ORIGINAL ARTICLE
Effectiveness of a Brief Group Cognitive Behavioral
Therapy for Auditory Verbal Hallucinations
A 6-Month Follow-up Study
Adriano Zanello, MA, Sylvia Mohr, PhD, Marco C.G. Merlo, MD, Philippe Huguelet, MD,
and Philippe Rey-Bellet, MD
Abstract: The current study investigated the effectiveness of a group cogni-
tive behavioral therapy for auditory verbal hallucinations (AVHs), the Voices
Group. This consists of seven specific sessions. Forty-one participants with
schizophrenic or schizoaffective disorders completed a battery of questionnaires.
The severity of psychiatric symptoms, beliefs about voices, quality of life, self-
esteem, clinical global impression, and functioning were assessed at baseline,
before and after intervention, and at the 6-month follow-up. After intervention,
there was a statistically significant reduction in the severity of AVHs. This result
remained stable at follow-up. The dropout rate was high. Some differences were
found in subjective experience of AVHs between the patients who completed
the intervention and those who dropped out. Altogether, these findings suggest
that a brief intervention has some positive benefits in patients struggling with
voices, which remain stable over time.
Key Words: Schizophrenia, group CBT, auditory verbal hallucinations
(J Nerv Ment Dis 2014;202: 144Y153)
A uditory verbal hallucinations (AVHs) are a distressing experience
for people hearing them. AVHs can also have deleterious effects on
quality of life (QOL), mood, anxiety, self-esteem, and social integra-
tion, and these increase the risk for aggressive behaviors (Braham et al.,
2004; Chadwick et al., 1996). Furthermore, positive symptoms unfor-
tunately often persist despite adequate levels of antipsychotic medica-
tion. Several studies have reported that 5% to 50% of patients with a
schizophrenia spectrum disorder continue to experience delusions or
AVHs (Brenner et al., 1990; Conley and Buchanan, 1997; Fowler et al.,
1995; Garety et al., 2000; Lam, 2008; Lewis et al., 2006). In a high
proportion of patients (40%), this may be due in part to problems of
adherence to drug treatment (Lam, 2008). Even with pharmacological
adherence, it becomes essential to enable patients to benefit from
nonpharmacological treatments as well. Among the latter, cognitive
behavioral therapy (CBT) is a field of therapy with wide applicability.
Several studies indicate that individual CBT therapies are clearly
effective at attenuating the frequency and the severity of negative
thoughts and beliefs related to AVHs (Trower et al., 2004; Valmaggia
et al., 2005; Wiersma et al., 2001). However, these one-to-one CBT
therapies are expensive because these are delivered by highly trained
therapists and do not fit the expectations of busy psychiatric clinics that
want to make specific treatments accessible to most patients insofar as
possible. Thus, brief CBT therapy in a group format is an alternative to
Department of Mental Health and Psychiatry, University Hospitals of Geneva, Chêne-
Bourg, Geneva, Switzerland.
Send reprint requests to Adriano Zanello, MA, Department of Mental Health and
Psychiatry, University Hospitals of Geneva, Belle-Idée, ch. du Petit Bel-Air 2,
1225 Chêne-Bourg, Geneva, Switzerland. E-mail: adriano.zanello@hcuge.ch.
Copyright * 2014 by Lippincott Williams & Wilkins
ISSN: 0022-3018/14/20202Y0144
DOI: 10.1097/NMD.0000000000000084
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individually tailored CBT treatments. Several studies have considered
group CBT for voices. Many of them showed some evidence that group
CBT tends to reduce negative and anxiogenic beliefs about AVHs
either at the level of frequency or at the level of content and degree
of conviction (e.g., Chadwick et al., 2000b; Dannahy et al., 2011;
McLeod et al., 2007; Pinkham et al., 2004; Trygstad et al., 2002).
Group CBT also has beneficial effects on depression, anxiety, distress,
self-esteem, social behavior, coping skills, and readmission at 6 months
(Barrowclough et al., 2006; Bechdolf et al., 2004; Dannahy et al., 2011;
Gledhill et al., 1998; Newton et al., 2005; Perlman and Hubbard, 2000;
Trygstad et al., 2002; Wykes et al., 2005, 1999). However, some studies
found that group CBT has no effect on AVH frequency and beliefs
about voices (Gledhill et al., 1998; Lee et al., 2002; Newton et al., 2005;
Penn et al., 2009; Wykes et al., 2005, 1999). Divergences among the
findings reported by the studies reviewed may be explained by meth-
odological and therapeutic factors. For instance, there is a huge differ-
ence in design (descriptive, quasi-experimental, and randomized and
a sample size that varied from 4 to 72), age of individuals included
(young, adults, and older patients), assessments, and type of group.
Hence, at present, it is not certain that providing group CBT contributes
to alleviating AVHs.
In addition, premature terminations are quite common in CBT
for psychosis; the rates vary from 0% to 45% (Wykes et al., 2008).
Reducing the likelihood of dropouts is crucial to avoid a situation in
which psychologically vulnerable patients hearing voices experience a
sense of treatment failure, which may have deleterious consequences
for other therapies that they might be offered in the future. Several
strategies could be incorporated into clinical practice to prevent the
risk for dropouts (see Ogrodniczuk et al., 2005). However, with patients
hearing voices, it is important to consider how they experience their
AVHs, how they manage them, and the nature of the frame of reference
(e.g., medical, relationships, spiritual) that they use to account for the
voices (Romme and Escher, 1998). Although this individual subjective
dimension of AVHs is considered to be the core aspect of the thera-
peutic alliance contributing to treatment adhesion (Hayward and
Fuller, 2010), previous group CBT for AVH studies has paid little at-
tention to it. This may in part explain the rates of early termination of
therapy. Therefore, more research is needed before using group CBT
for AVHs as routine treatment in addition to pharmacotherapy (Wykes,
2004). Moreover, in psychotherapy, research efficacy studies have to be
completed by effectiveness studies in clinical settings (Chambless and
Hollon, 1998).
The aim of the present study was to clarify further the effec-
tiveness of a brief time-limited specific group CBT for AVHs after
preparing the patients for therapy. In accordance with the literature
reviewed, we hypothesized that group CBTwould lessen the severity
of general psychopathology, particularly AVHs; reduce dysfunc-
tional beliefs about AVHs; and enhance the self-esteem, social
functioning, as well as QOL of patients hearing AVHs; by including
an individualized specific indication that focuses on subjective ex-
perience of AVHs, we expected to avoid a high rate of dropouts.
& Volume 202, Number 2, February 2014
The Journal of Nervous and Mental Disease & Volume 202, Number 2, February 2014
METHODS
Sample
Forty-one patients from different independent outpatient units
at the University Hospital of Geneva Department of Psychiatry
(Switzerland) were referred to the ‘‘Voices Group’’ (see Intervention)
by their case manager or psychiatrist if they were experiencing refrac-
tory and distressing AVHs. Diagnoses were reported by a review of the
patients’ charts and verified by administration of the Mini-International
Neuropsychiatric Interview, version 5 (MINI, Sheehan et al., 1998), to
screen for current or history of formally diagnosable psychiatric dis-
orders and substance abuse or dependence. Patients with a primary
neurological, organic, or developmental disability; outside the age
range of 18 to 65 years; with difficulties understanding French; and
with psychotic symptoms or behaviors interfering with group process
(e.g., severe disorganization, agitation, suicidal ideation, hostility, anti-
social and psychopathic behaviors, alcohol or substance abuse before
attending the group session) were excluded.
Measures
Subjective experience about voices was examined during the
indication phase between baseline and pregroup assessment. The effi-
ciency of treatment was evaluated using a battery of questionnaires
repeated at four points in time.
Subjective Experience About Voices
The Maastricht Voices Interview for Adults
The Maastricht Voices Interview for Adults (MAVIA; Romme
and Escher, 2000) is an exhaustive semistructured interview that ex-
amines the subjective experience of voices (e.g., origins, content, be-
liefs, sources, perception, emotional reactions, and coping strategies)
and stressful life events, which also includes traumatic life experiences.
The MAVIA provides information, which was summarized in the fol-
lowing categories, as proposed by Escher et al. (2002): a) first occur-
rence of voices (G15, 15Y29, or 929 years); b) number of voices (1 or
91); c) frequency of voices (frequent, almost every day; occasional,
weekly or monthly); d) source of voices (external, internal, or both);
e) dialogue with voices (present or absent); f ) emotional content of
voices (positive, negative, or variable); g) attribution of voices (real
person, spirit/ghost, symptom of an illness, or one aspect of own per-
sonality); h) coping (cognitive, behavioral, or physical); i) problems
caused by voices (present or absent); j) triggers (present or absent); and
k) emotional, physical, and sexual abuse during childhood (present or
absent). Three clinicians scored a random sample of 27 MAVIA tran-
scripts independently. Mean pairwise Cohen’s kappa coefficients were
calcuated for each MAVIA category. The Cohen’s J values ranged from
0.64 to 0.95, with a mean of 0.80 indicating substantial agreement
between assessors.
Repeated Measures
The Brief Psychiatric Rating ScaleYExpanded, Version 4.0
The Brief Psychiatric Rating ScaleYExpanded, Version 4.0
(BPRS 4.0; Ventura et al., 1993), is a semistructured interview as-
sessing the severity of psychopathology. It comprises 24 items, rated
on a scale from 1 (absent) to 7 (extremely severe). The French ver-
sion of the BPRS 4.0 was used (Zanello et al., 2004, unpublished
manual). Besides the total score and the mean subscore for ‘‘positive,’’
‘‘negative,’’ ‘‘anxiodepressive,’’ and ‘‘manic-hostility’’ dimensions
(Kopelowicz et al., 2008; Ventura et al., 2000), we also considered
separately the scores for the items ‘‘hallucinations’’ and ‘‘unusual
thoughts.’’ For the global BPRS 4.0 score, interrater reliability assessed
with intraclass correlation coefficient (ICC; Shrout and Fleiss, 1979)
was excellent (ICC, 0.87).
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Brief Group CBT for AVH
The Beliefs About Voices Questionnaire Revised
The Beliefs About Voices Questionnaire Revised (BAVQ-R;
Chadwick et al., 2000a) is a 35-item self-report questionnaire assessing
beliefs about voices. A mean score was calculated for the following
subscales: ‘‘benevolence,’’ ‘‘malevolence,’’ and ‘‘omnipotence’’ be-
liefs about AVHs as well as ‘‘engagement’’ and ‘‘resistance’’ coping
strategies. Each item is rated on a 4-point scale from 0 (disagree) to
3 (agree strongly). The French version of the BAVQ-R has adequate
internal consistency (> = 0.74) and construct validity and concurrent
validity (Monestes JL, Vavasseur-Desperriers J, Villatte M, Denizot L,
Loas G, Rusinek S Influence de la résistance aux hallucinations auditives
sur la dépression: étude au moyen du questionnaire révisé des croyances
à propos des voix [submitted for publication]).
The World Health Organization Quality of LifeYBREF
The World Health Organization Quality of LifeYBREF (WHOQOL-
BREF; WHOQOL Group, 1996) contains 26 self-rated items assessing
the QOL during the previous 2 weeks. The following scores were taken
into account: overall perceptions of QOL and general health items rated
on a 5-point scale from 1 to 5 as well as ‘‘physical,’’ ‘‘psychological,’’
‘‘social relationships,’’ and ‘‘environmental’’ QOL dimensions. Dimen-
sional scores may vary from 0 to 100, with higher scores indicating
better QOL. The WHOQOL-BREF French version has acceptable
internal consistency (> values range from 0.59 to 0.74; Baumann
et al., 2010).
The Self-Esteem Rating ScaleYShort Form
The Self-Esteem Rating ScaleYShort Form (SERS-SF; Lecomte
et al., 2006; Nugent and Thomas, 1993) is a self-rated 20-item ques-
tionnaire, scored from 1 (never) to 7 (always), that independently in-
vestigates positive and negative self-esteem. The French version of the
SERS-SF possesses good internal consistency (Cronbach’s > Q 0.87),
test-retest reliability (r Q 0.90), and convergent validity (r Q 0.72;
Lecomte et al., 2006); it also has good sensibility to change (Borras
et al., 2009).
The Clinical Global Impression
The Clinical Global Impression (CGI; Guy, 1976) is a single-
item instrument measuring general illness severity on a 5-point Likert
scale. Higher scores indicate higher severity. The CGI French ver-
sion was used (von Frenckell, 1996). The ICC calculated from a set of
20 patients independently coded by three clinicians was 0.87, indicating
strong agreement.
The Global Assessment Functioning Scale
The Global Assessment Functioning (GAF; American Psychiatric
Association, 1994) is a single-item measure of overall current psycho-
logical, social, and occupational functioning. The score may vary from
0 to 100, with higher scores indicating better global functioning. The
GAF French version was used (Boyer, 1996). Clinicians assessed the
GAF of 20 patients independently. The ICC was 0.69, indicating
moderate agreement.
Procedure
Study Design
A noncontrolled repeated-measures naturalistic study design,
in which each patient acted as his/her own control, was followed.
Because the whole intervention comprised three components: an in-
dication, an active ingredient (group CBT therapy), and follow-up
phase, assessments were repeated at baseline (time 0 = T0, 6 weeks
before the group), pretreatment (time 1 = T1, 1 week before the
group), posttreatment (time 2 = T2, 1 week after the group), and
follow-up (time 3 = T3, 6 months after the group), except for the
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Zanello et al. The Journal of Nervous and Mental Disease
MINI and the MAVIA, which were administered once during the
indication phase (T0YT1). Three clinical psychologists who were not
blinded to group allocation assessed the patients. Data collection
took place from February 2007 to December 2009. During this pe-
riod, six small groups were conducted, each consisting of three to
seven patients. The local ethics committee approved the study. The
patients participated in the study only after receiving detailed infor-
mation about it and signing a written consent document.
Intervention
Indication Phase
Because patients are often reluctant to speak about AVHs and
ask for help (Escher, 1998), there is an initial need to establish a ther-
apeutic alliance and to understand the global and historical context of
appraisal of voices in each patient. Therefore, the patients participated
in an individualized indication phase to minimize the likelihood of
dropouts and ensure group attendance. The indication phase included
a) formal assessment (as presented above); b) education about the
aims of group therapy, realistic expectations about group therapy,
possible difficulties of group attendance, possible relationships be-
tween voices, self-esteem and QOL, and the time-limited nature of
the group; and c) utilization of the MAVIA not only to gather sub-
jective information but also to enable patients to make sense of their
voices in a secure relationship with a clinician. Clinicians encouraged
the patients to explore the roots of their voices in a warm and secure
atmosphere, developing a strong therapeutic alliance. Two or three
1-hour sessions were necessary to complete the MAVIA, which took
place before the preintervention assessment.
Group Therapy
The Voices Group is a brief closed group therapy that followed
the manual produced by (Wykes et al. 1999) adapted to the French
context. It comprised seven sessions delivered once a week, lasting
12 hours. Each session focused on a main topic about AVHs, namely,
session 1: ‘‘engagement and information sharing about voices’’; session
2: ‘‘models of psychosis’’; session 3: ‘‘models of voices’’; session 4:
‘‘coping strategies’’; session 5: ‘‘voices as a stigma, effects of medi-
cation and drugs’’; session 6: ‘‘self-esteem’’; and session 7: ‘‘overall
model of coping with voices.’’ Relevant information was written on the
flip chart to enable memorization and to follow the group process.
Group facilitators were active, asking questions, and repeating and
summarizing information in a low-stress group atmosphere. Home-
work was assigned to the patients. It was impossible to take into ac-
count treatment quality and adherence, given some patients’ reluctance
to be audiotaped or videotaped and technical constraints. Two psy-
chotherapists (two psychologists or one psychologist and one nurse)
trained in CBT led the groups.
Treatment as Usual
During the study, all patients continued to receive treatment
as usual (TAU). This generally consisted of regular appointments
(every 2 or 3 weeks, or at a higher frequency when necessary) with a
psychiatrist, nurse, and social worker if needed. TAU also included an-
tipsychotic medication at a dosage that could be changed when clini-
cally required. Because TAU was delivered before and throughout the
study, it has been hypothesized to be ineffective on outcome measures.
Statistical Analysis
Owing to the small sample size, distribution-free univariate
statistics were used for comparisons of the variable distributions be-
tween ‘‘completer’’ and ‘‘noncompleter’’ groups (chi-square test and
Wilcoxon’s rank test). Efficacy of the Voices Group was verified by
applying Friedman’s analysis of variance for repeated measures. For
statistically significant variables, we also computed post hoc analysis
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& Volume 202, Number 2, February 2014
using the paired Wilcoxon’s rank test to compare differences between
assessment time points. Data were analyzed with the Statistical Package
for the Social Sciences version 17. The magnitude of change was es-
timated by calculating the effect size (ES) and interpreted as small, 0.20
or higher; medium, 0.50 or higher; and large, 0.80 or higher, according
to Cohen (1988). In addition, we applied the reliable change index
(RCI) and clinical significance (CS) criteria of Jacobson and Truax
(1991) to verify whether changes occurring were attributable to the
intervention rather than to measure error. The ES, RCI, and CS were
computed with the ClinTools Software, version 4.1 (Devilly, 2007).
RESULTS
Patients
Forty-one patients fulfilled the inclusion criteria. They agreed
to participate in the study and were assessed at baseline. Three patients
dropped out before the end of the first assessment. Thus, a group of
38 patients participated in the baseline assessments. This group, 42% of
whom were women, showed the following sociodemographic charac-
teristics: patients were middle aged (mean, 40 years; SD, 9), had a long
duration of illness (mean, 12 years; SD, 7), and had been hospital-
ized for a mean of 7 times (SD, 10). According to ICD-10, 71% met the
diagnostic criteria for schizophrenia; and 29%, for schizoaffective
disorders. Moreover, 24% (n = 9) were substance misusers, that is,
abuse of alcohol or of illicit drugs. Pharmacological treatment was of-
fered to the patients: 50% received a new antipsychotic; 37% received
combined antipsychotic; and 55% received anxiolytic, mood stabilizer,
hypnotic, or antidepressant medication. One fourth lived (24%) in
halfway houses; one half (53%), alone; and the others (23%), with
their parents. Most were single (71%), 21% were divorced, and 5%
were married. Most of them were on welfare (87%). Only 34% had
achieved professional training. Currently 71% did not have paid em-
ployment, 11% worked in sheltered houses, and 18% had paid em-
ployment (part time).
During the intervention (n = 15, 39%), the patients dropped out
(noncompleter group), most of them (n = 13, 87%) before group in-
tervention and two before the first three group sessions. Thus, group
attrition left 23 patients who completed treatment and assessments at
baseline, pregroup and postgroup, and follow-up (completer group).
Differences Between the Completer and
Noncompleter Groups
The completer and noncompleter groups were compared at
baseline. As shown in Table 1, none of the comparisons reached sta-
tistical significance either in sociodemographic or in clinical charac-
teristics (all p 9 0.10).
According to the variables extracted from the MAVIA, presented
in Table 2, the patients in the completer group never hear voices with
positive emotional content and have more varied explanations for their
voices. They are also more likely to consider their voices as a symptom
of an illness and to hear only one voice. There were no differences for
other MAVIA dimensions.
Effectiveness of the Intervention
Table 3 presents descriptive statistics across assessment times
on outcome variables for the completer group. Friedman’s analysis of
variance showed a significant decrease in the hallucinations item and
total symptoms severity score of the BPRS 4.0 without the hallucina-
tion item (p = 0.006), but we should mention that none of the difference
survived to Bonferroni’s correction for multiple comparisons. No other
changes reached statistical significance.
Assessment of hallucinations and the BPRS 4.0 was performed
using post hoc analyses. Results are presented in Table 4. Concerning
hallucinations, the reduction in their severity occurred from baseline
to posttreatment with a medium ES. This picture persisted from
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The Journal of Nervous and Mental Disease & Volume 202, Number 2, February 2014 Brief Group CBT for AVH

TABLE 1. Demographic and Clinical Characteristics by Completer and Noncompleter Groups

Completers Noncompleters Statistics
n = 23 % n = 15 % W 2
df p
Diagnosis
Schizophrenia 16 61 11 73
Schizoaffective disorder 7 39 4 27 0.06 1 0.80
Substance abuse
Sex
Male 14 61 8 53
Female 9 39 7 47 0.21 1 0.65
Living conditions
Halfway houses 6 26 3 20
Alone 14 61 6 40
With the family 3 13 6 40 3.68 2 0.16
Under guardianship 4 17 1 7 0.91 1 0.34
Marital status
Single 18 78 9 60
Married 1 4 1 7
Divorced/separated 4 17 4 27 0.86 2 0.65
Professional training 8 35 5 33 0.04 1 0.85
Activity
None 15 65 12 80
Sheltered 4 17 0 0
In the community 4 17 3 20 2.92 2 0.23
Receive disability benefits 20 87 13 87 0.01 1 0.98
Mean (SD) Median Mean (SD) Median z
Age in years 41 (9) 41 38 (10) 37 j0.76 0.46
Illness duration in years 13 (8) 14 10 (6) 7 j1.30 0.20
No. hospitalizations 8 (12) 3 3 (3) 2 j0.92 0.38
Severity of the illness (CGI) 4 (1) 5 4 (1) 4 j1.32 0.18
Psychiatric symptoms severity (BPRS 4.0)
Hallucinations item 5.3 (1.2) 6 5.1 (1.1) 6 j0.47 0.68
Unusual thoughts item 4.3 (1.3) 4 4.3 (1.6) 4 j0.08 0.94
Positive score 2.8 (0.6) 2.8 2.7 (0.5) 2.6 j0.62 0.55
Negative score 2.2 (1.1) 2.2 2.0 (1.0) 1.7 j0.28 0.80
Anxiodepressive score 3.1 (1.3) 3 2.7 (1.2) 2.8 j0.93 0.37
Manic-hostility score 1.4 (0.4) 1.3 1.3 (0.3) 1.2 j0.09 0.10
Total score 54 (12) 52 50 (8) 52 j0.88 0.38
Beliefs about voices (BAVQ-R)
Omnipotence 1.9 (0.7) 2.2 1.7 (0.6) 1.7 j0.89 0.38
Malevolence 2.0 (0.8) 2.1 1.8 (0.8) 2.2 j0.57 0.57
Benevolence 0.7 (0.8) 0.5 0.5 (0.6) 0.2 j0.73 0.49
Resistance 2.0 (0.7) 2.1 2.0 (0.7) 2.2 j0.26 0.80
Engagement 0.8 (0.7) 0.4 0.6 (0.5) 0.5 j0.37 0.73
Self-esteem (SERF-SF)
Positive 38 (9) 37 40 (11) 41 j0.50 0.63
Negative 39 (12) 40 31 (13) 31 j1.68 0.16
Psychosocial functioning (GAF) 43 (15) 40 44 (11) 45 j0.53 0.61
QOL (WHOQOL-BREF)
Overall QOL 52 (27) 50 55 (27) 50 j0.31 0.77
Overall general health 39 (21) 50 50 (31) 50 j1.22 0.25
Physical 52 (24) 57 51 (21) 57 j0.34 0.75
Psychological 48 (24) 54 49 (20) 54 j0.25 0.82
Social relationships 47 (24) 42 43 (24) 50 j0.70 0.49
Environment 59 (17) 56 54 (21) 61 j0.71 0.49

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Zanello et al. The Journal of Nervous and Mental Disease & Volume 202, Number 2, February 2014

baseline to follow-up. Interestingly, we found a strong trend with a
small ES for the group therapy intervention alone. The other post hoc
analyses did not reach statistical significance. Regarding total symptom
severity (minus the item hallucination), the decrease occurred from
baseline to follow-up with a medium ES. The other post hoc analyses
failed to reach statistical significance.
Reliable and Clinically Significant Change
Because inferential statistical analyses do not provide complete
information about the intervention, we performed RCI and CS. Be-
cause there is a lack of normative data for general population for
BPRS 4.0 score, to calculate RCI and CS, we used data drawn from
less severe patients, as recommended by Evans et al. (1998). Thus,
a sample (n = 99) of patients with unipolar depression having com-
pleted a 6- to 8-week intensive intervention was considered as the
referential group (Zanello et al., 2013). This group has a mean (SD)
BPRS 4.0 total score (without the hallucination item) of 38.95 (9.34)
and a mean (SD) hallucination item score of 1.26 (0.73). The BPRS 4.0
Cronbach’s > was 0.80, and the hallucination item test-retest correlation
was 0.60. The criteria chosen were the RCI z-score of less than or equal
to 1.96 or greater than or equal to 1.96 and the CS cutoff between the
referential group and clinical mean with at least 95% confidence.
Outcome of each patient was classified as recovered if both RCI and CS
criteria were met, improved if only RCI criteria were met, unchanged if
none of the two criteria were met, or deteriorated if RCI criteria were
met in the negative direction (Wise, 2004).
As shown in Table 4, changes were observed throughout the
different phases of intervention. For the hallucination item, some
improvements were already observed during the indication phase.
The proportion of reliable improvements increased after group ther-
apy, whereas some patients improved at follow-up. Few patients de-
teriorated during the intervention. For the BPRS 4.0 global score

TABLE 2. MAVIA Scores for Completer and Noncompleter Groups, Descriptive Statistics, and Results of the Comparisons
Completers Noncompleters
a
n = 22 % n = 13a % Statistics df p
a. First occurrence of voices
G15 yrs 6 27% 1 8%
15Y30 yrs 11 50% 8 62%
930 yrs 5 23% 4 31% W2 = 1.97 2 0.37
b. No. voices
1 voice 5 23% 0 0%
91 17 77% 13 100% W2 = 3.45 1 0.06
c. Voices frequency
Daily 15 68% 6 46% W2 = 1.65 1 0.20
d. Source of voices
Internal 7 32% 6 46% W2 = 1.09 1 0.30
External 8 36% 3 23%
Both 7 32% 4 31% W2 = 0.91 2 0.63
e. Presence of a dialogue with voices 14 64% 11 85% W2 = 1.76 1 0.18
f. Emotional content
Positive 0 0% 3 23%
Negative 12 55% 8 62%
Variable 10 45% 2 15% W2 = 7.03 2 0.03
g. Attribution of voices
Real person 16 73% 6 46% W2 = 2.47 1 0.12
Spirit/ghost 18 82% 9 69% W2 = 0.73 1 0.39
Symptom of illness 17 77% 6 46% W2 = 3.51 1 0.06
One aspect of personality 9 41% 4 31% W2 = 0.36 1 0.55
Median no. attributions 3 14% 1 8% z= j2.12 0.04
h. Coping
Cognitive 19 86% 13 100% W2 = 0.29 1 0.59
Behavioral 20 91% 10 77% W2 = 1.25 1 0.26
Physical 17 77% 5 38% W2 = 0.01 1 0.98
i. Coping efficiency
None 11 50% 7 54%
Little 8 36% 4 31%
Moderate 2 9% 2 15%
High 1 5% 0 0% W2 = j0.17 0.88
j. Disturbed in functioning by voices 18 82% 11 85% W2 = 0.05 1 0.83
k. Presence of triggers 21 95% 10 77% W2 = 21.77 1 0.10
l. Abuse (sexual, emotional, or physical) 14 64% 5 38% W2 = 2.59 1 0.11
a
Missing data for three patients.

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The Journal of Nervous and Mental Disease & Volume 202, Number 2, February 2014 Brief Group CBT for AVH

TABLE 3. Means and Standard Deviations for the 23 Completers at the Four Time Points and Results of the Comparisons
Time 0 Time 1 Time 2 Time 3
Friedman’s
Baseline Pregroup Postgroup 6-Months Follow-up
Variance
Mean SD Median Mean SD Median Mean SD Median Mean SD Median Analysis df p
Severity of the illness (CGI) 3.4 0.7 4 3.4 0.9 4 3.3 1.1 3 3.2 1.0 3 0.82 3 0.85
Psychiatric symptoms severity
(BPRS 4.0)
Hallucination item 5.3 1.1 6 5.1 1.2 5 4.6 1.5 5 4.7 1.5 5 8.52 3 0.04
Unusual thoughts item 4.4 1.3 4 4.3 1.3 4 4.1 1.4 4 4.0 1.7 4 5.01 3 0.17
Positive score 2.8 0.6 2.9 2.8 0.6 2.7 2.6 0.7 2.4 2.5 0.7 2.6 2.08 3 0.56
Negative score 2.1 1.0 2.3 2.1 0.9 2.0 2.2 0.9 2.7 1.9 1.0 1.7 1.56 3 0.67
Anxiodepressive score 3.1 1.3 3.0 2.7 1.2 2.5 2.8 1.4 2.5 2.7 1.2 2.7 2.60 3 0.46
Manic-hostility score 1.4 0.4 1.3 1.3 0.3 1.2 1.3 0.3 1.2 1.3 0.4 1.2 3.38 3 0.34
Total score without hallucination 49 11 47 46 11 46 46 11 46 44 9 44 12.62 3 G0.01
item
Beliefs about voices (BAVQ-R)
Omnipotence 1.9 0.7 2.2 1.9 0.7 2.0 1.9 0.7 1.8 1.7 0.6 1.8 3.99 3 0.26
Malevolence 1.9 0.8 2.0 1.9 0.6 2.0 1.8 0.8 2.0 1.7 0.8 1.7 2.65 3 0.75
Benevolence 0.7 0.8 0.5 0.7 0.7 0.6 0.5 0.7 0.2 0.7 0.8 0.2 6.82 3 0.08
Resistance 2.0 0.7 2.0 1.9 0.8 2.2 1.9 0.8 2.0 2.0 0.7 2.0 2.67 3 0.80
Engagement 0.8 0.7 0.6 0.7 0.6 0.5 0.6 0.7 0.4 0.7 0.6 0.4 2.63 3 0.52
Self-esteem (SERS-SF)
Positive 38 10 39 37 9 36 37 11 37 40 12 41 2.39 3 0.49
Negative j39 12 40 j37 13 40 j37 12 36 j37 11 35 3.92 3 0.27
Psychosocial functioning (GAF) 42 15 40 44 12 40 46 12 40 46 12 45 2.97 3 0.40
QOL (WHOQOL-BREF)
Overall QOL 54 28 50 52 26 50 55 28 50 57 22 50 1.18 3 0.76
Overall quality of health 39 21 50 41 25 50 42 23 50 46 21 50 2.51 3 0.47
I. Physical 53 24 57 52 17 57 50 18 54 53 18 54 0.10 3 0.99
II. Psychological 48 23 54 47 23 46 46 20 46 45 19 46 0.78 3 0.86
III. Social relationships 47 23 50 45 21 50 46 20 42 43 23 42 1.16 3 0.76
IV. Environment 59 18 62 60 18 56 61 20 66 62 19 66 3.59 3 0.31

(minus the hallucination item), the proportion of patients who improved However, it is worthwhile to mention that for both variables, the
remains very similar during the different intervention phases. A fifth evolution seems better when the whole intervention was considered
of the patients deteriorated during group therapy and at follow-up. (baseline versus postgroup and baseline versus follow-up).

TABLE 4. Results of the Post hoc Comparisons, Frequencies, and Percentage of Reliable Change and CS Across Time Assessments
Wilcoxon Deteriorated Unchanged Improved Recovered
z p ES n % n % n % n %
Hallucinations
A j1.20 0.23 0.08 1 4.34 19 82.60 3 13.04 0 0.00
B j1.95 0.051 0.37 1 4.34 15 65.21 5 21.73 2 8.69
C j0.29 0.77 0.07 3 13.04 16 69.56 4 17.39 0 0.00
D j2.40 0.02 0.52 2 8.69 13 56.52 5 21.73 3 13.04
E j1.99 0.05 0.44 2 8.69 15 65.21 3 13.04 3 13.04
BPRS 4.0 totala
A j1.83 0.07 0.27 0 0.00 18 78.26 4 17.39 1 4.34
B j0.27 0.78 0.00 5 21.73 12 52.17 3 13.04 3 13.04
C j1.27 0.20 0.19 5 21.73 12 52.17 3 13.04 3 13.04
D j1.83 0.07 0.27 1 4.34 19 82.60 2 8.69 1 4.34
E j2.21 0.03 0.50 0 0.00 17 73.91 4 17.39 2 8.69
a
BPRS total score minus hallucination item score.
A indicates indication phase T0 versus T1; B, group therapy T1 versus T2; C, Group follow-up T2 versus T3; D, therapy as a whole T0 versus T2; E, therapy as a whole follow-up T0
versus T3.

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Zanello et al. The Journal of Nervous and Mental Disease
The individual outcomes during the intervention (baseline to
postgroup and/or 6-months follow-up) were closely inspected. For
the severity of hallucination, 3 patients (13%) worsened and 1 (4%)
of them returned to baseline level, 11 (48%) improved but 5 (22%) of
them returned to baseline level, and 9 (39%) did not change. For the
total BPRS 4.0 score (minus the hallucination item), 1 (4%) wors-
ened and returned to baseline level, 9 (39%) improved, 3 (13%) of
them returned to baseline, and 13 (56%) did not change. Thus, for
both measures, six patients (26%) showed reliable improvement and
have similar scores to those observed in the depressive patients.
Homework
Homework assignments are considered an essential ingredient
of CBT. Thus, we assigned an individualized task to each patient.
The participants were encouraged to test the reality of their voices
(session 3) and to practice regularly one of the novel coping strategies
(e.g., humming, singing, listening to music, scheduling a time to listen
to voices, talking to someone, reading, reading out loud, ignoring the
voices, painting, exercise-fitness, ear plugs) learned in sessions 4, 5,
and 6. Homework was completed at least once by 17 patients (74%).
Group Attendance
Regarding group attendance, nearly half of the patients (n = 10;
44%) participated in the seven group sessions. Of the 13 patients (57%)
who missed group sessions, 9 (39%) missed one, 2 (12%) missed
two, and 2 (12%) missed three sessions. Some of these absences were
planned before the group started (e.g., appointment with a general
practitioner or social insurance authorities).
Dropouts
Given the high percentage of dropouts during the treatment
phase, we were interested in examining the reasons for these pre-
mature terminations. These are summarized in the following cate-
gories: a) voices (n = 5): one patient was not allowed by his voices
to participate in the group, three patients experienced an exacerbation
in the frequency and intensity of their voices, and one was ashamed
of the content of his voices; b) other psychotic symptoms (n = 2):
suspicion, unusual thoughts, and disorganization were too severe to
enable group attendance, leading one patient to be hospitalized;
c) physical illness (n = 2): one patient was admitted to a general
hospital for a serious cardiovascular disease; one patient died (acci-
dent); d) conflict with other therapies (n = 2): one left the group after
four sessions because her nurse offered her therapy for her voices in
an individual setting, and one was admitted to a special unit for
substance abuse; e) move (n = 2): one patient left Switzerland and
one moved outside the Geneva area; and f ) unknown (n = 3). Two of
these patients had to be admitted for a long stay in an acute psychi-
atric unit. It is important to mention that only two patients dropped
out during the voice group.
Participants’ Perspective on the Group
The participants’ perspective was explored at the last group
session and during the postgroup assessment conducted by informal
interview. Several participants acknowledged the usefulness of the
Voices Group because they learned and tried new coping skills for
AVHs. However, this seemed to be a minor consideration compared
with the value of meeting other hearers of voices. Some asked (n = 17;
74%) for a group that focused on voices to be continued, and 10
patients (44%) attended an open-ended Voices Group. Despite this
positive attitude, some found it difficult to participate in group ses-
sions because of social anxiety, because of their command voices
(e.g., ‘‘Voices don’t let me participate in groups’’), or because they were
scared to lose their voices (e.g., ‘‘I don’t want to get rid of my voices.
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Without them I would be totally alone and I cannot stand loneliness’’).
Most patients (n = 20; 87%) liked the small group size. They suggested
that the optimal group should not exceed four participants. They
thought that a group of this size would enable everyone to have the
attention of the group leaders and more opportunity to talk about their
experiences. All of them appreciated the general information about
AVHs delivered in the first group sessions and the intimate experi-
ences about voices shared with others without being judged as ‘‘mad’’
or as a less valuable person. Of the seven group sessions, the one
focused on self-esteem was the most appreciated.
TAU Effect
Because we observed a reduction in general psychopathology
during the indication phase, we examined the potential confounding
effects of the TAU throughout the three phases of the study. Unfor-
tunately, it was impossible to know whether the patients were offered
more appointments during the study. Therefore, we considered the
changes in medication prescriptions only. Given the heterogeneity of
medications and doses prescribed, two independent senior psychiatric
pharmacologists (P. H. and P. R-B.) were asked to rate the potential
clinical effect of medication changes through the time point assess-
ments. Rating was carried out on a 5-point scale (0, none; 1, uncertain;
2, possible; 3, probable; and 4, important clinical change expected).
There is moderate average agreement between the two assessors
(ICC, 0.70). Changes between time points in dose prescription were
modest: baseline versus pretreatment: mean, 1; SD, 1.06; pretreat-
ment versus posttreatment: mean, 0.82; SD, 1.11; posttreatment versus
follow-up: mean, 0.89; SD, 1.05, and do not reach statistical signif-
icance (Friedman’s analysis of variance, W2 = 0.45, df = 2, p = 0.80).
DISCUSSION
This naturalist study examined the hypothesis that brief group
CBT has a positive effect not only on AVHs but also on secondary
outcome measures such the severity of positive, negative, anxio-
depressive, and manic-hostility symptoms; beliefs about voices; QOL;
self-esteem; and global functioning in a group of outpatients with
schizophrenia or schizoaffective disorders. The main findings only
partially corroborated this general hypothesis.
First, as expected, the intervention contributed to reducing the
severity of voices from baseline to posttest. This effect is maintained
at 6-months follow-up. Part of this effect may be attributed to the
Voices Group. In fact, there was a strong statistical trend ( p = 0.051)
indicating that the voice group as such tends to have beneficial effects
on hallucinations. Nevertheless, the gains were modest as shown by
the ES. The ESs are similar to those reported in a recent meta-analysis
of studies of CBT for positive symptoms in psychosis (Wykes et al.,
2008). These findings support those of previous studies evidencing
that group CBT has a positive effect on AVHs (e.g., Dannahy et al.,
2011; McLeod et al., 2007; Trygstad et al., 2002; Wykes et al., 1999).
More interestingly, as demonstrated by individual reliable improve-
ment analyses, 26% of the patients clearly benefited from the inter-
vention. It should be mentioned that in few cases, the intervention
seems to be harmful.
Second, a significant decrease in the severity of general psy-
chopathology was observed only at follow-up. Thus, this result could
be attributed to not only the impact of the Voices Group alone but also
the intervention as a whole. It is unlikely that this reduction was
caused by medication because changes in doses prescribed were
considered to be very weak in clinical terms. Probably, it could be
explained by methodological factors (e.g., nonblinded assessment)
and by nonspecific therapeutic factors (Strupp and Hadley, 1979).
Among the latter, we can mention the feeling that the experience of
AVHs could be understood, respected, and accepted by clinicians with-
out fear of negative consequences (e.g., MAVIA) as well as realistic
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The Journal of Nervous and Mental Disease & Volume 202, Number 2, February 2014
expectations of the group treatment. Regarding general psychopathology,
our finding contrasts with other studies (e.g., Barrowclough et al., 2006;
Bechdolf et al., 2004, 2005; Pinkham et al., 2004; Wykes et al., 2005,
1999). Only two studies found results similar to ours (Newton et al.,
2005; Penn et al., 2009). The reliable and clinically significant changes
demonstrate that the intervention as a whole is beneficial for 26% of
patients and has no adverse effect. However, during the Voices Group
and during posttreatment and follow-up assessments, a nonnegligible
proportion of patients deteriorated. It is thus likely that for some pa-
tients, short-term and intense Voices Group therapy enhances general
distress (e.g., depression, anxiety, guilt, somatic concerns).
Third, contrary to our expectations, the intervention did not
improve self-esteem, QOL, beliefs about voices, severity of delusions,
or other dimensions of psychopathology and psychosocial function-
ing. These findings corroborate those reported in several other studies
showing that group CBT for voices has little influence on positive,
negative, depression-anxiety, and mania-hostility symptom dimen-
sions (Barrowclough et al., 2006; Chadwick et al., 2000b; Lee et al.,
2002; Newton et al., 2005; Penn et al., 2009; Wykes et al., 1999); on
beliefs about voices (Lee et al., 2002; Newton et al., 2005; Penn et al.,
2009; Wykes et al., 1999); on self-esteem (Lee et al., 2002; Newton
et al., 2005; Wykes et al., 2005, 1999); and on social functioning
(Barrowclough et al., 2006; Newton et al., 2005; Penn et al., 2009).
A possible explanation for this may be that the intervention was too
specific and brief to expect significant improvement in such secondary
outcome measures.
Fourth, despite the preparation of the patients during the in-
dication phase, we were unable to avoid a substantial proportion of
premature terminations. However, only few dropouts occurred dur-
ing the Voices Group, suggesting the importance of careful selection of
the patients. The analysis of the dropouts indicated that the majority
could be attributed to psychotic symptoms. Other studies also found
high attrition rates (Bechdolf et al., 2005; Penn et al., 2009; Wykes
et al., 1999), which are common in individuals with severe mental
disorders (Borras et al., 2009). A similar proportion of premature
terminations was also observed in anxiety disorders (Manicavasagar
et al., 2004). This suggests that a high attrition rate is inherent to
group therapy or to social anxiety rather than to diagnoses. Moreover,
in group therapy literature, it is well known that ‘‘the percentage
of premature terminators from group therapy ranges from 10% to as
high as 50%. The majority of these dropouts occur within the first six
sessions. This suggests that selection, composition and entry fac-
tors are responsible’’ (MacKenzie, 1990, p. 217). Of these factors,
geographical location and the subjective characteristics of voices
may explain the dropouts in this study. Because the patients came
from several different psychiatric units located in various urban areas,
it is possible that some patients found it too difficult to reach the unit
where the intervention was delivered. In fact, some patients com-
plained about their fear of using public transport facilities. Despite
that, the completer and noncompleter groups shared very similar
sociodemographic and clinical characteristics; they differed in some
subjective features. The patients from the noncompleter group were
less open to various beliefs about voices because they tended to have
only one and they experienced their voices more positively, either
cognitively or emotionally. These characteristics are known to be a
barrier to treatment (Jenner et al., 2008). These patients may fear
losing their voices, even if it is not the therapeutic goal of the inter-
vention, and refuse or leave therapy. It is also possible that chang-
ing beliefs about voices, a key component of CBT for voices, is too
challenging for some patients. A radical alternative explanation may
be that the patients in the noncompleter group saw no purpose in the
therapy because they had no or fewer problems associated with their
voices. This interpretation is supported by recent findings in healthy
individuals with AVHs who did not seek help and were not disturbed
by hearing voices (Sommer et al., 2010).
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Brief Group CBT for AVH
Finally, from the point of view of the participants’ perspective
of the group, the intervention seemed to improve socialization and
reduce the fear of sharing the experience of hearing voices with
others. This may be viewed as a step toward ‘‘normalization,’’ which is
another central feature of CBT treatments for some authors (e.g.,
Kingdon and Turkington, 1994).
Limitations
The present study has several limitations. First, we do not rule
out the possibility that the symptom reduction found here could be
caused by factors other than intervention. For instance, we have not
kept the dose of antipsychotic medication constant and controlled
the number of consultations with health clinicians during the study
phase. Second, we acknowledge that observation of the group is
anecdotal. In the future, it would be appropriate to include specific
scales for assessing group processes, satisfaction with therapy, and
therapeutic alliance. Third, we did not examine changes in coping
strategies occurring after the intervention. Finally, methodological
weaknesses should also be mentioned: a) the assessments were not
blind, which may have led to inflated ESs (Lynch et al., 2010; Wykes
et al., 2008); b) the sample size was too small to permit generalization
of the findings; and c) the study design could be criticized because no
appropriate control group was included. Clearly, this highlights the
need of other studies exploring more deeply the effectiveness of group
CBT for voices hearers.
CONCLUSIONS
This study suggests that the Voices Group English manual is
easy to adapt and to apply in other languages than English and in
different cultural contexts. The findings suggest that it could be a
promising approach to reducing the severity of voices and to helping
some patients make sense of their voices and share this experience
with others. However, despite being effective, the intervention was
clearly not sufficient to address the complexity of the difficulties
faced by patients with a schizophrenia spectrum disorder. Thus, this
specific intervention for AVHs should be integrated into a more
comprehensive, planned, and flexible treatment that also addresses
delusions, neurocognition, social cognition, self-esteem, social skills
as well as leisure activities, supported employment, and independent
living skills. This would probably help to enhance self-confidence,
avoid stigmatization, and improve global social functioning as
well as QOL.
In our opinion, the intervention could also be refined so that it
simultaneously provides individual and group therapies for AVHs to
strengthen the improvements made in the group and to limit drop-
outs. In routine practice, clinicians may also consider Voices Group
ingredients as techniques to use carefully in long-term slow-open group
interventions especially for severely ill patients who reluctantly adhere
to treatment.
Future research should address these issues and supply long-
term monitoring of the global efficiency and synergy of multiple in-
terventions simultaneously proposed to patients with schizophrenia.
DISCLOSURE
The authors declare no conflict of interest.
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