A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders q Frances Shawyer a, b, * , John Farhall a , Andrew Mackinnon c , Tom Trauer b, d, e , Eliza Sims f , Kirk Ratcliff g , Chris Larner h , Neil Thomas a, i , David Castle d, e , Paul Mullen b , David Copolov j a School of Psychological Science, La Trobe University, Victoria 3086, Australia b School of Psychology and Psychiatry, Monash University, Clayton, Victoria 3800, Australia c Centre for Youth Mental Health, University of Melbourne, Parkville, Victoria 3052, Australia d Department of Psychiatry, The University of Melbourne, Parkville, Victoria 3052, Australia e St Vincent’s Hospital Mental Health Service, Fitzroy, Victoria 3065, Australia f Victoria Harbour Medical Centre, Docklands, Victoria 3008, Australia g Northern Mobile Support and Treatment Service,131 Wood St, Preston, Victoria 3072, Australia h Word of Mouth Psychological Therapies, PO Box 2409, Moorabbin, Victoria 3189, Australia i Monash Alfred Psychiatry Research Centre and Swinburne University, The Alfred, Melbourne, Victoria 3004, Australia j Office of the Vice-Chancellor, Monash University, Clayton, Victoria 3800, Australia article info Article history: Received 9 December 2010 Received in revised form 27 November 2011 Accepted 30 November 2011 Keywords: Command hallucinations Psychosis Schizophrenia Cognitive Behaviour Therapy (CBT) Acceptance and Commitment Therapy (ACT) Randomised Controlled Trial (RCT) abstract Command hallucinations represent a special problem for the clinical management of psychosis. While compliance with both non-harmful and harmful commands can be problematic, sometimes in the extreme, active efforts to resist commands may also contribute to their malignancy. Previous research suggests Cognitive Behaviour Therapy (CBT) to be a useful treatment for reducing compliance with harmful command hallucinations. The purpose of this trial was to evaluate whether CBT augmented with acceptance-based strategies from Acceptance and Commitment Therapy could more broadly reduce the negative impact of command hallucinations. Forty-three participants with problematic command hallucinations were randomized to receive 15 sessions of the intervention “TORCH” (Treatment of Resistant Command Hallucinations) or the control, Befriending, then followed up for 6 months. A sub- sample of 17 participants was randomized to a waitlist control before being allocated to TORCH or Befriending. Participants engaged equally well with both treatments. Despite TORCH participants subjectively reporting greater improvement in command hallucinations compared to Befriending participants, the study found no significant group differences in primary and secondary outcome measures based on blinded assessment data. Within-group analyses and comparisons between the combined treatments and waitlist suggested, however, that both treatments were beneficial with a differential pattern of outcomes observed across the two conditions. Ó 2011 Elsevier Ltd. All rights reserved. Introduction Command hallucinations are one of the most troubling symptoms of psychosis with numerous studies suggesting that they are associated with seriously destructive behaviours (see Braham, Trower, & Birchwood, 2004 for most recent review). Evidence has increasingly accumulated over the past 20 years that psychotic symptoms, which were often immutable even with antipsychotic medication, can be reduced or their impact ameliorated using Cognitive Behavioural Therapy (CBT) (Wykes, Steel, Everitt, & Tarrier, 2007). In the first randomised controlled trial (RCT) to apply these methods to command hallucinations, Trower et al. (2004) tested whether cognitive therapy directed towards modifying beliefs related to the power of the voice would reduce compliance with command hallucinations and increase resistance compared to a treatment-as- usual (TAU) control condition. They found a reduction in compli- ance in both groups at 6 months, which was significantly stronger in the treatment group and maintained at 12-months follow-up. The q This trial was undertaken at The Mental Health Research Institute of Victoria. * Corresponding author. Southern Synergy, School of Psychology and Psychiatry, Monash University, c/- Wellington Rd, Clayton, Victoria 3800, Australia. Tel.: þ61 3 9902 9696; fax: þ61 3 9902 9900. E-mail addresses: fshawyer@gmail.com, frances.shawyer@monash.edu (F. Shawyer), j.farhall@latrobe.edu.au (J. Farhall), Andrew.Mackinnon@unimelb.edu. au (A. Mackinnon), Tom.TRAUER@svhm.org.au (T. Trauer), sims_eliza@yahoo.com. au (E. Sims), kirk.ratcliff@mh.org.au (K. Ratcliff), chris@wompt.com.au (C. Larner), n.thomas@alfred.org.au (N. Thomas), David.CASTLE@svhm.org.au (D. Castle), paul. mullen@monash.edu (P. Mullen), david.copolov@monash.edu (D. Copolov). Contents lists available at SciVerse ScienceDirect Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat 0005-7967/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2011.11.007 Behaviour Research and Therapy 50 (2012) 110e121