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CBT for Hearing Voices AOT

CBT for Hearing Voices AOT. Dr Rozmin Halari, Natalia Petros & RISE Ealing Assertive Outreach Team. Ealing AOT. Caseload 100 London Borough of Ealing Multi cultural and ethnic backgrounds Team approach

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CBT for Hearing Voices AOT

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

  2. Ealing AOT • Caseload 100 • London Borough of Ealing • Multi cultural and ethnic backgrounds • Team approach ……Unified & Proactive: All team members are involved in supporting all AOT service users. The approach helps with engagement….provides intensive support ….. High frequency of contact with the team strengthens engagement process….

  3. Why a CBT group?Service needs • One psychologist in the team • Increased need/not being able to meet the demand • Group • Cost effective • Positive effects of group • Needs assessment • -Care coordinators • -Clients/Carers • 44% were identified

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

  5. Hearing voices • Common symptom of psychosis (also present in non clinical populations) • Over 60% experience hearing voices • Anti psychotics- front line treatment • 25% to 50% continue to hear voices • Limitations • Non compliance • Persistent residual positive symptoms • Seek other interventions

  6. Existing interventions/groups • Service user led- support groups • E.g. Hearing Voices Network • CMHT’s- CBT for psychosis • Nature of clients • Selected group (In terms of cognitive abilities) • AOT • Difficult to engage • Non compliant/revolving door • Treatment resistant • No evidence of HVG in AOT

  7. Why a CBT groupEvidence Base I • Individual CBT- effective positive and negative symptoms (Wykes et al., 2005) • Not widely accessible for schizophrenia • Group approach – efficient, cost effective way of delivering this intervention • Few formal evaluations of a group approach. • Although positive results - uncontrolled

  8. Why a CBT groupEvidence Base II • Group based CBT for AH: • Improvement Severity of hallucinations(Wykes et al., 1999; Wykes et al., 2005; Drury et al., 1996) • Improvement Social functioning(Wykes et al., 2005) • Increase Insight (Wykes et al., 1999) • Lower depression (Gledhill et al., 1998) • Reduce negative beliefs about hearing voices (Pinkham et al., 2004) • Reduce distress related to hearing voices (Perlman and Hubbard, 2000; Newton et al. 2005) • Better coping (Gledhill et al., 1998, Falloon and Talbot, 1981) • Positive effects maintained; • 6months follow up(Wykes et al., 2005)

  9. Evidence base III • Penn et al. (2009) CBT vs enhance supportive therapy • Randomly allocated 65 patients • Group CBT (for HV) • Chronically ill group with SZ • Reduce negative beliefs about voices (and severity) • Reduce distress related to HV • Reduce overall symptoms and HV • Increase insight

  10. Assessment • Assessment • Brief history • Experience of groups • Assessment of voices • Neuropsychological impairments • Positive and negative syndrome scale (PANSS, Kay et al., 1989) • Previous psychology input • Letter sent with care-coordinator • Accepting clients • If not reasons explained

  11. Inclusion criteria • ICD-10 criteria for schizophrenia, schizoaffective disorder and bipolar disorder • Persistent and distressing AH (score 3 or above on hallucination item of PANSS; Kay et al., 1989) • Over 18 years • No substance misuse or medical disorder contributing to symptoms • No medication change planned

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

  13. Group • 20 participants randomly allocated to either CBT + TAU or TAU-alone (control). • Although history of non compliance with medication • All compliant • No medication changes were made • 95% attendance to group • 3/10- CBT and 1/10 – control previous psychological input

  14. Participant Demographics

  15. EvaluationOutcome Measures- Primary Psychotic Symptom Rating Scale (PSYRATS) for auditory hallucinations (Haddock et al., 1999) • 11 items assessing severity over past week • Frequency • Intensity • Distress, disruption • control • Total scores- severity of hallucinations Beliefs About Voices Questionnaire- revised (BAVQ-R)(Chadwick et al., 2000) • 35 items beliefs about voices- emotional and behavioural reactions • Subscales; malevolence, benevolence, resistance, engagement

  16. EvaluationOutcome Measures-secondary • Beck’s Depression Inventory II (BDI-II)(Beck et al., 1996) • Severity of depression • 21 items • Self reported depression • Beck Cognitive Insight Scale (BCIS) Beck et al., 2004) • 2 subscales: self certainty and self reflectiveness • 15 items • Service user evaluation

  17. Service User Evaluation • Completed short questionnaire post group • Better understanding of the different areas covered (e.g. role of medication, importance of coping, psychological model of AH) • Most and least useful • Presentation of sessions • Future improvements

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

  19. Intervention Aims • Triggers, behaviours and consequences • Develop and share cognitive and behavioural coping strategies to help deal with the voices • Share experiences reflect similarities and differences aid restructuring of beliefs • Accept the voices • Self esteem • Increase social support • Reduce Isolation • Share the experience • Learn from one another • Erase the stigma of voice hearing

  20. Intervention • Group CBT AH (Wykes et al., 1999)- manualised • Engagement and sharing of information- voices • Psychoeducation; Exploring models of psychosis • Content of AH (e.g. malevolent, benevolent) • Behavioural analyses of voices • Exploring beliefs about hallucinations/cognitive restructuring • Developing effective coping strategies • Improving self esteem • Modified Manual • Increased sessions from 7 to 10 sessions • Focussed on engagement, coping, role of medication

  21. Process • Initially • Some structure – reduce anxiety • Explore voice hearing experiences • Normalise and client led • Mindful of the nature of this client group • Focus on engagement • Team approach • Attendance to the group- encouraged between sessions • Session content discussed between sessions

  22. Results

  23. Clinical Characteristics

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

  25. Outcome measuresDescriptives BCIS - Higher scores on self reflectiveness and BCIS composite reflects better insight Lower scores on self certainty reflects better insight

  26. Results –Primary Outcome BAVQ Within the group • Significant time x measure x group interaction (F (3,16) =5.34, p <0.01) PSYRATS • Significant time x group interaction (F (1,18) =16.29, p <0.01) Differences pre and post in CBT+TAU group only • No between group differences at baseline on these measures (p>0.05)

  27. Results – Secondary Outcomes BDI • Within the group • Significant time x group interaction (F (1,18) =13.58, p <0.01) • Differences pre and post in CBT+TAU group only BCIS No significant main effects or interactions (p>0.05) • No between group differences at baseline on these measures (p>0.05)

  28. Where are the differences? • Paired t tests • CBT+TAU group; significant improvement on: • PSYRATS (p<0.01) • BDI (p<0.01) • BAVQ-Malevolent (p<0.01) • No improvement on the BCIS (p>0.05) • TAU-alone – no significant improvement on any of the primary or secondary outcome measures (p’s>0.05)

  29. Service user satisfaction • High levels of satisfaction reported • Better understanding of psychological model of voices • Increased repertoire of coping strategies • Better able to talk about about their experiences • Requested recovery focussed group -future

  30. Discussion I • Positive effect of CBT for AH • Consistent with previous studies (e.g. Wykes et al., 2005, Penn et al, 2009) • Factors contributing to these significant findings: • Intellectual Ability • Cultural differences • Sharing experiences allows for reflection and can consequently aid in the restructuring of beliefs • Team approach

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

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

  33. Conclusion • Short course of group CBT effective in improving severity of voices and reducing self-reported depression (scores on the BDI) • Long term follow up needed - effects maintained?

  34. Acknowledgements • Prof. Veena Kumari Institute of Psychiatry, • Prof. Til Wykes– Institute of Psychiatry, Kings College London Guidance, support and collaboration. • AOT for continual support without whom the group would not have been possible!!

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