Alan Meaden

Cognitive behaviour therapy to prevent harmful compliance with command hallucinations (COMMAND): a randomised controlled trial

BACKGROUND Acting on command hallucinations in psychosis can have serious consequences for the individual and for other people and is a major cause of clinical and public concern. No evidence-based treatments are available to reduce this risk behaviour. We therefore tested our new cognitive therapy to challenge the perceived power of voices to inflict harm on the voice hearer if commands are not followed, thereby reducing the hearers motivation to comply. METHODS In COMMAND, a single-blind, randomised controlled trial, eligible participants from three centres in the UK who had command hallucinations for at least 6 months leading to major episodes of harm to themselves or other people were assigned in a 1: 1 ratio to cognitive therapy for command hallucinations + treatment as usual versus just treatment as usual for 9 months. Only the raters were masked to treatment assignment. The primary outcome was harmful compliance. Analysis was by intention to treat. The trial is registered, number ISRCTN62304114. FINDINGS 98 (50%) of 197 participants were assigned to cognitive therapy for command hallucinations + treatment as usual and 99 (50%) to treatment as usual. At 18 months, 39 (46%) of 85 participants in the treatment as usual group fully complied with the voices compared with 22 (28%) of 79 in the cognitive therapy for command hallucinations + treatment as usual group (odds ratio 0·45, 95% CI 0·23-0·88, p=0·021). At 9 months the treatment effect was not significant (0·74, 0·40-1·39, p=0·353). However, the treatment by follow-up interaction was not significant and the treatment effect common to both follow-up points was 0·57 (0·33-0·98, p=0·042). INTERPRETATION This is the first trial to show a clinically meaningful reduction in risk behaviour associated with commanding voices. We will next determine if change in power was the mediator of change. Further more complex trials are needed to identify the most influential components of the treatment in reducing power and compliance. FUNDING UK Medical Research Council and the National Institute for Health Research.

Brief report: The development and psychometric properties of an observer-rated measure of engagement with mental health services

Engagement with mental health services is important if people with serious, long-standing mental health problems are to be adequately supported in the community. However, engagement of this client group is notoriously difficult. While research is needed to address reasons for disengagement, there are no existing measures of the engagement concept. This paper presents the development of an observer-rated, multi-item engagement measure, together with evidence in support of its reliability and validity. The measure is quick and easy to use, with significant clinical and research value.Engagement with mental health services is important if people with serious, long-standing mental health problems are to be adequately supported in the community. However, engagement of this client group is notoriously difficult. While research is needed to address reasons for disengagement, there are no existing measures of the engagement concept. This paper presents the development of an observer-rated, multi-item engagement measure, together with evidence in support of its reliability and validity. The measure is quick and easy to use, with significant clinical and research value.

Acting on voices: Omnipotence, sources of threat, and safety‐seeking behaviours

OBJECTIVES Previous research indicates that beliefs about voice power and omnipotence are associated with distress, depression, and compliance. The present study investigates whether acting on voices to mitigate perceived threat, in a broader sense than compliance, is driven by delusional beliefs, as the Chadwick, Birchwood, and Trower cognitive-behavioural model of voices would suggest. The role of safety behaviours in maintaining beliefs about voice omnipotence and distress is also examined. DESIGN A cross-sectional investigation of 30 individuals with current experience of auditory verbal hallucinations was conducted. METHOD Participants were assessed on self-report measures of voice topography, voice-related threat and distress, safety behaviour use, beliefs about voices, and depression and anxiety. RESULTS Three sources of threat were identified: physical harm, shame, and loss of control. Twenty-six individuals had recently used safety behaviours, believing them to be effective in threat reduction. The degree of safety behaviour use and voice-related distress were associated with voice omnipotence beliefs; mood or voice characteristics did not account for this relationship. The association of safety behaviours with increased distress was mediated by beliefs about voice omnipotence. CONCLUSIONS Acting on voices can be conceptualized as a form of safety seeking, associated with maintaining beliefs about voice omnipotence and distress.

Command Hallucinations: Cognitive Theory, Therapy, and Research

Command hallucinations (CH) are a distressing and high-risk group of symptoms that have long been recognized but little understood, with few effective treatments. Research shows that cognitive behavior therapy (CBT) is a promising treatment for hallucinations in general and therefore has a potential role in the treatment of CH. We propose that the development of an effective CBT for CH would be enhanced by a theory specific to this uniquely problematic symptom. In this article we describe and apply such a theory from evolutionary psychology, namely social rank theory, and review recent evidence for its application to hallucinations in general. Second, we present a treatment protocol developed in accordance with the principles of the theory specifically for CH, and describe an illustrative case. Finally, we outline the design and methodology of a new, randomized, controlled trial currently being undertaken to test the efficacy of the treatment. Further developments both in the protocol and in its evaluation are discussed.

Facial emotion recognition from moving and static point-light images in schizophrenia.

It is well established that schizophrenia is associated with difficulties recognising facial expressions of emotion. It has been suggested that this impairment could be specific to moving faces [Archer, J., Hay, D., Young, A., 1994. Movement, face processing and schizophrenia: evidence of a differential deficit in expression analysis. British Journal of Clinical Psychology, 33, 517-528]. The current study used point-light images to assess whether people with schizophrenia can interpret emotions from isolated patterns of facial movement in the absence of featural cues. Emotion recognition from moving and static images was assessed using a forced choice design with two sets of three emotions (anger, sadness and surprise; disgust, fear and happiness). The schizophrenia group was significantly better at recognising the emotions from moving images than static images. Although the control group was more accurate overall than the schizophrenia group, both groups presented the same characteristic patterns of performance across tasks. For example, in terms of which emotions were better recognised than others and the types of misidentifications that were made. Hence, it is concluded that people with schizophrenia are sensitive to the motion patterns which underlie individual expressions of emotion and can use this information to accurately recognise emotions.

Can engagement predict outcome in Assertive Outreach

Background: Much attention has been paid to examining the impact of Assertive Outreach management on hospital usage. However, little attempt has been made to examine the role of engagement in reducing hospital usage despite the emphasis placed on engagement when delivering care in such services. Aims: The main aim of this study was to see if engagement could predict future hospital usage. Method: An observer rated measure of engagement was completed on 32 clients under the management of an Assertive Outreach Team (AOT) at Time1. A regression was used to see if engagement scores at Time1 could predict hospital usage (admissions and bed days) at Time2. Results: There were no significant predictors of hospital usage from total engagement scores, individual dimensions of engagement or previous hospital usage. However, certain indices of engagement were found to be more important than others. Previous admissions were shown to account for some of the variance when predicting future admissions. Hospital usage was shown to reduce significantly at Time2 compared with Time1 and pre Assertive Outreach. Conclusions: Engagement may not be a predictor of hospital usage per se but may provide a platform for other interventions, which may lead to reductions in hospital usage.

The COMMAND trial of cognitive therapy to prevent harmful compliance with command hallucinations : predictors of outcome and mediators of change

Background Acting on harmful command hallucinations is a major clinical concern. Our COMMAND CBT trial approximately halved the rate of harmful compliance (OR = 0.45, 95% CI 0.23–0.88, p = 0.021). The focus of the therapy was a single mechanism, the power dimension of voice appraisal, was also significantly reduced. We hypothesised that voice power differential (between voice and voice hearer) was the mediator of the treatment effect. Methods The trial sample (n = 197) was used. A logistic regression model predicting 18-month compliance was used to identify predictors, and an exploratory principal component analysis (PCA) of baseline variables used as potential predictors (confounders) in their own right. Statas paramed command used to obtain estimates of the direct, indirect and total effects of treatment. Results Voice omnipotence was the best predictor although the PCA identified a highly predictive cognitive-affective dimension comprising: voices’ power, childhood trauma, depression and self-harm. In the mediation analysis, the indirect effect of treatment was fully explained by its effect on the hypothesised mediator: voice power differential. Conclusion Voice power and treatment allocation were the best predictors of harmful compliance up to 18 months; post-treatment, voice power differential measured at nine months was the mediator of the effect of treatment on compliance at 18 months.

The COMMAND trial of cognitive therapy for harmful compliance with command hallucinations (CTCH): a qualitative study of acceptability and tolerability in the UK.

Objectives To explore service user experiences of a 9-month cognitive behavioural therapy for command hallucinations in the context of a randomised controlled trial including their views on acceptability and tolerability of the intervention. Design Qualitative study using semistructured interviews. Setting The study took place across three sites: Birmingham, Manchester and London. Interviews were carried out at the sites where therapy took place which included service bases and participants’ homes. Participants Of 197 patients who consented to the trial, 98 received the Cognitive Behavior Therapy for Command Hallucinations (CTCH) intervention; 25 (15 males) of whom were randomly selected and consented to the qualitative study. The mean age of the sample was 42 years, and 68% were white British. Results Two superordinate themes were identified: participants’ views about the aspects of CTCH they found most helpful; and participants’ concerns with therapy. Helpful aspects of the therapy included gaining control over the voices, challenging the power and omniscience of the voices, following a structured approach, normalisation and mainstreaming of the experience of voices, and having peer support alongside the therapy. Concerns with the therapy included anxiety about completing CTCH tasks, fear of talking back to voices, the need for follow-up and ongoing support and concerns with adaptability of the therapy. Conclusions Interpretation: CTCH was generally well received and the narratives validated the overall approach. Participants did not find it an easy therapy to undertake as they were challenging a persecutor they believed had great power to harm; many were concerned, anxious and occasionally disappointed that the voices did not disappear altogether. The trusting relationship with the therapist was crucial. The need for continued support was expressed. Trial registration number ISRCTN62304114, Pre-results.