Randomized Controlled Trial of an Internet Cognitive Behavioral Skills- Based Program for Auditory Hallucinations in Persons With Psychosis

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1 Psychiatric Rehabilitation Journal 2017 American Psychological Association 2017, Vol. 40, No. 3, X/17/$ Randomized Controlled Trial of an Internet Cognitive Behavioral Skills- Based Program for Auditory Hallucinations in Persons With Psychosis Jennifer D. Gottlieb, Vasudha Gidugu, and Mihoko Maru Boston University Miriam C. Tepper, Matthew J. Davis, Jennifer Greenwold, and Ruth A. Barron Cambridge Health Alliance, Somerville, Massachusetts Brian P. Chiko Schizophrenia.com/Cognitive Health Innovations, Inc., San Francisco, California Kim T. Mueser Boston University Objective: Despite strong evidence supporting the effectiveness of cognitive behavioral therapy for psychosis (CBTp), most clinicians in the United States have received little or no training in the approach and access remains very low, indicating a potential role for technology in increasing access to this intervention. Coping With Voices (CWV) is a 10-session, interactive, Web-based CBTp skills program that was developed to meet this need, and was shown to be feasible and associated with reduced severity of auditory hallucinations in a previous pilot study. To more rigorously evaluate this program, a randomized controlled trial was conducted comparing the efficacy of CWV to usual care (UC). Method: The trial was conducted with a sample of 37 community mental health center clients with schizophrenia and moderate-to-severe auditory hallucinations, with assessments conducted at baseline, posttreatment, and 3-month follow-up. Results: Engagement in and satisfaction with the CWV program were high. Both the CWV and UC groups improved comparably in severity of auditory hallucinations and other symptoms over the treatment and at follow-up. However, participants in the CWV program showed significantly greater increases in social functioning and in knowledge about CBTp. Conclusions and Implications for Practice: The results suggest that the CWV program has promise for increasing access to CBTp, and associated benefits in the management of distressing psychotic symptoms and improving social functioning. Keywords: cognitive behavioral therapy, psychosis, auditory hallucinations, Internet-based psychotherapy, schizophrenia Cognitive behavioral therapy for psychosis (CBTp) is a structured intervention aimed at helping people better understand the development and maintaining factors of their psychotic symptoms (such as Editor s Note. Kathleen Furlong-Norman served as the action editor for this article. JAC This article was published Online First May 18, Jennifer D. Gottlieb, Center for Psychiatric Rehabilitation and Departments of Occupational Therapy and Psychology, Boston University; Vasudha Gidugu and Mihoko Maru, Center for Psychiatric Rehabilitation, Boston University; Miriam C. Tepper, Matthew J. Davis, Jennifer Greenwold, and Ruth A. Barron, Cambridge Health Alliance, Somerville, Massachusetts; Brian P. Chiko, Schizophrenia.com/Cognitive Health Innovations, Inc., San Francisco, California; Kim T. Mueser, Center for Psychiatric Rehabilitation and Departments of Occupational Therapy and Psychology, Boston University. During the study period, Brian Chiko founded Cognitive Health Innovations, a start-up company for web-based mental health interventions with interest in marketing products similar to the Coping with Voices program used in this research. As of 2013, this company is no longer active. Correspondence concerning this article should be addressed to Vasudha Gidugu, Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Avenue West, Boston, MA vasudha@bu.edu auditory hallucinations, paranoia, and delusions), and learn specific cognitive (e.g., cognitive restructuring ) and behavioral coping strategies in order to reduce the distress, problems functioning, and interference with the attainment of personal goals caused by these symptoms (Beck & Rector, 2000). CBTp has been shown to be effective at improving positive and negative symptoms as well as social functioning (Burns, Erickson, & Brenner, 2014; Jauhar et al., 2014; Wykes, Steel, Everitt, & Tarrier, 2008), and is recommended by treatment guidelines for schizophrenia in both the United States and United Kingdom (Dixon et al., 2010; National Collaborating Centre for Mental Health, 2009). However, despite two decades of research on CBTp, most clinicians in the United States have received little or no training in the approach, and access remains low (Mueser & Noordsy, 2005; Rollinson et al., 2007; Kimhy et al., 2013). Limited resources for treating serious mental illnesses, plus an overburdened community mental health workforce, necessitate creative solutions to increase access to evidence-based treatments within routine clinical settings for people with psychosis (Aarons, Hurlburt, & Horwitz, 2011; Institute of Medicine, 2006). Technology-delivered interventions have potential for addressing this problem in a cost-effective manner by allowing flexible delivery of effective treatments in the community without extensive training of mental health workers. Technology is becoming increasingly infused into the daily lives of people worldwide, including those with serious mental illness. 283

2 284 GOTTLIEB ET AL. For example, surveys report that the majority of persons with serious mental illness report using cell phones and text messaging, owning or having access to a computer, being interested in using their phone to facilitate mental health treatment (Ben-Zeev, 2012; Miller, Stewart, Schrimsher, Peeples, & Buckley, 2015). Additionally, for persons with schizophrenia, recently developed mobilephone applications aimed at improving illness management have been found to be user-friendly and effective (e.g., Granholm, Ben-Zeev, Link, et al., 2012; Palmier-Clause et al., 2012). Nevertheless, few computer Web-based interventions for persons with psychotic symptoms have been developed. An exception is that by Leff et al. (2014), who recently reported the results of an intervention to reduce psychosis in persons with medication-resistant auditory hallucinations through the creation of an avatar of their persecutor which interacts directly with the individual via a computer operated by a therapist in another room. While this intervention is innovative, it requires an experienced therapist to serve in the role of the avatar, and therefore does not address the problem of low access to CBTp. To explore the potential of computer-based treatment to increase access to CBTp, we developed a 10-module, computerized CBTp intervention for auditory hallucinations: Coping With Voices (CWV). In an open-trial pilot study at two community mental health clinics, we demonstrated the feasibility, acceptability, and preliminary effectiveness of CWV delivered via individual laptop computers and proctored by staff in 21 outpatients with schizophrenia-spectrum disorders (Gottlieb et al., 2013). Participants attended weekly individual appointments to work on the program at their own pace, with a proctor nearby to answer questions and help with any technical glitches. Participants reported high satisfaction with the program, showed significant increases in CBT knowledge, and reported significant reductions in auditory hallucinations and overall symptoms between baseline and posttreatment assessments. During exit interviews, participants also suggested program improvements (e.g., inclusion of video), which were incorporated into a revision of the program, which was used in the current study. The promising results of the pilot study suggested the need for more rigorous, controlled research on the CWV program. This article describes the results of such a study. Method A randomized controlled trial comparing the CWV program with usual care (UC) was conducted at a Boston metro-area community mental health clinic. This clinic is part of a comprehensive service system providing primary, specialty, and mental health care to a diverse population of 140,000 patients. CBTp had not previously been offered at this clinic. This research was approved by the institutional review boards at Jennifer D. Gottlieb s academic institution and the study clinic. All participants provided informed consent. Data collection occurred between May 2012 and February Participants Participants were 37 adults with psychotic disorders receiving outpatient services at the study clinic (CWV 19, UC 18). Inclusion criteria were (a) schizophrenia, schizoaffective disorder, or psychosis not otherwise specified diagnosis (determined by chart review and confirmed by the primary clinician); (b) at least moderate level of auditory hallucinations (score of 4 or higher on the Hallucinations item of the Expanded Brief Psychiatric Rating Scale (BPRS; Lukoff, Nuechterlein, & Ventura, 1986); (c) between the ages of 18 and 70; (d) no exposure to CBTp within the past 3 years; (e) no current suicidal ideation or hospitalization within the past month; (f) taking stable dose of antipsychotic medication for at least 1 month; (g) no active substance abuse/dependence; (h) English speaking, with at least eighth-grade reading level, measured by the Wide Range Achievement Test (WRAT; Wilkinson & Robertson, 2006); and (i) no dementia, measured by Mini Mental State Examine (MMSE) score of 24 (Cummings, 1993; Folstein, Folstein, & McHugh, 1975). Participant characteristics are summarized in Table 1. Measures Outcome measures included severity of auditory hallucinations (including evaluation of distress, preoccupation, and interference related to voices), other psychiatric symptoms, and functioning. Process measures included Internet usage, CBT knowledge, and program satisfaction. All measures were administered at baseline, posttreatment, and 3 months posttreatment by a trained interviewer who was blind to treatment group allocation. Auditory hallucinations primary outcome measures. The Expanded BPRS is a widely used 24-item semistructured interview to assess psychopathology (Lukoff et al., 1986). The Auditory Hallucinations item was used to measure changes in severity of voices. The Psychotic Symptom Rating Scales (PSYRATS; Haddock, McCarron, Tarrier, & Faragher, 1999) is a 17-item dimensional measure of psychotic symptom severity that provides a total score and Auditory Hallucinations (AH) and Delusions subscales. The PSYRATS takes a more multifaceted approach to the evaluation of hallucinations, in keeping with the CBTp model, with the Auditory Hallucinations subscale, including ratings of frequency, intensity, loudness, associated distress, perceived degree of controllability, and interference from voices. Secondary symptom and functioning-based outcome measures. Secondary measures included the PSYRATS Delusions subscale; the BPRS total score and subscales (including Psychosis, Depression, and Negative Symptoms; Velligan et al., 2005); the Beliefs about Voices Questionnaire Revised (Chadwick, Sambrooke, Rasch, & Davies, 2000), a 35-item self-report measure evaluating AH-related beliefs and emotional or behavioral reactions to them; the Paranoia Scale (Fenigstein & Vanable, 1992); the Beck Depression Inventory II (Beck, Steer, & Brown, 1996); and the Beck Anxiety Inventory (Beck & Steer, 1993). The Beck Cognitive Insight Scale (Beck, Baruch, Balter, Steer, & Warman, 2004), a 15-item self-report instrument measuring self-reflectiveness, certainty, and overconfidence in interpretations of anomalous experiences, was used to measure overall cognitive insight. The Specific Levels of Functioning (SLOF) scale (Schneider & Struening, 1983), which has strong psychometric properties in people with schizophrenia (Bowie et al., 2008), was used to measure psychosocial adjustment in the domains of interper-

3 COMPUTER-BASED CBT FOR AUDITORY HALLUCINATIONS 285 Table 1 Baseline Characteristics of Study Sample Coping With Voices Usual care treatment Variable Mean SD Mean SD t test df p Continuous Age MMSE IQ BPRS total BPRS Auditory Hallucinations PSYRATS total PSYRATS Auditory Hallucinations BAVQ Paranoia Scale BDI BAI BCIS-CI BCIS Self-Reflectiveness BCIS Self-Certainty SLOF CBT Knowledge (maximum score 29) Internet use (1 everyday to 6 never) Variable N % N % 2 df p Categorical Gender Male % % Female % % Race White % % Black % % Asian % More than one race % % Other % Ethnicity Hispanic 1 5.3% 1 5.6% Non-Hispanic % % Marital status Ever married % % Never married % % Living situation Independent % % Nonindependent % % Education Did not complete high school % % High school % % Post high school % % Reading level High school % % Post high school % % Employment Employed % % Not employed % % Note. MMSE Mini Mental State Examine; BPRS Brief Psychiatric Rating Scale; PSYRATS Psychotic Symptom Rating Scales; BAVQ Beliefs About Voices Questionnaire; BDI Beck Depression Inventory; BAI Beck Anxiety Inventory; BCIS-CI Beck Cognitive Insight Scale composite index; SLOF Specific Levels of Functioning; CBT cognitive behavioral therapy. p.05. sonal relationships, social acceptability, work, and daily living activities. Cognitive measures at baseline. In addition to the WRAT and MMSE which were administered at baseline to determine eligibility for the study with respect to reading level and the absence of dementia, the Vocabulary and Matrix Reasoning subscales of the Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999) was used to estimate IQ at baseline only. Self-report participant survey measures. Participants prior experience using computers and Internet in their daily lives was evaluated at baseline with a measure constructed for this study.

4 286 GOTTLIEB ET AL. To evaluate learning and retention of basic CBTp concepts taught in CWV, a brief, multiple-choice/true false CBT Knowledge test was used. This test was previously developed for the pilot study of the CWV program (Gottlieb et al., 2013), and was found to improve significantly after completion in the program. A sample item from the test is Some things that may contribute to hearing voices include a) attention problems, b) drugs and alcohol, c) stress, d) all of the above. The CWV Program Client Satisfaction Survey is a feedback measure designed for this study, with 21 Likert scale and 18 open-ended qualitative items, administered by interview to CWV participants only. Process measures for coping with voices participants. For participants in CWV, data were collected about number of sessions, time spent on program per session, and rate of homework completion. Procedure Recruitment and assessment. Participants were recruited and referred at the mental health agency by clinic staff and posted study flyers. Upon referral, participants were screened by the assessor and then completed the baseline interview. Eligible clients were then randomized (offsite, by a staff member unaffiliated with the study) to either CWV or UC. In order to ensure comparable periods of time between the baseline and subsequent assessments for the two groups, UC participants were individually yoked to CWV participants for the time between the baseline and posttreatment assessments. All participants were paid for completing each assessment, but CWV participants were not paid for CWV program visits. The Coping With Voices program. CWV is an interactive, self-paced, Web-based program, developed by Jennifer D. Gottlieb (with software originally developed by Brian P. Chiko). The program utilizes many of the guidelines established by Rotondi et al. (2007) for effective Website design for individuals with schizophrenia and accompanying cognitive difficulties. CWV takes a skills-based approach that incorporates many of the traditional elements of CBT and CBTp, such as education about and normalization of psychotic symptoms, self-assessment and goal-setting, enhancing behavioral coping strategies enhancement, cognitive restructuring, homework to practice skills, and relapse prevention (Morrison & Barratt, 2010). The overarching goal of the CWV program is to teach users CBT-based skills in order to reduce the distress, preoccupation, and day-to-day interference of voices, and to improve overall quality of life. The program is highly interactive and self-paced, and includes animated tutorials and videos, exercises and games, tracking of symptoms and goals, and independent skills practice worksheets. Participants progress sequentially through a series of lesson plans or modules, building skills cumulatively throughout the program (Gottlieb et al., 2013). Table 2 contains the CWV program topics, modules, and client materials. Participants who were randomized to CWV began the program within 2 weeks of completing their baseline assessment. Sessions took place on laptop computers in a private room with a proctor (i.e., a program assistant, not a therapist) situated in an adjacent room to allow the participant to work privately on the program. For each session the proctor set up the participant up on the computer, occasionally checked in on progress, provided basic technical support as needed, reviewed homework worksheets, answered questions, scheduled the next appointment, and made an appointment reminder call. Statistical Analyses Descriptive statistics were computed to summarize participant characteristics, baseline cognitive functioning, program participation, and satisfaction data. T tests and chi-square analyses were conducted to compare the groups on baseline characteristics. Prior to conducting linear regression analyses, the distribution of dependent variables was examined to determine normality. Two participants with outlier scores on the CBT Knowledge test were identified (i.e., scores 2 SDs below the mean score of the sample), both in the UC group, one at baseline and the other at the follow-up assessment. Both participants were dropped from the analyses of changes in CBT Knowledge as a dependent variable, and the first participant was also dropped from the analyses of CBT Knowledge at baseline as a moderator of treatment. Mixed-model linear regression analyses were used to compare groups on the outcome measures over time. For these analyses, baseline score was included as a covariate; posttreatment and follow-up scores were the repeated dependent measures; and group, time, and their interaction were the independent variables. The group effect is the primary test of whether the CWV and UC groups differed at posttreatment and follow-up after controlling for baseline. The Group Time interaction is a test of whether the two groups changed differentially between posttreatment and follow-up, controlling for baseline. Effect sizes were computed based on Cohen s d using the posttreatment means for the primary outcome measures and secondary outcomes where there were significant group differences. We also evaluated changes over time using linear mixed-effects models with time as the only independent variable. In addition, we explored whether baseline levels of Internet use, CBT Knowledge, age, or IQ moderated the effects of CWV program on outcomes. Four sets of mixed-model linear regression analyses were conducted similar to those described above, one set for each moderator variable, which in addition to the same independent variables also included the moderator and the Group Moderator interaction. For these analyses, the main effect of the moderator variable (e.g., baseline Internet usage) is a test of whether participants in both groups with low levels of that variable improved less at posttreatment and follow-up on the dependent measure (e.g., severity of AH) than those with higher levels; whereas the Moderator Group interaction is a test of whether the effect of the moderator on outcomes differed between the CWV and UC groups. For example, if participants in both groups with lower levels of the moderator variable Internet usage at baseline improved less in the severity of AH, the main effect of baseline Internet usage would be significant. On the other hand, if participants in the CWV group with lower levels of Internet usage at baseline improved less in severity of AH than participants with higher levels, whereas in the UC group level of Internet usage at baseline was unrelated to change in severity of AH, the Moderator Group interaction effect would be significant. As the primary question with the moderator analyses was whether any potential moderator variables influenced the effectiveness of the CWV program on improving outcomes, the Moderator Group interaction in these analyses was the effect of primary interest.

5 COMPUTER-BASED CBT FOR AUDITORY HALLUCINATIONS 287 Table 2 Components of Coping With Voices Program Module no. Lesson plan Practice exercises Associated cognitive behavioral strategies Homework worksheets 1 Program orientation/self-assessment CBT/AH knowledge quiz Self-monitoring of AH Tracking thoughts and feelings What is cognitive behavioral therapy Thought feeling model Psychoeducation Tracking my voices (CBT) tutorial Thoughts and feelings exercise Thought feeling model 2 Homework review Cognitive distortions quiz AH symptom tracking Tracking my voices Daily voices log Daily voices log Psychoeducation Tracking my thinking styles Inaccurate thinking styles tutorial Inaccurate thinking styles Thought feeling behavior game model Inaccurate thinking styles Game I Cognitive distortions 3 HW review; daily voices log Daily voices log AH symptom tracking Tracking my voices Inaccurate thinking styles Games I& II Inaccurate thinking styles Thought feeling behavior Tracking my thinking games model styles Cognitive distortions 4 HW review; daily voices log Coping with voices quiz AH symptom tracking Tracking my voices Coping with voices tutorial Daily voices log Psychoeducation Tracking my thinking styles Voices and feelings exercise Thought feeling behavior model 5 HW review; daily voices log Daily voices log AH symptom tracking My new coping Behavioral coping strategies Game I Behavioral coping strategies game Coping strategy enhancement strategies Tracking my voices 6 HW review; daily voices log Daily voices log AH symptom tracking Challenging what the voices say Behavioral coping strategies Game II Challenging what your voices say: I Behavioral coping strategies game Cognitive restructuring practice Coping strategy enhancement Cognitive restructuring (AH content) My new coping strategies 7 HW review; daily voices log Daily voices log AH symptom tracking Challenging what the voices say Challenging what your voices say: II Cognitive restructuring practice Cognitive restructuring (AH content) My new coping strategies 8,9 HW review; daily voices log Daily voices log AH symptom tracking Challenging my beliefs about the voices Challenging beliefs about your voices Cognitive restructuring practice Cognitive restructuring (beliefs about AH) 10 HW review; daily voices log Daily voices log AH symptom tracking N/A Post self-assessment & results Post-self-assessment Self-monitoring AH Session summaries Relapse prevention planning Progress review/attributions of change Note. Program review Progress letter to self Maintaining gains Relapse prevention CBT cognitive behavioral therapy; AH auditory hallucinations; HW homework; N/A not applicable. Challenging what the voices say My new coping strategies Results The two groups differed significantly at baseline on two variables: Participants in UC had higher anxiety on the Beck Anxiety Inventory and a lower rate of employment than the CWV participants (see Table 1). Assessment Completion Rates and Intervention Exposure The assessment completion rate across the study was 86% for posttreatment and 81% for the 3-month follow-up, and was comparable between treatment groups. A high proportion of partici-

6 288 GOTTLIEB ET AL. pants randomized to CWV completed all 10 modules (15 of 19 or 79%). The remaining four participants dropped out after completing five or fewer modules. The 15 CWV completers finished the program over an average of 11 visits (range: 9 24; SD 3.60), spent an average of 82.7 min on the program per visit (range: min; SD min), and completed an average of 71% (range: 11% 100%) of the homework assignments. Program Satisfaction Participants rated the CWV program positively overall, including the amount of information covered (87% rated just enough), the level of difficulty of the skills and information given (easy to understand [47%] or very easy to understand [53%]), and program flow (67% rated very good). About two thirds (67%) of the participants rated the program very interesting and engaging, while 27% rated it as somewhat engaging, and only 7% rated it as not engaging. All participants rated the program as very useful (67%) or useful (33%). Participants also indicated that the program helped (67%) or helped very much (33%) in managing their symptoms. Approximately 80% indicated that they would recommend the program to a friend or Table 3 Clinical Outcomes in the Coping With Voices Versus Usual Care Groups Measure Baseline (N 19) Coping With Voices Posttest (N 15) relative with similar difficulties. The individual components of the programs (e.g., exercises, activities) were also positively evaluated by participants, with an average rating of 7.8 on a 10-point scale, between 1(not at all helpful) and 10 (extremely helpful). Primary Outcome Measures: Auditory Hallucinations The means and standard deviations for the two groups at baseline, posttreatment, and follow-up are presented in Table 3. The mixed-model linear regression analyses indicated no significant group or Group Time effects for any of the hallucination variables. The effect sizes were small for both BPRS AH (0.09) and PSYRATS AH (0.17). There was an overall significant decrease in symptoms over time on BPRS AH, F(1, 31) 10.33, p.003, and PSYRATS AH, F(1, 31) 12.70, p.001. Secondary Outcome Measures Mixed-model linear regression analyses of the secondary outcome variables indicated significant group effects favoring CWV on three variables: overall SLOF, F(1, 28) 4.68, p.039, effect Follow-up (N 15) Baseline (N 18) Usual care Posttest (N 17) Follow-up (N 15) BPRS Total (12.36) (11.05) 49.6 (8.39) (13.16) (11.14) (12.44) Auditory hallucinations 5.79 (.97) 5.33 (1.23) 5.13 (1.12) 5.83 (1.04) 5.00 (2.17) 4.53 (2.35) Depression (4.37) 9.46 (3.71) (3.96) (5.45) (5.05) (4.89) Psychosis (3.75) (3.80) (3.22) (3.49) (4.23) (3.71) Negative symptom 5.57 (2.24) 5.80 (2.27) 5.26 (2.28) 6.88 (2.69) 6.29 (2.11) 6.06 (2.01) PSYRATS Total (15.48) (14.64) 48 (16.94) (14.74) (20.49) (21.27) Auditory hallucinations (8.22) 37.4 (6.74) (11.71) (7.27) (14.01) (16.6) Delusions (10.73) (9.51) (8.85) (11.59) (10.52) (10.28) SLOF Total (9.5) (11.28) (12.78) (11.70) a (13.33) (13.79) Interpersonal relationships (3.74) 25.6 (3.18) 25.6 (3.64) 23 (5.33) 22 (4.33) (3.97) Social acceptability (1.93) 26.4 (1.59) (1.53) (2.47) (3.15) (2.31) Community living (4.35) 49 (5.23) (5.07) (5.77) (6.06) 46 (8.12) Work skills (4.24) 24.6 (4.35) 25 (4.34) (4.1) (4.61) (5.97) CBT Knowledge (4.53) (2.15) (3.19) (3.89) b (2.79) c (3.68) d Paranoia Scale (15.12) 47 (16.08) (17.69) (20.25) (19.96) (19.79) BCIS Composite index 6.9 (4.09) 6.73 (5.47) 8.13 (6.93) 5.05 (5.67) 5.96 (4.65) 6.83 (4.94) Self-reflectiveness (3.85) (3.93) (6.03) (5.23) (4.88) (5.60) Self-certainty 5.78 (2.99) 6.06 (3.34) 5.33 (2.41) 7.27 (3.70) 7.03 (3.90) 7.20 (3.85) BAVQ Total (11.40) (10.54) (10.95) (15.89) 38.5 (15.81) 39.6 (16.12) Malevolence 6.68 (5.35) 6.06 (4.43) 5.00 (4.48) 7.47 (5.51) 6.68 (5.97) 7.00 (4.27) Beneficence 5.47 (4.97) 5.00 (4.7) 3.66 (3.92) 6.81 (5.57) 4.37 (4.86) 5.06 (4.44) Omnipotence 7.22 (3.24) 5.26 (3.1) 5.53 (4.05) 8.45 (4.69) 7.62 (5.09) 5.93 (3.28) Resistance (6.35) 14.8 (6.33) (5.41) 15.5 (7.66) (7.52) (7.23) Engagement 6.18 (5.02) 5.8 (4.75) 4.04 (4.65) 7.05 (4.97) 4.62 (4.01) 6.26 (6.74) BDI II (9.01) (7.17) (7.65) (14.44) (12.90) (15.91) BAI (10.69) 16.8 (9.00) (9.67) (12.51) (12.13) (14.51) Note. BPRS Brief Psychiatric Rating Scale; PSYRATS Psychotic Symptom Rating Scales; SLOF Specific Levels of Functioning; CBT cognitive behavioral therapy; BCIS Beck Cognitive Insight Scale; BAVQ Beliefs About Voices Questionnaire; BDI Beck Depression Inventory; BAI Beck Anxiety Inventory. a N 16. b N 16. c N 14. d N 13.

7 COMPUTER-BASED CBT FOR AUDITORY HALLUCINATIONS 289 size (ES).43; SLOF Interpersonal Functioning, F(1, 28) 9.86, p.004, ES.42; and CBT Knowledge, F(1, 26) 16.79, p.0004, ES.62. There was an overall significant decrease over time for both groups on PSYRATS total, F(1, 31) 7.15, p.011; overall Beliefs About Voices Questionnaire (BAVQ), F(1, 30) 12.03, p.001; BAVQ Omnipotence, F(1, 30) 7.79, p.009; BAVQ Beneficence, F(1, 30) 6.11, p.019; BPRS total, F(1, 31) 5.34, p.027; and BPRS Psychosis, F(1, 31) 11.51, p.001 (see Table 4). The mixed-model linear regression moderator analyses indicated no significant effects for the interaction between group and three of the moderator variables, including baseline Internet use, CBT knowledge, and IQ. Thus, these variables did not predict differential benefit for participants randomized to CWV versus UC. There was a significant Group Age interaction effect for the Negative Symptoms subscale of BPRS, indicating that age moderated the effects of CWV on negative symptoms, F(1, 27) 7.46, p.01. We explored this interaction by categorizing the participants into a younger versus older group based on a median split of the sample (median age 43 years) and examining the negative symptoms scores over time for the different age groups within each condition. The primary differences between the CWV and UC groups appeared to be with the older participants and not the younger ones. The older participants in CWV had relatively stable negative symptoms Table 4 Results of Mixed-Model Regression from baseline to the posttreatment and follow-up assessments (Ms , , , respectively), whereas the older participants in UC group got worse (Ms , , , respectively). The younger participants in both groups improved slightly over time (CWV: Ms , , , respectively; UC: Ms , , , respectively). Discussion Participants randomized to CWV had high rates of participation in the program, with 79% completing all 10 sessions. This rate is similar to the 81% participation rate reported in the pilot study (Gottlieb et al., 2013). Furthermore, as in the prior study, participants indicated high satisfaction with the program, with most reporting that it was interesting, engaging, easy to understand, and helpful. These findings support the feasibility of using a selfpaced, computer-based CBTp skills program for people experiencing psychotic symptoms. Contrary to our hypotheses, there were no differences between CWV and UC on the AH primary outcome measures, with participants in both groups improving significantly from baseline to posttreatment and follow-up. Study participation required stable pharmacological treatment for at least 1 month and at least mod- Measure df F Group F Time F Group Time F Baseline BPRS BPRS AH BPRS Depression BPRS Psychosis BPRS Negative symptom PSYRATS PSYRATS AH PSYRATS DS SLOF SLOF IR SLOF SA SLOF CL SLOF WS CBT Knowledge BCIS SR BCIS SC BCIS CI Paranoia BAVQ BAVQ M BAVQ B BAVQ O BAVQ R BAVQ E BDI BAI Note. Numerator df is 1. The table includes denominator df, which is the same for all effects for each outcome. BPRS Brief Psychiatric Rating Scale; AH auditory hallucinations; PSYRATS Psychotic Symptom Rating Scales; DS Delusions subscale; SLOF Specific Levels of Functioning; IR interpersonal relationships; SA Social acceptability; CL Community living; WS Work skills; CBT cognitive behavioral therapy; BCIS Beck Cognitive Insight Scale; SR self-reflectiveness; SC self-confidence; CI composite index; BAVQ Beliefs About Voices Questionnaire; BAVQ M BAVQ Malevolence; BAVQ B BAVQ Beneficence; BAVQ O BAVQ Omnipotence; BAVQ R BAVQ Revised; BAVQ E BAVQ Engagement; BDI Beck Depression Inventory; BAI Beck Anxiety Inventory. p.05. p.01.

8 290 GOTTLIEB ET AL. erately severe AH, although these symptoms were not necessarily stable. Longitudinal research has shown that psychotic symptoms are often not stable over time (Goghari, Harrow, Grossman, & Rosen, 2013; Harrow & Jobe, 2010). The fact that participants in both groups improved in AH suggests that these symptoms may have fluctuated naturally over time, with periods of greater severity and distress coinciding with meeting the study inclusion criteria and higher motivation to seek treatment. Consistent with this interpretation, participants in both groups also improved in delusions, depression, and overall symptom severity. Although participants in both groups showed similar improvements in AH and other symptoms, those in CWV improved significantly more in social functioning on the SLOF, and on the Interpersonal Relationship subscale of the SLOF. Social anxiety is a common problem in people with schizophrenia (Freeman et al., 2015; Lysaker & Salyers, 2007; Penn, Hope, Spaulding, & Kucera, 1994), and evidence suggests that poor social adjustment in schizophrenia is at least partly mediated by defeatist performance beliefs (Grant & Beck, 2009). Furthermore, CBTp has been found to improve social functioning (Wykes et al., 2008), and recent research indicates that CBTp may reduce such beliefs and improve negative symptoms and social functioning (Granholm, Holden, Link, McQuaid, & Jeste, 2013). The basic tenets of cognitive restructuring (incorporated within CBTp) that negative emotional and behavioral reactions to events are influenced by individuals thoughts about those events, and that careful examination of those beliefs often reveals that they are inaccurate are applicable to the broad range of situations people encounter, including internal events (e.g., AH) or external events (e.g., running into an acquaintance on the street). CWV participants may have learned how to use cognitive restructuring as a skill for coping more effectively with distress related to a variety of situations other than hearing voices, such as social situations. Similarly, rather than simply reducing the frequency and severity of auditory hallucinations, an overarching goal of CBTp applied to hallucinations is to help people become less entangled and preoccupied with their voices such that they build skills and confidence to be able to live and prosper in their daily lives despite hearing voices. Therefore, it is possible that the CWV program improved participants day-to-day functioning because of the specific CBT skills taught, even though those skills did not appear to influence the severity of hallucinations severity or the distress associated with them. Since social functioning tends to be more stable over time than psychotic symptoms, the benefits of learning CBT skills may have been more apparent in the social rather than symptom domain. CWV program participants improved more in the CBT Knowledge test than UC participants, but the two groups did not differ on the Beck Cognitive Insight Scale (BCIS). The Knowledge test was designed specifically for the purposes of this study, in order to evaluate participants learning of information taught in the program, such as discerning types of cognitive distortions like catastrophizing as they pertain to evaluating voices content, and recognizing healthy coping strategies to deal with intrusive voices. In contrast, the BCIS is oriented toward evaluating predispositions or attitudes related to self-confidence and certainty in one s judgments, rather than factual information. It is possible that CWV participants were able to acquire critical CBT skills without changing their attitudes or confidence in their judgments. This study had some limitations. Although CWV participants worked on their own in the program, the sessions took place at a mental health clinic where a proctor was available to offer encouragement and assistance (and reminder calls for subsequent appointments). It is possible that the high participant satisfaction and its effects would not generalize to individuals who use the program in a different setting or without support. This program has continued to be evaluated as part of a larger study involving a suite of Web and mobile-based psychosocial interventions for persons with schizophrenia (Brunette et al., 2016), and these data are currently being analyzed. One next step for this research would be to evaluate the effects of CWV when used at home, either with or without proctor support, or via mobile device in place of a computer. In addition, a similar program, Coping With Paranoia, has been developed by Jennifer D. Gottlieb and Vasudha Gidugu and is currently being evaluated in a community mental health setting as well. Conclusion The findings from this study support the feasibility of implementing a self-paced, computerized CBTp skill-based program for people with serious mental illness experiencing distressing AH. While participants in both groups improved over time in the severity of their symptoms, only those in the CWV program improved in social functioning. This program is not a substitute for in-person, intensive formulation-based traditional CBTp (Kingdon & Turkington, 2004; Morrison, Renton, Dunn, Williams, & Bentall, 2004), which has been shown to be effective, but remains inaccessible to many people. However, these results may have promise for increasing access to CBTp self-management skills that could help people with serious mental illness cope more effectively with challenges, and achieve a better quality of life. References Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research, 38, Beck, A. T., Baruch, E., Balter, J. M., Steer, R. A., & Warman, D. M. (2004). A new instrument for measuring insight: The Beck Cognitive Insight Scale. Schizophrenia Research, 68, /S (03) Beck, A. T., & Rector, N. A. (2000). Cognitive therapy of schizophrenia: A new therapy for the new millennium. American Journal of Psychotherapy, 54, Beck, A. T., & Steer, R. A. (1993). The Beck Anxiety Inventory manual. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory II. San Antonio, TX: Psychological Corporation. Ben-Zeev, D. (2012). Mobile technologies in the study, assessment, and treatment of schizophrenia. Schizophrenia Bulletin, 38, dx.doi.org/ /schbul/sbr179 Ben-Zeev, D., Scherer, E. A., Gottlieb, J. D., Rotondi, A. J., Brunette, M. F., Achtyes, E. D.,... Kane, J. M. (2016). m-health for schizophrenia: Patient engagement with a mobile phone intervention following hospital discharge. JMIR Mental Health, 3(3), e34. Bowie, C. R., Leung, W. W., Reichenberg, A., McClure, M. M., Patterson, T. L., Heaton, R. K., & Harvey, P. D. (2008). Predicting Schizophrenia

9 COMPUTER-BASED CBT FOR AUDITORY HALLUCINATIONS 291 Patients Real World Behavior with Specific Neuropsychological and Functional Capacity Measures. Biological Psychiatry, 63, Brunette, M. F., Rotondi, A. J., Ben-Zeev, D., Gottlieb, J. D., Mueser, K. T., Robinson, D. G.,...Kane, J. M. (2016). Coordinated technologydelivered treatment to prevent rehospitalization in schizophrenia: A novel model of care. Psychiatric Services, 67, Burns, A. M. N., Erickson, D. H., & Brenner, C. A. (2014). Cognitivebehavioral therapy for medication-resistant psychosis: A meta-analytic review. Psychiatric Services, 65, appi.ps Chadwick, P., Sambrooke, S., Rasch, S., & Davies, E. (2000). Challenging the omnipotence of voices: Group cognitive behavior therapy for voices. Behaviour Research and Therapy, 38, Cummings, J. L. (1993). Mini-Mental State Examination. Norms, normals, and numbers. Journal of the American Medical Association, 269, Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., Dickinson, D., Goldberg, R. W.,... the Schizophrenia Patient Outcomes Research Team (PORT). (2010). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin, 36, Fenigstein, A., & Vanable, P. A. (1992). Paranoia and self-consciousness. Journal of Personality and Social Psychology, 62, Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Freeman, D., Emsley, R., Dunn, G., Fowler, D., Bebbington, P., Kuipers, E.,... Garety, P. (2015). The stress of the street for patients with persecutory delusions: A test of the symptomatic and psychological effects of going outside into a busy urban area. Schizophrenia Bulletin, 41, Goghari, V. M., Harrow, M., Grossman, L. S., & Rosen, C. (2013). A 20-year multi-follow-up of hallucinations in schizophrenia, other psychotic, and mood disorders. Psychological Medicine, 43, Gottlieb, J. D., Romeo, K. H., Penn, D. L., Mueser, K. T., & Chiko, B. P. (2013). Web-based cognitive-behavioral therapy for auditory hallucinations in persons with psychosis: A pilot study. Schizophrenia Research, 145, Granholm, E., Ben-Zeev, D., Link, P. C., Bradshaw, K. R., & Holden, J. L. (2012). Mobile Assessment and Treatment for Schizophrenia (MATS): A pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations. Schizophrenia Bulletin, 38, Granholm, E., Holden, J., Link, P. C., McQuaid, J. R., & Jeste, D. V. (2013). Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: Defeatist performance attitudes and functional outcome. American Journal of Geriatric Psychiatry, 21, Grant, P. M., & Beck, A. T. (2009). Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophrenia Bulletin, 35, Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS). Psychological Medicine, 29, Harrow, M., & Jobe, T. H. (2010). How frequent is chronic multiyear delusional activity and recovery in schizophrenia: A 20-year multifollow-up. Schizophrenia Bulletin, 36, Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use conditions. Washington, DC: Author. Jauhar, S., McKenna, P. J., Radua, J., Fung, E., Salvador, R., & Laws, K. R. (2014). Cognitive-behavioural therapy for the symptoms of schizophrenia: Systematic review and meta-analysis with examination of potential bias. British Journal of Psychiatry, 204, /bjp.bp Kimhy, D., Tarrier, N., Essock, S., Malaspina, D., Cabannis, D., & Beck, A. T. (2013). Cognitive behavioral therapy for psychosis Training practices and dissemination in the United States. Psychosis: Psychological, Social and Integrative Approaches, 5, / Kingdon, D. G., & Turkington, D. (2004). Cognitive therapy of schizophrenia. New York, NY: Guilford Press. Leff, J., Williams, G., Huckvale, M., Arbuthnot, M., & Leff, A. P. (2014). Avatar therapy for persecutory auditory hallucinations: What is it and how does it work? Psychosis, 6, Lukoff, D., Nuechterlein, K. H., & Ventura, J. (1986). Manual for the Expanded Brief Psychiatric Rating Scale (BPRS). Schizophrenia Bulletin, 12, Lysaker, P. H., & Salyers, M. P. (2007). Anxiety symptoms in schizophrenia spectrum disorders: Associations with social function, positive and negative symptoms, hope and trauma history. Acta Psychiatrica Scandinavica, 116, Miller, B. J., Stewart, A., Schrimsher, J., Peeples, D., & Buckley, P. F. (2015). How connected are people with schizophrenia? Cell phone, computer, , and social media use. Psychiatry Research, 225, Morrison, A. P., & Barratt, S. (2010). What are the components of CBT for psychosis? A Delphi study. Schizophrenia Bulletin, 36, dx.doi.org/ /schbul/sbp118 Morrison, A. P., Renton, J. C., Dunn, H., Williams, S., & Bentall, R. P. (2004). Cognitive therapy for psychosis: A formulation-based approach. New York, NY: Brunner-Routledge. Mueser, K. T., & Noordsy, D. L. (2005). Cognitive behavior therapy for psychosis: A call to action. Clinical Psychology: Science and Practice, 12, National Collaborating Centre for Mental Health. (2009). Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care (Vol. 82, Updated ed.). London, UK: National Institute for Health and Clinical Excellence. Palmier-Claus, J. E., Ainsworth, J., Machin, M., Barrowclough, C., Dunn, G., Barkus, E.,... Lewis, S. W. (2012). The feasibility and validity of ambulatory self-report of psychotic symptoms using a smartphone software application. BMC Psychiatry, 12, X Penn, D. L., Hope, D. A., Spaulding, W., & Kučera, J. (1994). Social anxiety in schizophrenia. Schizophrenia Research, 11, dx.doi.org/ / (94) Rollinson, R., Haig, C., Warner, R., Garety, P., Kuipers, E., Freeman, D.,... Fowler, D. (2007). The application of cognitive-behavioral therapy for psychosis in clinical and research settings. Psychiatric Services, 58, Rotondi, A. J., Sinkule, J., Haas, G. L., Spring, M. B., Litschge, C. M., Newhill, C. E.,... Anderson, C. M. (2007). Designing websites for persons with cognitive deficits: Design and usability of a psychoeducational intervention for persons with severe mental illness. Psychological Services, 4, Schneider, L. C., & Struening, E. L. (1983). SLOF: A behavioral rating scale for assessing the mentally ill. Social Work Research & Abstracts, 19,

10 292 GOTTLIEB ET AL. Velligan, D., Prihoda, T., Dennehy, E., Biggs, M., Shores-Wilson, K., Crismon, M. L.,... Shon, S. (2005). Brief psychiatric rating scale expanded version: How do new items affect factor structure? Psychiatry Research, 135, Wechsler, D. (1999). Wechsler Abbreviated Scale of Intelligence (WASI). San Antonio, TX: Pearson. Wilkinson, G. S., & Robertson, G. J. (2006). Wide Range Achievement Test 4 professional manual. Lutz, FL: Psychological Assessment Resources. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, Received June 28, 2016 Revision received November 15, 2016 Accepted January 12, 2017 Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process. If you are interested in reviewing manuscripts, please write APA Journals at Reviewers@apa.org. Please note the following important points: To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review. To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research. To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, social psychology is not sufficient you would need to specify social cognition or attitude change as well. Reviewing a manuscript takes time (1 4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly. APA now has an online video course that provides guidance in reviewing manuscripts. To learn more about the course and to access the video, visit

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