Effectiveness of a brief group cognitive behavioral therapy for auditory verbal hallucinations: a 6-month follow-up study.

ORIGINAL ARTICLE

Effectiveness of a Brief Group Cognitive Behavioral Therapy for Auditory Verbal Hallucinations A 6-Month Follow-up Study Adriano Zanello, MA, Sylvia Mohr, PhD, Marco C.G. Merlo, MD, Philippe Huguelet, MD, and Philippe Rey-Bellet, MD

Abstract: The current study investigated the effectiveness of a group cognitive behavioral therapy for auditory verbal hallucinations (AVHs), the Voices Group. This consists of seven specific sessions. Forty-one participants with schizophrenic or schizoaffective disorders completed a battery of questionnaires. The severity of psychiatric symptoms, beliefs about voices, quality of life, selfesteem, clinical global impression, and functioning were assessed at baseline, before and after intervention, and at the 6-month follow-up. After intervention, there was a statistically significant reduction in the severity of AVHs. This result remained stable at follow-up. The dropout rate was high. Some differences were found in subjective experience of AVHs between the patients who completed the intervention and those who dropped out. Altogether, these findings suggest that a brief intervention has some positive benefits in patients struggling with voices, which remain stable over time. Key Words: Schizophrenia, group CBT, auditory verbal hallucinations (J Nerv Ment Dis 2014;202: 144Y153)

A

uditory verbal hallucinations (AVHs) are a distressing experience for people hearing them. AVHs can also have deleterious effects on quality of life (QOL), mood, anxiety, self-esteem, and social integration, and these increase the risk for aggressive behaviors (Braham et al., 2004; Chadwick et al., 1996). Furthermore, positive symptoms unfortunately often persist despite adequate levels of antipsychotic medication. Several studies have reported that 5% to 50% of patients with a schizophrenia spectrum disorder continue to experience delusions or AVHs (Brenner et al., 1990; Conley and Buchanan, 1997; Fowler et al., 1995; Garety et al., 2000; Lam, 2008; Lewis et al., 2006). In a high proportion of patients (40%), this may be due in part to problems of adherence to drug treatment (Lam, 2008). Even with pharmacological adherence, it becomes essential to enable patients to benefit from nonpharmacological treatments as well. Among the latter, cognitive behavioral therapy (CBT) is a field of therapy with wide applicability. Several studies indicate that individual CBT therapies are clearly effective at attenuating the frequency and the severity of negative thoughts and beliefs related to AVHs (Trower et al., 2004; Valmaggia et al., 2005; Wiersma et al., 2001). However, these one-to-one CBT therapies are expensive because these are delivered by highly trained therapists and do not fit the expectations of busy psychiatric clinics that want to make specific treatments accessible to most patients insofar as possible. Thus, brief CBT therapy in a group format is an alternative to

Department of Mental Health and Psychiatry, University Hospitals of Geneva, CheˆneBourg, Geneva, Switzerland. Send reprint requests to Adriano Zanello, MA, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Belle-Ideé, ch. du Petit Bel-Air 2, 1225 Cheˆne-Bourg, Geneva, Switzerland. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0144 DOI: 10.1097/NMD.0000000000000084

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individually tailored CBT treatments. Several studies have considered group CBT for voices. Many of them showed some evidence that group CBT tends to reduce negative and anxiogenic beliefs about AVHs either at the level of frequency or at the level of content and degree of conviction (e.g., Chadwick et al., 2000b; Dannahy et al., 2011; McLeod et al., 2007; Pinkham et al., 2004; Trygstad et al., 2002). Group CBT also has beneficial effects on depression, anxiety, distress, self-esteem, social behavior, coping skills, and readmission at 6 months (Barrowclough et al., 2006; Bechdolf et al., 2004; Dannahy et al., 2011; Gledhill et al., 1998; Newton et al., 2005; Perlman and Hubbard, 2000; Trygstad et al., 2002; Wykes et al., 2005, 1999). However, some studies found that group CBT has no effect on AVH frequency and beliefs about voices (Gledhill et al., 1998; Lee et al., 2002; Newton et al., 2005; Penn et al., 2009; Wykes et al., 2005, 1999). Divergences among the findings reported by the studies reviewed may be explained by methodological and therapeutic factors. For instance, there is a huge difference in design (descriptive, quasi-experimental, and randomized and a sample size that varied from 4 to 72), age of individuals included (young, adults, and older patients), assessments, and type of group. Hence, at present, it is not certain that providing group CBT contributes to alleviating AVHs. In addition, premature terminations are quite common in CBT for psychosis; the rates vary from 0% to 45% (Wykes et al., 2008). Reducing the likelihood of dropouts is crucial to avoid a situation in which psychologically vulnerable patients hearing voices experience a sense of treatment failure, which may have deleterious consequences for other therapies that they might be offered in the future. Several strategies could be incorporated into clinical practice to prevent the risk for dropouts (see Ogrodniczuk et al., 2005). However, with patients hearing voices, it is important to consider how they experience their AVHs, how they manage them, and the nature of the frame of reference (e.g., medical, relationships, spiritual) that they use to account for the voices (Romme and Escher, 1998). Although this individual subjective dimension of AVHs is considered to be the core aspect of the therapeutic alliance contributing to treatment adhesion (Hayward and Fuller, 2010), previous group CBT for AVH studies has paid little attention to it. This may in part explain the rates of early termination of therapy. Therefore, more research is needed before using group CBT for AVHs as routine treatment in addition to pharmacotherapy (Wykes, 2004). Moreover, in psychotherapy, research efficacy studies have to be completed by effectiveness studies in clinical settings (Chambless and Hollon, 1998). The aim of the present study was to clarify further the effectiveness of a brief time-limited specific group CBT for AVHs after preparing the patients for therapy. In accordance with the literature reviewed, we hypothesized that group CBTwould lessen the severity of general psychopathology, particularly AVHs; reduce dysfunctional beliefs about AVHs; and enhance the self-esteem, social functioning, as well as QOL of patients hearing AVHs; by including an individualized specific indication that focuses on subjective experience of AVHs, we expected to avoid a high rate of dropouts.

The Journal of Nervous and Mental Disease

& Volume 202, Number 2, February 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.



METHODS Sample Forty-one patients from different independent outpatient units at the University Hospital of Geneva Department of Psychiatry (Switzerland) were referred to the ‘‘Voices Group’’ (see Intervention) by their case manager or psychiatrist if they were experiencing refractory and distressing AVHs. Diagnoses were reported by a review of the patients’ charts and verified by administration of the Mini-International Neuropsychiatric Interview, version 5 (MINI, Sheehan et al., 1998), to screen for current or history of formally diagnosable psychiatric disorders and substance abuse or dependence. Patients with a primary neurological, organic, or developmental disability; outside the age range of 18 to 65 years; with difficulties understanding French; and with psychotic symptoms or behaviors interfering with group process (e.g., severe disorganization, agitation, suicidal ideation, hostility, antisocial and psychopathic behaviors, alcohol or substance abuse before attending the group session) were excluded.

Measures Subjective experience about voices was examined during the indication phase between baseline and pregroup assessment. The efficiency of treatment was evaluated using a battery of questionnaires repeated at four points in time.

Subjective Experience About Voices The Maastricht Voices Interview for Adults The Maastricht Voices Interview for Adults (MAVIA; Romme and Escher, 2000) is an exhaustive semistructured interview that examines the subjective experience of voices (e.g., origins, content, beliefs, sources, perception, emotional reactions, and coping strategies) and stressful life events, which also includes traumatic life experiences. The MAVIA provides information, which was summarized in the following categories, as proposed by Escher et al. (2002): a) first occurrence of voices (G15, 15Y29, or 929 years); b) number of voices (1 or 91); c) frequency of voices (frequent, almost every day; occasional, weekly or monthly); d) source of voices (external, internal, or both); e) dialogue with voices (present or absent); f ) emotional content of voices (positive, negative, or variable); g) attribution of voices (real person, spirit/ghost, symptom of an illness, or one aspect of own personality); h) coping (cognitive, behavioral, or physical); i) problems caused by voices (present or absent); j) triggers (present or absent); and k) emotional, physical, and sexual abuse during childhood (present or absent). Three clinicians scored a random sample of 27 MAVIA transcripts independently. Mean pairwise Cohen’s kappa coefficients were calcuated for each MAVIA category. The Cohen’s J values ranged from 0.64 to 0.95, with a mean of 0.80 indicating substantial agreement between assessors.

Repeated Measures The Brief Psychiatric Rating ScaleYExpanded, Version 4.0 The Brief Psychiatric Rating ScaleYExpanded, Version 4.0 (BPRS 4.0; Ventura et al., 1993), is a semistructured interview assessing the severity of psychopathology. It comprises 24 items, rated on a scale from 1 (absent) to 7 (extremely severe). The French version of the BPRS 4.0 was used (Zanello et al., 2004, unpublished manual). Besides the total score and the mean subscore for ‘‘positive,’’ ‘‘negative,’’ ‘‘anxiodepressive,’’ and ‘‘manic-hostility’’ dimensions (Kopelowicz et al., 2008; Ventura et al., 2000), we also considered separately the scores for the items ‘‘hallucinations’’ and ‘‘unusual thoughts.’’ For the global BPRS 4.0 score, interrater reliability assessed with intraclass correlation coefficient (ICC; Shrout and Fleiss, 1979) was excellent (ICC, 0.87). * 2014 Lippincott Williams & Wilkins

Brief Group CBT for AVH

The Beliefs About Voices Questionnaire Revised The Beliefs About Voices Questionnaire Revised (BAVQ-R; Chadwick et al., 2000a) is a 35-item self-report questionnaire assessing beliefs about voices. A mean score was calculated for the following subscales: ‘‘benevolence,’’ ‘‘malevolence,’’ and ‘‘omnipotence’’ beliefs about AVHs as well as ‘‘engagement’’ and ‘‘resistance’’ coping strategies. Each item is rated on a 4-point scale from 0 (disagree) to 3 (agree strongly). The French version of the BAVQ-R has adequate internal consistency (> = 0.74) and construct validity and concurrent validity (Monestes JL, Vavasseur-Desperriers J, Villatte M, Denizot L, Loas G, Rusinek S Influence de la re´sistance aux hallucinations auditives sur la de´pression: e´tude au moyen du questionnaire re´vise´ des croyances a` propos des voix [submitted for publication]).

The World Health Organization Quality of LifeYBREF The World Health Organization Quality of LifeYBREF (WHOQOLBREF; WHOQOL Group, 1996) contains 26 self-rated items assessing the QOL during the previous 2 weeks. The following scores were taken into account: overall perceptions of QOL and general health items rated on a 5-point scale from 1 to 5 as well as ‘‘physical,’’ ‘‘psychological,’’ ‘‘social relationships,’’ and ‘‘environmental’’ QOL dimensions. Dimensional scores may vary from 0 to 100, with higher scores indicating better QOL. The WHOQOL-BREF French version has acceptable internal consistency (> values range from 0.59 to 0.74; Baumann et al., 2010).

The Self-Esteem Rating ScaleYShort Form The Self-Esteem Rating ScaleYShort Form (SERS-SF; Lecomte et al., 2006; Nugent and Thomas, 1993) is a self-rated 20-item questionnaire, scored from 1 (never) to 7 (always), that independently investigates positive and negative self-esteem. The French version of the SERS-SF possesses good internal consistency (Cronbach’s > Q 0.87), test-retest reliability (r Q 0.90), and convergent validity (r Q 0.72; Lecomte et al., 2006); it also has good sensibility to change (Borras et al., 2009).

The Clinical Global Impression The Clinical Global Impression (CGI; Guy, 1976) is a singleitem instrument measuring general illness severity on a 5-point Likert scale. Higher scores indicate higher severity. The CGI French version was used (von Frenckell, 1996). The ICC calculated from a set of 20 patients independently coded by three clinicians was 0.87, indicating strong agreement.

The Global Assessment Functioning Scale The Global Assessment Functioning (GAF; American Psychiatric Association, 1994) is a single-item measure of overall current psychological, social, and occupational functioning. The score may vary from 0 to 100, with higher scores indicating better global functioning. The GAF French version was used (Boyer, 1996). Clinicians assessed the GAF of 20 patients independently. The ICC was 0.69, indicating moderate agreement.

Procedure Study Design A noncontrolled repeated-measures naturalistic study design, in which each patient acted as his/her own control, was followed. Because the whole intervention comprised three components: an indication, an active ingredient (group CBT therapy), and follow-up phase, assessments were repeated at baseline (time 0 = T0, 6 weeks before the group), pretreatment (time 1 = T1, 1 week before the group), posttreatment (time 2 = T2, 1 week after the group), and follow-up (time 3 = T3, 6 months after the group), except for the www.jonmd.com


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MINI and the MAVIA, which were administered once during the indication phase (T0YT1). Three clinical psychologists who were not blinded to group allocation assessed the patients. Data collection took place from February 2007 to December 2009. During this period, six small groups were conducted, each consisting of three to seven patients. The local ethics committee approved the study. The patients participated in the study only after receiving detailed information about it and signing a written consent document.

Intervention

using the paired Wilcoxon’s rank test to compare differences between assessment time points. Data were analyzed with the Statistical Package for the Social Sciences version 17. The magnitude of change was estimated by calculating the effect size (ES) and interpreted as small, 0.20 or higher; medium, 0.50 or higher; and large, 0.80 or higher, according to Cohen (1988). In addition, we applied the reliable change index (RCI) and clinical significance (CS) criteria of Jacobson and Truax (1991) to verify whether changes occurring were attributable to the intervention rather than to measure error. The ES, RCI, and CS were computed with the ClinTools Software, version 4.1 (Devilly, 2007).

Indication Phase

RESULTS

Because patients are often reluctant to speak about AVHs and ask for help (Escher, 1998), there is an initial need to establish a therapeutic alliance and to understand the global and historical context of appraisal of voices in each patient. Therefore, the patients participated in an individualized indication phase to minimize the likelihood of dropouts and ensure group attendance. The indication phase included a) formal assessment (as presented above); b) education about the aims of group therapy, realistic expectations about group therapy, possible difficulties of group attendance, possible relationships between voices, self-esteem and QOL, and the time-limited nature of the group; and c) utilization of the MAVIA not only to gather subjective information but also to enable patients to make sense of their voices in a secure relationship with a clinician. Clinicians encouraged the patients to explore the roots of their voices in a warm and secure atmosphere, developing a strong therapeutic alliance. Two or three 1-hour sessions were necessary to complete the MAVIA, which took place before the preintervention assessment.

Group Therapy The Voices Group is a brief closed group therapy that followed the manual produced by (Wykes et al. 1999) adapted to the French context. It comprised seven sessions delivered once a week, lasting 12 hours. Each session focused on a main topic about AVHs, namely, session 1: ‘‘engagement and information sharing about voices’’; session 2: ‘‘models of psychosis’’; session 3: ‘‘models of voices’’; session 4: ‘‘coping strategies’’; session 5: ‘‘voices as a stigma, effects of medication and drugs’’; session 6: ‘‘self-esteem’’; and session 7: ‘‘overall model of coping with voices.’’ Relevant information was written on the flip chart to enable memorization and to follow the group process. Group facilitators were active, asking questions, and repeating and summarizing information in a low-stress group atmosphere. Homework was assigned to the patients. It was impossible to take into account treatment quality and adherence, given some patients’ reluctance to be audiotaped or videotaped and technical constraints. Two psychotherapists (two psychologists or one psychologist and one nurse) trained in CBT led the groups.

Treatment as Usual During the study, all patients continued to receive treatment as usual (TAU). This generally consisted of regular appointments (every 2 or 3 weeks, or at a higher frequency when necessary) with a psychiatrist, nurse, and social worker if needed. TAU also included antipsychotic medication at a dosage that could be changed when clinically required. Because TAU was delivered before and throughout the study, it has been hypothesized to be ineffective on outcome measures.

Statistical Analysis Owing to the small sample size, distribution-free univariate statistics were used for comparisons of the variable distributions between ‘‘completer’’ and ‘‘noncompleter’’ groups (chi-square test and Wilcoxon’s rank test). Efficacy of the Voices Group was verified by applying Friedman’s analysis of variance for repeated measures. For statistically significant variables, we also computed post hoc analysis 146


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Patients Forty-one patients fulfilled the inclusion criteria. They agreed to participate in the study and were assessed at baseline. Three patients dropped out before the end of the first assessment. Thus, a group of 38 patients participated in the baseline assessments. This group, 42% of whom were women, showed the following sociodemographic characteristics: patients were middle aged (mean, 40 years; SD, 9), had a long duration of illness (mean, 12 years; SD, 7), and had been hospitalized for a mean of 7 times (SD, 10). According to ICD-10, 71% met the diagnostic criteria for schizophrenia; and 29%, for schizoaffective disorders. Moreover, 24% (n = 9) were substance misusers, that is, abuse of alcohol or of illicit drugs. Pharmacological treatment was offered to the patients: 50% received a new antipsychotic; 37% received combined antipsychotic; and 55% received anxiolytic, mood stabilizer, hypnotic, or antidepressant medication. One fourth lived (24%) in halfway houses; one half (53%), alone; and the others (23%), with their parents. Most were single (71%), 21% were divorced, and 5% were married. Most of them were on welfare (87%). Only 34% had achieved professional training. Currently 71% did not have paid employment, 11% worked in sheltered houses, and 18% had paid employment (part time). During the intervention (n = 15, 39%), the patients dropped out (noncompleter group), most of them (n = 13, 87%) before group intervention and two before the first three group sessions. Thus, group attrition left 23 patients who completed treatment and assessments at baseline, pregroup and postgroup, and follow-up (completer group).

Differences Between the Completer and Noncompleter Groups The completer and noncompleter groups were compared at baseline. As shown in Table 1, none of the comparisons reached statistical significance either in sociodemographic or in clinical characteristics (all p 9 0.10). According to the variables extracted from the MAVIA, presented in Table 2, the patients in the completer group never hear voices with positive emotional content and have more varied explanations for their voices. They are also more likely to consider their voices as a symptom of an illness and to hear only one voice. There were no differences for other MAVIA dimensions.

Effectiveness of the Intervention Table 3 presents descriptive statistics across assessment times on outcome variables for the completer group. Friedman’s analysis of variance showed a significant decrease in the hallucinations item and total symptoms severity score of the BPRS 4.0 without the hallucination item (p = 0.006), but we should mention that none of the difference survived to Bonferroni’s correction for multiple comparisons. No other changes reached statistical significance. Assessment of hallucinations and the BPRS 4.0 was performed using post hoc analyses. Results are presented in Table 4. Concerning hallucinations, the reduction in their severity occurred from baseline to posttreatment with a medium ES. This picture persisted from * 2014 Lippincott Williams & Wilkins





TABLE 1. Demographic and Clinical Characteristics by Completer and Noncompleter Groups Completers n = 23

Diagnosis Schizophrenia Schizoaffective disorder Substance abuse Sex Male Female Living conditions Halfway houses Alone With the family Under guardianship Marital status Single Married Divorced/separated Professional training Activity None Sheltered In the community Receive disability benefits Age in years Illness duration in years No. hospitalizations Severity of the illness (CGI) Psychiatric symptoms severity (BPRS 4.0) Hallucinations item Unusual thoughts item Positive score Negative score Anxiodepressive score Manic-hostility score Total score Beliefs about voices (BAVQ-R) Omnipotence Malevolence Benevolence Resistance Engagement Self-esteem (SERF-SF) Positive Negative Psychosocial functioning (GAF) QOL (WHOQOL-BREF) Overall QOL Overall general health Physical Psychological Social relationships Environment

* 2014 Lippincott Williams & Wilkins

Noncompleters %

n = 15

Statistics %

W

2

df

p

16 7

61 39

11 4

73 27

0.06

1

0.80

14 9

61 39

8 7

53 47

0.21

1

0.65

6 14 3 4

26 61 13 17

3 6 6 1

20 40 40 7

3.68 0.91

2 1

0.16 0.34

18 1 4 8

78 4 17 35

9 1 4 5

60 7 27 33

0.86 0.04

2 1

0.65 0.85

65 17 17 87 Median 41 14 3 5

12 0 3 13 Mean (SD) 38 (10) 10 (6) 3 (3) 4 (1)

80 0 20 87 Median 37 7 2 4

2.92 0.01 z j0.76 j1.30 j0.92 j1.32

2 1

0.23 0.98

15 4 4 20 Mean (SD) 41 (9) 13 (8) 8 (12) 4 (1)

0.46 0.20 0.38 0.18

5.3 (1.2) 4.3 (1.3) 2.8 (0.6) 2.2 (1.1) 3.1 (1.3) 1.4 (0.4) 54 (12)

6 4 2.8 2.2 3 1.3 52

5.1 (1.1) 4.3 (1.6) 2.7 (0.5) 2.0 (1.0) 2.7 (1.2) 1.3 (0.3) 50 (8)

6 4 2.6 1.7 2.8 1.2 52

j0.47 j0.08 j0.62 j0.28 j0.93 j0.09 j0.88

0.68 0.94 0.55 0.80 0.37 0.10 0.38

1.9 (0.7) 2.0 (0.8) 0.7 (0.8) 2.0 (0.7) 0.8 (0.7)

2.2 2.1 0.5 2.1 0.4

1.7 (0.6) 1.8 (0.8) 0.5 (0.6) 2.0 (0.7) 0.6 (0.5)

1.7 2.2 0.2 2.2 0.5

j0.89 j0.57 j0.73 j0.26 j0.37

0.38 0.57 0.49 0.80 0.73

38 (9) 39 (12) 43 (15)

37 40 40

40 (11) 31 (13) 44 (11)

41 31 45

j0.50 j1.68 j0.53

0.63 0.16 0.61

52 (27) 39 (21) 52 (24) 48 (24) 47 (24) 59 (17)

50 50 57 54 42 56

55 (27) 50 (31) 51 (21) 49 (20) 43 (24) 54 (21)

50 50 57 54 50 61

j0.31 j1.22 j0.34 j0.25 j0.70 j0.71

0.77 0.25 0.75 0.82 0.49 0.49

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baseline to follow-up. Interestingly, we found a strong trend with a small ES for the group therapy intervention alone. The other post hoc analyses did not reach statistical significance. Regarding total symptom severity (minus the item hallucination), the decrease occurred from baseline to follow-up with a medium ES. The other post hoc analyses failed to reach statistical significance.

Reliable and Clinically Significant Change Because inferential statistical analyses do not provide complete information about the intervention, we performed RCI and CS. Because there is a lack of normative data for general population for BPRS 4.0 score, to calculate RCI and CS, we used data drawn from less severe patients, as recommended by Evans et al. (1998). Thus, a sample (n = 99) of patients with unipolar depression having completed a 6- to 8-week intensive intervention was considered as the referential group (Zanello et al., 2013). This group has a mean (SD)

BPRS 4.0 total score (without the hallucination item) of 38.95 (9.34) and a mean (SD) hallucination item score of 1.26 (0.73). The BPRS 4.0 Cronbach’s > was 0.80, and the hallucination item test-retest correlation was 0.60. The criteria chosen were the RCI z-score of less than or equal to 1.96 or greater than or equal to 1.96 and the CS cutoff between the referential group and clinical mean with at least 95% confidence. Outcome of each patient was classified as recovered if both RCI and CS criteria were met, improved if only RCI criteria were met, unchanged if none of the two criteria were met, or deteriorated if RCI criteria were met in the negative direction (Wise, 2004). As shown in Table 4, changes were observed throughout the different phases of intervention. For the hallucination item, some improvements were already observed during the indication phase. The proportion of reliable improvements increased after group therapy, whereas some patients improved at follow-up. Few patients deteriorated during the intervention. For the BPRS 4.0 global score

TABLE 2. MAVIA Scores for Completer and Noncompleter Groups, Descriptive Statistics, and Results of the Comparisons Completers a

a. First occurrence of voices G15 yrs 15Y30 yrs 930 yrs b. No. voices 1 voice 91 c. Voices frequency Daily d. Source of voices Internal External Both e. Presence of a dialogue with voices f. Emotional content Positive Negative Variable g. Attribution of voices Real person Spirit/ghost Symptom of illness One aspect of personality Median no. attributions h. Coping Cognitive Behavioral Physical i. Coping efficiency None Little Moderate High j. Disturbed in functioning by voices k. Presence of triggers l. Abuse (sexual, emotional, or physical) a

148

Noncompleters

n = 22

%

n = 13a

%

6 11 5

27% 50% 23%

1 8 4

5 17

23% 77%

15

Statistics

df

p

8% 62% 31%

W2 = 1.97

2

0.37

0 13

0% 100%

W2 = 3.45

1

0.06

68%

6

46%

W2 = 1.65

1

0.20

7 8 7 14

32% 36% 32% 64%

6 3 4 11

46% 23% 31% 85%

W2 = 1.09

1

0.30

W2 = 0.91 W2 = 1.76

2 1

0.63 0.18

0 12 10

0% 55% 45%

3 8 2

23% 62% 15%

W2 = 7.03

2

0.03

16 18 17 9 3

73% 82% 77% 41% 14%

6 9 6 4 1

46% 69% 46% 31% 8%

W2 = W2 = W2 = W2 = z=

1 1 1 1

0.12 0.39 0.06 0.55 0.04

19 20 17

86% 91% 77%

13 10 5

100% 77% 38%

W2 = 0.29 W2 = 1.25 W2 = 0.01

1 1 1

0.59 0.26 0.98

11 8 2 1 18 21 14

50% 36% 9% 5% 82% 95% 64%

7 4 2 0 11 10 5

54% 31% 15% 0% 85% 77% 38%

W2 W2 W2 W2

1 1 1

0.88 0.83 0.10 0.11

= = = =

2.47 0.73 3.51 0.36 j2.12

j0.17 0.05 21.77 2.59

Missing data for three patients.

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TABLE 3. Means and Standard Deviations for the 23 Completers at the Four Time Points and Results of the Comparisons Time 0

Time 1

Mean

SD

Time 3

Friedman’s Variance Median Mean SD Median Mean SD Median Mean SD Median Analysis df

Baseline

Severity of the illness (CGI) 3.4 0.7 Psychiatric symptoms severity (BPRS 4.0) Hallucination item 5.3 1.1 Unusual thoughts item 4.4 1.3 Positive score 2.8 0.6 Negative score 2.1 1.0 Anxiodepressive score 3.1 1.3 Manic-hostility score 1.4 0.4 Total score without hallucination 49 11 item Beliefs about voices (BAVQ-R) Omnipotence 1.9 0.7 Malevolence 1.9 0.8 Benevolence 0.7 0.8 Resistance 2.0 0.7 Engagement 0.8 0.7 Self-esteem (SERS-SF) Positive 38 10 Negative j39 12 Psychosocial functioning (GAF) 42 15 QOL (WHOQOL-BREF) Overall QOL 54 28 Overall quality of health 39 21 I. Physical 53 24 II. Psychological 48 23 III. Social relationships 47 23 IV. Environment 59 18

Time 2

Pregroup

Postgroup

6-Months Follow-up

p

4

3.4

0.9

4

3.3

1.1

3

3.2

1.0

3

0.82

3

6 4 2.9 2.3 3.0 1.3 47

5.1 4.3 2.8 2.1 2.7 1.3 46

1.2 1.3 0.6 0.9 1.2 0.3 11

5 4 2.7 2.0 2.5 1.2 46

4.6 4.1 2.6 2.2 2.8 1.3 46

1.5 1.4 0.7 0.9 1.4 0.3 11

5 4 2.4 2.7 2.5 1.2 46

4.7 4.0 2.5 1.9 2.7 1.3 44

1.5 1.7 0.7 1.0 1.2 0.4 9

5 4 2.6 1.7 2.7 1.2 44

8.52 5.01 2.08 1.56 2.60 3.38 12.62

3 0.04 3 0.17 3 0.56 3 0.67 3 0.46 3 0.34 3 G0.01

2.2 2.0 0.5 2.0 0.6

1.9 1.9 0.7 1.9 0.7

0.7 0.6 0.7 0.8 0.6

2.0 2.0 0.6 2.2 0.5

1.9 1.8 0.5 1.9 0.6

0.7 0.8 0.7 0.8 0.7

1.8 2.0 0.2 2.0 0.4

1.7 1.7 0.7 2.0 0.7

0.6 0.8 0.8 0.7 0.6

1.8 1.7 0.2 2.0 0.4

3.99 2.65 6.82 2.67 2.63

3 3 3 3 3

0.26 0.75 0.08 0.80 0.52

39 40 40

37 j37 44

9 13 12

36 40 40

37 j37 46

11 12 12

37 36 40

40 j37 46

12 11 12

41 35 45

2.39 3.92 2.97

3 3 3

0.49 0.27 0.40

50 50 57 54 50 62

52 41 52 47 45 60

26 25 17 23 21 18

50 50 57 46 50 56

55 42 50 46 46 61

28 23 18 20 20 20

50 50 54 46 42 66

57 46 53 45 43 62

22 21 18 19 23 19

50 50 54 46 42 66

1.18 2.51 0.10 0.78 1.16 3.59

3 3 3 3 3 3

0.76 0.47 0.99 0.86 0.76 0.31

(minus the hallucination item), the proportion of patients who improved remains very similar during the different intervention phases. A fifth of the patients deteriorated during group therapy and at follow-up.

0.85

However, it is worthwhile to mention that for both variables, the evolution seems better when the whole intervention was considered (baseline versus postgroup and baseline versus follow-up).

TABLE 4. Results of the Post hoc Comparisons, Frequencies, and Percentage of Reliable Change and CS Across Time Assessments Wilcoxon

Hallucinations A B C D E BPRS 4.0 totala A B C D E

Deteriorated

Unchanged

Improved

Recovered

z

p

ES

n

%

n

%

n

%

n

%

j1.20 j1.95 j0.29 j2.40 j1.99

0.23 0.051 0.77 0.02 0.05

0.08 0.37 0.07 0.52 0.44

1 1 3 2 2

4.34 4.34 13.04 8.69 8.69

19 15 16 13 15

82.60 65.21 69.56 56.52 65.21

3 5 4 5 3

13.04 21.73 17.39 21.73 13.04

0 2 0 3 3

0.00 8.69 0.00 13.04 13.04

j1.83 j0.27 j1.27 j1.83 j2.21

0.07 0.78 0.20 0.07 0.03

0.27 0.00 0.19 0.27 0.50

0 5 5 1 0

0.00 21.73 21.73 4.34 0.00

18 12 12 19 17

78.26 52.17 52.17 82.60 73.91

4 3 3 2 4

17.39 13.04 13.04 8.69 17.39

1 3 3 1 2

4.34 13.04 13.04 4.34 8.69

a

BPRS total score minus hallucination item score. A indicates indication phase T0 versus T1; B, group therapy T1 versus T2; C, Group follow-up T2 versus T3; D, therapy as a whole T0 versus T2; E, therapy as a whole follow-up T0 versus T3.


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The individual outcomes during the intervention (baseline to postgroup and/or 6-months follow-up) were closely inspected. For the severity of hallucination, 3 patients (13%) worsened and 1 (4%) of them returned to baseline level, 11 (48%) improved but 5 (22%) of them returned to baseline level, and 9 (39%) did not change. For the total BPRS 4.0 score (minus the hallucination item), 1 (4%) worsened and returned to baseline level, 9 (39%) improved, 3 (13%) of them returned to baseline, and 13 (56%) did not change. Thus, for both measures, six patients (26%) showed reliable improvement and have similar scores to those observed in the depressive patients.

Without them I would be totally alone and I cannot stand loneliness’’). Most patients (n = 20; 87%) liked the small group size. They suggested that the optimal group should not exceed four participants. They thought that a group of this size would enable everyone to have the attention of the group leaders and more opportunity to talk about their experiences. All of them appreciated the general information about AVHs delivered in the first group sessions and the intimate experiences about voices shared with others without being judged as ‘‘mad’’ or as a less valuable person. Of the seven group sessions, the one focused on self-esteem was the most appreciated.

Homework

TAU Effect

Homework assignments are considered an essential ingredient of CBT. Thus, we assigned an individualized task to each patient. The participants were encouraged to test the reality of their voices (session 3) and to practice regularly one of the novel coping strategies (e.g., humming, singing, listening to music, scheduling a time to listen to voices, talking to someone, reading, reading out loud, ignoring the voices, painting, exercise-fitness, ear plugs) learned in sessions 4, 5, and 6. Homework was completed at least once by 17 patients (74%).

Because we observed a reduction in general psychopathology during the indication phase, we examined the potential confounding effects of the TAU throughout the three phases of the study. Unfortunately, it was impossible to know whether the patients were offered more appointments during the study. Therefore, we considered the changes in medication prescriptions only. Given the heterogeneity of medications and doses prescribed, two independent senior psychiatric pharmacologists (P. H. and P. R-B.) were asked to rate the potential clinical effect of medication changes through the time point assessments. Rating was carried out on a 5-point scale (0, none; 1, uncertain; 2, possible; 3, probable; and 4, important clinical change expected). There is moderate average agreement between the two assessors (ICC, 0.70). Changes between time points in dose prescription were modest: baseline versus pretreatment: mean, 1; SD, 1.06; pretreatment versus posttreatment: mean, 0.82; SD, 1.11; posttreatment versus follow-up: mean, 0.89; SD, 1.05, and do not reach statistical significance (Friedman’s analysis of variance, W2 = 0.45, df = 2, p = 0.80).

Group Attendance Regarding group attendance, nearly half of the patients (n = 10; 44%) participated in the seven group sessions. Of the 13 patients (57%) who missed group sessions, 9 (39%) missed one, 2 (12%) missed two, and 2 (12%) missed three sessions. Some of these absences were planned before the group started (e.g., appointment with a general practitioner or social insurance authorities).

Dropouts Given the high percentage of dropouts during the treatment phase, we were interested in examining the reasons for these premature terminations. These are summarized in the following categories: a) voices (n = 5): one patient was not allowed by his voices to participate in the group, three patients experienced an exacerbation in the frequency and intensity of their voices, and one was ashamed of the content of his voices; b) other psychotic symptoms (n = 2): suspicion, unusual thoughts, and disorganization were too severe to enable group attendance, leading one patient to be hospitalized; c) physical illness (n = 2): one patient was admitted to a general hospital for a serious cardiovascular disease; one patient died (accident); d) conflict with other therapies (n = 2): one left the group after four sessions because her nurse offered her therapy for her voices in an individual setting, and one was admitted to a special unit for substance abuse; e) move (n = 2): one patient left Switzerland and one moved outside the Geneva area; and f ) unknown (n = 3). Two of these patients had to be admitted for a long stay in an acute psychiatric unit. It is important to mention that only two patients dropped out during the voice group.

Participants’ Perspective on the Group The participants’ perspective was explored at the last group session and during the postgroup assessment conducted by informal interview. Several participants acknowledged the usefulness of the Voices Group because they learned and tried new coping skills for AVHs. However, this seemed to be a minor consideration compared with the value of meeting other hearers of voices. Some asked (n = 17; 74%) for a group that focused on voices to be continued, and 10 patients (44%) attended an open-ended Voices Group. Despite this positive attitude, some found it difficult to participate in group sessions because of social anxiety, because of their command voices (e.g., ‘‘Voices don’t let me participate in groups’’), or because they were scared to lose their voices (e.g., ‘‘I don’t want to get rid of my voices. 150

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DISCUSSION This naturalist study examined the hypothesis that brief group CBT has a positive effect not only on AVHs but also on secondary outcome measures such the severity of positive, negative, anxiodepressive, and manic-hostility symptoms; beliefs about voices; QOL; self-esteem; and global functioning in a group of outpatients with schizophrenia or schizoaffective disorders. The main findings only partially corroborated this general hypothesis. First, as expected, the intervention contributed to reducing the severity of voices from baseline to posttest. This effect is maintained at 6-months follow-up. Part of this effect may be attributed to the Voices Group. In fact, there was a strong statistical trend ( p = 0.051) indicating that the voice group as such tends to have beneficial effects on hallucinations. Nevertheless, the gains were modest as shown by the ES. The ESs are similar to those reported in a recent meta-analysis of studies of CBT for positive symptoms in psychosis (Wykes et al., 2008). These findings support those of previous studies evidencing that group CBT has a positive effect on AVHs (e.g., Dannahy et al., 2011; McLeod et al., 2007; Trygstad et al., 2002; Wykes et al., 1999). More interestingly, as demonstrated by individual reliable improvement analyses, 26% of the patients clearly benefited from the intervention. It should be mentioned that in few cases, the intervention seems to be harmful. Second, a significant decrease in the severity of general psychopathology was observed only at follow-up. Thus, this result could be attributed to not only the impact of the Voices Group alone but also the intervention as a whole. It is unlikely that this reduction was caused by medication because changes in doses prescribed were considered to be very weak in clinical terms. Probably, it could be explained by methodological factors (e.g., nonblinded assessment) and by nonspecific therapeutic factors (Strupp and Hadley, 1979). Among the latter, we can mention the feeling that the experience of AVHs could be understood, respected, and accepted by clinicians without fear of negative consequences (e.g., MAVIA) as well as realistic * 2014 Lippincott Williams & Wilkins




expectations of the group treatment. Regarding general psychopathology, our finding contrasts with other studies (e.g., Barrowclough et al., 2006; Bechdolf et al., 2004, 2005; Pinkham et al., 2004; Wykes et al., 2005, 1999). Only two studies found results similar to ours (Newton et al., 2005; Penn et al., 2009). The reliable and clinically significant changes demonstrate that the intervention as a whole is beneficial for 26% of patients and has no adverse effect. However, during the Voices Group and during posttreatment and follow-up assessments, a nonnegligible proportion of patients deteriorated. It is thus likely that for some patients, short-term and intense Voices Group therapy enhances general distress (e.g., depression, anxiety, guilt, somatic concerns). Third, contrary to our expectations, the intervention did not improve self-esteem, QOL, beliefs about voices, severity of delusions, or other dimensions of psychopathology and psychosocial functioning. These findings corroborate those reported in several other studies showing that group CBT for voices has little influence on positive, negative, depression-anxiety, and mania-hostility symptom dimensions (Barrowclough et al., 2006; Chadwick et al., 2000b; Lee et al., 2002; Newton et al., 2005; Penn et al., 2009; Wykes et al., 1999); on beliefs about voices (Lee et al., 2002; Newton et al., 2005; Penn et al., 2009; Wykes et al., 1999); on self-esteem (Lee et al., 2002; Newton et al., 2005; Wykes et al., 2005, 1999); and on social functioning (Barrowclough et al., 2006; Newton et al., 2005; Penn et al., 2009). A possible explanation for this may be that the intervention was too specific and brief to expect significant improvement in such secondary outcome measures. Fourth, despite the preparation of the patients during the indication phase, we were unable to avoid a substantial proportion of premature terminations. However, only few dropouts occurred during the Voices Group, suggesting the importance of careful selection of the patients. The analysis of the dropouts indicated that the majority could be attributed to psychotic symptoms. Other studies also found high attrition rates (Bechdolf et al., 2005; Penn et al., 2009; Wykes et al., 1999), which are common in individuals with severe mental disorders (Borras et al., 2009). A similar proportion of premature terminations was also observed in anxiety disorders (Manicavasagar et al., 2004). This suggests that a high attrition rate is inherent to group therapy or to social anxiety rather than to diagnoses. Moreover, in group therapy literature, it is well known that ‘‘the percentage of premature terminators from group therapy ranges from 10% to as high as 50%. The majority of these dropouts occur within the first six sessions. This suggests that selection, composition and entry factors are responsible’’ (MacKenzie, 1990, p. 217). Of these factors, geographical location and the subjective characteristics of voices may explain the dropouts in this study. Because the patients came from several different psychiatric units located in various urban areas, it is possible that some patients found it too difficult to reach the unit where the intervention was delivered. In fact, some patients complained about their fear of using public transport facilities. Despite that, the completer and noncompleter groups shared very similar sociodemographic and clinical characteristics; they differed in some subjective features. The patients from the noncompleter group were less open to various beliefs about voices because they tended to have only one and they experienced their voices more positively, either cognitively or emotionally. These characteristics are known to be a barrier to treatment (Jenner et al., 2008). These patients may fear losing their voices, even if it is not the therapeutic goal of the intervention, and refuse or leave therapy. It is also possible that changing beliefs about voices, a key component of CBT for voices, is too challenging for some patients. A radical alternative explanation may be that the patients in the noncompleter group saw no purpose in the therapy because they had no or fewer problems associated with their voices. This interpretation is supported by recent findings in healthy individuals with AVHs who did not seek help and were not disturbed by hearing voices (Sommer et al., 2010). * 2014 Lippincott Williams & Wilkins


Finally, from the point of view of the participants’ perspective of the group, the intervention seemed to improve socialization and reduce the fear of sharing the experience of hearing voices with others. This may be viewed as a step toward ‘‘normalization,’’ which is another central feature of CBT treatments for some authors (e.g., Kingdon and Turkington, 1994).

Limitations The present study has several limitations. First, we do not rule out the possibility that the symptom reduction found here could be caused by factors other than intervention. For instance, we have not kept the dose of antipsychotic medication constant and controlled the number of consultations with health clinicians during the study phase. Second, we acknowledge that observation of the group is anecdotal. In the future, it would be appropriate to include specific scales for assessing group processes, satisfaction with therapy, and therapeutic alliance. Third, we did not examine changes in coping strategies occurring after the intervention. Finally, methodological weaknesses should also be mentioned: a) the assessments were not blind, which may have led to inflated ESs (Lynch et al., 2010; Wykes et al., 2008); b) the sample size was too small to permit generalization of the findings; and c) the study design could be criticized because no appropriate control group was included. Clearly, this highlights the need of other studies exploring more deeply the effectiveness of group CBT for voices hearers.

CONCLUSIONS This study suggests that the Voices Group English manual is easy to adapt and to apply in other languages than English and in different cultural contexts. The findings suggest that it could be a promising approach to reducing the severity of voices and to helping some patients make sense of their voices and share this experience with others. However, despite being effective, the intervention was clearly not sufficient to address the complexity of the difficulties faced by patients with a schizophrenia spectrum disorder. Thus, this specific intervention for AVHs should be integrated into a more comprehensive, planned, and flexible treatment that also addresses delusions, neurocognition, social cognition, self-esteem, social skills as well as leisure activities, supported employment, and independent living skills. This would probably help to enhance self-confidence, avoid stigmatization, and improve global social functioning as well as QOL. In our opinion, the intervention could also be refined so that it simultaneously provides individual and group therapies for AVHs to strengthen the improvements made in the group and to limit dropouts. In routine practice, clinicians may also consider Voices Group ingredients as techniques to use carefully in long-term slow-open group interventions especially for severely ill patients who reluctantly adhere to treatment. Future research should address these issues and supply longterm monitoring of the global efficiency and synergy of multiple interventions simultaneously proposed to patients with schizophrenia. DISCLOSURE The authors declare no conflict of interest. REFERENCES American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (DSM-IV) (4th ed). Washington, DC: American Psychiatric Association. Barrowclough C, Haddock G, Lobban F, Jones S, Siddle R, Roberts C, Gregg L (2006) Group cognitive-behavioural therapy for schizophrenia: Randomised controlled trial. Br J Psychiatry. 189:527Y532. Baumann C, Erpelding M, Re´gat S, Colin JF, Briançon S (2010) The WHOQOLBREF questionnaire: French adult population norms for the physical health,

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