1. 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

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

3. 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

4. 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

5. 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?

6. Psychological
Flexibility
Behavioural
Responses
to voices
Perceived power
of voices
Distress
&
Disruption

7. 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

8. 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)

9. 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%)

10. 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)

11. 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)
3.9
2 – 15 (15)
TCQ Punishment
12.4
3.5
6 – 20 ( 24)
TCQ Re-appraisal
14.4
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)

12. Pearson’s Correlation
Psychological flexibility (AAQ-II)
Pearson’s Correlation
Sig.
Depression
-.65
p < .001
Anxiety
-.48
KIMS – Accept Without Judgement
.53
Acceptance without judgement (KIMS)
-.40
p < .01
-.38
Thought Control: Punishment
-.59
Thought Control: Re-appraisal
-.44
Voice Omnipotence
-.41
Resistance to voices (behavioural)
-.45

13. 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

14. Appraisals of omnipotence
Model
Predictors 
AdjustedR2 p
1 Appraisals
Malevolence
Benevolence
.48
.50
.30
.001
2 Appraisals + Acceptance
Acceptance (KIMS)
Psych Flex (AAQ)
-.39
-.01
.43
F change
p < .01

15. Amount of voice distress
Model
Predictors 
AdjustedR2 p 1
Malevolence
Degree of –ve content
Behavioural resistance
.26
.14
.20
.15
.05 2
Adding Acceptance
Behavioural resistance Acceptance (KIMS)
Psych Flexibility (AAQ)
.04
.35
-.32
-.44
F change
p< .05

16. Life disruption from voices
Model
Predictors 
AdjustedR2 p 1
Degree of –ve content
Omnipotence
.33
.27
.16
.01 2
Adding Acceptance
Acceptance (KIMS)
Psych Flexibility (AAQ)
.24
.37
-.38
-.24
.23
F change
n.s.
(.07)

17. Responding to voices Dependent variable Predictors  AdjustedR2 p
Behavioural Resistance 1
Omnipotence
Thoughts: Punishment
Malevolence
.26
.24
.23
.27
<.001 2
Adding Acceptance
Acceptance (KIMS)
Psych Flexibility (AAQ)
.14
.01
-.39
-.05
.36
F change
n.s.
(.06)
Behavioural Engagement
Benevolence
.65
.43

18. General distress (BDI+BAI)
Model
Predictors 
AdjustedR2 p 1
Omnipotence
Thoughts:Punishment
.07
.45
.20
.01 2
Adding Acceptance
Acceptance (KIMS)
Psych Flexibility (AAQ)
-.01
.33
.02
-.54
.44
F change
p < .001

19. 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.

20. 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

21. 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?

23. Thanks! Eric.Morris@kcl.ac.uk