mindfulness skills & psychological flexibility with distressing voices
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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. - PowerPoint PPT PresentationTRANSCRIPT
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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
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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 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
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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
BehaviouralResponsesto voices
Perceived powerof 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 (N=35) and
inpatient settings (N=15)
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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%)
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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 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)
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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
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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 < .01
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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
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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 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
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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
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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.
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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?