Mindfulness Skills & Psychological Flexibility with distressing voices

Eric Morris, Emmanuelle Peters & Philippa Garety

Institute 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)

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)

• Less “contextual” measures

Clinical Implications/Questions• What does the AAQ-2 measure? • 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 functional contextual 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?

Eric.Morris@iop.kcl.ac.uk