Original Article

The Effect of Attentional Avoidance, Attentional Focusing, and Mindfulness on the Frequency of Voice-Hearing and Associated Distress in People with Schizophrenia: A Randomized Controlled trial

Abstract

Objective: The objective of this study was to determine the most effective coping mechanism to deal with auditory hallucinations that reduces the frequency of voice-hearing and associated distress. In the present randomized controlled trial, each of the three coping mechanisms of attentional avoidance, attentional focusing, and mindfulness were used in one group and the fourth group was the control group.

Method: A total of 64 patients with schizophrenia, categorized in three groups of attentional avoidance, attentional focusing and mindfulness and one control group, were asked to listen to an ambiguous auditory task depending on the type of their coping mechanism. After determining the baseline of distress, the task was performed in duplicate for each group. After playing the auditory task for the first time, participants were asked to rate out the level of their distress and compliance with instructions, and they were asked to estimate the likely number of words they had heard. After the second time, they were asked to note the words they hear during the task and rate out their distress and compliance with instructions again at the end of the task.

Results: There was a significant difference between groups in terms of distress with a medium effect size of 0.47. The post hoc analysis revealed that mindfulness group reported less distress compared to the attentional focusing group (P = 0.017) and the control group (P = 0.027). Also, a significant difference existed between groups in terms of the frequency of the identified words, with a moderately strong effect size of 0.59, and a very good statistical power of 0.99. The post hoc analysis showed that attentional avoidance (P = 0.013) and attentional focusing (P = 0.011) groups heard fewer words than the control group.

Conclusion: Attention is a good target for treating psychotic patients with auditory hallucinations. Also, manipulation of attention can affect the frequency of auditory hallucinations and associated distress.

1. Clarke P, Jones AM, Hayward M. Increasing access to brief Coping Strategy Enhancement for distressing voices: a service valuation exploring a possible role for briefly-trained therapists. Cogn Behav Therap. 2021;14:e16.
2. McCarthy-Jones S, Hayward M, Waters F, Sommer IE. Editorial: Hallucinations: New Interventions Supporting People with Distressing Voices and/or Visions. Front Psychol. 2016;7:1418.
3. Perona-Garcelán S, López-Jiménez AM, Bellido-Zanin G, Senín-Calderón C, Ruiz-Veguilla M, Rodríguez-Testal JF. The relationship with the voices as a dialogical experience: The role of self-focused attention and dissociation. J Clin Psychol. 2020;76(3):549-58.
4. Langlois T, Sanchez-Rodriguez R, Bourcier A, Lamy P, Callahan S, Lecomte T. Impact of the group intervention" Accept Voices©" for the management of auditory hallucinations. Psychiatry Res. 2020;291:113159.
5. Suessenbacher-Kessler S, Gmeiner A, Diendorfer T, Schrank B, Unger A, Amering M. A relationship of sorts: gender and auditory hallucinations in schizophrenia spectrum disorders. Arch Womens Ment Health. 2021;24(5):709-20.
6. Swyer A, Powers AR, 3rd. Voluntary control of auditory hallucinations: phenomenology to therapeutic implications. NPJ Schizophr. 2020;6(1):19.
7. Ward T, Garety PA, Jackson M, Peters E. Clinical and theoretical relevance of responses to analogues of psychotic experiences in people with psychotic experiences with and without a need-for-care: an experimental study. Psychol Med. 2020;50(5):761-70.
8. Fielding-Smith SF, Greenwood KE, Wichers M, Peters E, Hayward M. Associations between responses to voices, distress and appraisals during daily life: an ecological validation of the cognitive behavioural model. Psychol Med. 2022;52(3):538-47.
9. Tully S, Wells A, Morrison AP. Attentional avoidance increases voice hearing in an analogue task in people with psychosis: An experimental study. Psychiatry Res. 2017;257:186-92.
10. Lüdtke T, Platow-Kohlschein H, Rüegg N, Berger T, Moritz S, Westermann S. Mindfulness Mediates the Effect of a Psychological Online Intervention for Psychosis on Self-Reported Hallucinations: A Secondary Analysis of Voice Hearers From the EviBaS Trial. Front Psychiatry. 2020;11:228.
11. Wykes T, van der Gaag M. Is it time to develop a new cognitive therapy for psychosis--cognitive remediation therapy (CRT)? Clin Psychol Rev. 2001;21(8):1227-56.
12. Morris R, Griffiths O, Le Pelley ME, Weickert TW. Attention to irrelevant cues is related to positive symptoms in schizophrenia. Schizophr Bull. 2013;39(3):575-82.
13. Capobianco L, Heal C, Bright M, Wells A. What Comes First Metacognition or Negative Emotion? A Test of Temporal Precedence. Front Psychol. 2019;10:2507.
14. Turkington D, Lebert L, Spencer H. Auditory hallucinations in schizophrenia: helping patients to develop effective coping strategies. BJPsych Adv. 2016;22(6):391-6.
15. Singh G, Sharan P, Kulhara P. Role of coping strategies and attitudes in mediating distress due to hallucinations in schizophrenia. Psychiatry Clin Neurosci. 2003;57(5):517-22.
16. Musiek F, Ballingham TM, Liu B, Paulovicks J, Swainson B, Tyler K, et al. Auditory hallucinations: An audiological perspective. Hear J. 2007;60(9):32-52.
17. Mian L, Lattanzi GM, Tognin S. Coping strategies in individuals at ultra-high risk of psychosis: A systematic review. Early Interv Psychiatry. 2018;12(4):525-34.
18. Chadwick P, Hughes S, Russell D, Russell I, Dagnan D. Mindfulness groups for distressing voices and paranoia: a replication and randomized feasibility trial. Behav Cogn Psychother. 2009;37(4):403-12.
19. Chadwick P, Strauss C, Jones AM, Kingdon D, Ellett L, Dannahy L, et al. Group mindfulness-based intervention for distressing voices: A pragmatic randomised controlled trial. Schizophr Res. 2016;175(1-3):168-73.
20. Hodann-Caudevilla RM, Díaz-Silveira C, Burgos-Julián FA, Santed MA. Mindfulness-Based Interventions for People with Schizophrenia: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2020;17(13):4690.
21. Louise S, Fitzpatrick M, Strauss C, Rossell SL, Thomas N. Mindfulness- and acceptance-based interventions for psychosis: Our current understanding and a meta-analysis. Schizophr Res. 2018;192:57-63.
22. qMoran O, Larsson A, McHugh L. Investigating cognitive fusion, mindfulness and experiential avoidance in relation to psychosis-like symptoms in the general population. J Contextual Behav Sci. 2021;21:136-43.
23. Perona-Garcelán S, García-Montes JM, López-Jiménez AM, Rodríguez-Testal JF, Ruiz-Veguilla M, Ductor-Recuerda MJ, et al. Relationship between self-focused attention and mindfulness in people with and without hallucination proneness. Span J Psychol. 2014;17:E20.
24. Shawyer F, Thomas N, Morris EM, Farhall J. Theory on voices. In: Morris EM, Johns LC, Oliver JE, editors. Acceptance and commitment therapy and mindfulness for psychosis. John Wiley & Sons; 2013. p. 12-32.
25. Strauss C, Thomas N, Hayward M. Can we respond mindfully to distressing voices? A systematic review of evidence for engagement, acceptability, effectiveness and mechanisms of change for mindfulness-based interventions for people distressed by hearing voices. Front Psychol. 2015;6:1154.
26. van der Valk R, van de Waerdt S, Meijer CJ, van den Hout I, de Haan L. Feasibility of mindfulness-based therapy in patients recovering from a first psychotic episode: a pilot study. Early Interv Psychiatry. 2013;7(1):64-70.
27. Sawilowsky SS. New effect size rules of thumb. J Mod Appl Stat Methods. 2009;8(2):26.
28. Gamaiunova L, Brandt PY, Bondolfi G, Kliegel M. Exploration of psychological mechanisms of the reduced stress response in long-term meditation practitioners. Psychoneuroendocrinology. 2019;104:143-51.
29. Naunheim MR, Dai JB, Rubinstein BJ, Goldberg L, Weinberg A, Courey MS. A visual analog scale for patient-reported voice outcomes: The VAS voice. Laryngoscope Investig Otolaryngol. 2020;5(1):90-5.
30. Anderson A, Hartley S, Morrison A, Bucci S. The effect of rumination and distraction on auditory hallucinatory experiences: An analogue experimental study. J Behav Ther Exp Psychiatry. 2020;69:101592.
31. McKay M, Wood JC, Brantley J. The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. New Harbinger Publications; 2019.
32. Feelgood SR, Rantzen AJ. Auditory and visual hallucinations in university students. Pers Individ Dif. 1994;17(2):293-6.
33. Valmaggia LR, Bouman TK, Schuurman L. Attention training with auditory hallucinations: A case study. Cogn Behav Pract. 2007;14(2):127-33.
34. Farhall J, Greenwood KM, Jackson HJ. Coping with hallucinated voices in schizophrenia: a review of self-initiated strategies and therapeutic interventions. Clin Psychol Rev. 2007;27(4):476-93.
35. Hartley S, Haddock G, Vasconcelos e Sa D, Emsley R, Barrowclough C. The influence of thought control on the experience of persecutory delusions and auditory hallucinations in daily life. Behav Res Ther. 2015;65:1-4.
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IssueVol 18 No 2 (2023) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijps.v18i2.12361
Keywords
Auditory Hallucinations Engagement Distress Mindfulness Resistance Schizophrenia
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1.
Madani M, Hossein Sabet F, Borjali A. The Effect of Attentional Avoidance, Attentional Focusing, and Mindfulness on the Frequency of Voice-Hearing and Associated Distress in People with Schizophrenia: A Randomized Controlled trial. Iran J Psychiatry. 2023;18(2):108-118.