2.24 (.60) 4.17 (.80) 66.69 (21.22) 9.08 (4.63) 14.90 (6.73) 12.49 (5.48) 7.67 (5.70)
1.90*** (.70) [d ¼ .57] 3.57*** (.83) [d ¼ .75] 53.47*** (23.59) [d ¼ .62] 9.03 (4.32) [d ¼ .01] 14.46 (6.37) [d ¼ .07] 12.93 (5.93) [d ¼ .10] 6.76 (5.69) [d ¼ .16]
1.86*** (.72) [d ¼ .63] 3.41*** (1.03) [d ¼ .95] 55.56** (26.98) [d ¼ .52] 9.29 (4.36) [d ¼ .05] 14.20 (6.27) [d ¼ .10] 12.27 (5.44) [d ¼ .02] 6.25* (5.47) [d ¼ .25]
Significant differences are indicated for post-group and follow-up scores in comparison to pre-group scores: *p < .05; **p < .01; ***p < .001. Effect sizes (d) are given for pre-group to post-group change and for pre-group to follow-up change.
completed the CORE-OM (n ¼ 53), 24 (45%) showed a reliable improvement; 2 people (4%) showed a reliable deterioration in their CORE-OM score; and 27 people (51%) showed no reliable change. When comparing pre-group and follow-up CORE-OM data (n ¼ 50), 27 participants (54%) showed reliable improvement, five people (10%) a reliable deterioration, and 18 people (36%) showed no reliable change. In terms of maintenance of change, of those 24 people who showed reliable clinical improvement post-group, 20 (83%) also showed reliable improvement at follow-up; one person showed a reliable deterioration in CORE-OM score at both post-group and follow-up. Given the nature of group interventions, there is a danger of violating the assumption of independence of observations. Following the analyses, the data were re-analysed using a random effects model to account for potential dependence of observations and all significant findings remained significant. This suggests that the data did not violate the assumption of independence. Finally, because of the lengthening of the final three groups, in order to evaluate the relationship for completers between number of sessions attended and pre-post group CORE-OM outcome with total, a Spearman’s correlation was conducted. This showed no significant correlation between the number of sessions attended and outcome (rho(53) ¼ .05, p ¼ .73). 3.2. Voice distress and control Table 2 shows means and standard deviations of voice-distress and voice-control scores at the three time points. Data did not conform to the normal distribution and so non-parametric analyses were conducted. For voice-distress ratings an initial Freidman’s analysis revealed a significant effect over time (c2(2) ¼ 39.21, p < .001). Post-hoc analyses using Wilcoxon Signed Ranks Test revealed significant differences between Time 1 and Time 2 (Z (62) ¼ 4.65, p < .001), between Time 1 and Time 3 (Z(62) ¼ 4.70, p < .001;) and between Time 2 and Time 3 (Z(62) ¼ 2.18, p < .05). On ratings of voice-control, a Freidman’s analysis revealed a significant effect over time (c2(2) ¼ 21.07, p < .001). Post-hoc Wilcoxon analyses revealed significant differences between Time 1 and Time 2 (Z(62) ¼ 4.44, p < .001), between Time 1 and Time 3 (Z (62) ¼ 3.08, p < .01) but not between Time 2 and Time 3 (Z (62) ¼ 1.17, p ¼ .24). As reliability data were not available it was not possible to calculate a reliable change index for the voice-distress or voice-control measures. 3.3. VAY Table 2 shows means and standard deviations on the VAY. Repeated measures ANOVAs found no main effects of time for Voice Dominance (F(2,122) ¼ 1.29, p ¼ .27), Hearer Distance (F(2) ¼ 2.37,
p ¼ .10) or Voice Intrusiveness (F(2,122) ¼ .33, p ¼ .72). There was a main effect for Hearer Dependence (F(2,122) ¼ 5.21, p < .01). Posthoc Bonferroni-adjusted pairwise comparisons revealed a significant change from pre-group to follow-up (mean difference ¼ 1.76, p < .05) but no significant differences from pre-group to post-group (mean difference ¼ 1.06, p ¼ .21) or from post-group to follow-up (mean difference ¼ .71, p ¼ .45). 4. Discussion The present study evaluates PBCT groups e a combined CBT and mindfulness approach e for people hearing distressing, treatmentresistant voices for a minimum of two years and an average of 14 years. Groups were aimed at improving general well-being, and reducing distress and voice omnipotence. A reduction in voice properties (frequency, loudness, content, location) is not an aim in acceptance-based therapy (e.g. Bach & Hayes, 2002) e nor was it in traditional CBT for psychosis (Chadwick et al., 1996). All assessments were carried out by researchers not involved in delivering groups. Also, it is a strength that all groups were run by two experienced therapists, as this has been found to link to outcome in CBT groups for psychosis (Wykes et al., 2005). Results demonstrated statistically significant improvements, with a medium effect size, in the primary outcome measure of general well-being (COREOM), and visual analogue ratings of voice-distress and control. The medium effect sizes reported compare favourably with those reported elsewhere (e.g. Barrowclough et al., 2006). At post-group 24 (45%) participants showed reliable change on the CORE-OM and at follow-up, 27 (51%) showed reliable change. Of the 24 people to show reliable change post-group, 20 (83%) also did so at follow-up (i.e. their improvement was stable over time). A central aim in PBCT is to support people to relate differently to distressing experiences such as voices. Participants in the present study became less dependent upon their voices at follow-up than at baseline, as measured by the VAY (though multiple comparisons were done, so caution is needed). There was no significant change on the dominance, intrusiveness or distance scales. These findings may reflect issues of sensitivity to change, as certain items on the VAY assess voice content, a dimension not targeted by PBCT. A further issue concerns the theoretical underpinnings of the VAY. The concept of relationship with voices is complex and can have at least three meanings: first, in the mindfulness sense, how does a person relate to a voice in the moment of contact (e.g. with avoidance); second, what is a person’s general relational disposition towards a voice (e.g. resistance or engagement: Chadwick & Birchwood, 1994); and third, to what degree does behaviour towards a voice reflect and conform to general theories of social relating. It is this third definition which inspired the VAY (Hayward et al., 2008). The lack of substantial change on the VAY may thus
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reflect two further factors. First, relationship with voices within the PBCT groups was framed in the first two senses listed above, and not in terms of social relating theory (i.e. seeing a voice as like other social relationships). Second, within mindfulness-based therapy, voice hearers would not be encouraged to distance themselves from voices. The reliability, validity and generalisability of findings in the present study are limited by a number of factors. First, the lack of a randomised design and comparison treatment mean it is possible the changes observed were due either to factors outside the group, or were nonspecific effects of being in a therapeutic group. In relation to the latter possibility, two large and well-controlled studies of group CBT for psychosis (Barrowclough et al., 2006; Wykes et al., 2005) attest to the difficulty of effecting change through CBT group work e and in the present study the mean PSYRATS hallucination score at baseline is slightly higher than in the Wykes study (here 30.9 as against Wykes’ 29.1 for CBT group and 26.8 for control group). A factor limiting generalisation is the gender ratio, with approximately twice as many women as men, as against a more usual 60:40 split in favour of men (Pilling et al., 2002). A further factor limiting generalisation is the ratings of voice-control at baseline, which are lower than in Chadwick et al. (2000) e 67% as against 87%. Perhaps linked to this, the present sample is comparatively old (e.g. see Pilling et al., 2002) and with long voice hearing history. Finally, the last observation carried forward method to handle missing data has been criticised, e.g. for assuming stability since the last observation. Hamer and Simpson (2009) advocate the use of mixed methods that allow for estimation of participants’ responses after dropout using data prior to the dropout. However, this approach may not have benefitted the current study due to the small sample size. PBCT integrates traditional CBT for psychosis and mindfulness, with its explicit emphasis on acceptance of voice hearing. Following the development of ACT (Hayes et al., 1999) and other mindfulness-based therapies, the need for acceptance of uncontrollable sensations such as voices has become much more explicit. In this context, acceptance of voices means a person accepting that trying to avoid and control them is not possible and self-defeating, and therefore consciously choosing to relate to them differently. ACT has a strong evidence base across a range of disorders (PBCT does not), and is grounded in a clear behavioural model e relational frame theory (Hayes et al., 1999). Unlike ACT, PBCT retains a traditional CBT emphasis on using guided discovery and behavioural experiments to work with meaning (e.g. a belief in omnipotence, or a negative schema) e always in a collaborative, client centred way. Indeed, working with meaning given to and relationship with inner experience are not independent (Chadwick, 2006). For example, clients discover in mindfulness practice that they can sometimes allow voices to come into awareness and pass or fade without resistance or struggle, and that this does not lead to feared consequences (e.g. unless I resist and struggle, the voices will overwhelm and destroy me). One impact of this type of metacognitive insight (Teasdale et al., 2002) can be to weaken a voice’s omnipotence. This example illustrates how mindfulness and CBT can be complementary. In summary, the present study offers early-phase evidence for the value of PBCT groups for people with treatment-resistant distressing voices, and supports an RCT which as well as looking robustly at outcomes would also consider suitability, mechanisms of change and mediators. Looking across the research on group based CBT for distressing voices (Chadwick et al., 2000; Wykes et al., 2005, 1999) and positive symptoms (Barrowclough et al., 2006) there is evidence that group therapy can yield significant
improvement in a range of cognitive, emotional and behavioural variables e general well-being, distress, voice omnipotence, selfesteem, hopelessness, social behaviour e and perhaps these, rather than symptom reduction, might be more suitable primary outcomes, at least for acceptance-based therapies if not all CBT for psychosis. Acknowledgements This study was supported by a grant from Sussex Partnership NHS Foundation Trust. Thanks are due to all the individuals who participated within the study, and to members of the research team: Anna Day, Claire Tredgett, Sara Meddings, Lucy Brierley, Caroline Gashe and Nicola Motton. References Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129e1139. Barrowclough, C., Haddock, G., Lobban, F., Jones, S., Siddel, R., Roberts, C., et al. (2006). Group cognitive-behavioural therapy for schizophrenia: randomised controlled trial. British Journal of Psychiatry, 189, 527e532. Chadwick, P. (2006). Person-based cognitive therapy for distressing psychosis. Chichester: John Wiley & Sons Ltd. Chadwick, P., & Birchwood, M. (1994). The omnipotence of voices. A cognitive approach to auditory hallucinations. The British Journal of Psychiatry, 164, 190e201. Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices, and paranoia. Chichester: John Wiley & Sons Ltd. Chadwick, P., Hughes, S., Russell, D., Russell, I., & Dagnan, D. (2009). Mindfulness groups for distressing voices and paranoia: a replication and feasibility trial. Behavioural and Cognitive Psychotherapy, 37, 403e412. Chadwick, P., Newman-Taylor, K., & Abba, N. (2005). Mindfulness groups for people with psychosis. Behavioural and Cognitive Psychotherapy, 33, 351e359. Chadwick, P., Sambrooke, S., Rasch, S., & Davies, E. (2000). Challenging the omnipotence of voices: group cognitive behavior therapy for voices. Behaviour Research and Therapy, 38, 993e1003. Evans, C., Mellor-Clark, J., Margison, F., Barkham, M., Audin, K., Connell, J., et al. (2000). CORE: clinical outcomes in routine evaluation. Journal of Mental Health, 9, 247e255. Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. Behavior Research Therapy, 44, 415e437. Gledhill, A., Lobban, F., & Sellwood, W. (1998). Group CBT for people with schizophrenia: a preliminary evaluation. Behavioural and Cognitive Psychotherapy, 26, 63e75. Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: the psychotic symptoms rating scale (PSYRATS). Psychological Medicine, 29, 879e889. Hamer, R. M., & Simpson, P. M. (2009). Last observation carried forward versus mixed models in the analysis of psychiatric clinical trials. American Journal of Psychiatry, 166, 639e641. Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behaviour therapy. Behaviour Therapy, 35, 639e665. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guildford. Hayward, M. (2003). Interpersonal relating and voice hearing: to what extent does relating to the voice reflect social relating? Psychology and Psychotherapy: Theory, Research and Practice, 76, 369e383. Hayward, M., Denney, J., Vaughan, S., & Fowler, D. (2008). The voice and you (VAY): development and psychometric evaluation of a measure of relationships with voices. Clinical Psychology & Psychotherapy, 15, 45e52. Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12e19. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., et al. (2002). Psychological treatments in schizophrenia: I. metaanalysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763e782. Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: empirical evidence. Journal of Consulting and Clinical Psychology, 70, 275e287. Wykes, T., Hayward, P., Thomas, N., Green, N., Surguladze, S., Fannon, D., et al. (2005). What are the effects of group cognitive behaviour therapy for voices? A randomized control trial. Schizophrenia Research, 77, 201e210. Wykes, T., Parr, A., & Landau, S. (1999). Group treatment of auditory hallucinations; exploratory study of effectiveness. British Journal of Psychiatry, 175, 180e185.
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Journal of Behavior Therapy and Experimental Psychiatry journal homepage: www.elsevier.com/locate/jbtep
Group person-based cognitive therapy for distressing voices: Pilot data from nine groups Laura Dannahy a, Mark Hayward c, d, *, Clara Strauss c, d, Wendy Turton e, Emma Harding f, Paul Chadwick b a
Hampshire Partnership NHS Foundation Trust, Andover CMHT, 68b Junction Road, Andover, Hampshire SP10 3QX, UK King’s College London, Institute of Psychiatry, Department of Psychology, PO77 Henry Wellcome Building, De Crespigny Park, London SE5 8AF, UK Sussex Partnership NHS Foundation Trust, Sussex Education Centre, Millview, Nevill Avenue, Hove, East Sussex BN3 7HZ, UK d Psychology Department, University of Surrey, Guildford, Surrey GU2 7HX, UK e Psychosocial Interventions for Psychosis Service, Osborn Centre, Osborn Road, Fareham PO16 7ES, UK f South London and Maudsley NHS Foundation Trust, Support and Recovery 1, St Giles House, St Giles Road, London SE5 7UD, UK b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 June 2009 Received in revised form 24 July 2010 Accepted 29 July 2010
The present study examines the impact of group Person-Based Cognitive Therapy (PBCT) for distressing voices within an uncontrolled evaluation. In particular it utilizes a framework of acceptance of voices and self to enhance well-being and reduce distress and perceived voice-control. Sixty-two participants entered one of nine PBCT groups conducted over 8e12 sessions. Fifty participants completed therapy. Measures of well-being, distress, control and relating characteristics were completed pre- and posttherapy and at brief follow-up. Data were subjected to an intention-to-treat analysis. The groups achieved significant benefits in terms of well-being, distress, control and dependence upon the voice. The present study is the first to report significant improvement in both distress and control. Consequently, Group PBCT for distressing voices may prove a useful addition to existing psychological interventions and is worthy of further investigation. The findings are discussed in relation to clinical implications and limitations. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Schizophrenia & psychotic states Cognitive therapy Group therapy & treatment outcome
1. Introduction In cognitive-behaviour therapy (CBT) for psychosis the majority of outcome research has focussed on individual therapy. Uncontrolled studies of group CBT found improvements on measures of psychotic symptoms (Gledhill, Lobban, & Sellwood, 1998; Wykes, Parr, & Landau, 1999), and on perceived voice-control and power (Chadwick, Sambrooke, Rasch, & Davies, 2000). Two subsequent well-controlled randomised studies of group CBT versus treatment as usual found no significant treatment effect in severity of voices in a sample of 85 voice hearers (Wykes et al., 2005) or positive symptom improvement in a sample of 113 people with persistent distressing positive symptoms (Barrowclough et al., 2006). However, it might be argued that the primary aim of CBT for psychosis is to reduce distress and disturbance in response to psychotic experience, rather than to reduce or eliminate psychotic experience (Chadwick, Birchwood, & Trower, 1996). With this in
* Corresponding author. Tel.: þ44 1483 689441. E-mail address: [email protected] (M. Hayward). 0005-7916/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2010.07.006
mind the randomised trials of group CBT for psychosis look more encouraging. Barrowclough et al. (2006) found that people attending a CBT for psychosis group reported significant improvements on measures of self-esteem and hopelessness in comparison to people receiving their usual care e two important psychosocial outcomes. Similarly, Wykes et al. (2005) found that CBT group participants, in comparison to control participants, reported significant improvements in social functioning. However, the Barrowclough study did not find improvement on a measure of anxiety and depression or on a measure of global functioning. One way in which the effectiveness of CBT for psychosis may be enhanced is through inclusion of so called ‘third wave’ acceptancebased theory and practice (Hayes, 2004). Whilst traditional CBT for psychosis focussed primarily on identifying and changing thoughts and beliefs about psychotic experiences, third wave approaches focus primarily on how people relate with and respond to these and other experiences (e.g. through mindfulness practice). There is emerging evidence supporting individual and group third wave CBT approaches for psychosis. Bach and Hayes (2002), in a randomised study, found that rehospitalisation rates over a four month period were halved for participants receiving four individual sessions of Acceptance and Commitment Therapy (ACT), in
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comparison to participants receiving their usual treatment. A replication by Gaudiano and Herbert (2006) found affective and symptom improvement at discharge, though did not find a significant reduction in rehospitalisation. Two small studies of mindfulness groups for people with treatment-resistant positive symptoms of psychosis both found significant pre-post group improvement in general well-being (Chadwick, Hughes, Russell, Russell, & Dagnan, 2009; Chadwick, Newman-Taylor, & Abba, 2005). Person-Based Cognitive Therapy (PBCT: Chadwick, 2006) integrates traditional CBT for psychosis and mindfulness practice, with its explicit emphasis on acceptance of voice hearing. Whilst PBCT retains the central ABC formulation (Chadwick et al., 1996) of the voice hearing experience, it builds upon it in three main ways. First, there is an explicit emphasis on acceptance of the voice hearing experience. Whilst this was implicit within an ABC formulation of voices (where a voice experienced at point A is not controllable) the development of therapies such as Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999) has brought the importance of acceptance to the fore. In PBCT this is established mainly through Socratic dialogue and 10 minute mindfulness practice. Second, there is greater emphasis on identifying and testing out positive self-schema and self-acceptance. Third, there is an even greater focus on relationship with voices (e.g. Chadwick & Birchwood, 1994; Hayward, 2003). The present study represents a first phase of evaluation of PBCT groups for distressing voices to determine effectiveness and feasibility of a larger-scale, randomised controlled trial. Baseline, outcome and one month follow-up data are reported. Consistent with both the ABC model and an acceptance-based approach, it is hypothesised that, following the group, participants will report significant improvements in general well-being, voice-distress, perceived voice-control and relationship with voices. 2. Method 2.1. Participants Nine groups were run across two neighbouring NHS Trusts in the South of England. Ethical approval was obtained in both Trusts. Participants were all receiving standard psychiatric care, including medication. Inclusion criteria were that: the individual had been experiencing treatment-resistant and subjectively distressing voices for at least the preceding two years, with voice-distress rated at 3 or greater on at least one of the two PSYRATS voice-distress items (Haddock, McCarron, Tarrier, & Faragher, 1999). The exclusion criteria were evidence of an organic psychosis or disabling use of alcohol or illicit substances. Diagnosis was not an exclusion criterion as a symptom model was adopted. Power analysis suggested that 52 participants would be needed to obtain 80% power, assuming a medium effect size on the COREOM (based on d ¼ .53 from Chadwick et al., 2005). Seventy-nine people were referred and all were offered an assessment. Seventeen of these were not invited to attend a group; seven people did not hear distressing voices, eight declined to participate and two had attended a previous CBT group. Thus, 62 people (22 men and 40 women) were invited to attend a PBCT group (78% of those referred). Mean age was 41.1 years (sd ¼ 9.2 years). Fifty-five of these had an ICD 10 diagnosis of schizophrenia or schizoaffective disorder. The remaining seven people had a diagnosis of ‘psychosis’ (N ¼ 5), a non-specified personality disorder (N ¼ 1) or PTSD (N ¼ 1) (Fig. 1). Of the 62 people invited to a PBCT group 50 people (81% of those invited) were considered ‘completers’ in that they attended six or more sessions, with the remaining 12 attending fewer than six sessions. Reasons for not attending six or more sessions were:
moving out of the region (N ¼ 2), reporting early recovery or improvement (N ¼ 2), physical ill health (N ¼ 2), requesting individual therapy (N ¼ 2), major life events (N ¼ 1), sporadic attendance (N ¼ 2) and an inpatient admission (N ¼ 1). When research is based in a symptom model, rather than a syndrome model, it is important to describe the symptomatic experience as fully as possible. To achieve this in the present study, prior to therapy participants completed the PSYRATS Auditory Hallucinations Rating Scale (Haddock et al., 1999). The mean total PSYRATS voices score was 30.90 (sd ¼ 3.34) out of a possible 44. Individual item mean scores were rated as follows (range 1e4): frequency ¼ 2.94, duration ¼ 3.03, location ¼ 2.41, loudness ¼ 2.74, origin ¼ 3.00, amount of negative content ¼ 3.63, degree of negative content ¼ 3.71, amount of distress ¼ 3.50, intensity of distress ¼ 3.49, disruption to life ¼ 2.14 and controllability of voices ¼ 3.36. Participants had heard voices for an average of 14.3 years (sd ¼ 9.7 years). 2.2. Measures Given the focus on psychosocial outcome measures, the primary outcome measure was general psychosocial well-being (COREOM), and secondary measures were used of voice-distress, voicecontrol and relationship with voice. As the focus was not on symptom reduction PSYRATS was not used as an outcome measure. 2.2.1. Clinical outcomes in routine evaluation-outcome measure (CORE-OM) The CORE-OM is a 34-item scale of mental health which includes subscales of well-being, problems, functioning and risk. Item scores range from 0 to 4, with higher scores indicating deteriorating mental health and responders are asked to consider the past week only in giving their responses. The CORE-OM was developed for use in routine clinical practice, where it has established psychometric properties and is particularly valuable as an outcome measure due to its sensitivity to change (Evans et al., 2000). 2.2.2. Voice-control Analogue rating scales of subjective experience are well established in the clinical literature and have been shown to be sensitive to change when rating distress and control in relation to voices (Chadwick et al., 2000). In this study participants were asked to rate the perceived control voices had over them on an analogue scale in response to the question: ‘How much control does your voice have over you?’ Ratings were given on a 10 cm analogue scale ranging from 0 (‘none at all’) to 100 (‘total control over me’). 2.2.3. Voice-distress Participants were asked to rate their voice-distress on a 5-point, analogue scale ranging from 1 (‘not at all distressed’) to 5 (‘very distressed indeed’). 2.2.4. Voice and You (VAY: Hayward, Denney, Vaughan, & Fowler, 2008) The VAY is a 28-item measure of interrelating between the hearer and his/her predominant voice. Relating is measured across four scales: two concerning the hearer’s perception of the relating of the voice e voice dominance and voice intrusiveness; and two concerning the relating of the hearer e hearer distance and hearer dependence. Each item is measured on a four-point Likert scale (0e3), generating the following range of scores for each scale: Voice Dominance, 0e21; Voice Intrusiveness, 0e15; Hearer Distance, 0e21; and Hearer Dependence, 0e27. The VAY has good internal consistency (a > .75 for all scales) and acceptable test-retest reliability (r > .7 for all scales).
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113
Initial referrals by care coordinators and psychiatrists (n = 79)
Excluded (n=17)
Assessed for the study (n = 79)
Not meeting inclusion criteria (n=10) Not willing to participate (n=7)
Allocated to PBCT group (n = 62)
Group intervention (n = 62)
Non-completers (fewer than 6 sessions) (n = 12) Moving away (n=2) Early recovery (n=2) Physical ill health (n=2) Requesting individual therapy (n=2) Major life events (n=1) Sporadic attendance (n=2) Inpatient admission (n=1)
Post-group assessment (n = 53)
One-month follow-up assessment (n = 50)
Data analysis (intention to treat analyses) (n = 62)
Fig. 1. Flowchart illustrating pathways through study.
2.3. Procedure 2.3.1. Assessment All participants were assessed by a research assistant at three time points: prior to therapy (Time 1), within a week of therapy ending (Time 2), and one month after the therapy (Time 3). Due to differences in recruitment strategy, the first 24 participants were additionally assessed one month before Time 1 (Time 0) in order to ascertain stability of baseline. At first contact, inclusion and exclusion criteria were verified. Participants were encouraged to discuss any concerns about attending the group before being asked to complete the PSYRATS screening measures and four outcome measures. 2.3.2. Group person-based cognitive therapy (PBCT) Groups were closed with each session lasting 90 min, including a 10 min break. The first six groups ran for up to nine weekly
sessions. Following participant feedback the final three groups ran for up to 12 weekly sessions to allow more time to deliver the protocol (the content of the protocol was constant across all groups). The groups were facilitated by two clinical psychologists experienced in CBT for psychosis. Measures of therapy adherence were not taken due to participant concerns about audio recording sessions. In order to establish adherence a detailed, session-bysession protocol was produced. A handout was produced and distributed after each session, summarising the main discussion points and allowing adherence to the protocol to be checked. If required, telephone contact with the research assistant was available for participants between sessions. Following Chadwick et al.’s (2000) study of group CBT for voices, the therapeutic relationship was characterised by free flowing dialogue, guided discovery and Rogerian principles of acceptance and empathy for the client. PBCT builds upon traditional CBT for psychosis. The PBCT groups thus retained the three central
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elements from Chadwick et al. (2000). These are, first a commitment to understanding people’s current experience of voice hearing. The first two sessions were spent exploring people’s thoughts and feelings about coming to the group, and how this impacted on voices, establishing ground rules, and exploring three themes: when the voices first began; participant’s own ideas about why they hear voices; and the impact of hearing voices on their lives. The second central element of traditional group based CBT is organising people’s experience within a cognitive framework. At session 3 the ABC framework was introduced, together with the concept of learning to live with voices in a way that reduced distress and disturbance and allowed maximum self-acceptance and quality of life. Participants’ current relationship with voices, characterised by omnipotence and fear, emerged as a major obstacle to this. The third central element from traditional CBT then began e that of using Socratic dialogue and behavioural experiments to explore change in current relationship with voices, and especially perceived omnipotence. In addition to these traditional elements, the PBCT groups included further key ingredients. First, a primary aim of the group was to promote acceptance of voices. In this context, acceptance of voices means accepting that trying to avoid and control them is not possible and self-defeating, and therefore consciously choosing to find a way of living more peacefully with them. Second, acceptance was supported through formal 10-min mindfulness meditation practice developed specifically for people with psychosis (Chadwick, 2006, chap. 5) plus reflection. All participants experienced psychotic experience during meditation practice. During meditation, participants are guided to bring full awareness to difficult voices, feelings, thoughts and images, and also to become aware of habitual coping reactions and their effects emotionally and in the body. Participants practice letting go of these reactions and learn to allow voices and other difficult cognitions and feelings to come into awareness and fade or pass without getting caught up in habitual reacting. Meditation and discussion lead to insight that struggling, judging and ruminating on psychotic experience creates distress, while mindful observation and acceptance of psychotic experience is empowering and calming. Third, PBCT seeks to delineate negative self-schema, by challenging experientially the idea that the whole self is bad, flawed, inadequate, and to facilitate people to express and then embody in their everyday lives positive schematic experience. This broadening of the sense of self further supports acceptance of psychotic experience as simply one part of the self. The final sessions focussed on consolidation of skills, reflections on the group, and ending. 2.4. Strategy for statistical analysis Intention-to-treat analyses are reported for all 62 participants using the last observation carried forward method (e.g. Time 1 data will be substituted for Time 2 data and Time 2 data for Time 3 data).
This method provides a conservative estimate of outcome as it assumes no change for people who drop out. After assessing if data met assumptions for parametric analysis means were compared for each outcome measure across the three time points using either repeated measures ANOVA with post-hoc Bonferroni-adjusted pairwise comparisons or, for non-parametric data, Freidman analyses with post-hoc Wilcoxen tests. As this study evaluated therapy groups, in order to take account of the potential violation of the assumption of independence of observations data were also analysed using a random effects model to identify and correct for any differences in outcome in comparison to the main analyses. 3. Results Sixty-two people were invited to attend one of the nine PBCT groups. Fifty people attended at least six group therapy sessions (81% of participants). All 62 people completed the measures at Time 1, 53 completed them at Time 2 and 50 completed measures at all time points. The last observation carried forward method was used to replace missing data, with 15 percent and 19 percent of data replaced using this method at Time 2 and Time 3 respectively. It can be assumed that data met assumptions for parametric analyses unless otherwise stated. Due to differences in recruitment strategy, the first 24 participants completed the assessment measures at two pregroup time points one month apart (Time 0 and Time 1) e all subsequent participants completed only one pre-group assessment. Table 1 shows means and standard deviations on the measures at Time 0 and Time 1. It can be seen that, using paired t-tests, the differences on the measures between the two time points were all non-significant. There is a statistical trend for CORE-OM scores to worsen between the two time points, though the difference in means are small and multiple comparisons were conducted. 3.1. Primary outcome: CORE-OM Table 2 shows means and standard deviations of CORE-OM scores at the three time points. An intention-to-treat analysis using repeated measures ANOVA of CORE-OM scores across the three time points revealed a significant main effect of time (F(2,122) ¼ 12.17, p < .001). Bonferroni-adjusted post-hoc pairwise comparisons revealed significant differences in CORE-OM score from pre-group to post-group (mean difference ¼ .34, p < .001) and from pre-group to follow-up (mean difference ¼ .38, p < .001). There were no significant differences in CORE-OM score from post-group to follow-up (mean difference ¼ .42, p ¼ 1.0). The percentage of participants showing a reliable pre-group to post-group change on the CORE-OM (i.e. a change unlikely to be due to measurement error) was calculated using the method described by Jacobson and Truax (1991). At post-group, of those participants who
Table 1 Mean baseline scores on outcome measures taken one month apart (Time 0 and Time 1) prior to the intervention (N ¼ 24). CORE-OM total/4
VAY dominance/21
VAY intrusiveness/15
VAY Hearer dependence/27
VAY distance/21
Voice-control/100
Voice-distress/5
Time 0 Mean (sd)
2.09 (.61)
16.50 (3.73)
10.50 (3.59)
9.08 (5.11)
14.00 (4.23)
71.76 (20.39)
3.92 (.50)
Time 1 Mean (sd)
2.24 (.71)
16.08 (5.40)
10.46 (4.05)
9.00 (5.44)
13.88 (4.48)
70.92 (17.29)
4.04 (.15)
P
.082
.560
.929
.910
.838
.858
.524
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Table 2 Intention-to-treat pre-group, post-group and one month follow-up means and standard deviations on all outcome scales (N ¼ 62). Scale (min possibleemax possible)
CORE-OM total (0e4) Voice-distress (1e5) Voice-control (0e100) VAY Voice Intrusiveness (0e15) VAY Voice Dominance (0e21) VAY Hearer Distance (0e21) VAY Hearer Dependence (0e27)
Time 1
Time 2
Time 3
Pre-group
Post-group
One month follow-up
Mean (sd)
Mean (sd) [d]
Mean (sd) [d]
2.24 (.60) 4.17 (.80) 66.69 (21.22) 9.08 (4.63) 14.90 (6.73) 12.49 (5.48) 7.67 (5.70)
1.90*** (.70) [d ¼ .57] 3.57*** (.83) [d ¼ .75] 53.47*** (23.59) [d ¼ .62] 9.03 (4.32) [d ¼ .01] 14.46 (6.37) [d ¼ .07] 12.93 (5.93) [d ¼ .10] 6.76 (5.69) [d ¼ .16]
1.86*** (.72) [d ¼ .63] 3.41*** (1.03) [d ¼ .95] 55.56** (26.98) [d ¼ .52] 9.29 (4.36) [d ¼ .05] 14.20 (6.27) [d ¼ .10] 12.27 (5.44) [d ¼ .02] 6.25* (5.47) [d ¼ .25]
Significant differences are indicated for post-group and follow-up scores in comparison to pre-group scores: *p < .05; **p < .01; ***p < .001. Effect sizes (d) are given for pre-group to post-group change and for pre-group to follow-up change.
completed the CORE-OM (n ¼ 53), 24 (45%) showed a reliable improvement; 2 people (4%) showed a reliable deterioration in their CORE-OM score; and 27 people (51%) showed no reliable change. When comparing pre-group and follow-up CORE-OM data (n ¼ 50), 27 participants (54%) showed reliable improvement, five people (10%) a reliable deterioration, and 18 people (36%) showed no reliable change. In terms of maintenance of change, of those 24 people who showed reliable clinical improvement post-group, 20 (83%) also showed reliable improvement at follow-up; one person showed a reliable deterioration in CORE-OM score at both post-group and follow-up. Given the nature of group interventions, there is a danger of violating the assumption of independence of observations. Following the analyses, the data were re-analysed using a random effects model to account for potential dependence of observations and all significant findings remained significant. This suggests that the data did not violate the assumption of independence. Finally, because of the lengthening of the final three groups, in order to evaluate the relationship for completers between number of sessions attended and pre-post group CORE-OM outcome with total, a Spearman’s correlation was conducted. This showed no significant correlation between the number of sessions attended and outcome (rho(53) ¼ .05, p ¼ .73). 3.2. Voice distress and control Table 2 shows means and standard deviations of voice-distress and voice-control scores at the three time points. Data did not conform to the normal distribution and so non-parametric analyses were conducted. For voice-distress ratings an initial Freidman’s analysis revealed a significant effect over time (c2(2) ¼ 39.21, p < .001). Post-hoc analyses using Wilcoxon Signed Ranks Test revealed significant differences between Time 1 and Time 2 (Z (62) ¼ 4.65, p < .001), between Time 1 and Time 3 (Z(62) ¼ 4.70, p < .001;) and between Time 2 and Time 3 (Z(62) ¼ 2.18, p < .05). On ratings of voice-control, a Freidman’s analysis revealed a significant effect over time (c2(2) ¼ 21.07, p < .001). Post-hoc Wilcoxon analyses revealed significant differences between Time 1 and Time 2 (Z(62) ¼ 4.44, p < .001), between Time 1 and Time 3 (Z (62) ¼ 3.08, p < .01) but not between Time 2 and Time 3 (Z (62) ¼ 1.17, p ¼ .24). As reliability data were not available it was not possible to calculate a reliable change index for the voice-distress or voice-control measures. 3.3. VAY Table 2 shows means and standard deviations on the VAY. Repeated measures ANOVAs found no main effects of time for Voice Dominance (F(2,122) ¼ 1.29, p ¼ .27), Hearer Distance (F(2) ¼ 2.37,
p ¼ .10) or Voice Intrusiveness (F(2,122) ¼ .33, p ¼ .72). There was a main effect for Hearer Dependence (F(2,122) ¼ 5.21, p < .01). Posthoc Bonferroni-adjusted pairwise comparisons revealed a significant change from pre-group to follow-up (mean difference ¼ 1.76, p < .05) but no significant differences from pre-group to post-group (mean difference ¼ 1.06, p ¼ .21) or from post-group to follow-up (mean difference ¼ .71, p ¼ .45). 4. Discussion The present study evaluates PBCT groups e a combined CBT and mindfulness approach e for people hearing distressing, treatmentresistant voices for a minimum of two years and an average of 14 years. Groups were aimed at improving general well-being, and reducing distress and voice omnipotence. A reduction in voice properties (frequency, loudness, content, location) is not an aim in acceptance-based therapy (e.g. Bach & Hayes, 2002) e nor was it in traditional CBT for psychosis (Chadwick et al., 1996). All assessments were carried out by researchers not involved in delivering groups. Also, it is a strength that all groups were run by two experienced therapists, as this has been found to link to outcome in CBT groups for psychosis (Wykes et al., 2005). Results demonstrated statistically significant improvements, with a medium effect size, in the primary outcome measure of general well-being (COREOM), and visual analogue ratings of voice-distress and control. The medium effect sizes reported compare favourably with those reported elsewhere (e.g. Barrowclough et al., 2006). At post-group 24 (45%) participants showed reliable change on the CORE-OM and at follow-up, 27 (51%) showed reliable change. Of the 24 people to show reliable change post-group, 20 (83%) also did so at follow-up (i.e. their improvement was stable over time). A central aim in PBCT is to support people to relate differently to distressing experiences such as voices. Participants in the present study became less dependent upon their voices at follow-up than at baseline, as measured by the VAY (though multiple comparisons were done, so caution is needed). There was no significant change on the dominance, intrusiveness or distance scales. These findings may reflect issues of sensitivity to change, as certain items on the VAY assess voice content, a dimension not targeted by PBCT. A further issue concerns the theoretical underpinnings of the VAY. The concept of relationship with voices is complex and can have at least three meanings: first, in the mindfulness sense, how does a person relate to a voice in the moment of contact (e.g. with avoidance); second, what is a person’s general relational disposition towards a voice (e.g. resistance or engagement: Chadwick & Birchwood, 1994); and third, to what degree does behaviour towards a voice reflect and conform to general theories of social relating. It is this third definition which inspired the VAY (Hayward et al., 2008). The lack of substantial change on the VAY may thus
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reflect two further factors. First, relationship with voices within the PBCT groups was framed in the first two senses listed above, and not in terms of social relating theory (i.e. seeing a voice as like other social relationships). Second, within mindfulness-based therapy, voice hearers would not be encouraged to distance themselves from voices. The reliability, validity and generalisability of findings in the present study are limited by a number of factors. First, the lack of a randomised design and comparison treatment mean it is possible the changes observed were due either to factors outside the group, or were nonspecific effects of being in a therapeutic group. In relation to the latter possibility, two large and well-controlled studies of group CBT for psychosis (Barrowclough et al., 2006; Wykes et al., 2005) attest to the difficulty of effecting change through CBT group work e and in the present study the mean PSYRATS hallucination score at baseline is slightly higher than in the Wykes study (here 30.9 as against Wykes’ 29.1 for CBT group and 26.8 for control group). A factor limiting generalisation is the gender ratio, with approximately twice as many women as men, as against a more usual 60:40 split in favour of men (Pilling et al., 2002). A further factor limiting generalisation is the ratings of voice-control at baseline, which are lower than in Chadwick et al. (2000) e 67% as against 87%. Perhaps linked to this, the present sample is comparatively old (e.g. see Pilling et al., 2002) and with long voice hearing history. Finally, the last observation carried forward method to handle missing data has been criticised, e.g. for assuming stability since the last observation. Hamer and Simpson (2009) advocate the use of mixed methods that allow for estimation of participants’ responses after dropout using data prior to the dropout. However, this approach may not have benefitted the current study due to the small sample size. PBCT integrates traditional CBT for psychosis and mindfulness, with its explicit emphasis on acceptance of voice hearing. Following the development of ACT (Hayes et al., 1999) and other mindfulness-based therapies, the need for acceptance of uncontrollable sensations such as voices has become much more explicit. In this context, acceptance of voices means a person accepting that trying to avoid and control them is not possible and self-defeating, and therefore consciously choosing to relate to them differently. ACT has a strong evidence base across a range of disorders (PBCT does not), and is grounded in a clear behavioural model e relational frame theory (Hayes et al., 1999). Unlike ACT, PBCT retains a traditional CBT emphasis on using guided discovery and behavioural experiments to work with meaning (e.g. a belief in omnipotence, or a negative schema) e always in a collaborative, client centred way. Indeed, working with meaning given to and relationship with inner experience are not independent (Chadwick, 2006). For example, clients discover in mindfulness practice that they can sometimes allow voices to come into awareness and pass or fade without resistance or struggle, and that this does not lead to feared consequences (e.g. unless I resist and struggle, the voices will overwhelm and destroy me). One impact of this type of metacognitive insight (Teasdale et al., 2002) can be to weaken a voice’s omnipotence. This example illustrates how mindfulness and CBT can be complementary. In summary, the present study offers early-phase evidence for the value of PBCT groups for people with treatment-resistant distressing voices, and supports an RCT which as well as looking robustly at outcomes would also consider suitability, mechanisms of change and mediators. Looking across the research on group based CBT for distressing voices (Chadwick et al., 2000; Wykes et al., 2005, 1999) and positive symptoms (Barrowclough et al., 2006) there is evidence that group therapy can yield significant
improvement in a range of cognitive, emotional and behavioural variables e general well-being, distress, voice omnipotence, selfesteem, hopelessness, social behaviour e and perhaps these, rather than symptom reduction, might be more suitable primary outcomes, at least for acceptance-based therapies if not all CBT for psychosis. Acknowledgements This study was supported by a grant from Sussex Partnership NHS Foundation Trust. Thanks are due to all the individuals who participated within the study, and to members of the research team: Anna Day, Claire Tredgett, Sara Meddings, Lucy Brierley, Caroline Gashe and Nicola Motton. References Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129e1139. Barrowclough, C., Haddock, G., Lobban, F., Jones, S., Siddel, R., Roberts, C., et al. (2006). Group cognitive-behavioural therapy for schizophrenia: randomised controlled trial. British Journal of Psychiatry, 189, 527e532. Chadwick, P. (2006). Person-based cognitive therapy for distressing psychosis. Chichester: John Wiley & Sons Ltd. Chadwick, P., & Birchwood, M. (1994). The omnipotence of voices. A cognitive approach to auditory hallucinations. The British Journal of Psychiatry, 164, 190e201. Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices, and paranoia. Chichester: John Wiley & Sons Ltd. Chadwick, P., Hughes, S., Russell, D., Russell, I., & Dagnan, D. (2009). Mindfulness groups for distressing voices and paranoia: a replication and feasibility trial. Behavioural and Cognitive Psychotherapy, 37, 403e412. Chadwick, P., Newman-Taylor, K., & Abba, N. (2005). Mindfulness groups for people with psychosis. Behavioural and Cognitive Psychotherapy, 33, 351e359. Chadwick, P., Sambrooke, S., Rasch, S., & Davies, E. (2000). Challenging the omnipotence of voices: group cognitive behavior therapy for voices. Behaviour Research and Therapy, 38, 993e1003. Evans, C., Mellor-Clark, J., Margison, F., Barkham, M., Audin, K., Connell, J., et al. (2000). CORE: clinical outcomes in routine evaluation. Journal of Mental Health, 9, 247e255. Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. Behavior Research Therapy, 44, 415e437. Gledhill, A., Lobban, F., & Sellwood, W. (1998). Group CBT for people with schizophrenia: a preliminary evaluation. Behavioural and Cognitive Psychotherapy, 26, 63e75. Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: the psychotic symptoms rating scale (PSYRATS). Psychological Medicine, 29, 879e889. Hamer, R. M., & Simpson, P. M. (2009). Last observation carried forward versus mixed models in the analysis of psychiatric clinical trials. American Journal of Psychiatry, 166, 639e641. Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behaviour therapy. Behaviour Therapy, 35, 639e665. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guildford. Hayward, M. (2003). Interpersonal relating and voice hearing: to what extent does relating to the voice reflect social relating? Psychology and Psychotherapy: Theory, Research and Practice, 76, 369e383. Hayward, M., Denney, J., Vaughan, S., & Fowler, D. (2008). The voice and you (VAY): development and psychometric evaluation of a measure of relationships with voices. Clinical Psychology & Psychotherapy, 15, 45e52. Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12e19. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., et al. (2002). Psychological treatments in schizophrenia: I. metaanalysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763e782. Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: empirical evidence. Journal of Consulting and Clinical Psychology, 70, 275e287. Wykes, T., Hayward, P., Thomas, N., Green, N., Surguladze, S., Fannon, D., et al. (2005). What are the effects of group cognitive behaviour therapy for voices? A randomized control trial. Schizophrenia Research, 77, 201e210. Wykes, T., Parr, A., & Landau, S. (1999). Group treatment of auditory hallucinations; exploratory study of effectiveness. British Journal of Psychiatry, 175, 180e185.