Information for Professionals
Groupwork for people with Psychosis who Hear Voices: a Preliminary Evaluation.
Abstract
This study uses psychosocial interventions within an integrated model of group work for people with schizophrenia and schizoaffective disorder who hear voices. Preliminary results are encouraging. They show improvements in voice hearing and also anxiety, depression, delusional thinking and suicidality. Some clinical guidelines are presented and ideas for future research are considered.
Authors:
Coupland, Keith, RMN, BSc.(Hons.), Thorn Diploma
Davis, Eric, BSc. (Hons.), M.Sc., PhD., Thorn Diploma and Advanced Thorn Diploma.
Macdougall, Vicky, Dip.S.W. MSc.
Edgar, Kate, BSc.(Hons.)
Contact Address:
Brownhill Resource Centre
Swindon Road
Cheltenham
GL5I 9EZ
Phone:01242 275070
Fax: 01242 272421
An Integrated model of Groupwork for people with Psychosis who Hear Voices: a Preliminary Evaluation.
ACKNOWLEDGEMENTS: This study was supported by a grant from Barnwood House Trust, Gloucester, without which the work could not have taken place. We gratefully acknowledge the earlier comments by, Tim Bradshaw, Paul Patterson and Ron Coleman. We would also like to thank the members of the group who have taught us so much.
Introduction
People experiencing symptoms of severe mental illness (SMI) often feel isolated with poor social functioning and poor quality of life (Oliver et al 1996). They experience higher levels of anxiety, depression, suicidality and suicides than the general population. We believed this situation is capable of being changed by increasing hope and self efficacy through peer support in groups.
Background
Traditional practice in behavioural psychology concentrated on either distracting the patient or ignoring references by the patient to the voice hearing experience, with the hope that the patient would concentrate on ‘real’ experiences. The effect of this approach may well have been to discourage the discussion about the voice hearing experience but without eradicating it (Chadwick, Birchwood and Trower 1996).
The ten years in particular has seen an explosion of interest in trying to apply psychological techniques to help in the management of psychosis, (e.g. Birchwood & Tarrier, 1992). Such endeavours have usually been targeted at individuals or families. Researchers such as Chadwick and Birchwood (1994), Haddock, Bentall and Slade (1993), and Garety and Hemsley (1987) have attempted to tackle positive symptoms of auditory hallucinations or voices and delusional beliefs by means of cognitive-behavioural approaches (see also Davis and Coupland 2000). There have been some reported attempts at group work for people with serious mental illness. Kapur, Ramage and Walker (1986) in their review of acute psychiatric in-patient group work found that reduction of anxiety at the outset of the group was important. This is because high levels of anxiety reduce the ability of individuals to deal with important information, (e.g. Hawton, Salkovskis, Kirk and Clark, 1989). Kanas (1988) argued that group work for people with psychosis is important because group members feel less loneliness, isolation, stigma and misunderstanding about psychiatric diagnosis - particularly schizophrenia, following groupwork.
This is further echoed by Kibel (1981) who in reviewing 50 years of group work asserts that adopting a ‘normalising approach’ to distressing auditory hallucinations and delusions form a crucial part of psychological progress (see also Kingdon and Turkington, 1991 for a similar approach with individuals). Other influential group work by Yalom (1983) suggests that it is the concept of universality - the knowledge that other people share similar problems - that is important in furthering psychological improvements. This was reinforced by the work of Caley (1996) who used a problem - centred approach (combined with case management) in group work for people with serious mental illness (SMI). She found that such focused and structured group work resulted in the amelioration of positive symptoms and increased social functioning. In addition, Gledhill, Lobban and Sellwood (1998) have attempted to apply cognitive-behavioural interventions in group work with people with schizophrenia. They found that after group intervention, all patients were less depressed, the majority had higher levels of self-esteem and greater knowledge about schizophrenia. Also, certain group members felt more able to cope with their symptoms. Moreover, patients felt less isolated and half of the group members stated a preference for group over individual treatment. A randomised controlled trial for groupwork for voice hearers showed a reduction in symptoms and improved insight and self esteem, comparable to CBT for individuals (Wykes, Parr and Landau, 1999).
Present study
The present study uses problem solving psychosocial interventions within an integrated framework of group therapy for psychosis (Kanas 1998). However, unlike Gledhill, et al’s (1998) study, the focus of group work is more symptom specific. It directly addresses the “symptoms” of voice hearing. Also, the group was formally assessed and evaluated by an independent research psychologist.
The following predictions were made for our group members:
- A reduction in persistent positive symptoms - specifically voice hearing (that is audio hallucinations).
- Reduced depression and anxiety.
- Reduced resistance (emotional and behavioural) due to voices re-rated as less malevolent (following Chadwick and Birchwood, 1994; 1995).
- Increased engagement (emotional and behavioural) due to voices re-rated as benevolent (also following Chadwick and Birchwood, 1994; 1995).
- An increase in social functioning because of a reduction in feelings of isolation.
Method
Participants
Six participants were invited to attend. Five had a primary diagnosis of schizophrenia, which met DSM III-R criteria (American Psychiatric Association, 1987). One further participant had originally been given a diagnosis of schizophrenia, but this had since been changed to schizoaffective disorder. All participants were referred to the authors (ED, KC and VM), for specific help in the ‘voices group', which had been discussed with community key workers (all C.P.N.’S) and consultant psychiatrists. Patients admitted to the study were on a ‘first come first served’ basis. Inclusion criteria were that patients must have a primary diagnosis of schizophrenia or schizo-affective disorder and they should be experiencing persistent voices. This should be chronic, more than five years in duration. All had to be taking regular neuroleptic medication. Exclusion criteria were; an ongoing problem with alcohol or drug abuse; a neurological or organic disorder, or not known to Gloucestershire Partnership NHS Trust and Gloucestershire Social Services.
There were five men and one woman. Their ages ranged between 23-47 years with a median age of 33 years. The median duration of illness was 11 years ranging from 5-17 years. All members had been known to the service for at least five years. The age at onset was 18-33 years with a median of 21 years. The number of hospital admissions ranged from 2-10 with a median of 4. The time since last admission ranged from 9 months to 3 years. The members were single, unemployed (except 1 participant engaged in occasional casual work), living in the community, receiving neuroleptic medication, attended the local Social Services day centres and were in receipt of Disability Living Allowance.
Measures
Symptoms were rated using the Psychiatric Assessment Scale (KGV, Krawiecka, Goldberg and Vaughan, (1977)), which was revised by Lancashire (1994), see also Coupland, Davis and Gregory (2001). It is a semi-structured interview tool that is very useful for discovering the detailed phenomenology of psychosis. Also the Social Functioning Scale (SFS - Birchwood, Smith, Cochrane, Wetton and Copestake, 1990) was used. In addition, the Beliefs About Voices Questionnaire (BAVQ - Chadwick and Birchwood 1995), and Cognitive Assessment of Voice Interview Schedule (CAVIS - Chadwick, Birchwood and Trower 1996), were used. All measures were administered prior to the group starting (except the CAVIS) by KE the research psychologist, who was specially trained to use the measures.
Process
Clinical Psychologist (ED), Community Psychiatric nurse (KC), Social Worker (VM) and Research Psychologist (KE) devised the group, which was facilitated by KC and VM - both experienced practitioners in groupwork. ED provided ongoing clinical supervision directly after each group session.
The group was held in a Social Services day centre close to the centre of Cheltenham. It ran for 12 consecutive weeks, with a two week gap so that the group could discuss future options. It then resumed with the same group members for a further 12 weeks. This pattern has continued for four years with a "slow open" policy of introducing new members. Each session lasted for one-and-a-half hours. This was divided into two 45-minute intervals (to allow for cognitive capabilities) with a 15-minute break for coffee, biscuits and cigarettes. Continuous attendance was encouraged. One participant dropped out almost immediately, saying that he simply did not want to attend further, giving no further specific details. A further member of the group declined to continue because the group format felt too stressful. This participant was the only woman in the group. Several women have attended the group since.
The first session focussed on the establishment of ground rules acceptable to the facilitators and participants. Thus, the number and duration of sessions was specified. Each person was given the opportunity and time to express their thoughts and feelings and turn-taking was encouraged. A mixture of seriousness and humour was agreed upon in a mutually supportive environment. All members agreed to abide by strict rules of confidentiality so that information was only to be discussed within the group. If people felt the need to leave the group - then it was made clear that their ongoing treatment would not be adversely affected. The facilitators made themselves available at the end of each group session; to ensure individual members well being and further contact numbers were given.
Actual group sessions (following the initial establishment of ground rules) followed a prescribed format. An agenda was drawn up to focus on weekly items. Education and information were initially given regarding schizophrenia and schizoaffective disorder to help facilitate in the initial group formation. Feedback and review of events, including homework and diaries were discussed and outcome(s) and learning evaluated. More homework was allocated on the basis of issues identified in the sessions. This was then followed by a formal relaxation exercise at the end of each session led by VM in order to help reduce any anxiety that group members might have felt.
The first 12 sessions began with a general discussion of the above needs and concerns. In the early sessions, the facilitators provided clear structure to the sessions and were active in promoting discussion. The sessions were problem-centred with a collaborative, flexible and here-and-now focus. Education about schizophrenia and psychosis was provided early in the sessions. Next, a functional analysis (using the CAVIS, Chadwick and Birchwood, 1994) of voice-hearing experiences was conducted together with the identification of current coping strategies. This was combined with techniques of anxiety management so that a degree of early behavioural control over the voices was established using Coping Strategy Enhancement (CSE - Tarrier, Beckett and Harwood et al, 1993). By session eight, participants felt more confident in talking about intimate details associated with their voice-hearing experiences and early life experiences were also discussed. Use of an A-B-C schedule (as used by Chadwick, Birchwood and Trower (1996) helped this process. Tentative conceptualisations of voice hearing and early life experiences were explored combined with formal assessments (Chadwick, et al, 1996). Finally, the various (malevolent) voices were subjected to structured verbal challenges and behavioural experiments.
By the end of the first block of 12 sessions members reported that the work felt ‘incomplete’, and asked for a further 12 sessions after a two week break. The membership of the group remained the same for the subsequent 12 sessions.
Evaluation
Baseline interviews and questionnaires were completed with KE prior to session one. These were repeated after 12 sessions and then again after 24 sessions.
Results
Table 1: Pre, middle and post KGV scores for the group.
| Category | Participant1 | Participant2 | Participant3 | Participant4 |
||||||||
| Anxiety |
2 | 3 | 1 | 3 | 2 | 2 | 4 | 2 | 3 | 2 | 2 | 1 |
| Depressed Mood |
1 | 2 | 1 | 2 | 1 | 2 | 1 | 0 | 2 | 2 | 0 | 0 |
| Suicidality |
2 | 2 | 2 | 1 | 0 | 0 | 3 | 1 | 2 | 0 | 0 | 0 |
| Elevated Mood |
1 | 2 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 0 |
| Hallucinations |
4 | 4 | 0 | 4 | 3 | 3 | 4 | 4 | 3 | 4 | 4 | 4 |
| Delusions |
4 | 4 | 3 | 4 | 3 | 3 | 4 | 4 | 3 | 4 | 4 | 3 |
| Flattened Affect |
0 | 0 | 1 | 3 | 3 | 2 | 4 | 3 | 2 | 1 | 1 | 0 |
| Incongruity |
2 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 0 |
| Overactivity |
1 | 1 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 3 | 2 | 1 |
| Psychomotor-retardation |
0 | 0 | 0 | 2 | 1 | 0 | 3 | 3 | 3 | 1 | 0 | 0 |
| Incoherence |
0 | 0 | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 2 | 1 | 1 |
| Poverty of Speech |
0 | 0 | 0 | 0 | 0 | 0 | 2 | 1 | 2 | 0 | 0 | 0 |
| Abnormal Movements |
0 | 0 | 0 | 1 | 1 | 3 | 2 | 2 | 0 | 3 | 3 | 2 |
| Co-operation |
0 | 0 | 0 | 0 | 0 | 0 | 2 | 0 | 1 | 0 | 0 | 0 |
| TOTAL |
17 | 19 | 8 | 22 | 16 | 16 | 31 | 21 | 23 | 23 | 18 | 12 |
KGV scores; 0= not present, 1=possibly a symptom, 2= definite symptom, 3=severe symptom, 4=very severe symptom
Table 2: SFS Scores
| Participant 1 | Participant 2 | Participant 3 | Participant 4 |
|||||||||
| Category |
pre | mid | post | pre | mid | post | pre | mid | post | pre | mid | post |
| Social Withdrawal |
104 | 116 | 116 | 110 | 124 | 124 | 124 | 133 | 133 | 116 | 110 | 116 |
| Relationships |
>145 | >145 | >145 | 132 | 131 | 123 | >145 | >145 | >145 | >145 | >145 | >145 |
| Social Activities |
111 | 123 | 123 | 132 | 131 | 123 | 96 | 111 | 119 | 117 | 127 | 127 |
| Recreational Activities |
96 | 98 | 101 | 116 | 129 | 129 | 103 | 108 | 108 | 105 | 113 | 113 |
| Independence (Competence) |
81 | 84 | 84 | 107 | 114 | 114 | 100 | 103 | 111 | 114 | 114 | 114 |
| Independence (Performance) |
79 | 94 | 92 | 121 | 116 | 116 | 105 | 90 | 114 | 107 | 103 | 110 |
| Employment |
81 | 81 | 81 | 95 | 95 | 95 | 95 | 95 | 95 | 109 | 116 | 116 |
Note: A score of 100 indicates a median score for people with a diagnosis of schizophrenia.
Table 3: BAVQ Scores
| Participant 1 | Participant 2 | Participant 3 | Participant 4 |
|||||||||
| category |
pre | mid | post | pre | mid | post | pre | mid | post | pre | mid | post |
| malevolence |
6 | 4 | 4 | 4 | 0 | 1 | 6 | 6 | 6 | 5 | 4 | 5 |
| benevolence |
1 | 2 | 1 | 3 | 5 | 3 | 0 | 0 | 0 | 0 | 0 | 0 |
| resistance feeling | 4 | 4 | 4 | 4 | 2 | 3 | 4 | 4 | 4 | 4 | 4 | 3 |
| resistance behaviour |
4 | 5 | 3 | 0 | 2 | 4 | 5 | 5 | 5 | 5 | 4 | 5 |
| engagement feeling | 0 | 0 | 0 | 1 | 4 | 2 | 0 | 0 | 0 | 0 | 0 | 0 |
| engagement behaviour | 0 | 0 | 0 | 3 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 |
Table 4: Demographic details of participants
| category | Participant 1 | Participant 2 | Participant 3 | Participant 4 |
| gender |
male | male | male | male |
| diagnosis |
schizoaffective | schizophrenia | schizophrenia | schizophrenia |
| age |
26 | 34 | 38 | 47 |
| age at onset |
19 | 19 | 18 | 33 |
| voice hearing |
7 years | 15 years | 20 years | 14 years |
Discussion of predictions
- The frequency of voices as measured by the KGV reduced dramatically for participant 1, reduced for 2 and 3, and remained the same for 4. Also, and unexpectedly, there was a reduction in delusional thinking - from 4 to 3, for all participants.
- In terms of prediction two - there is mixed support. Thus, for anxiety a reasonable reduction was observed for all participants but depression did not fall as much as expected.
- For prediction three there is also mixed support. Malevolent voices reduced in intensity for participants 1 and 2 but stayed the same for participants 3 and 4. Chadwick and Birchwood (1994, 1995) suggest that a score of 4 or greater is indicative of malevolence.
- Prediction four was rejected. Neither the group as a whole, nor individual member re-rated any of their voices as being benevolent. Consequently, there was no evidence of emotional or behavioural engagement.
- Prediction five received good overall support. Areas of particular improvement centred upon a decrease in social withdrawal; an increase in social activities and an increase in recreational activities. There were also more modest gains for independent competence and performance. There was no change in employment levels.
Discussion
To summarise, the results indicate that a group approach has been helpful for this small sample and has been for the many more people who have entered the groups since. There were improvements due to a clear reduction in anxiety, voice-hearing and delusional thinking. There were more modest decreases in the level of depressed mood and also suicidality. Social functioning also improved across a range of dimensions.
The work of Chadwick and Birchwood (1994, 1995) led us to hypothesise that a thorough examination of voices in terms of personal history, structured verbal challenge and behavioural experimentation would lead to a change in people’s relationship with their voices. Their work has shown that people tend to engage with voices perceived as benevolent but resist voices perceived as malevolent. Since the group began there has been published a thorough assessment process for voice hearers (The Maastricht Interview in Romme and Escher, 2000). Although Close and Garety (1998) did not wholly support this, and suggest that voice hearing experience in itself is very distressing for people. However, our present group members all experienced voices that were overwhelmingly malevolent. Perhaps this is not surprising, because Romme and Escher (1989) suggest that many people who hear voices do not seek psychiatric help because they experience benevolent and therefore, perhaps, helpful voices.
The complex relationship between voice-hearing and associated beliefs, emotion and behaviour is illustrated by this study. Thus, there was a clear decrease in the actual frequency of voice-hearing across three group members. However, only one person experienced a significant decrease in the perceived malevolence of his voice, and this in turn produced neither emotional nor behavioural change. In addition, while there was a decrease in perceived malevolence for one person, this did not prompt a change in perception so that the voice was subsequently re-rated as benevolent. Therefore, reduced frequency of voice hearing does not automatically lead to reduced malevolence. One possibility - which remains untested - is that future cognitive changes might accrue with increased exposure to the group. This might then lead to associated reduction in emotional and behavioural reaction.
During the evaluation the group members contributed the following:
Group Member 1
" I found the group extremely helpful. The information and education was particularly useful. I liked the social aspect - the mixing of ideas. The group helped me understand what was happening. It gave me an understanding of myself. I know now that the voices are actually within me- I mean they're not coming from outside, from things like Angels. The group was excellent because it taught me that there was nothing to be ashamed of with my mental illness and the voices. I am not alone. Everyone had a go at speaking- it was really fairly run."
Group Member 2
" It was an open and friendly group- I felt I wasn't the only one with problems. I learnt a lot. It was good not to have to bottle it up. I looked forward to every group. I liked the way the facilitators looked to my experiences because I've been through it- they wanted to hear my insight. I'm really pleased the group was available and I'm looking forward to it's starting again."
Group Member 3
" The group was really helpful. It helped me let out my feelings- it was really relaxing not to have to bottle things up. Discussing our problems helped me. Coming to the group made my anxiety much better. I was able to identify with others problems. I felt uneasy in the first session but after that I started to enjoy it- each session went really fast."
Group Member 4
“I really enjoyed the group, particularly realising that others were in the same position. It was enlightening to understand a bit about the voices and I am pleased I could contribute my poems. The group made me feel safe. I looked forward to every meeting.”
In addition, the different group members used different techniques to help them to cope with their voices.
Table 5.
Skills Used by Participants to cope with the negative voices
| Poetry | Listening to music |
| Reading | Talking back to them |
| Talking | Making fun of them |
| Medication | Visualising 'Bombing' them |
| Singing | Smoking |
| Television | Talking to others about them |
So group member 1 exerted more control over his malevolent voices by allocating a certain time each day when he would 'allow' them to converse with him. Group member 2 found that talking to others and watching the television helped. Group member 3 found that listening to a relaxation tape with headphones was beneficial. Group member 4 felt that writing poetry and using visual imagery by which he 'bombed' the voices within his imagination helped. This underscores the importance of groupwork not only because they felt that they could share ideas, but also because it showed that there were commonalties and differences with how voices were coped with. In fact Buccheri, Trygstad, Kanas, Waldron and Dowling (1996), and Buccheri, Trygstad, Kanas, and Dowling (1997), also suggest that in their groups for voice hearers that a wide range of strategies are helpful to cope with voices.
Given that all group members had experienced voice hearing for many years it might be the case that certain cognitive schemata associated with voice hearing are highly resistant to change. It is of interest that the one group member who managed to significantly alter the malevolent perception of his voices had experienced voices for six years - much less than other group members. Thus, a related issue could centre on the earlier timing of group intervention to perhaps prevent the emergence of secondary psychological handicaps associated with (malevolent) voice-hearing (Birchwood, McGorry and Jackson, 1997).
Another important issue regarding our group was the level of controllability over voice-hearing. Although this was not explicitly measured, members reported feeling more in control after the early emphasis on coping strategy enhancement (Tarrier et al, 1993). In fact, this early behavioural work was deemed essential prior to a more cognitive approach. Close and Garety (1998), suggest that the experience of feeling in control is highly important for voice hearers and may have beneficial effects in terms of protecting self-esteem.
The present study, in line with Gledhill et al (1998), also revealed that group members felt less isolated and stigmatised. This probably helped in the improvement of overall social functioning levels. The central concepts of reduced stigma, isolation and universality (the recognition that other people share similar problems) has been prominent in the group work of Kapur et al (1986), Kanas et al (1988), Kibel et al (1981), and Yalom (1983), and is felt to be important in promoting progress within the preset study.
Clinical Implications
In terms of current clinical guidelines it is important that group work is targeted and symptom-specific and also independently rated to avoid potential bias on the part of facilitators (Gledhill et al 1998). Other recommendations are that facilitators be flexible, and that the group is problem-centred, structured (containing an education component), and contains a here-and-now emphasis in which coping strategies (see Table 5.) are implemented early within the group. Coping strategy enhancement and cognitive work should be combined within a normalising rationale. Clinical supervision is also required. The minimum number of sessions required to produce beneficial group cohesion was larger than anticipated. Also because many of the people with SMI experience difficulty in processing information, sessions must be presented at a pace that is compatible for group participation. Repetition of group information is usually required too.
Future Work
In terms of future research, the group work would benefit from linking the evaluation as a series of case studies and doing much more detailed phenomenological investigation of the individuals experience (Coupland 2000) to determine if the present encouraging results could be repeated or extended. The composition of the group has changed and there are regularly seven or eight members and two facilitators. The authors have helped in the setting up of further 'hearing voices groups' in Cheltenham and other parts of Gloucestershire, because of these initial encouraging results. Also, a longitudinal study might allow for greater potential change with regard to disturbing beliefs about voices. The ‘hearing voices group’ that forms the basis for the current study, continues to run in twelve-week blocks, following a “slow open” approach to new members. Evaluation is ongoing and continuous and research data continues to show demonstrable benefits for patients using this medium. It may be the case, that prolonged exposure to this group for chronic voice-hearers as a kind of "top up effect" might be important in promoting further beneficial change.
Furthermore, while there were measurable improvements for anxiety, depression, hallucinations, delusions and social functioning, the authors felt that other important clinical improvements were not satisfactorily captured. Thus, quality of life (Oliver et al 1996) and subjective assessment measures e.g. for self-esteem and attributional processes regarding voice hearing might be useful in future research. These would be required due to the complexity of outcome measurement in SMI (Repper and Brooker, 1998). Another factor that needs to be taken into account is gender (Castle, McGrath and Kulkarni 2000). Previous research has shown this to be an important factor and one of the group facilitators has undertaken a study of the issues involved with members of the group (Macdougall 1998). The primary finding was that if there are issues of sexual abuse this is difficult to divulge in a group of mixed gender. This needs to be further researched with the possible outcome of separately gendered groups. The issue of past trauma including sexual abuse is thought to have a large impact on maintaining malevolent voices and self-harm (Allen 2001). Discussions about trauma, self harm and self acceptance (Dryden 1998)all feature in the groupwork now.
Finally, the present research was conducted with voice hearers with a history of 5 years or more. Further research might concentrate on a group comparison of 'long term' versus 'early- in- the- course voice hearers.' Workers such as Birchwood, McGorry and Jackson (1997) have demonstrated that CBT (to date using individuals with SMI) yields significant benefits when applied in the early stages of psychosis. If such findings could be extended to groupwork then this may be a powerful- and perhaps cost effective- medium by which people's distress can in future, be reduced at an earlier stage. The group has functioned as an aid to recovery for its members and this process of recovery needs further study.
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