Mindfulness Skills & Psychological Flexibility with distressing voices
Eric Morris, Emmanuelle Peters & Philippa GaretyInstitute of Psychiatry, King’s College London
South London & Maudsley NHS Foundation Trust
ACT, mindfulness and psychosis• Acceptance based approaches focus on changing
the relationship to thoughts and feelings (rather than directly changing content) to increase behavioural flexibility
• Some preliminary evidence with psychosis (e.g., Bach & Hayes, 2002; Chadwick, Newman Taylor & Abba, 2005; Gaudiano & Herbert, 2006)
• Models consider distress and disability resulting from experiential avoidance, over-literality about thoughts/experiences, inability to persist with valued actions
Voice hearing and distress/disability
• Cognitive models suggest that distress and disability associated with voices is partly a function of appraisals of voice power and intentions (e.g., Chadwick & Birchwood, 1994; Beck & Rector, 2003)
• Acceptance models, in addition, consider how people relate to appraisals in general (“fused” literality vs observing, mindful), with the aim of finding ways to influence this relating
Relationship of experiential Relationship of experiential avoidance with psychosis?avoidance with psychosis?
Indirect evidence suggesting this:
• people who cope poorly with voices tend to rely largely upon distraction and thought-suppression strategies (Romme and Escher, 1993).
• suppression-based coping strategies may exacerbate intrusive thoughts, psychological distress, autonomic arousal, and auditory hallucinations (Morrison, Haddock and Tarrier, 1995).
• Interventions based on distraction when compared to focusing (Haddock et al., 1998) appear to come at personal cost – with poorer outcomes for self esteem during treatment
Focus of the current study
• What relationships are there between psychological flexibility, mindfulness skills and previously found predictors of distress and disability in voice hearing?
• Does acceptance and mindfulness have any additional predictive power?
Psychological Flexibility
BehaviouralResponsesto voices
Perceived powerof voices
Distress &
Disruption
Measuring Psychological Flexibility & Mindfulness
Acceptance and Action Questionnaire – II (Bond et al, submitted) • Measures experiential avoidance/ acceptance and
willingness (based on ACT constructs)
Kentucky Inventory of Mindfulness Skills (Baer, Smith & Allen, 2004)• Measures skills in mindfulness, based on DBT constructs:
Observe, Describe, Act with Awareness, Accept Without Judgement
Design & Participants
• Using a cross-sectional design, involving the participation of distressed voice hearers (N = 50)– Diagnosed with mental illness and receiving
treatment for auditory hallucinations– Recruited from community (N=35) and
inpatient settings (N=15)
DemographicsDemographics• 33 male, 17 female• Mean age = 31.8 (range 18 – 56)• Mean length of time hearing voices = 9 years (range 3
months – 33 years)• Chart ICD Diagnoses:
– F20 – F29 = 45 (90%)– Mood disorder F30 – 39 = 5 (10%)
• Prescribed current medication for psychosis: 47 (94%)• Ethnicity: White 18 (36%), Black 22 (44%), Mixed 4
(8%), Asian 3 (6%), Other 3 (6%)• Employment: Unemployed 37 (74%), student 7 (14%),
Employed p/t 3 (6%), Employed f/t 3 (6%)
Measures• Psychological flexibility & Mindfulness (AAQ-II &
KIMS)
• Voice Appraisals– Beliefs about Voices Questionnaire- Revised (Chadwick, Lees & Birchwood, 2000)
• General Distress - BDI & BAI
• Coping with thoughts - Thought Control Questionnaire (Wells & Davies, 1994)
• Multidimensional assessment of voices - PSYRATS-auditory hallucinations subscale (Haddock et al., 1999)
Descriptives for sampleDescriptives for sampleMean s.d. Range (Total)
PSYRATS-AH 29.7 4.7 17 – 39 (44)
BDI 22.4 11.9 0 – 52 (63)
BAI 23.4 13.8 3 – 55 (63)
AAQ-II 37.2 8.2 22 – 58 (70)
KIMS-Accept w/o judgement 24.8 8.0 11 – 45 (45)
Omnipotence 10.4 3.8 0 – 17 (18)
Benevolence 4.3 4.6 0 – 16 (18)
Malevolence 9.6 4.1 0 – 17 ( 18)
Resistance (behavioural) 10.4 3.9 2 – 15 (15)
TCQ Punishment 12.4 3.5 6 – 20 ( 24)
TCQ Re-appraisal 14.4 3.5 6 – 20 (24)
Previously published samples: Student (mean = 29.6, s.d. 6.5).
Borderline PD (mean = 21.5, s.d. 7.5)(Baer, Smith & Allen, 2004)
Previous published samples:Student & community (mean = 50.7, s.d. 9.2)
Substance misuse (mean = 39.8, s.d. 12.5)(Bond, et al, submitted)
Psychological flexibility (AAQ-II) Pearson’s Correlation
Sig.
Depression -.65 p < .001
Anxiety -.48 p < .001
KIMS – Accept Without Judgement .53 p < .001
Acceptance without judgement (KIMS)
Depression -.40 p < .01
Anxiety -.38 p < .01
Thought Control: Punishment -.59 p < .001
Thought Control: Re-appraisal -.44 p < .01
Voice Omnipotence -.41 p < .01
Resistance to voices (behavioural) -.45 p < .001
Data analysis strategy
• To assess the study questions a series of hierarchical regression analyses were conducted
• Independent variables were chosen on the basis of correlation statistical significance with the dependent variable, and entered in Step 1
• Then as Step 2 the KIMS (Acceptance) and AAQ-II (Psychological Flexibility) variables were entered
Appraisals of omnipotence
Model Predictors AdjustedR2 p
1 Appraisals Malevolence
Benevolence
.48
.50
.30 .001
2 Appraisals + Acceptance
Malevolence
Benevolence
Acceptance (KIMS)
Psych Flex (AAQ)
.48
.48
-.39
-.01
.43 F change
p < .01
Amount of voice distressModel Predictors AdjustedR2 p
1 Malevolence
Degree of –ve content
Behavioural resistance
.26
.14
.20
.15 .05
2
Adding Acceptance
Malevolence
Degree of –ve content
Behavioural resistance Acceptance (KIMS)
Psych Flexibility (AAQ)
.20
.04
.35
-.32
-.44
.26 F change
p< .05
Life disruption from voices
Model Predictors AdjustedR2 p
1 Degree of –ve content
Omnipotence
.33
.27
.16 .01
2
Adding Acceptance
Degree of –ve content
Omnipotence
Acceptance (KIMS)
Psych Flexibility (AAQ)
.24
.37
-.38
-.24
.23 F change
n.s.
(.07)
Responding to voicesDependent variable
Predictors AdjustedR2 p
Behavioural Resistance
1
Omnipotence
Thoughts: Punishment
Malevolence
.26
.24
.23
.27 <.001
2
Adding Acceptance
Omnipotence
Thoughts: Punishment
Malevolence
Acceptance (KIMS)
Psych Flexibility (AAQ)
.14
.01
.14
-.39
-.05
.36 F change
n.s.
(.06)
Behavioural Engagement
Benevolence .65 .43 <.001
General distress (BDI+BAI)
Model Predictors AdjustedR2 p
1 Omnipotence
Thoughts:Punishment
.07
.45
.20 .01
2
Adding Acceptance
Omnipotence
Thoughts:Punishment
Acceptance (KIMS)
Psych Flexibility (AAQ)
-.01
.33
.02
-.54
.44 F change
p < .001
Summary of ResultsAcceptance and psychological flexibility add
modest predictive power for: • general distress, • voice-specific amount of distress, • and appraisals of omnipotence. when combined with previously identified
independent variables in cognitive models. Non-significant, but “trend”, relationships for
predicting disruption and resistance to voices.
Study limitations
• Cross-sectional design• Sample (distressed voice hearers)• Use of general measures of mindfulness and
psychological flexibility (compared to symptom specific measures, e.g. Voices Acceptance and Action Scale; Shawyer et al., 2007)
• Using topographic rather than “contextual” measures
Clinical Implications/Questions• What does the AAQ-2 measure? (links with affect)• There may be some modest predictive power in
incorporating mindfulness and acceptance for understanding some aspects of distressed voice hearing (taking just a predictive model stance)
• But from a contextual CBT stance we are also looking for variables to influence, not simply explain…
• ACT model suggests that non-judgemental awareness of experiences is a skill that can be taught – can this be done with distressed voice hearers and does it allow them to have greater response flexibility?