Randomized Controlled Trial of Group Cognitive-Behavioural Therapy vs Enhanced Supportive Therapy - Research Paper Example

A Critical Review A Randomized Controlled Trial of Group Cognitive-Behavioural Therapy vs. Enhanced Supportive Therapy for Auditory Hallucinations (David L. Penn, Piper S. Meyer, Elizabeth Evans, R.J. Wirth, Karen Cai, Margaret Burchinal) Summary Individual CBT has been proven effective ancillary treatment for positive and negative symptoms of schizophrenia. However, only few benefit from it due to its limited accessibility. One way seen to maximise CBT intervention is through group therapy, thus this study, which aims to examine the efficacy of group CBT for auditory hallucinations compared with enhanced ST. The researchers used blind randomized clinical trials (RCT) on a carefully selected convenience sample of sixty-five participants coming from two different mental/health facilities in central North Carolina. From this, five study cohorts were organized with each cohort grouped in two: one group receiving CBT and the other one receiving ST. Data on all participants assessed at baseline, post-treatment, 3 month, and 12-month follow-up on measures of symptoms, mood, self-esteem, insight, social functioning, and hospitalizations by research assistants blind to treatment group were treated with importance and analysed utilising the general linear models (GLM) comparing outcomes (continuous variables) across time for the two treatment groups and also for categorical outcomes. Primary results of the study which centre on the beliefs as to the severity of voices and global auditory hallucinations were measured utilising the Psychotic Symptom Rating Scales for auditory hallucinations (PSYRATS) and the Belief about Voices Questionnaire—Revised (BAVQ-R), while the secondary outcomes which include psychotic symptoms, self-esteem, social functioning, insight, depression, and hospitalization were measured through interview and self-report utilising Social Functioning Scale (SFS); the Beck Depression Inventory II (BDI-II); the Rosenberg Self-Esteem Scale (RSES); and the Beck Cognitive Insight Scale (BCIS). Results of the study indicate that both interventions are beneficial although on different outcomes: Enhanced ST was specifically effective in reducing auditory hallucinations, while group CBT was found specifically effective in reducing general psychotic symptoms. The inconsistency of these results with other recent group CBT studies – Barrowclough et al. (2006), Bechdolf et al. (2004) nor Wykes et al. (2005) – may be attributed to the basic differences of the participants in this study from those previous current studies which may have resulted to differences in a number of variables. More importantly, although enhance ST and group CBT have proven effective in different outcomes, the positive impact of enhanced ST on beliefs about auditory hallucinations suggests that combining CBT and ST elements might be particularly promising for treatment of medication resistant psychotic symptoms. Strengths of the Study The researchers have positively pinpointed the strengths of this study which they enumerated as follows: the use of raters blind to treatment assignment, utilization of psychometrically sound outcome measures, characterization of the participants, and clearly differentiated treatments, and the tolerability of group CBT (i.e., drop-out and attendance rates) as being comparable to other recent studies of group CBT for psychosis. Such identification reflects the researchers’ utmost carefulness in making this study well-rounded. It also shows the researchers’ in-depth understanding of the intervention being tested. Additional strengths of the study are the careful procedures by which the experiment was conducted and the meticulous process by which data were measured and analysed. A plethora of instruments were utilised from the selection of participants to the study outcomes just to ensure valid results. In fact, this meticulous process by which this study was conducted is very evident in the research paper itself which presented the study in details. Weaknesses of the Study The researchers did also state what they considered weak points in their study which they enumerated as follows: a moderate sample size that only allowed a moderate or large differences between group CBT and enhanced ST treatments, the brevity of the CBT protocol (i.e., 12 sessions), the lack of independent ratings of therapist competence (in addition to the weekly supervision that the PI provided to study clinicians), the lack of periodic blindness checks, and the omission of a treatment as usual (TAU) only comparison group, which according to the researchers prevented them to confidently conclude that the observed symptom reduction effect of both interventions was indeed the intervention’s strength and not the passage of time. Although the researchers belittle this weakness arguing that previous researches have proven the effectiveness of CBT over TAU. In addition to this, since the study was comparative in nature, this research study failed to clearly point out which among the elements of group CBT and enhanced ST were found better in treating psychotic symptoms. This weakness is significant especially so that the researchers view that combining CBT and ST elements might be particularly promising for treatment of medication resistant psychotic symptoms. The question here would be: Which among the elements of these two interventions could be useful and why? Furthermore, although undeniably the strength of this research study is quantitative, its weakness is qualitative as it did not attempt to fully explain the possible reasons as to why the outcomes of the study turned this way. In the first place, the study did not state its hypothesis and did not even bother to explain why among the many available interventions did it chose to study the effectiveness of group CBT vis-a-vis enhanced ST? Can the effectiveness of group CBT for auditory hallucinations not be measured without comparing it with other intervention, specifically enhanced ST? Conclusion Despite its limitations and weaknesses, this study remains a positive laudable effort as it has contributed to the quest for effective ancillary treatment of auditory hallucinations among individuals with schizophrenia. Moreover, although this study failed to establish the efficacy of group CBT over enhanced ST for auditory hallucinations, this study remains significant. What make this study significant are its findings which are different from previous current studies, as it has opened new possibilities – combining CBT and ST elements as a promising treatment for medication resistant psychotic symptoms and new insights in the implementation of group CBT – “that group CBT may be especially tolerable for more educated clients with schizophrenia/schizoaffective disorder with persistent auditory hallucinations” (Penn, Meyer, Evans, Wirth, Cai, & Burchinal, 2009, p. 55) and that the efficacy of group CBT is in reducing general and total psychotic symptoms. Above all these, this study has proven the feasibility of group CBT. Thus it can now benefit more persons with schizophrenia. A Critical Review More than Just a Place to Talk: Young People’s Experiences of Group Psychological Therapy as an Early Intervention for Auditory Hallucinations (Elizabeth Newton, Michael Larkin, Ruth Melhuish and Til Wykes) Summary The exceedingly agonizing effect of auditory hallucinations (hearing voices) especially during adolescents, which have been found correlated to increased risk of downwards socio-economic shift, depression and suicide in later years, remain unsuccessfully addressed despite the high probability of its responsiveness to psychological intervention during a three-year critical period following symptom-onset. With two of the researchers working clinically within a broadly CBT framework with adolescents with psychosis, and the other two researchers generally more interested in fully grasping people’s experience, attitude and coping mechanism with auditory hallucinations, and with individual cognitive-behavioural therapy for psychosis yielding positive results in the UK and in the US, this study was conducted purposely to explore the experience of group-CBT amongst a group of young people experiencing distressing auditory hallucinations. A qualitative research utilising idiographic approach – centres on “the interplay of factors which may be quite specific to the individual” (Smith, 2008, p. 14) – this study carefully examined the experiences of adolescents with auditory hallucinations who engaged in a group psychological treatment for voices wherein participants’ accounts were utilised to explore their experiences of group therapy and to identify the implications of these experiences for future treatment protocols. Four groups, each having either five or six participants, were run based on a cognitive-behavioural model. All participants were experiencing distressing auditory hallucinations which had not responded significantly to treatment with medication A subset of eight participants (five female and three male) drawn from the 2nd and 3rd group, who had completed a cognitive-behavioural group intervention, were interviewed using a semi-structured interview schedule. Then gathered data, which were based on interview transcripts – verbatim extracts, were carefully analysed according to the principles of interpretative phenomenological analysis (IPA). As to the results of the study, two super-ordinate themes emerged from the analysis of the qualitative data: first, ‘A place to explore shared experiences’ is primarily experiential in content, includes four sub-themes, which are (1) a safe place to talk, (2) normalizing and destigmatizing, (3) learning from and helping others, and (4) the role of the facilitators; and second, an inductive account of coping with auditory hallucinations is more interpretative, and to some extent, more speculative as it explores the cyclical relationship between four aspects of the participants’ experiences of hearing voices: the content of the voices, the participants’ preferred explanations and beliefs about the source of the voices, the participants’ perception of the power of these voices (and conversely of their own control over them), their emotional responses to these experiences, and their coping repertoire for managing these experiences. Findings of the study revealed the following: (1) Participants valued both peer support and professional intervention in an environment where they felt safe discussing their difficult experiences; (2) Phenomenological accounts suggested that the voices group successfully provided a safe place to talk about the very personal experience of hearing voices; (3) Reduction of the stigma attached to hearing voices, via psycho-education provided in the group, and by exposure to peers with auditory hallucinations, can be viewed as a positive effect of the group; (4) an external explanation for voices may temporarily reduce distress, while recognizing that an internal explanation over which a person has no control (e.g. voices are an illness and can only be cured by medicine) may also be maladaptive; (5) Family intervention, in conjunction with treatment as usual, has been demonstrated significantly to reduce relapse rate Strengths of the Study The strength of this study lies mainly on the employed research method – its qualitative nature, the use of semi-structured interview to extract data, and the meticulous structure of analysis using IPA in interpreting the qualitative data, as it was able to draw concrete positive and satisfactory results as to the efficacy of group CBT in helping young people experiencing distressing auditory hallucinations understand their experiences and enable them to cope with these subjective phenomena. As the researchers said: “By using semi-structured interviews and IPA, the current study not only allowed us to understand more about our participants’ experiences, but as a consequence, we also understand more about our clinical intervention” (Newton, Larkin, Melhuish, & Wykes, 2007, p. 145). Given the very nature of the problem that this study wishes to understand – coping with auditory hallucinations, this study had shown that the best way to a person’s mind is no other than giving that person the condition to be able to freely speak out his/her mind while the researcher listens to him/her without any pre-judgment. Furthermore, as semi-structured interview although may appear simple compared with other instruments, require positive rapport between the interviewer and the interviewee to be able to extract the necessary information from the respondent, the burden of the success of this instrument depends largely on the interviewer – the ability to think of questions during the interview, the patience to listen attentively to the interviewee, and the ability to comprehend the interviewee’s account. Thus, having been able to have the participants tell their own stories in a group, having been able to extract information that cannot be easily observed, and having been able to analyse gathered data – as the “depth of qualitative information may be difficult to analyse (for example, deciding what is and is not relevant)” (Focused Semi-structured Interviews, n.d., p. 1) attest to the researchers’ aptitude in utilising this instrument, and in conducting this method of research. Although it is true that generally, semi-structured interview has its inherent limitations, the most serious of which is validity as “the researcher has no real way of knowing if the respondent is lying” (Ibid) or not, consistency of data and the result of the study itself had shown that this limitation had been overcome. Weaknesses of the Study The weakness of the study lies in its inability to generalise its result, because it has been conducted only to a very limited number of participants. Although, this could be replicated in other sets of participants in order to prove the validity of the claims of this study. Another seen weakness of this study is the way it was presented in its written report. The presentation is not easy to comprehend as the interrelationships of its points were not clearly presented, although the title of the article, which appears mind-boggling, has somewhat provided this cue. Conclusion This study had provided a concrete basis on the usefulness of group CBT among a group of young people experiencing distressing auditory hallucinations, as ‘Voices groups’ are appreciated by these young people as sources of therapy, information, and support. Compared with other studies that had used the quantitative method, this study seems to prove that the effectiveness of group CBT is in using this intervention via qualitative method. And although, the study was only of limited population, nevertheless its findings have offered promising results in helping adolescents with auditory hallucinations. References Focused (Semi-structured) Interviews. (n.d.). Sociological Research Skills: Research Methods. Retrieved 15 February 2010 from http://www.sociology.org.uk/methfi.pdf Newton, Elizabeth, Larkin, Michael, Melhuish, Ruth and Wykes, Til. (2007). “More than just a place to talk: Young people’s experiences of group psychological therapy as an early intervention for auditory hallucinations.” Psychology and Psychotherapy: Theory, Research and Practice, 80, 127-149. Penn, David L., Meyer, Piper S., Evans, Elizabeth, Wirth, R.J., Cai, Karen, and Burchinal, Margaret. (2009). “A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations.” Schizophrenia Research, 109, 52-59. Read More