Mindfulness Skills

1
Mindfulness Skills Psychological Flexibility
with distressing voices

• Eric Morris, Emmanuelle Peters Philippa Garety
• Institute of Psychiatry, Kings College London
• South London Maudsley NHS Foundation Trust

2
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

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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

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Relationship of experiential 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

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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?

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Psychological Flexibility
Behavioural Responses to voices
Perceived power of voices
Distress Disruption
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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

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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 (N35) and inpatient
  settings (N15)

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Demographics

• 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)

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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)

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Descriptives for sample
Mean 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)
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Psychological flexibility (AAQ-II) Pearsons Correlation Sig.
Depression -.65 p lt .001
Anxiety -.48 p lt .001
KIMS Accept Without Judgement .53 p lt .001
Acceptance without judgement (KIMS)
Depression -.40 p lt .01
Anxiety -.38 p lt .01
Thought Control Punishment -.59 p lt .001
Thought Control Re-appraisal -.44 p lt .01
Voice Omnipotence -.41 p lt .01
Resistance to voices (behavioural) -.45 p lt .001
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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

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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 lt .01
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Amount of voice distress
Model 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 plt .05
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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)
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Responding to voices
Dependent variable Predictors ? AdjustedR2 p
Behavioural Resistance 1 Omnipotence Thoughts Punishment Malevolence .26 .24 .23 .27 lt.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 lt.001
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General distress (BDIBAI)
Model Predictors ? AdjustedR2 p
1 Omnipotence ThoughtsPunishment .07 .45 .20 .01
2 Adding Acceptance Omnipotence ThoughtsPunishment Acceptance (KIMS) Psych Flexibility (AAQ) -.01 .33 .02 -.54 .44 F change p lt .001
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Summary of Results

• Acceptance 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.

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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

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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?

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Eric.Morris_at_iop.kcl.ac.uk