Group Cognitive-Behavioral Therapy for Auditory Hallucinations: A Pilot Study

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Group Cognitive-Behavioral Therapy for Auditory Hallucinations: A Pilot Study

A m y E. P i n k h a m , A n d r e w T. Gloege, Steven F l a n a g a n , a n d David L. P e n n , University o f N o r t h Carolina at Chapel H i l l

In this article, we describe a pilot study that investigated the effectiveness of group cognitive behavioral therapy (CBT) for auditory hallucinations. Eleven inpatients with either chronic schizophrenia or schizoaffective disorder participated in 2 CBT groups of differ- ing treatment duration (i.e., 7 versus 20 sessions). The results showed that participation in both groups was associated with signifi- cant positive changes in the participants' beliefs about their voices and with a trend for reduced negative reactions to the voices. These changes were not a function of premorbid cognitive functioning. Finally, duration of treatment did not affect participants' beliefs or distress associated with the voices. Implications for future clinical research in this area are discussed.

UDITORY HALLUCINATIONS occur frequently among individuals who have been diagnosed with schizophrenia and are a defining feature of the disorder. In fact, 16 studies, reviewed by Slade and Bentall (1988), indicate that, on average, 60% of individuals who are diagnosed with schizophrenia experience auditory hallucinations.

These hallucinations vary widely in the number of voices an individual hears, the physical characteristics of the voices, and the content of what the voices say; however, individuals who hear hallucinations often describe the experience as distressing, which is consistent with evidence that abusive language is the most common form of auditory hallucination (Nyani & David, 1996). Additionally, some researchers postulate that auditory hallucinations may contribute to and maintain depression and low self-esteem in individuals with schizophrenia (Wykes, Parr, & Landau, 1999).

The first line of treatment for auditory hallucinations is andpsychotic medication; however, estimates indicate that as many as 25% to 50% of individuals with schizophrenia experience residual positive symptoms of psychosis, despite proper levels of medication (Kane &

Marder, 1993; Pantelis & Barnes, 1996; WiersIna, Nien- huis, & Sloof, 1998). Given the periodic medication resis- tance of auditory hallucinations, several psychological interventions have been explored. These interventions have employed thought stopping, exposure with anxiety reduction, self-monitoring, and distraction techniques such as listening to music, subvocal counting, or wearing earplugs (see Haddock et al., 1998; Shergill, Murray, &

McGuire, 1998, for reviews). Recently, several new ap- proaches have been adapted from cognitive behavior

Cognitive and Behavioral Practice 11, 9 3 - 9 8 , 2 0 0 4 107%7229/04/93 -9851.00/0

[~ Continuing Education Quiz located on p. 131.

therapy (CBT) that appear to be beneficial. Controlled trials of individual CBT for psychosis indicate that this ap- proach has been successful in reducing overall symptoms (see Bustillo, Lauriello, Horan, & Keith, 2001; Gould, Mueser, Bolton, Mays, & Goff, 2001; Norman & Towns- end, 1999, for reviews). Further, randomized controlled trials of individual CBT have demonstrated that individuals who receive CBT are more likely to maintain improve- ment during follow-up than individuals who receive other forms of treatment. Sensky et al. (2000) compared individual CBT to a nonspecific befriending intervention and found that at the end of treatment, both interventions led to significant clinical improvements in which both positive and negative symptoms were reduced; however, only the CBT group maintained these gains at a 9- month follow-up (see Tarrier et al., 1999, 2000, for excep- tions). Similarly, a study comparing individual CBT with standard care demonstrated that for the CBT group, a reduction in the frequency of auditory hallucinations as well as the intensity of and distress associated with these hallucinations was evident at a 9-month follow-up (Kuipers et al., 1998). These findings indicate that individual CBT for residual symptoms is especially effective for reducing auditory hallucinations (Tarrier et al., 2001).

The success of individual CBT has prompted researchers to examine more efficient means of administer- ing CBT for residual psychotic symptoms. One such way is to present the intervention in a group format, and the few studies that have examined group CBT have reported positive findings. Gledhill, Lobban, and Sellwood (1998) found that a group CBT intervention was associated with participants being better able to cope with symptoms, and having lower depression, higher self-esteem, and greater knowledge about schizophrenia. Wykes et al.

(1999) utilized a wait-list control design and reported that following group CBT, participants reported a reduction in the experience of auditory hallucinations and an

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94 Pinkham et al.

i n c r e a s e d p e r c e p t i o n o f c o n t r o l over the voices. Likewise, six o f n i n e individuals who p a r t i c i p a t e d in a CBT-based self-control skills g r o u p r e p o r t e d t h a t t h e i r voices were less distressing a n d less distracting at the e n d o f treat- m e n t ( P e r h n a n & H u b b a r d , 2000). Finally, Chadwick, S a m b r o o k e , Rasch, a n d Davies (2000) r e p o r t e d t h a t individuals who p a r t i c i p a t e d in t h e i r g r o u p CBT for a u d i t o r y hallucinations h a d less conviction in beliefs that the voices were o m n i p o t e n t a n d that they h a d n o c o n t r o l over the voices following t r e a t m e n t . T h e s e results p r o v i d e encour- a g e m e n t t h a t g r o u p CBT may d e c r e a s e the severity o f psychotic symptoms, a l t h o u g h , at this time, only o n e con- t r o l l e d trial has b e e n c o m p l e t e d (i.e., Wykes et al., 1999).

Thus, g r o u p CBT has p r o m i s e for r e d u c i n g the negative effects o f h e a r i n g voices a n d may aid participants in their efforts to c o p e with a u d i t o r y hallucinations.

T h e above g r o u p CBT studies for a u d i t o r y hallucinations were c o n d u c t e d e i t h e r with g r o u p s c o m p r i s e d solely o f o u t p a t i e n t s o r a c o m b i n a t i o n o f o u t p a t i e n t a n d i n p a t i e n t p a r t i c i p a n t s . L i t d e is known, t h e r e f o r e , a b o u t w h e t h e r g r o u p CBT is effective for i n p a t i e n t s with c h r o n i c s c h i z o p h r e n i a . Since i n p a t i e n t s are likely to have m o r e severe p a t h o l o g y t h a n o u t p a t i e n t s , as well as g r e a t e r t r e a t m e n t r e f r a c t o r y symptoms, a trial o f g r o u p treat- m e n t with c h r o n i c a l l y ill i n p a t i e n t s r e p r e s e n t s a m o r e rig- o r o u s test o f the effectiveness o f CBT for h a l l u c i n a t i o n s t h a n has h i t h e r t o b e e n c o n d u c t e d .

T h e p u r p o s e o f this study was to c o n d u c t a n initial evaluation o f g r o u p CBT for a u d i t o r y h a l l u c i n a t i o n s o n an i n p a t i e n t s a m p l e o f individuals with c h r o n i c psychotic symptoms. To o u r knowledge, t h e r e are n o p u b l i s h e d studies o n g r o u p CBT for a u d i t o r y h a l l u c i n a t i o n s a m o n g inpatients. F u r t h e r m o r e , with the e x c e p t i o n o f P e r l m a n a n d H u b b a r d (2000), which f o c u s e d o n self-control skills, n o n e o f the above g r o u p CBT studies were c o n d u c t e d in the U n i t e d States. T h e r e f o r e , this study r e p r e s e n t s an initial a t t e m p t to a p p l y i m p o r t a n t clinical t e c h n i q u e s devel- o p e d in the U n i t e d K i n g d o m , p a r t i c u l a r l y those t h a t focus o n r e d u c t i o n o f a u d i t o r y hallucinations, to work with i n p a t i e n t s in the U n i t e d States. A final p u r p o s e o f this study was to e x a m i n e w h e t h e r the d u r a t i o n o f g r o u p CBT has a n effect o n a u d i t o r y hallucinations. Specifically, we c o m p a r e the original Wykes et al. (1999) p r o t o c o l , c o m p r i s e d o f 7 sessions, to an e x p a n d e d p r o t o c o l o f 20 sessions in which topics were e x p l o r e d in g r e a t e r d e p t h . D u r a t i o n o f t r e a t m e n t was investigated b e c a u s e o f the possibility t h a t i n p a t i e n t s with c h r o n i c s c h i z o p h r e n i a may r e q u i r e t r e a t m e n t c o n d u c t e d over a g r e a t e r time p e r i o d t h a n o u t p a t i e n t s in o r d e r for clinical gains to accrue. It was h y p o t h e s i z e d t h a t (a) a CBT g r o u p i n t e r v e n t i o n for voices w o u l d have a significant effect o n p a r t i c i p a n t s ' beliefs a b o u t t h e i r voices, a n d (b) the longer, m o r e ex- t e n d e d p r o t o c o l w o u l d result in g r e a t e r t r e a t m e n t gains t h a n the s h o r t e r t r e a t m e n t p r o t o c o l .

Method Participants

Individuals were r e c r u i t e d via t r e a t m e n t teams t h a t h a d b e e n notified a b o u t the p r o p o s e d study, a n d p o t e n - tim p a r t i c i p a n t s were r e f e r r e d for g r o u p CBT by these individual t r e a t m e n t teams, which i n c l u d e d a psychiatrist, psychologist, social worker, nurse, a n d two h e a l t h techni- cians. Eligible individuals were those who e x p e r i e n c e d medication-resistant auditory hallucinations a n d r e p o r t e d t h a t these e x p e r i e n c e s were distressing. M e d i c a t i o n resis- tance was d e f i n e d as p e r s i s t e n t a u d i t o r y h a l l u c i n a t i o n s d e s p i t e b e i n g o n a stable dose o f n e u r o l e p t i c s (i.e., b e i n g o n the m e d i c a t i o n for at least 3 m o n t h s ) , a n d all individuals were c u r r e n t l y t a k i n g atypical antipsychotics. Indi- viduals who d e n i e d h e a r i n g voices a n d those who experi- e n c e d n o distress d u e to t h e i r voices were e x c l u d e d f r o m the sample. Eleven i n p a t i e n t s t h a t m e t DSM-/Vcriteria for e i t h e r s c h i z o p h r e n i a (n -- 5) o r schizoaffective d i s o r d e r (n = 6) p a r t i c i p a t e d in the study. Diagnoses were deter- m i n e d b a s e d o n c h a r t review, a n d the s a m p l e c o m p r i s e d 8 males a n d 3 females, o f w h o m 63.6% were Caucasian.

T h e average age o f p a r t i c i p a n t s was 39.6 years a n d they h a d b e e n h o s p i t a l i z e d for an average o f 44.6 m o n t h s

( m i n i m u m -- 3 months, m a x i m u m = 228 months, m o d e = 20 m o n t h s ) p r i o r to p a r t i c i p a t i n g in t h e groups.

Measures

Auditory Hallucinations Rating Scale (PSYRATS, Haddock, McCarron, Tarri~ & Faragher, 1999). T h e PSYRATS is an 11-item, interview-based m e a s u r e t h a t assesses the e m o - tional c o n t e n t , physical characteristics, a n d cognitive in- t e r p r e t a t i o n o f a u d i t o r y hallucinations. R e p o r t e d reliability for e a c h i t e m r a n g e s f r o m 1.0 to .788 ( H a d d o c k et al., 1999). In the c u r r e n t study, we a d m i n i s t e r e d the PSYRATS as a self-report m e a s u r e (Wykes et al. 1999). C r o n b a c h ' s a l p h a was .56 at the initial assessment a n d .63 at the post- i n t e r v e n t i o n assessment, i n d i c a t i n g m o d e r a t e i n t e r n a l reliability. 1

Beliefs About Voices Questionnaire-Revised (BA VQ-R; Chad- wick, Lees, & Birchwood, 2000). T h e BAVQ is a self-report m e a s u r e t h a t assesses the individual's beliefs, e m o t i o n s , a n d b e h a v i o r a b o u t a u d i t o r y hallucinations. S a m p l e items i n c l u d e statements such as, "My voice is p u n i s h i n g m e for s o m e t h i n g I have d o n e " a n d "My voice m a k e s m e feel down," a n d the p a r t i c i p a n t is asked to state to w h a t d e g r e e they a g r e e with e a c h statement. A l t h o u g h t h e BAVQ-R has five subscales, only the total score was u s e d in this study as it is c o n s i d e r e d to b e a m o r e c o m p r e h e n s i v e

t Because no significant differences were found between the groups, all retiabiliV calculations were computed by combining Groups 1 and 2. Additionally, in order to achieve acceptable reliability for this study, Item 5 of the PSYRATS was omitted from the analyses.

Omission of this item did not alter any substantive results.

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G r o u p CBT for Auditory Hallucinations 95

r e p r e s e n t a t i o n o f an individual's r e a c t i o n to a u d i t o r y hallucinations. T h e r e p o r t e d m e a n C r o n b a c h ' s a l p h a for the m e a s u r e ' s five subscales was .86, a n d e a c h subscale h a d a d e q u a t e reliability r a n g i n g b e t w e e n .74 a n d .88.

Similarly, the total score reliability for this study was ac- c e p t a b l e with C r o n b a c h ' s a l p h a o f .85 at p r e t r e a t m e n t assessment a n d .84 at p o s t t r e a t m e n t assessment.

Positive and Negative Syndrome Scale (PANSS; Kay, Opler,

&Fiszbein, 1992). T h e PANSS is a s t r u c t u r e d clinical interview d e s i g n e d to assess t h e severity o f positive a n d negative symptoms. F o r the p u r p o s e s o f this study, o n l y t h e h a l l u c i n a t o r y b e h a v i o r i t e m was used, which consists o f a series o f questions c o n c e r n i n g the f r e q u e n c y a n d quality o f a u d i t o r y h a l l u c i n a t i o n s as well as the d e g r e e to which they affect t h i n k i n g a n d behavior. This m e a s u r e has ade- q u a t e i n t e r n a l reliability (.73 to .83 for e a c h o f the scales) a n d h i g h test-retest reliability (.89 a n d .82 for the positive a n d negative scales, respectively). Raters h a d b e e n previ- ously t r a i n e d to a d e q u a t e reliability (ICC > .80 with a cri- t e r i o n rater).

Wide Range Achievement Test-III (WRA T3; Wilkinson, 1993).

T h e WRA~F3 was u s e d to assess t h e r e a d i n g ability o f e a c h p a r t i c i p a n t to o b t a i n an estimate o f p r e m o r b i d g e n e r a l intelligence.

P r o c e d u r e

Two g r o u p s were c o n d u c t e d in this study. T h e first g r o u p followed t h e m a n u a l d e v e l o p e d by Wykes et al.

(1999; discussed below). T h e s e c o n d g r o u p , c o n d u c t e d 4 m o n t h s after c o m p l e t i o n o f t h e first g r o u p , followed an e x p a n d e d version o f the Wykes et al. m a n u a l . O n e individual who was in t h e first g r o u p was also r e f e r r e d for a n d i n c l u d e d in the s e c o n d g r o u p . F o r m a l a t t e n d a n c e r e c o r d s were n o t k e p t for e i t h e r g r o u p ; however, b o t h sets o f g r o u p l e a d e r s r e p o r t e d that a t t e n d a n c e was high.

T h e PSYRATS a n d BAVQ-R were a d m i n i s t e r e d to e a c h p a r t i c i p a n t in b o t h g r o u p s at the t i m e o f referral a n d at the e n d o f the g r o u p . T h e PANSS was a d d e d to the assess- m e n t b a t t e r y after c o m p l e t i o n o f G r o u p 1 a n d thus was a d m i n i s t e r e d pre- a n d p o s t i n t e r v e n t i o n for G r o u p 2 only.

T h e s e measures were a d m i n i s t e r e d e i t h e r by hospital staff o r by the g r o u p CBT leadersY T h e WRAT3 was a d d e d to the b a t t e r y at the e n d o f G r o u p 2 to a d d r e s s the post-hoe q u e s t i o n o f w h e t h e r cognitive f u n c t i o n i n g c o u l d affect the p a r t i c i p a n t s ' ability to b e n e f i t f r o m the intervention. Thus, t h e WRAT3 was a d m i n i s t e r e d postinter- v e n t i o n for G r o u p 2. 3

2Although it could be argued that allowing the assessments to be administered by the group leaders may have introduced demand characteristics that could have influenced the data for Group 2, this is unlikely because many of the measures were self-report and no group significant differences existed between Group 1, in which hospital staff conducted the assessments, and Group 2.

3 Raters were not blind to treatment condition.

Intervention

G r o u p 1 followed the Wykes et al. m a n u a l a n d m e t for seven 1-hour weekly sessions. Each session a d d r e s s e d a p a r t i c u l a r topic:

Session 1: s h a r i n g o f i n f o r m a t i o n a b o u t the voices Session 2: m o d e l s o f psychosis

Session 3: m o d e l s o f h a l l u c i n a t i o n Session 4: effective c o p i n g strategies Session 5: stigma a n d the role o f m e d i c a t i o n Session 6: i m p r o v i n g self-esteem

Session 7: overall m o d e l o f c o p i n g with the voices G r o u p 2 followed a n e x p a n d e d version o f t h e Wykes et al. m a n u a l that was revised by o n e o f us (DLP) to b e t t e r m e e t the clinical n e e d s o f a n i n p a t i e n t p o p u l a t i o n . This revised m a n u a l e x t e n d e d the g r o u p to 20 sessions a n d m e t for 1 h o u r twice weekly. O n l y m i n o r alterations were m a d e to the c o n t e n t o f the o r i g i n a l m a n u a l ; the m a i n c h a n g e s were that m o r e time was s p e n t o n difficult topics a n d a d d i t i o n a l h o m e w o r k was assigned. T h e i n t e r v e n t i o n was as follows:

Sessions 1 - 3 : s h a r i n g o f e x p e r i e n c e s a n d i n f o r m a t i o n a b o u t voices a n d n o r m a l i z a t i o n

Session 4: p s y c h o e d u c a t i o n a n d m o d e l s o f psychosis Session 5: t i l e m e a n d c o n t e n t o f e x p e r i e n c e s

Sessions 6 - 1 0 : b e h a v i o r a l analysis o f voices with par- ticular e m p h a s i s o n the A n t e c e d e n t s - B e l i e f s - C o n s e q u e n c e s (ABC) m o d e l

Sessions 1 1 - 1 3 : establishing c o n t r o l over the voices within the c o n t e x t o f the ABC m o d e l ( i n c r e a s i n g a n d d e c r e a s i n g strategies)

Sessions 1 4 - 1 7 : c o p i n g with the voices Session 18: stigma

Sessions 1 9 - 2 0 : overall m o d e l o f c o p i n g with voices a n d t e r m i n a t i o n

Thus, the overall goal o f the i n t e r v e n t i o n is to a p p l y cognitive-behavioral techniques to auditory hallucinations.

T h e initial sessions focus o n b u i l d i n g r a p p o r t a m o n g the g r o u p m e m b e r s a n d the therapists a n d o n p o i n t i n g o u t to p a r t i c i p a n t s that m a n y o t h e r individuals have experiences similar to t h e i r own. S o m e t i m e is s p e n t t e a c h i n g c u r r e n t theories o f psychosis a n d e x p l a i n i n g c o m m o n l y used treatments. CBT techniques, such as self-monitoring a n d c o p i n g strategies, are at tile h e a r t o f the intervention.

Self-monitoring is e m p l o y e d by asking participants to m o n - itor their thoughts a n d actions p r i o r to, during, a n d after h e a r i n g voices. This allows for the identification o f any pat- terns that may be p r e s e n t a n d encourages a functional ana- lytic a p p r o a c h to their experiences. After c o m p l e t i n g these exercises, individuals begin to utilize c o p i n g strategies when they h e a r voices a n d are asked to m o n i t o r the effectiveness o f these c o p i n g strategies. Over the course o f treatment, multiple c o p i n g strategies are tried, a n d participants

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96 Pinkham e t al.

Table 1

Demographic Information for the Final Sample

Group 1 Group 2

Age 40.6 (11.67) 37.8 (4.66)

Gender

Males 4 4

Females 1 1

Qualifying diagnosis

Schizophrenia 4 1

Schizoaffective 1 4

Note. All diagnoses were derived from chart reviews.

are e n c o u r a g e d to c o n t i n u e u s i n g t h e strategies t h a t al- low- t h e m to f e e l m o r e c o n t r o l o v e r t h e i r v o i c e s a n d t h a t r e d u c e t h e a m o u n t o f distress t h e y e x p e r i e n c e . 4

R e s u R s

All p a r t i c i p a n t s in e a c h g r o u p successfully c o m p l e t e d t r e a t m e n t , w i t h t h e e x c e p t i o n o f o n e i n d i v i d u a l w h o was d i s c h a r g e d p r i o r to g r o u p c o m p l e t i o n . T h i s i n d i v i d u a l ' s d a t a w e r e e x c l u d e d f r o m t h e analyses. Additionally, f o r t h e p a r t i c i p a n t w h o c o m p l e t e d b o t h g r o u p s , o n l y d a t a c o l l e c t e d f r o m G r o u p 1 w e r e i n c l u d e d in t h e analysis.

T h e s e m o d i f i c a t i o n s b r o u g h t t h e n u m b e r o f p a r t i c i p a n t s in e a c h g r o u p to five. 5 T a b l e 1 s u m m a r i z e s t h e d e m o - g r a p h i c c h a r a c t e r i s t i c s o f t h e two g r o u p s o f final partici- p a n t s in t h e study.

Preliminary Analyses

P r i o r to a d d r e s s i n g tile h y p o t h e s e s , we c o n d u c t e d p r e - l i m i n a r y analyses to e x a m i n e w h e t h e r t h e two g r o u p s d i f f e r e d o n any o f t h e d e m o g r a p h i c o r b a s e l i n e clinical variables. C h i - s q u a r e tests r e v e a l e d t h a t t h e g r o u p s d i d n o t s i g n i f i c a n t l y d i f f e r o n g e n d e r , X2(t, N = 10) = .000, ns, d i a g n o s i s , X2(1, N = 10) = 3.600, ns, o r ethnicity, X2(1, N = 10) = .476, ns. A d d i t i o n a l l y , a M A N O V A was c o n - d u c t e d to e x a m i n e w h e t h e r t h e two g r o u p s d i f f e r e d in a g e o r l e n g t h o f c u r r e n t h o s p i t a l i z a t i o n . T h e M A N O V A was n o t significant, Wilks's h = .791, F(2, 7) = .927, ns, t h u s i n d i c a t i n g t h a t t h e g r o u p s d i d n o t significantly d i f f e r o n t h e c o m b i n e d v a r i a b l e s o f a g e o r l e n g t h o f hospitaliza- tion. A s e c o n d M A N O V A was c o n d u c t e d o n t h e b a s e l i n e clinical v a r i a b l e s (i.e., BAVQ-R a n d PSYRATS). T h i s analysis was n o t significant, Wilks's X = .846, F(2, 7) = .637, ns,

4A revised manual is available upon request.

5 Full regression diagnostics did indicate potential oudiers on each measure; however, given that no one individual was deviant on all measures and the extremely small size of this sample, the decision was made to leave the data set intact, and results should be interpreted cautiously.

Table 2

Pre- and Posttreatment Mean Scores on the Clinical Measures as a Function of CBT Group

Group 1 Group 2

Pre- Post- Pre- Post-

treatment treatment treatment treatment BAVQ-R 52.6 (22.69) 40.8 (21.78) 61.8 (10.62) 55.6 (9.66) PSYRATS 25.4 (6.31) 21.8 (4.15) 27.4 (5.98) 22.4 (8.56)

PANSS N / A N / A 5.4 (.89) 4.6 (.55)

Note. Standard deviadons are in parentheses. BAVQ-R = Beliefs About Voices Questionnaire-Revised; PSYRATS = Auditory Halluci- nations Rating Scale; PANSS = Positive and Negative Syndrome Scale.

i n d i c a t i n g t h a t t h e g r o u p s d i d n o t d i f f e r o n t h e c o m b i n e d b a s e l i n e clinical m e a s u r e s .

Primary Analyses

To test t h e h y p o t h e s i s t h a t t h e l o n g e r p r o t o c o l w o u l d l e a d to g r e a t e r t r e a t m e n t gains t h a n t h e s h o r t e r p r o t o c o l , we c o n d u c t e d a M A N O V A o n t h e raw c h a n g e s c o r e s o n t h e BAVQ-R a n d PSYRATS (see T a b l e 2 f o r m e a n s c o r e s f o r e a c h g r o u p ) . T h e o m n i b u s test r e v e a l e d t h a t g r o u p was n o t a s i g n i f i c a n t p r e d i c t o r o f t h e c o m b i n e d o u t c o m e m e a s u r e s ; t h e m a g n i t u d e o f t h e c h a n g e b e t w e e n p r e - a n d p o s t t r e a t m e n t d i d n o t d i f f e r as a f u n c t i o n o f g r o u p , Wilks's X = .9088, F(2, 7) = .35, ns. A d d i t i o n a l l y , n o sig- n i f i c a n t u n i v a r i a t e effects w e r e f o u n d ; g r o u p was n o t significantly r e l a t e d to c h a n g e o v e r t i m e in e i t h e r t h e BAVQ-R, F(1, 8) = .80, ns, o r i n t h e PSYRATS, F(1, 8) = .10, ns. T h u s , c o n t r a r y to o u r h y p o t h e s i s , t h e l o n g e r p r o t o c o l d i d n o t r e s u l t in g r e a t e r t r e a t m e n t gains t h a n t h e s h o r t e r p r o t o c o l .

G i v e n t h e s e f i n d i n g s , t h e two g r o u p s w e r e c o m b i n e d to test o u r o t h e r h y p o t h e s i s t h a t g r o u p C B T w o u l d h a v e a n e f f e c t o n b e l i e f s a n d r e a c t i o n s to a u d i t o r y h a l l u c i n a - tions. S i m p l e t tests w e r e c o m p u t e d to d e t e r m i n e if t h e a m o u n t o f c h a n g e s e e n o n e a c h m e a s u r e a f t e r t r e a t m e n t significantly d i f f e r e d f r o m zero. Results d e m o n s t r a t e d t h a t a s i g n i f i c a n t i m p r o v e m e n t was e v i d e n t b e t w e e n t h e p r e - a n d p o s t t r e a t m e n t s c o r e s o n t h e BAVQ-R, t(9) = 2.91, p < .05, e f f e c t size = .51. T h e a m o u n t o f i m p r o v e - m e n t b e t w e e n p r e - a n d p o s t t r e a t m e n t s c o r e s o n t h e PSYRATS a p p r o a c h e d statistical s i g n i f i c a n c e , t(9) =- 2.07, p = .0689, e f f e c t size = .7213, a n d f o r t h e i n d i v i d u a l s in G r o u p 2 only, t h e a m o u n t o f c h a n g e o n t h e PANSS d i d n o t significantly d i f f e r f r o m z e r o , t(4) = 2.14, p = .0993, e f f e c t size = 1.1188).6

6 Significance values were not corrected for alpha inflation due to the small sample size and the obvious loss of power associated with such a correction.

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Group CBT for Auditory Hallucinations 97

Table 3

Pre- and Post-treatment Mean Scores on the Clinical Measures

Pretreatment Posttreatment

BAVQ-R 57.2 (17.39) 48.2 (17.69)

PSYRATS 26.5 (5.85) 22.l (6.35)

PANSS 5.4 (.89) 4.6 (.54)

Note. Standard deviations are in parentheses, and scores for the PANSS are for Group 2 only. BAVQ-R = Beliefs About Voices Questionnaire- Revised; PSYRATS = Auditory Hallucinations Rating Scale; PANSS = Positive and Negative Syndrome Scale.

It is i n t e r e s t i n g to n o t e that a l t h o u g h the results for the PSYRATS a n d PANSS did n o t reach c o n v e n t i o n a l statistical significance, the m e a n scores for the PSYRATS a n d PANSS did decrease following t r e a t m e n t . Scores o n the PSYRATS decreased from a m e a n of 26.5 to 22.1 after t r e a t m e n t , a n d scores o n the PANSS decreased from a n average of 5.4 to 4.6, i n d i c a t i n g some i m p r o v e m e n t (see Table 3 for complete pre- a n d p o s t t r e a t m e n t scores for the c o m b i n e d groups). Thus, the marginally significant results, despite large effect sizes for b o t h tests, a p p e a r to be d u e to the low statistical power o f the study r a t h e r t h a n a n absence o f a t r e a t m e n t effect (Cohen, 1988).

Supplementary Analyses

To address the post-hoc hypothesis that intellectual f u n c t i o n i n g may i n f l u e n c e a participant's ability to b e n e - fit from the group, multivariate regression was used to ex- a m i n e the predictive ability o f p r e m o r b i d intellectual ability. T h e o m n i b u s test revealed that r e a d i n g ability was n o t predictive of the c o m b i n e d clinical o u t c o m e mea- sures, Wilks's X = .1174, F(1, 3) = 2.51, ns, or for each m e a s u r e individually (BAVQ-R: F [1, 3] = 2.32, ns; P S Y R - ATS: F[1, 3] = 1.45, ns; PANSS: F[1, 3] = .03, ns). Thus, p r e m o r b i d intellectual f u n c t i o n i n g was n o t related to t r e a t m e n t response i n this sample.

Finally, recall that o n e individual participated in b o t h groups. As a post-hoc analysis, we e x a m i n e d this partici- p a n t ' s pre- a n d p o s t t r e a t m e n t BAVQ-R a n d PSYRATS scores for each g r o u p (Figure 1). T h e p a r t i c i p a n t showed i m p r o v e m e n t in his o r h e r beliefs r e g a r d i n g auditory hal-

70

30 ~a~- PS'tRATS

10 0

Fte-group I Post-group1 Pre-~roup2 Post-goqo2

Figure t. Scores on the clinical measures for the individual who participated in both groups.

l u c i n a t i o n s following the first g r o u p a n d t h e n experi- e n c e d a n increase i n negative beliefs p r i o r to b e g i n n i n g the s e c o n d group. W h a t is most interesting, however, is the d e c l i n e i n distress associated with his o r h e r voices after c o m p l e t i o n of the s e c o n d group. This single case design suggests a specific t r e a t m e n t effect a n d indicates that individuals may receive greater benefits from re- p e a t e d exposure to the principles a n d t e c h n i q u e s t a u g h t in the group.

D i s c u s s i o n

This study evaluated the effects o f a g r o u p cognitive- behavioral therapy for i n p a t i e n t s with persistent auditory hallucinations. T h e results revealed that distress associated with symptoins was r e d u c e d at the e n d of the treat- m e n t a n d that this i m p r o v e m e n t did n o t differ as a function o f protocol length. T h a t is, the two t r e a t m e n t groups that differed i n protocol l e n g t h b o t h showed significant r e d u c t i o n s i n multiple d i m e n s i o n s o f auditory hallucinations such as distressing beliefs a b o u t the voices a n d fre- q u e n c y of auditory hallucinations.

Perhaps the most i m p o r t a n t e x t e n s i o n of this study to previous work i n this area is that it was c o n d u c t e d only with inpatients. Individuals who are hospitalized often ex- p e r i e n c e m o r e severe symptoms t h a n outpatients, a n d the fact that i m p r o v e m e n t was seen even i n this symptom- atic a n d chronically ill p o p u l a t i o n suggests that the treat- m e n t has g o o d potential. Further, the clinical utility of this t r e a t m e n t appears to be quite good. I n o t h e r words, this study shows that g r o u p CBT is a clinicaUy feasible in- t e r v e n t i o n for auditory h a l l u c i n a t i o n s a n d has p r o m i s i n g direct clinical benefits. A self-report m e a s u r e was a d m i n - istered to the participants of the s e c o n d g r o u p at the con- clusion o f t r e a t m e n t , a n d all participants r e p o r t e d feel- ings o f greater c o n t r o l over their voices, less distress associated with their voices, a n d greater knowledge a b o u t their voices. All of these i m p r o v e m e n t s were a t t r i b u t e d to participation in the group.

It is u n c l e a r what a c c o u n t e d for the lack of t r e a t m e n t d u r a t i o n effects. O n e possibility is that the clinical effects are solnewhat rapid. T h e f i n d i n g that intellectual func- t i o n i n g d i d n o t limit participants' abilities to b e n e f i t f r o m the g r o u p indirectly supports this hypothesis, as o n e m i g h t expect persons with cognitive i m p a i r m e n t s to b e n - efit f r o m greater f r e q u e n c y of treatment. T h e r e f o r e , the effectiveness of the briefer g r o u p CBT suggests that this i n t e r v e n t i o n may be a cost- a n d t/me-efficient m e t h o d for delivering psychosocial treatments.

T h e r e are a few limitations to this study, such as the lack o f a c o n t r o l group, r a n d o m a s s i g n m e n t to groups, follow-up assessments, a n d b l i n d i n g of raters. A l t h o u g h lack of a c o n t r o l g r o u p may a p p e a r to be the most impor- t a n t limitation, it s h o u l d be n o t e d that almost all of the

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98 P i n k h a m e t al.

p a r t i c i p a n t s w e r e l o n g - t e r m , c h r o n i c p a t i e n t s w h o s h o w e d l i t t l e t o n o i m p r o v e m e n t i n t h e i r a u d i t o r y h a l l u c i n a t i o n s o v e r t h e c o u r s e o f t h e i r stay a t t h e h o s p i t a l . T h u s , it is l i k e l y t h a t t h e i m p r o v e m e n t s s e e n h e r e c a n b e a t t r i b u t e d t o t h e i n t e r v e n t i o n r a t h e r t h a n t r e a t m e n t as u s u a l . 7 H o w - ever, g i v e n t h e o t h e r l i m i t a t i o n s m e n t i o n e d a b o v e , t h e s e r e s u l t s s h o u l d b e i n t e r p r e t e d w i t h c a u t i o n , a n d a d d i - t i o n a l t r i a l s s h o u l d b e c o n d u c t e d t o r u l e o u t p o s s i b l e c o n - f o u n d s t h a t t h r e a t e n i n t e r n a l validity. N o n e t h e l e s s , t h e h e u r i s t i c a n d c l i n i c a l v a l u e o f t h i s s t u d y s h o u l d n o t b e ig- n o r e d . O n a v e r a g e , i n d i v i d u a l s r e p o r t e d s i g n i f i c a n t l y less d i s t r e s s a s s o c i a t e d w i t h t h e i r v o i c e s f o l l o w i n g t r e a t - m e n t , a n d all m e a s u r e s i n d i c a t e d f a v o r a b l e r e s u l t s . A d - d i t i o n a l l y , t h e e f f e c t sizes f o r t h e t e s t s o f t h e a m o u n t o f c h a n g e o n e a c h m e a s u r e f r o m p r e - t o p o s t t r e a t m e n t w e r e all l a r g e . T h i s is p a r t i c u l a r l y p r o m i s i n g g i v e n t h e n a t u r a l i s t i c s e t t i n g o f t h i s s t u d y a n d s m a l l s a m p l e size.

I n all, i t a p p e a r s t h a t g r o u p c o g n i t i v e - b e h a v i o r a l t r e a t - m e n t f o r v o i c e s is a p r o m i s i n g a n d p o t e n t i a l l y e c o n o m - i c a l t r e a t m e n t f o r i n d i v i d u a l s w i t h m e d i c a t i o n - r e s i s t a n t a u d i t o r y h a l l u c i n a t i o n s .

R e f e r e n c e s

Bustillo,J. R., Lauriello,J., Horan, W. E, & Keith, S.J. (2001). The psychological treatment of schizophrenia: An update. American Jour- hal of Psychiatry, 158, 163-175.

Chadwick, E, Lees, S., & Birchwood, M. (2000). The revised Beliefs About Voices Questionnaire (BAVQ-R). British Journal of Psychia-

try, 177,229-232.

Chadwick, E, Sambrooke, S., Rasch, S., & Davies, E. (2000). Challeng- ing the omnipotence of voices: Group cognitive behavior therapy for voices. Behavior Research and Therapy, 38, 993-1003.

Cohen, J. (1988). Statistical power for the behavioral sciences (2nd ed.).

Hillsdale, NJ: Erlbaum.

Gledhill, A., Lobban, E, & Sellwood, W. (1998). Group CBT for people with schizophrenia: A preliminary evaluation. Behavioural and Cog-

nitive Ps~chotherapy, 26, 63-75.

Gould, R. A., Mueser, K. T., Bolton, E., Mays, E., & Goff, D. (2001).

Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, 335-342.

Haddock, G., McCarron,J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS). Psvehological Medicine, 29, 879-889.

Haddock, G., Tarrier, N., Spaulding, W., Yusupoff, L., Kinney, C., &

McCarthy, E. (1998). Individual cognitive-behavior therapy in the treatment of hallucinations and delusions. Clinical Psychology Review, 18, 821-838.

Kane,J. M., & Marder, S. R. (1993). Psychopharmacologic treatment of schizophrenia. Schizophrenia Bulletin, 19, 287-302.

7We are grateful to an anonymous reviewer for bringing this to our attention.

Kay, S. R., Opler, L. A., & Fiszbein, A. (1992). Positive and negative syn- drome scale: Manual. Toronto: Multi-Health Systems.

Kuipers, E., Fowler, D., Garety, E, Chisholm, D., Freeman, D., Dunn, G., Bebbington, E, & Hadley, C. (1998). London-East Anglia ran- domised controlled trial of cognitive-behavioural therapy for psychosis, III: Follow-up and economic evaluation at 18 months.

British Journal of Psychiatry, 173, 61-68.

Norman, R. M. G., & Townsend, L. A. (1999). Cognitive-behavioral therapy for psychosis: A status report. Canadian Journal of Psychia- try, 44, 245-252.

Nyani, T. H., & David, A. S. (1996). The auditory hallucination: A phe- nomenological survey. PsyehologicalMedicine, 26, 177-189.

Pantelis, C., & Barnes, T. R~ (1996). Drug strategies and treatment resistant schizophrenia. Australia and New Zealand Journal of Psychi- atry, 30, 20-37.

Perlman, L. M., & Hubbard, B. A. (2000). A self-control skills group for persistent auditory hallucinations. Cognitive and Behavioral Prac- tice, 7, 17-21.

Sensky, T., Turkington, D., Kingdon, D., Scott,J. L., Scott,J., Siddle, R., O'Carroll, M., & Barnes, T. (2000). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57, 165-172.

Shergill, S. S., Murray, R. M., & McGuire, R K. (1998). Auditory hallucinations: A review of psychological treatments. Schizophrenia Research, 32, 137-150.

Slade, R D., & Bentall, R. R (1988). Sensory deception: A scientific analysis of hallucination. Baltimore: The Johns Hopkins University Press.

Tarrier, N., Kinney, C., McCarthy, E., Humphreys, L., Wittkowski, A., &

Morris, J. (2000). Two- year follow-up of cognitive-behavioral therapy and supportive counseling in the treatment of persistent symptoms in chronic schizophrenia.Journal of Consulting and Clin- ical Psychology, 68, 1-6.

Tarrier, N., Kinney, C., McCarthy, E., Wittkowski, A., Yusupoff, L., Gledhill, A., Morris, J., & Humphreys, L. (2001). Are some types of psychotic symptoms more responsive to cognitive-behaviour therapy? Behavioural and Cognitive Psychotherapy, 29, 45-55.

Tarrier, N., Wittkowski, A., Kinney, C., McCarthy, E., Morris,J., & Hum- phreys, L. (1999). Durability of the effects of cognitive-behavioral therapy in the treatment of chronic schizophrenia: 12-month follow-up. British Journal of Psychiatry, 174, 500-504.

Weirsma, D., Nienhuis, EJ., & Slooff, C.J. (1998). Natural course of schizophrenic disorders: A 15-year follow-up of a Dutch incidence cohort. Schizophrenia Bulletin, 24, 75-85.

Wilkinson, G. S. (1993). WRAT3: Wide range achievement test. Wilming- ton, DE: Wide Range.

Wykes, T., Parr, A., & Landau, S. (1999). Group treatment of auditory hallucinations: Exploratory study of effectiveness. British Journal of Psychiatry, 175, 180-185.

The authors thank the patients and staff at John Umstead Hospital for their participation in this study, particularly Drs. Edward Eastman and Tom Guthrie for their facilitation of the study protocol, Patrick Curran, Ph.D., for his statistical consultation, and Til Wykes, Ph.D., for sending us her treatment protocol.

Address correspondence to David L. Penn, Ph.D., Associate Professor, University of North Carolina-Chapel Hill, Department of Psychology, Davie Hall, CB#3270, Chapel Hill, NC 27599-3270;

e-mail: [email protected].

Received: August 6, 2002 Accepted: July 30, 2003