Neil Thomas Psychological interventions for voices: Key ...classic.vitaminw.no/kunde/affu/FilVedlegg/Thomas.pdf · Neil Thomas Psychological interventions for voices: Key developments

Neil Thomas

Psychological interventions for voices: Key developments and research

priorities

[email protected] Satellite meeting of the International Consortium for Hallucinations Research, Trondheim, Norway, Sep 2014

ICHR Psychological Therapies Workgroup

- CBT for psychosis as the dominant paradigm and the recent debate about effect sizes

- The need for a more specific research agenda for voices

- Two key areas of development

- Acceptance and mindfulness based therapies

- Going beyond the expert psychotherapy model

Outline

- Hallucinations can be a source of distress and interference with functioning

- Limitations of medication

- Consumer perspectives:

- Importance of personal recovery:

- Taking charge of self-managing mental health

- Pursuing a meaningful and satisfying life alongside the presence of ongoing symptoms

- An experience which is often personally meaningful yet hard to make sense of

Why are we interested in psychological interventions?

“CBT for psychosis”

The development of CBT for psychosis (CBTp)

Clinical practice guideline recommendations

Acute treatment

“Offer cognitive behavioural therapy (CBT) to all people with schizophrenia… either during the acute phase or later” (para. 1.3.4.1)

Recovery phase

“Offer CBT to assist in promoting recovery in people with persisting positive and negative symptoms and for people in remission” (para. 1.4.3.1)

CBT for psychosis

Therapeutic framework emphasising

• Adapting to psychotic experiences

• Normalising perspective

• Building up an adaptive shared formulation of

psychosis, highlighting roles of

– Appraisals of psychotic experiences

– Cognitive processes (biases, attention, etc)

– Maintaining cycles

– Developmental origins

• Testing out specific appraisals of experiences

and broader schemas impacting upon distress or

disability

CBT for psychosis: specific methods for voices

Key target appraisals of voice experience

• Voice power, e.g. “the voices can make bad

things happen to my loved ones”

• Omniscience, e.g. “the voices can predict the

future”

• Hearer control over experience

• Voice identity and explanatory beliefs for

origin of voices

• Related delusions, e.g. “they are telling

everybody what I am thinking”

• Specific voice content

Randomised controlled trials of CBT for psychosis

Wykes et al. Schizophr Bull 2008

Swinburne

The ongoing focus on CBTp RCTs in 2014

Battle of the meta-analyses

Lynch et al. Psychol Med 2010


Jauhar et al. Br J Psychiatry 2014


Overall symptoms: d = 0.33 * Positive symptoms: d = 0.23 * Negative symptoms: d = 0.13 Hallucinations: d = 0.34 * But significant heterogeneity of effect sizes between studies

Jauhar et al. Br J Psychiatry 2014

Battle of the meta-analyses: persisting symptoms

Burns et al. Psychiatr Serv 2014

15

Battle of the meta-analyses: effects on hallucinations

Van der Gaag et al. Schizophr Res 2014

For people with a diagnosis of schizophrenia and current experiences of psychosis, seeing a therapist for a series of

sessions focused on adapting to psychotic experiences seems to be, on average:

(1) more helpful in reducing the impact of voices than not seeing a therapist (TAU)

(2) probably more helpful in reducing the impact of voices than meeting with a therapist to talk about other things (control

therapy).

Battle of the meta-analyses: the result

Limitations of CBTp trial design

Broad participant

group eg voices or

delusions

Individualised intervention

eg CBTp

Broad outcome

measures

eg PANSS

Specific

outcome

eg PSYRATS

• CBTp is no more than a broad framework

• Hence few meaningful conclusions from most trials about: • Specific therapy methods • The magnitude of specific outcomes

• Which specific methods are useful for hallucinations

• Applicability to hallucinations in people with non-schizophrenia diagnoses

• What types of voice experiences different methods are most useful for, e.g. commanding/threatening vs critical voices

• Methods for working with hallucinations which are not in the form of voices

What CBTp trials don’t tell us

Thomas et al. Schizophr Bull 2014

- 2 RCTs of CBT targeting power beliefs for people with harmful command hallucinations vs TAU:

- Trower et al, 2004 N=38

- COMMAND Trial - Birchwood et al, 2014, N=197

- Reduction in compliance with harmful commands

- Mediated by changes in perceived voice power

- However, not a consistent effect on voice-related distress

Trials of focused individual CBT for voices

Trower et al. Br J Psychiatry 2004; Birchwood et al. Lancet Psychiatry 2014

1. Beyond broad outcomes and therapy approaches to specific therapeutic targets and methods

2. Developing therapies to target identified mechanisms in voices

3. Improved outcome measurement

4. Understand individual differences between voice hearers

5. Beyond “auditory” and “schizophrenia”

6. Addressing limitations of the reach of CBTp

A more focused research agenda for interventions










Targets of therapies for voices in current literature

Therapy target Examples

Range/effectiveness of coping strategies Element of CBTp, eg Tarrier et al 1993, 1998

Discussion of coping in voices groups

Seeing voices as a mental phenomenon Element of CBTp

Perceived power of voices/subjective

control over experience

Key element of CBTp, esp. command hallucinations,

Chadwick & Birchwood 1994

Ability to disengage and decentre from

voice experience

Mindfulness training, eg Chadwick 2003;

Acceptance and commitment, eg Thomas et al 2013;

Element of CBTp, eg Hutton et al 2014.

Understanding voices in context of past

experiences and self/other representations

Longden et al 2012, Corstens et al 2011

Element of CBTp

Self-esteem and self-compassion COMET, eg van der Gaag et al 2012

Compassionate Mind, eg Mayhew & Gilbert 2008

Specific traumatic memories/imagery Imagery rescripting , eg Ison et al 2014

Prolonged exposure, eg de Bont et al 2013

EMDR, eg van der Berg et al 2012

Relating between hearer and voices Hayward et al 2009; Leff et al, 2013.












voice experience







Element of CBTp


















voice experience







Element of CBTp








- Mindfulness groups/Person based cognitive therapy

- Group format including training in meditation skills

- Integrated with broader peer discussion of experiences

- Acceptance and commitment therapy

- Range of components facilitating the person letting go of unproductive struggle with internal experiences and focus on living in line with values alongside their presence

- Includes mindfulness skills training plus other experiential exercises, such as clarifying personal values, defusing specific thought/voice content

Acceptance and mindfulness based interventions

Social

Verbal

Intrusive

• Has characteristics of human addressing or talking about the hearer

• Meaningful verbal content related to the hearer’s ongoing activity, thoughts, memories, etc.

• Audible, real seeming, loud, inescapbale stimulus

Layers of salience of voices as a stimulus

Thomas et al. In Morris et al (Ed) ACT and mindfulness for psychosis . Wiley, 2013

Acceptance and mindfulness based interventions

Khoury et al. Schizophr Res 2014

- N = 96 schizophrenia related disorders and persisting medication-refractory voices or delusions

- Randomised to receive:

- 8 sessions ACT

- 8 sessions manualised befriending intervention

- Four experienced therapists, supervised by Steven Hayes, validation of fidelity

- Blind assessment at pre, post and 6 months post, incl:

- PANSS

- PSYRATS-AH

- Voices Acceptance and Action Scale

Lifengage Trial of ACT for psychosis

Thomas et al. BMC Psychiatry 2014

Client self-report feedback

Did discussion make psychosis problems better, worse or no different?

Mann-Whitney U test p=.02

Lifengage Trial

Between-group post intervention effects on PSYRATS voices scales controlling for voice frequency

1. Belief voices are real ns

2. Distress p < .01

3. Interference with functioning p < .05

Lifengage trial

Shaywer et al, in prep

1. Usefulness of therapy

- General endorsement as useful

- Acceptance, defusion, mindfulness, values/goals

2. Symptomatic and behavioural changes attributed to ACT processes

3. Variation in understanding and connecting with therapy

- Not all clients connected with metaphors and exercises as intended

- Mindfulness and defusion sometimes led to transient increase in experiences

Thematic analysis of participant experiences of ACT

Bacon et al, Behav Cogn Psychother 2014

- First full RCT of an acceptance and mindfulness-based intervention for persisting psychosis

- Promising impacts on voice-related distress and disability

- Findings not definitive - does need further trialling

- However a danger of “ACTp” as another “CBTp”

- Need to examine and refine specific application to voices

- Impact of discrete elements such as mindfulness training

- Further adaptations of intervention to context of psychosis

Acceptance and mindfulness for voices: next steps









- Primarily tailored to work of clinical psychologists

- Requires training and experience in both psychological therapies and work with psychosis

- Workforce availability issues

- Dissemination efforts (eg THORN) were not particularly successful

- Variable client demand for formal therapies

36

Can we address limitations of the reach of CBTp?

Farhall & Thomas. Aus NZ J Psychiatry 2014

- Need interventions which can be delivered by a broader workforce

- Capitalising on growth of

- Graduate level mental health workers

- Peer workforce

- Potential use of technology to aid delivery

37

The need to go beyond expert psychotherapy

Walker & Bryant (2013) meta-synthesis of qualitative studies on peer support: experiences of people in recovery include

- Peers as positive role models

- Increased hope and motivation

- Extend social network

- Facilitate building rapport

What do people get from peer contact?

Walker & Bryant (2013). Psychiatr Rehab J, 36, 28-34.

Online resources for severe mental illness Can we promote personal recovery?

Example: MI Recovery

Thomas, Nunan, Leitan, Anderson, Porter & Farhall, in prep.

- 8 session peer-facilitated course on personal recovery

- Significant improvements relative to a stable 3 month baseline on measures of:

- Empowerment p < .001

- Social connectedness p < .001

- Internalised stigma p < .001

- In both completer and intention-to-treat analyses

- Maintained at 3 month follow-up

• Contact with peers advocated within the Hearing Voices Movement as helpful in promote recovery in voice hearers (Corstens et al, 2014)

– Mainly in form of hearing voices groups

– One-to-one peer support has evolved in places where peer expertise is well developed

• However:

– No clear framework for integrating one-to-one peer support with work on voices

– Outcome research on one-to-one peer support has involved targeting recovery broadly, rather than with a specific focus such as hearing voices (Lloyd-Evans et al, 2014)

Peer work for voices

41

Changing the relationship

with voices

Making sense of voices

Telling the story

Promote empowered and accepting relationship with voices

Development of a deeper understanding of voice characteristics, phenomenology, content, identities

Discussing life history, establishing a context for emergence of voices

Sh

are

d liv

ed

exp

erie

nce

Peer work for voices

• Collaborative research with Hearing Voices Network in Victoria (Voices Vic)

• Intervention framework – 12 x 1 hour weekly sessions with one of two peer workers – Peer workers had lived experience of hearing voices – Manualised, regular group supervision

• Pilot randomised controlled trial:

– Random allocation: peer work vs waiting list – Blind assessments of subjective experience of voices and personal

recovery pre- and post-intervention

• Feasibile to deliver

• Results in analysis

Voice Exchange project

Potentials for online provision

• Peer stories

http://www.ted.com/talks/eleanor_longden_the_voices_in_my_head

Potentials of online format

Use of video:

- Positive recovery stories

- Illustrating and modelling skills

Use of forums/commenting:

- Promote connection with others with shared experiences

- Able to use lived experience to give to others

Overall aim: to examine the therapeutic use of Internet-based technology in mental health services

Development and trialling of:

- Single online portal for mental health workers to use with clients and consumers and carers to access directly

- Therapeutic materials on mental health self-management and personal recovery

- Videos featuring peers discussing lived experience

- Designed for tablet use by mental health staff across clinical and CMMH sectors

SMART Research Program

1. A focus overall outcomes of CBTp obscures understanding the specifics of interventions for voices

2. We need to establish a research base on methods for working with the range of voice experiences beyond reducing targeting voice power - Interventions which promote people disengaging and decentring from voices offer one possible path of investigation

3. We need to develop interventions that are not reliant upon expert psychotherapy - Methods which can be used by the broader mental health workforce are a key area for ongoing development

Conclusions

Thank you

[email protected]

@voicesclinic

Neil Thomas Psychological interventions for voices: Key ...classic.vitaminw.no/kunde/affu/FilVedlegg/Thomas.pdf · Neil Thomas Psychological interventions for voices: Key developments

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