Download Voices Clinic - Sussex Partnership NHS Foundation Trust

Voices Clinic
www.voicesclinic.co.uk
Introduction
Distressing voices (auditory hallucinations) are experienced by
approximately 70% of patients with a diagnosis of schizophrenia and can
have devastating effects due to high levels of distress, depression, impaired
social functioning, delayed recovery and an increased risk of suicide.
Distressing voices are also common in patients with other diagnoses.
The National Institute for Health and Care Excellence (NICE) recommend
Cognitive Behaviour Therapy for Psychosis (CBTp) for the treatment of
distressing voices (NICE, 2014). However, it is widely acknowledged that
there are gaps in the provision of psychological therapies with only
10% of those who could benefit from CBT receiving it (Schizophrenia
Commission, 2012).
The Voices Clinic is designed to cross diagnostic and service boundaries
to improve access to innovative evidence-based therapies for distressing
voices while continuing to research their effectiveness. The clinic is
available to an increasing number of patients across our assessment
and treatment services who hear distressing voices. All patients accepted
into the clinic are offered high-quality evidence-based therapies for
voices that are consistent with NICE guidelines. The therapies are tailored
to individual need and include therapies based on the principles of
Cognitive Behavioural Therapy (CBT) and Mindfulness, offered in both
individual and group formats.
Although psychological therapy is helpful for many people who hear
distressing voices, not everyone benefits (Thomas, Hayward et al, 2014).
The Voices Clinic seeks to improve our understanding of voice-hearing
experiences and enhance the effectiveness of the therapy that we offer.
Patients
Which therapies are available?
On average, patients have heard voices for around 16 years at the time
of the initial assessment. About half of the patients referred to the clinic
were female, and half male.
The Voices Clinic offers two therapies within a stepped-care model
referred to as Levels 1 and 2.
If a patient remains distressed by voices after the brief
therapy, they are offered a Level 2 therapy.
The most commonly self-reported diagnoses of patients are:
• Schizophrenia (28%)
• Borderline Personality Disorder (BPD)/Emotionally-Unstable
Personality Disorder (EUPD) (13%)
• Schizoaffective Disorder (6%)
• Other e.g Post-traumatic Stress Disorder (PTSD)/Complex Trauma
or Depression (6%).
• Mixed (34%)
• Unknown (3%)
• No diagnosis (7%)
Level 2:
Referrals/ retention
Level 1:
Brief individual therapy – a four session individual therapy
using the principles of Coping Strategy Enhancement (CSE;
Tarrier et al., 1993) is offered to all patients. The therapy
seeks to identify and systematically implement coping
strategies from the patient’s existing repertoire of strategies.
• 157 referrals accepted in the two years since opening the clinic.
• 121 patients completed a baseline assessment.
• 119 patients (98% of those who completed a baseline assessment)
were offered Level 1 Therapy - indicating a high level of appropriate
referrals.
• 107 patients (90% of those offered Level 1 therapy) attended at least
one Level 1 therapy session.
• 79 patients (74% of those who attended at least one Level 1 therapy
session) completed or are still receiving Level 1 therapy.
• 30 patients (45% of those who completed Level 1 therapy) completed
or are still receiving Level 2 therapy.
Group Person-based Cognitive Therapy (PBCT) –
a 12-session therapy that integrates cognitive behaviour
therapy for psychosis (CBTp) (exploring and challenging
beliefs about self and voices) with a mindfulness-based
approach (Chadwick et al, 2016).
Patients who are not able to attend Group PBCT are
offered individual Relating Therapy over eight sessions
as an alternative.
Outcomes
Data has been analysed for 64 patients who have completed Level 1 therapy and 25 patients who have completed Level 2 therapy. Comparison of their
baseline scores and post-therapy scores indicated that high proportions of patients have shown statistically significant improvements (see Table 1). The
differences between the means are also presented in Table 1. Although the degree of clinical change varies by outcome, the amount of change in Voice
Related Distress following Level 2 is clinically significant.
Table 1: Proportions of patients showing an improvement & differences between the baseline and the Level 1/Level 2 mean outcome scores
Count
Referral pathways
Flow diagram of referral and therapy pathways in Voices Clinic
Level 1
compared to
baseline
Proportion
improved
Level 2
compared to
baseline
Proportion
improved
Outcomes
N
Recovery
(CHOICE)
Mental Wellbeing
(SWEMWBS)
Voice Frequency
(PSYRATS)
Anxiety
(DASS)
Voice Related
Distress
(PSYRATS)
Depression
(DASS)
64
63%
57%
55%
53%
52%
45%
+0.6*
+0.3
-0.7*
-1.3*
-1.6*
-1.1*
75%
84%
58%
48%
75%
64%
+1.5*
+3.6*
-1.3*
-0.9
-4.0*
-2.6*
Difference
between means
25
Difference
between means
Note: * indicates a p-value <0.05 from a t-test comparing baseline scores to the post-therapy score; CHOICE = Choice of outcome in CBT for psychoses; SWEMWBS
= short Warwick Edinburgh Mental Wellbeing Scale; DASS = Depression, Anxiety & Distress Scale; PSYRATS = Psychotic Symptoms Rating Scale.
ATS
assessment
Feedback from patients
Suspected distressing
voices
Yes
No
Usual ATS care
Referral to
Voices Clinic
Feedback from individual patients suggests that the Voices Clinic:
Inappropriate
referrals
Voices Clinic
Assessment
Many patients referred to the Voices Clinic have never attended talking
therapy or report not having anybody to talk to about hearing voices.
The brief Level 1 therapy was designed to provide an opportunity for
patients to talk about these experiences. Patients’ feedback indicates that
attending individual therapy not only helped them to talk to a therapist,
but also prepared them for sharing experiences with other patients in
group therapy at Level 2.
Offer to all
patients
“Therapy was
quite good and made
me feel alive”.
“Made me feel
someone actually
believed me.”
• normalises voice-hearing
• promotes personal control over voices
• increases confidence to challenge negative content of voices
Level 1
therapy
• impacts the quality of what voices are saying
“I felt
relieved. I wasn’t
ridiculed. I didn’t feel
so lonely.”
• provides practical guidance on achieving goals
• allows experiences to be shared in a non-judgemental way
• positively impacts personal & work life
• encourages taking an active role in ensuring one’s own wellbeing
Discharge from
Voices Clinic
“The group made
me realise that I’m still
a valuable member
of society.”
• helps individuals to practice mindful acceptance of voices
• helps to increase the understanding of voices
Research Network
& Clinic Studies
“I felt listened to.
I didn’t feel judged.”
“It helped me
look at things differently.
Helped me to set goals. Helped
me to deal with the voice
differently and to manage
it better.”
Review
Level 2 therapy
(group)
Level 2 therapy
(individual)
Review
Review
Discharge from
Voices Clinic
Recent innovations
Further information
An app has been developed to support patients both during and when
they leave the Voices Clinic. The ‘Choices’ app facilitates the continued
use of coping strategies, mindfulness and assertive responding, and can
be individualised to reflect the specific learning of individual patients.
If you require further information please contact
Dr Mark Hayward, Clinic Director.
e-mail: [email protected]
Tel: 01273 242034
Mobile: 07770 331160
Address: Research & Development, Sussex Education Centre, Sussex Partnership
NHS Foundation Trust, Mill View Hospital Site, Nevill Avenue, BN3 7HZ.
The Voices Clinic has been made available to patients within Lewes
Prison and Early Intervention in Psychosis Services. As these services
cannot offer group therapy, they are piloting a four-session individual
CBT therapy at Level 2 that focuses upon appraisals of self and voices.
Key References
Chadwick, P., Strauss, C., Jones, A-M., Kingdon, D., Ellett, L., Dannahy,L., Hayward, M. (2016) Group mindfulness-based intervention for distressing voices: A pragmatic randomised
controlled trial Schizophrenia Research. 10.1016/j.schres.2016.04.001
NICE (2014). Psychosis and schizophrenia in adults: Treatment and management (Clinical guidelines, CG178). London, UK.
The Schizophrenia Commission (2012). The Abandoned Illness: a report from the Schizophrenia Commission. London; Rethink Mental Illness.
Tarrier, N., Beckett, R., Harwood, S., Baker, A., Yusupoff, L. & Ugarteburu, I. (1993). A trial of two cognitive-behavioural methods of treating drug-resistant symptoms in schizophrenic
outpatients. I: Outcome. British Journal of Psychiatry, 162, 524–532.
Thomas, N. Hayward, M. Peters, E. van der Gaag, M. Bentall, R.P. Jenner, J. et al (2014). Psychological Therapies for Auditory Hallucinations (Voices): Current Status and
Key Directions for Future Research. Schizophrenia Bulletin, 40 (suppl. 4), S202-S212.
If you would like to refer a patient to the Voices Clinic then please speak
to the patient then send their details to
[email protected]
Dedicated to Research
www.sussexpartnership.nhs.uk/research