Dr Rozmin Halari, Natalia Petros
&
RISE Ealing Assertive Outreach Team

 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….

 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

 Team decision
 Service user/carer involvement (needs assessment)
 Enables:
 Ownership


Support participation

 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


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Non compliance
Persistent residual positive symptoms
Seek other interventions

 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



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Difficult to engage
Non compliant/revolving door
Treatment resistant
No evidence of HVG in AOT

 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

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

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

 Assessment

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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

 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

 Continued use of illegal substances known to affect symptoms
 Alcohol misuse

 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

CHARACTERISTIC CBT
GROUP
(N=10)
CONTRO
L GROUP
(N=10)
TOTAL
GROUP
GENDER MALE/FEMALE 4/6 5/5 20
AGE
ETHNICITY
MEAN
SD
[RANGE]
BLACK AFRICAN
46.5
(9.76)
[33-67]
39.9
(9.07)
[27-55]
10% (1) 40% (4)
BLACK BRITISH 20% (2) 10% (1)
43.2
(9.77)
[27-67]
25% (5)
15% (3)
BLACK CARRIBEAN 0% (0) 10% (1) /5% (1)
WHITE BRITISH
SOUTH ASIAN
OTHER
20% (2)
40% (4)
10% (1)
20% (2)
10% (1)
10% (1)
20% (4)
25% (5)
10% (2)


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


Beck’s Depression Inventory II (BDI-II)(Beck et al., 1996)
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Severity of depression
21 items
Self reported depression
 Beck Cognitive Insight Scale (BCIS) Beck et al., 2004)

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2 subscales: self certainty and self reflectiveness
15 items
 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)
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
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Most and least useful
Presentation of sessions
Future improvements

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

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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

 Group CBT AH (Wykes et al., 1999)- manualised

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Engagement and sharing of information- voices
Psychoeducation; Exploring models of psychosis

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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

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

CHARACTERISTIC
DIAGNOSIS
MEDICATION
DURATION OF ILLNESS
Paranoid Schizophrenia
Schizoaffective Disorder
Bipolar Disorder
Atypical Antipsychotics
Typical Antipsychotics
Both Atypical and Typical
Antipsychotics
Anti-manic Medication
Antidepressants
Benzodiazepines
Side Effect Medication
1-10 Years
11-20 Years
21-30 Years
31-40 Years
4
1
6
2
1
3
1
1
CBT Group
8
2
4
0
0
6
N
Control Group
5
4
7
1
1
3
3
4
4
2
0
2
1
0
% OF TOTAL
25%
10%
5%
35%
25%
50%
20%
5%
65%
30%
5%
45%
55%
5%

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

MEASURES
CBT Group
PRE
MEAN SD
POST
MEAN SD
BAVQ BEN
BAVQ MAL
BAVQ RES
BAVQ ENG
PSYRATS
BCIS SC
BCIS SR
BCIS composite
BDI
8.1
8.1
11.7
9.8
28.6
22
11.7
10.3
22.5
3.5
3.1
4.6
6.2
5.6
3.7
2.3
4.96
7.5
7.1
6.2
10.6
7.9
23.8
21.3
12.1
9.2
18.8
3.6
3.1
3.3
4.6
3.9
4.1
2.5
5.73
7.1
MEAN
PRE
SD
Treatment as usual
POST
MEAN SD
7.5
7.7
12.3
10.4
26.2
21.7
11.6
10.4
18.8
2.1
2.6
3.1
4.2
6.5
5.8
4
9.1
4.9
7.8
7.6
12.8
10.5
26.5
21.7
11.6
9.7
19
2.3
3.1
3.6
4.3
6.9
5.8
4
9.15
4.5
BCIS Higher scores on self reflectiveness and BCIS composite reflects better insight
Lower scores on self certainty reflects better insight

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)

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)

 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)

 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



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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

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

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

 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?

•
•
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!!