Sunteți pe pagina 1din 8

Journal of the American Psychiatric Nurses Association

Behavioral Management of Persistent


Auditory Hallucinations in
Schizophrenia: Outcomes From a
10-Week Course
Louise Trygstad, RN, CNS, DNSc, Robin Buccheri, RN, MHNP, DNSc, Glenna Dowling, RN, PhD,
Roberta Zind, RN, CS, MS, Kathy White, RN, FNP, MS, Jan Johnson Griffin, RN, CS, NP, MS,
Susan Henderson, RN, BA Applied Sci. (Nursing), Lynda Suciu, RN, CS, MS, Susan Hippe, RN, NP, MS,
Merrie J. Kaas, RN, CS, DNSc, Cheryl Covert, RN, CS, MS, Patrice Hebert, RN, MSN

BACKGROUND: Medication-resistant, persistent auditory hallucinations are pervasive in persons with


schizophrenia. Behavior strategies are often very effective as adjunctive therapy to decrease the
negative characteristics of this symptom.
OBJECTIVES: The purpose of this multi-site intervention study was to examine the short-term effects of
a 10-week course to teach behavior management of persistent auditory hallucinations on seven char-
acteristics of auditory hallucinations (i.e., frequency, loudness, self-control, clarity, tone, distractibility,
and distress), anxiety, and depression.
STUDY DESIGN: A quasi-experimental repeated measured design was used. The sample included 62
outpatients with schizophrenia who reported daily persistent auditory hallucinations. Measures in-
cluded the Characteristics of Auditory Hallucinations Questionnaire, the tension-anxiety subscale of
the Profile of Mood States, and the Beck Depression Inventory II.
RESULTS: Preintervention scores for the frequency (p < .001), self-control (p < .03), clarity (p < .01),
tone (p < .03), distractibility (p < .006), and distress (p < .001) improved compared with preinterven-
tion scores. Postintervention scores on anxiety and depression were also significantly lower than
preintervention scores (p < .02, p < .001, respectively).
CONCLUSIONS: Teaching behavior management of persistent auditory hallucinations in a standardized
10-week course is clinically effective and can be incorporated into many existing outpatient programs.
(J Am Psychiatr Nurses Assoc [2002]. 8, 84-91.)

Research supported by grants from University of San Fran-


cisco Faculty Development Funds, Sigma Theta Tau–Beta Roberta Zind, RN, CS, MS, is a clinical nurse specialist at
Gamma Chapter, American Nurses Foundation, and Mather Veterans Administration Outpatient Mental
American Psychiatric Nurses Association/Zeneca–Best Health Clinic in Sacramento, California.
Treatment of Schizophrenia in a Behavioral Health Care Kathy White, RN, FNP, MS, is a nurse practitioner at
Program Award. Veterans Administration, Northern California Health
Louise Trygstad, RN, CNS, DNSc, is a professor at the Care System in Mare Island, California.
School of Nursing, University of San Francisco. Jan Johnson Griffin, RN, CS, NP, MS, is a nurse practitio-
Robin Buccheri, RN, MHNP, DNSc, is a professor at the ner at Muir Diablo Primary Care in Antioch, California.
School of Nursing, University of San Francisco. Susan Henderson, RN, BA Applied Sci. (Nursing) is a
Glenna Dowling, RN, PhD, is the director of the Institute lecturer in nursing at Monash University, Gippsland Cam-
on Aging Research Center and associate adjunct professor pus in Victoria, Australia.
at the University of California, San Francisco. Lynda Suciu, RN, CS, MS, is a clinical nurse specialist at

84 APNA Web site: www.apna.org Vol. 8, No. 3


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Journal of the American Psychiatric Nurses Association Trygstad et al.

P eople with schizophrenia continue to report persis-


tent auditory hallucinations, or “voices,” despite rig-
orous pharmacologic treatment and the introduction of
terly intervals over a year (Buccheri, Trygstad, Kanas,
Waldren, & Dowling, 1996; Buccheri, Trygstad, Kanas, &
Dowling, 1997). This article presents immediate postint-
new psychotropic medications (Carter, Mackinnon, & Co- ervention effects of the 10-week course. Participants were
polov, 1996). Even after inpatient treatment, Miller (1996) followed for 1 year after completion of the intervention,
found that 56% of patients reported persistent hallucina- and these long-term effects will be reported in a future
tions. Persistent auditory hallucinations are one of the two publication.
most bothersome symptoms reported by persons with
schizophrenia, with up to 98% experiencing related ad- BACKGROUND
verse effects including heightened anxiety, depression,
The University of California San Francisco (UCSF)
suicide, homicide, substance abuse, inappropriate behav-
Symptom Management Faculty Group (1995) developed
ior, and social withdrawal (American Psychiatric Associa-
a conceptual model of symptom management that guided
tion, 1997; Betempts & Ragiel, 1994; Carter, et al.; Freder-
this study and other related work. This preliminary, yet
ick & Killeen, 1998). This persistence of symptoms de-
comprehensive, model of symptom management has
spite treatment clearly indicates a need for adjuncts to
three primary dimensions: the symptom experience,
pharmacologic therapy in the clinical management of
symptom-management strategies, and symptom out-
persistent auditory hallucinations.
comes. Key assumptions underlying the model are that
effective symptom management begins and ends with an
PURPOSE assessment of the symptom from the client’s perspective,
The overall purpose of this multi-site intervention study requires a partnership between the client and health care
was to examine the short and long term effects of a providers, and goes beyond the prescription of medica-
10-week course in which behavior management strate- tions to include a variety of interventions.
gies were taught to participants with schizophrenia who
experienced persistent auditory hallucinations. The pri-
mary aim was to examine the effects of teaching behavior Most patients are able to find techniques
management strategies in a group setting on seven char- that decrease their symptoms, and in some
acteristics of auditory hallucinations (i.e., frequency, loud- cases, complete relief is achieved (Carter et
ness, self-control, clarity, tone, distractibility, and distress). al., 1996).
Secondary aims included examination of mood states
(i.e., level of anxiety and depression). This study built on
the previous work of the principal investigators in which Behavior Strategies in Managing Auditory
participants who attended a similar course showed symp- Hallucinations
tom improvement immediately postcourse and at quar-
A growing body of literature suggests that behavior
strategies can be effective in managing auditory halluci-
Oakland Veterans Administration Outpatient Mental nations. Behavior management strategies (e.g., self-mon-
Health Clinic in Oakland, California. itoring, watching television, listening to music with ear-
Susan Hippe, RN, NP, MS, is a nurse practitioner at Cas- phones, or talking with someone) (Corrigan & Storzbach,
cadia Behavioral Healthcare in Portland, Oregon. 1993; Margo, Hemsley, & Slade, 1981; Nelson, Thrasher, &
Merrie J. Kaas, RN, CS, DNSc, is an associate professor at Barnes, 1991) combined with antipsychotic medications
the School of Nursing, University of Minnesota in Minne- (Breier & Strauss, 1983; Lehman, Thompson, Dixon, &
apolis, Minnesota. Scott, 1995) are the most widely used and described
Cheryl Covert, RN, CS, MS, is a clinical nurse specialist at treatments for assisting people with schizophrenia to man-
Minneapolis Veterans Administration Medical Center in age the symptoms of persistent auditory hallucinations.
Minneapolis, Minnesota. At least seven published reports describe more than
Patrice Hebert, RN, MSN, is a psychiatric clinical nurse 70 patient-initiated techniques for dealing with audi-
specialist at Associates in Psychiatry and Psychology in tory hallucinations (Breier & Strauss, 1983; Carr 1988;
Rochester, Minnesota. Falloon & Talbot, 1981; Frederick & Cotanch, 1995;
O’Sullivan, 1994; Romme & Escher, 1989; Tarrier,
Reprint requests: Robin Buccheri, RN, DNSc, School of
1987). Most patients are able to find techniques that
Nursing, University of San Francisco, 2130 Fulton Street,
San Francisco, CA 94117. decrease their symptoms, and in some cases, complete
relief is achieved (Carter et al., 1996). Case studies of
Copyright © 2002 by the American Psychiatric Nurses therapist-teaching behavior management strategies
Association.
(Allen, Halperin, & Friend, 1985; Alford & Turner, 1976;
1078-3903/2002/$35.00 ⫹ 0 66/1/125223 Feder, 1982; Slade, 1972; Turner, Hersen, & Bellack,
doi:10.1067/mpn.2002.125223 1977) led to more rigorous research, which examined

June 2002 APNA Web site: www.apna.org 85


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Trygstad et al. Journal of the American Psychiatric Nurses Association

teaching a few strategies to small numbers of patients group setting with people who have similar experiences.
(Buccheri et al., 1996; Buccheri et al., 1997; Margo et Possible benefits from group participation include sup-
al., 1981; Nelson et al., 1991). These studies consis- port, universality, and installation of hope (Yalom, 1985).
tently demonstrate symptom improvement; however, Kanas (1919) described group treatment for patients with
the degree of improvement and individual responses to schizophrenia as particu- larly appropriate to achieve the
specific strategies varies widely. benefits discussed by Yalom and to help clients improve
interpersonal relationships and learn to cope with psy-
Characteristics of Auditory Hallucinations chotic symptoms. Participants in the Buccheri et al. study
The characteristics of auditory hallucinations are often (1996) described benefits similar to those described by
used as outcome variables or indicators of symptom im- Kanas and Yalom. These benefits included: universality
provement to assess the effectiveness of behavior inter- (“I’m not the only one”); validation of their own experi-
ventions (Allen et al., 1985; Bentall, Haddock, & Slade, ence, such as the circumstances regarding the onset of
1994; Buccheri et al., 1996; Collins, Cull, & Sireling, 1989; auditory hallucinations; an opportunity to learn about
Margo et al., 1981; Nelson et al., 1991; Turner et al., 1977). auditory hallucinations and how others manage them,
A review of the literature (27 studies) by Shergill, Murray, such as whether to answer the voices in public; an op-
and McGuire (1998) found that psychological treatment of portunity to be a role model and/or find a role model; and
auditory hallucinations often leads to a decrease in dis- encouragement and hope from observing other members
tress and an increased sense of control, but not a reduc- of the group who experienced a decrease in some dis-
tion in the frequency of auditory hallucinations. tressing characteristics of auditory hallucinations.

Anxiety and Depression


Possible benefits from group participation
Persons with schizophrenia have high rates of comor- include support, universality, and installation
bidity for anxiety and depression (Kendler, Gallagher, of hope (Yalom, 1985).
Abelson, & Kessler, 1996). Morbidity is increased regard-
less of whether the affective disturbance is at a symptom
or disorder level (American Psychiatric Association, 1997). In summary, this review of the literature highlights the
Affective disorder is strongly correlated with suicide, pervasiveness of persistent auditory hallucinations in per-
which is the leading cause of premature death in persons sons with schizophrenia and the benefits that behavior
with schizophrenia (Conwell, Cholette, & Duberstein, management strategies can have on symptom severity.
1998; Fenton, McGlashan, Victor, & Blyler, 1997). This risk However, research on the comparative effectiveness of
is significant, with 9% to 24% of persons with schizophre- specific behavior strategies and effective measurement of
nia committing suicide (Conwell et al.). specific outcome variables is limited and inconsistent.
Hustig and Hafner (1990) reported that patients who
experienced more intrusive and distressing hallucinations METHODS
were more anxious and depressed than patients with less Design
intrusive and distressing hallucinations. They suggested
that further work be done to alter the mood of people This study employed a quasi-experimental, repeated
who experience persistent auditory hallucinations and measures design.
called for researchers to study the effects of strategies that
decrease anxiety and depression on auditory hallucina- Sample
tions. Buccheri et al. (1996) and Buccheri et al. (1997) A nonprobability sample of people with schizophrenia
taught behavior management strategies in a 12-week who were experiencing persistent auditory hallucinations
course that incorporated a support-group format and re- was used. Subjects were recruited for 10 groups in nine
laxation exercises specifically designed to target anxiety different outpatient settings. The sample consisted of 72
and depression. This intervention resulted in clinical im- subjects whose diagnosis of schizophrenia had been con-
provement in anxiety and depression from preinterven- firmed by a board-certified psychiatrist using Diagnostic
tion assessment to postintervention assessment and and Statistical Manual of Mental Disorders, fourth edition
throughout the entire 12 month follow-up period. (American Psychiatric Association, 1994) criteria. Subjects
underwent screening by the investigators and met the
Group Format in Treating Psychotic Symptoms following inclusion criteria: reported having persistent
Carter et al. (1996) suggested “an approach that intro- auditory hallucinations for at least 10 minutes a day for the
duces patients to a range of strategies, encourages exper- past 3 months; reported a desire to learn new strategies to
imentation and monitors outcomes” (p. 164). Experiment- manage their auditory hallucinations; were taking stable
ing with a wide array of strategies and learning from the doses of antipsychotic medication for at least 4 weeks
experiences of self and others are best accomplished in a before entry into the study; were able to read and write in

86 APNA Web site: www.apna.org Vol. 8, No. 3


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Journal of the American Psychiatric Nurses Association Trygstad et al.

English; and did not have a severe cognitive deficit as as the opposite of comforting voices. Participants rated
defined by a score of ⬎24 on the Mini-Mental Status Exam their auditory hallucinations as very comforting, moder-
(Folstein, Folstein, & McHugh, 1975). All patients with ately comforting, sometimes comforting—sometimes dis-
severe substance abuse were excluded from the study. tressing, moderately distressing, or very distressing.
Ten subjects were dropped from the study when they did Distractibility. Distractibility is a characteristic of au-
not adhere to the protocol; the final sample size was 62. ditory hallucinations that describes the person’s ability to
The mean age of participants was 44.1 years with a ignore the voices and focus on something else (e.g.,
range of 23 to 72 years. The mean age of onset of voices talking with someone or watching television). Behavior
was 24.8 years with a range of 1 to 47 years. Participants strategies that require “holding or focusing of attention”
had, on average, heard voices for approximately 20 years. seem to provide some relief to those who hear distressing
Of the 62 study participants, 72.6% (n ⫽ 45) were male voices (Buccheri, et al., 1996; Carter et al., 1996; Frederick
and 27.4% (n ⫽ 17) female. The gender bias towards & Cotanch, 1995; Tarrier, 1987). Participants rated their
males was influenced by the study sites. Four of the 10 auditory hallucinations as very easy to ignore, minimally
groups were in Veterans Administration facilities. These distracting, moderately distracting, very distracting, or
four groups were nearly all male. Ethnicity is also reflec- unable to pay attention to anything else.
tive of the data collection sites; 8 of the 10 sites were in Loudness. Loudness is a characteristic of auditory hal-
urban areas in Northern California. Participants were 71% lucinations that describes the volume of the voices. Hustig
(n ⫽ 44) Caucasian, 14.5% (n ⫽ 9) African American, and Hafner (1990) asked participants to record the loud-
4.8% (n ⫽ 3) Latino, 6.5% (n ⫽ 4) Chinese, and 2.8% (n ⫽ ness of their auditory hallucinations on a 5-point Likert-
2) other. The majority of participants (62.9%, n ⫽ 39) type item with responses ranging from very loud to very
were single, while 17.7% (n ⫽ 11) were married, and quiet. For this study, this characteristic was modified to
19.4% (n ⫽ 12) were widowed or divorced. About one include terms frequently used by clients (Buccheri et al.,
third (32.2%, n ⫽ 20) had some paid or volunteer em- 1996; Buccheri et al., 1997). Participants rated the loud-
ployment, whereas approximately two-thirds (67.7%, n ⫽ ness as whispering, could hardly hear, speaking softly,
42) had no employment or volunteer work. normal speaking tone, speaking loudly, or shouting.
Frequency. Frequency is a characteristic of auditory
Measurement and Instrumentation hallucinations that refers to how often the voices are
Characteristics of Auditory Hallucinations. The heard. This characteristic has been used as an outcome
Characteristics of Auditory Hallucinations Questionnaire measure in many studies but has yielded mixed results,
(CAHQ) is a seven item instrument compiled by the in- especially when examining grouped versus individual
vestigators. The CAHQ asks participants to rate the char- data. For example, Hustig et al. (1990) examined the
acteristics of their auditory hallucinations during the past effects of listening to two different audiotapes (relaxing
24 hours. Four items (clarity, tone, distractibility, loud- and arousing) on the frequency of hearing voices for 10
ness) were adapted from items developed by Hustig and subjects. They found that listening to either of the tapes
Hafner (1990); three items (frequency, self-control, and did not affect frequency of voices for the group means
distress) were drawn from the literature review (Allen et but was effective for three persons. Buccheri et al.
al., 1995; Breier & Strauss, 1983; Chadwick & Birchwood, (1996) and Buccheri et al. (1997) found similar results
1994; Hustig, Tran, Hafner, & Miller, 1990; Shergill, Mur- with a sample of 12. Participants rated their auditory
ray, & McGuire, 1998; Slade, 1974). Similar to the Hustig hallucinations as only once or twice, sometimes, half the
and Hafner diary, the CAHQ uses a Likert-type scale time, very often, or constantly.
ranging from 1 to 5. Hustig and Hafner report adequate Self-control. Self-control is the person’s ability to
reliability (.74) based on test-retest correlations. decrease or stop the voices. Kanfer (1971) developed a
Clarity. Clarity is a characteristic of auditory hallu- model of self-control which had three phases: self-
cinations that describes to what degree the voices are monitoring, self-evaluation, and self-reinforcement.
either clear or muddled (Hustig & Hafner, 1990). As Breier and Strauss (1983) operationally defined the
auditory hallucinations improve, voices become more three phases of Kanfer’s model of self-control— detec-
mumbled and easier to ignore (Buccheri et al., 1996). tion of behavior, evaluation of the behavior, use of a
Participants rated the clarity of their voices as very strategy to control the behavior—and then tested the
mumbled, moderately mumbled, sometimes mum- model with a small sample of psychiatric patients. The
bled—sometimes clear, moderately clear, or very clear. researchers found that some people were able to con-
Tone. Tone is a characteristic of auditory hallucinations trol their psychotic symptoms. In this study, partici-
that relates to whether the voices are perceived as com- pants rated their level of self-control over their auditory
forting or distressing. This characteristic of auditory hallu- hallucinations as totally in control, pretty much in con-
cinations has been labeled differently by various research- trol, a little in control, very little in control, and not in
ers. Hustig and Hafner (1990) described distressing voices control at all.

June 2002 APNA Web site: www.apna.org 87


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Trygstad et al. Journal of the American Psychiatric Nurses Association

Distress. Distress is the degree of suffering that the ipants and to stress the value of each person’s experience.
person experiences in response to hearing voices. Dis- Course facilitators were nurses with experience with pa-
tress and being bothered, worried, and upset are words tients with schizophrenia and with group facilitation
used to describe this experience. Carter et al. (1996) skills; most had Master’s or Doctoral degrees. In each
reported that 81% of subjects were worried or upset by class, participants were taught and practiced one behav-
their hallucinations. Participants rated their level of ioral strategy. The following strategies were taught in the
distress as not distressed, minimally distressed, moder- course: self-monitoring, talking with someone, listening
ately distressed, very distressed, or extremely distressed. to music with or without earphones, watching television,
saying “stop”/ignoring what the voices say to do, using an
Symptom Management Notebook ear plug, relaxation techniques, keeping busy with an
Participants were also given a Symptom Manage- enjoyable activity and/or helping others, and practicing
ment Notebook to help teach self-monitoring. Com- communication related to taking medication and not us-
pleting the notebook served to remind subjects to prac- ing drugs and alcohol.
tice the strategies twice a day.
Anxiety
In each class, participants were taught and
The Tension-Anxiety subscale of the Profile of Mood practiced one behavior strategy.
States (POMS) (McNair, Lorr, & Droppleman, 1992)
consists of nine items and is measured on a 5-point
Likert scale, ranging from 0 not at all, to 4 extremely. A The structure of each weekly class was as follows:
higher score is indicative of more anxiety/tension. ● Participants completed the CAHQ while course facili-
Lower mean scores indicate less anxiety. The POMS tators collected the Symptom Management Notebook
has been used with a variety of physically and mentally from the previous week (5 minutes).
ill patients and healthy persons. Internal reliability for ● Course facilitators asked each participant to describe his
the tension-anxiety subscale is ⬎.90, and test-retest or her experience with the strategy of the past week.
reliability pretreatment is .70 (McNair et al.). Participants could respond to course facilitators or one
another with questions or comments (15 minutes).
Depression ● Course facilitators taught the new strategy for the week
The Beck Depression Inventory, second edition (BDI- and why and how it might be helpful. Participants asked
II) (Beck, Steer, & Brown, 1998) is a 21-item self-report questions and made comments as desired (10 minutes).
instrument that assesses the presence and degree of de- ● The new strategy was practiced by all individuals in the
pressive symptoms in adults and is scored on a 4-point course including the course facilitators. Questions, com-
scale. Two of the items assess possible suicide risk. ments, and experiences were discussed (15 minutes).
Higher scores indicate higher levels of depression. The ● Symptom Management Notebooks for the next week
BDI-II builds on 35 years of psychometric data from the were distributed (5 minutes).
first two versions of the Beck Depression Inventory. The The investigators developed a manual for the 10-week
initial psychometric data for the BDI-II are from a sample course to clarify class structure and climate and to ensure
of 500 psychiatric outpatients with a variety of diagnoses. consistency across courses and between facilitators. Con-
Reliability measures include internal consistency (coeffi- sistency was needed both in the delivery of the interven-
cient alpha ⫽ .92) and test-retest stability (correlation tion and in data collection. The investigators met or talked
⫽.93, p ⬍ .001). Validity measures include content valid- with each course facilitator before implementation of the
ity and construct validity (Beck et al., 1996). course and reviewed the manual, data collection proce-
dures, and instrument administration. The investigators
STUDY PROTOCOL maintained regular telephone contact with course facili-
The study took place in three phases: preinterven- tators to answer questions and to ensure consistency
tion assessment, intervention (10-week course), and across data collection sites.
postintervention assessment.
Post-Intervention Assessment
Preintervention Assessment
At the conclusion of the course (last class session),
The preintervention assessment occurred in group
participants completed the CAHQ, the tension-anxiety
meetings. Participants completed the CAHQ, the Ten-
subscale of the POMS, and BDI-II.
sion-Anxiety subscale of the POMS, and the BDI-II.
Intervention: The 10-week Course RESULTS
The 10-week course was taught in a structured group It was expected that subjects who attended the be-
format designed to foster safe interactions among partic- havior-management strategy classes for auditory hallu-

88 APNA Web site: www.apna.org Vol. 8, No. 3


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Journal of the American Psychiatric Nurses Association Trygstad et al.

Table 1. Comparison of Pre-Intervention and Post-Intervention Means for Characteristics of Auditory Hallucinations,
Anxiety, and Depression
Pre- Post- t-value
intervention intervention (significance
Variable M (SD) M (SD) n level) df
Characteristics of auditory hallucinations
Frequency 2.69 (1.40) 2.07 (1.37) 61 3.38 (p ⬍ .001)
df ⫽ 60
Loudness 2.53 (1.15) 2.19 (1.18) 59 1.83 (p ⬍ .072)
df ⫽ 58
Self-control 2.90 (1.17) 2.39 (1.38) 59 2.21 (p ⬍ .03)
df ⫽ 58
Clarity 3.58 (1.33) 2.97 (1.53) 60 2.54 (p ⬍ .01)
df ⫽ 59
Tone 3.02 (1.28) 2.57 (1.45) 61 2.22 (p ⬍ .03)
df ⫽ 60
Distractibility 2.75 (1.37) 2.12 (1.35) 59 2.88 (p ⬍ .006)
df ⫽ 58
Distress 2.58 (1.19) 2.08 (1.26) 59 2.39 (p ⬍ .02)
df ⫽ 58
Anxiety 16.61 (7.91) 14.86 (7.81) 59 2.40 (p ⬍ .02)
df ⫽ 58
Depression 20.51 (12.07) 16.33 (10.32) 57 3.51 (p ⬍ .001)
df ⫽ 56
Note. df ⫽ degrees of freedom.

cinations would experience improvement in the char- to 5 extremely helpful. The mean helpfulness score was
acteristics of their auditory hallucinations and have less 3.81 (SD ⫽ .97, n ⫽ 52) with 13 (25%) of the participants
anxiety and depression. reporting that the course was extremely helpful, 22 (42%)
The results strongly supported these expectations. helpful, 12 (23%) moderately helpful, 4 (8%) minimally
Paired t-tests revealed that postintervention CAHQ item helpful, and 1 (2%) not helpful. Thus, 98% of the partici-
means were significantly lower than preintervention on pants reported that the course was at least minimally
frequency (p ⬍ .001), self-control (p ⬍ .03), clarity (p ⬍ helpful, and 90% of the participants reported that the
.01), tone (p ⬍ .03), distractibility (p ⬍ .006), and distress course was at least moderately helpful.
(p ⬍ .02). Only one characteristic, loudness, did not
change significantly. Post-intervention scores on anxiety
and depression were also significantly lower than pre- After attending the 10-week course,
intervention scores (p ⬍ .02, p ⬍ .001, respectively) (Ta- participants reported that their auditory
ble 1). hallucinations were less frequent, less
threatening in tone, more mumbled, and
ADDITIONAL FINDINGS easier to ignore.
Helpfulness of Course
Clients’ perception of helpfulness of the course is
DISCUSSION
different from the effectiveness reflected in the de-
crease in mean scores for characteristics of auditory Behavior management strategies for persistent audi-
hallucinations, depression, and anxiety. Participants tory hallucinations learned in a group setting were
were asked each week what was and was not helpful to clinically effective in decreasing anxiety, depression,
them about the lesson. Responses from the weekly and six of seven characteristics of auditory hallucina-
feedback included: “Knowing I am not going through tions. After attending the 10-week course, participants
life being ill by myself”; “Hearing others share”; “Real- reported that their auditory hallucinations were less
izing perhaps there is a way to manage voices and frequent, less threatening in tone, more mumbled, and
perhaps they do have a pattern”; and “Learning new easier to ignore. Participants also felt less distress, less
methods for coping with difficult voices.” anxious and depressed, and more in control.
During the last class, participants were asked to rate the The short-term effects of this intervention are signif-
helpfulness of the course in learning how to manage their icant. Confidence in the generalizability of these find-
voices on a 5-point scale ranging from 1 not at all helpful ings to other persons and other settings is limited by

June 2002 APNA Web site: www.apna.org 89


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Trygstad et al. Journal of the American Psychiatric Nurses Association

using a convenience sample and a one-group design, mental health professionals who have group training
including only participants who were stable on medi- and experience facilitating groups with people who
cation in an outpatient setting and focusing on short- have schizophrenia. Teaching behavior management
term effects of the intervention. The investigators are of persistent auditory hallucinations to clients who
currently analyzing longitudinal follow-up data to as- wish to learn has minimal risks and could be easily
sess the long-term effects of this intervention. incorporated into existing outpatient programs.
This study demonstrates that clients can learn and The results of this study show that people who suffer
use behavior strategies to manage their auditory hallu- from auditory hallucinations can significantly benefit
cinations. This study also illustrates that a group setting from learning behavior management strategies. Hope-
is a particularly useful venue in which to have clients fully, this intervention will become widely available to
learn new strategies. In a group setting, clients see that those who are tormented by auditory hallucinations.
they are not alone, that is, that others suffer from the “When an effective psychosocial intervention is avail-
same symptoms. Participants were encouraged when able to remedy a disabling aspect of schizophrenia,
they saw others finding strategies that worked for them. just as when a better medication is available, its appli-
By teaching the strategies in a group, clients are given cation should help define the current standard of care”
the chance to practice and discuss the effectiveness of (Fenton & Scholler, 2000, p. 3).
new strategies with others who have experience man-
aging their auditory hallucinations. SUMMARY
The investigators are currently examining which be-
havior strategies are effective for participants with spe- The purpose of this multi-site study was to examine
cific characteristic profiles. This may allow us to answer the short-term effects of a 10-week course on seven
the question posed by Fenton and Schooler (2000) characteristics of auditory hallucinations (i.e., fre-
“What works best for whom?” (p. 2). For example, are quency, loudness, self-control, clarity, tone, distractibil-
earplugs more effective in left-handed versus right- ity, and distress), anxiety, and depression. All except
handed persons, or are headphones more effective one were significantly reduced. Medication-resistant
when voices are heard outside the head versus inside auditory hallucinations are pervasive in persons with
the head? The results of these analyses could provide schizophrenia. The results from this study contribute to
specific strategies for participants with certain charac- the body of knowledge and the scientific basis for
teristics rather than having them try to practice all of the nursing practice for persons with schizophrenia who
strategies. have persistent auditory hallucinations. Teaching be-
The researchers are also exploring the characteristics havior strategies in a class setting that combines edu-
of those participants who improved, stayed the same, cation, skills training, and support was effective, low
or declined on each measure. This will allow answers cost, and had minimal risks.
to questions such as: Did participants who had heard
voices longer show the most improvement in the char-
acteristics of their hallucinations after attending the REFERENCES
10-week course? Did participants who heard voices Allen, H.A., Halperin, J., & Friend, R. (1985). Removal and diversion
inside their head report no change in their anxiety and tactics and the control of auditory hallucinations. Behaviour Re-
depression whereas those who heard voices outside search and Therapy, 23, 601-605.
their head report less anxiety and depression after Alford, G.S., & Turner, S.M. (1976). Stimulus interference and condi-
tioned inhibition of auditory hallucinations. Journal of Behavior
attending the 10-week course?
Therapy and Experimental Psychiatry, 7, 155-160.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
Teaching behavior management of persistent American Psychiatric Association (APA). (1997). Practice guidelines
auditory hallucinations to clients who wish to for the treatment of patients with schizophrenia. American Jour-
learn has minimal risks and could be easily nal of Psychiatry, 154(4) (Suppl.), 1-63.
incorporated into existing outpatient Beck, A.T., Steer, R.A., & Brown, G.K. (1996). BDI-II manual. San
Antonio, TX: Harcourt Brace & Co.
programs. Bentall, R.P., Haddock, G., & Slade, P.D. (1994). Cognitive behavior
therapy for persistent auditory hallucinations: From theory to
therapy. Behavior Therapy, 25, 51-66.
IMPLICATIONS FOR NURSING PRACTICE Betempts, E.J., & Ragiel, C. (1994). Psychiatric epidemiology: Facts
The intervention tested in this study, group teaching and myths on mental health and illness. Journal of Psychosocial
Nursing, 32(5), 23-27.
of behavior strategies to manage auditory hallucina- Breier, A., & Strauss, J.S. (1983). Self-control in psychotic disorders.
tions, combines education, skills training, and support. Archives of General Psychiatry, 40, 1141-1145.
This low cost, low-tech intervention could be incorpo- Buccheri, R.K., Trygstad, L., Kanas, N., & Dowling, G.A. (1997).
rated into the practice of psychiatric nurses or other Symptom management of auditory hallucinations in schizophre-

90 APNA Web site: www.apna.org Vol. 8, No. 3


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016
Journal of the American Psychiatric Nurses Association Trygstad et al.

nia: Results of one year follow-up. Journal of Psychosocial Nurs- Jenner, J.A. van de Willige, G., & Wiersma, D. (1998). Effectiveness of
ing and Mental Health Services, 35(12), 20-28. cognitive therapy with coping training for persistent auditory
Buccheri, R.K., Trygstad, L., Kanas, N., Waldron, B., & Dowling, G.A. hallucinations: A retrospective study of attenders of a psychiatric
(1996). Auditory hallucinations in schizophrenia: Group experi- out-patient department. Acta Psychiatrica Scandinavica, 98, 384-
ence in examining symptom management and behavior strate- 389.
gies. Journal of Psychosocial Nursing and Mental Health Services, Kanfer, F.H. (1971). The maintenance of behavior by self-generated
34(2), 12-25. stimuli and reinforcement. In A. Jacobs & L.B. Sachs (Eds.), The
Carr, V. (1988). Patients’ techniques for coping with schizophrenia: psychology of private events: Perspectives on covert response sys-
An exploratory study. British Journal of Medical Psychology, 61, tems (pp. 38-59). New York: Academic Press.
339-352. Kanas, N. (1996). Group therapy for schizophrenic patients. Wash-
Carter, D.M., Mackinnon, A., & Copolov, D.L. (1996). Patients’ strat- ington, DC: American Psychiatric Press.
egies for coping with auditory hallucinations. Journal of Nervous Kendler, K.S., Gallagher, T.J., Abelson, J.M., & Kessler, R. (1996).
and Mental Disease, 184, 159-164. Lifetime prevalence, demographic risk factors, and diagnostic
Chadwick, P., & Birchwood, M. (1994). The omnipotence of voices: validity of nonaffective psychosis as assessed in a US community
A cognitive approach to auditory hallucinations. British Journal sample—the national comorbidity survey. Archives of General
of Psychiatry, 164. 190-201. Psychiatry, 53, 1022-1031.
Collins, M.N., Cull, C.A., & Sireling, L. (1989). Pilot study of treatment Lehman, A.F., Thompson, J.W., Dixon, L.B., & Scott, J.E. (1995).
of persistent auditory hallucinations by modified auditory input. Schizophrenia: Treatment outcomes research—Editors’ introduc-
British Medical Journal, 12, 431-432. tion. Schizophrenia Bulletin, 21, 561-566.
Conwell, Y., Cholette, J., & Duberstein, P.R. (1998). Suicide and Margo, A., Hemsley, D.R., & Slade, P.D. (1981). The effects of varying
schizophrenia: Identifying risk factors and preventive strategies. auditory input on schizophrenic hallucinations. British Journal of
Medscape: Psychiatry & Mental Health, 3. Retrieved August 15, Psychiatry, 139, 122-127.
1999 from http//psychiatry.medscape.com McNair, D.M., Lorr, M., & Droppleman, L.F. (1992). Edits manual for
Corrigan, P.W., & Storzbach, D.M. (1993). Behavioral interventions
the Profile of Mood States. San Diego, CA: EDITS/Educational and
for alleviating psychotic symptoms. Hospital and Community
Industrial Testing Service.
Psychiatry, 44, 341-347.
Miller, L.H. (1996). Qualitative changes in hallucinations. American
Done, D.J., Frith, C.D., & Owens, D.C. (1986). Reducing persistent
Journal of Psychiatry, 153, 265-267.
auditory hallucinations by wearing an ear-plug. British Journal of
Nelson, H.E., Thrasher, S., & Barnes, T.R. (1991). Practical ways of
Clinical Psychology, 25, 151-152.
alleviating auditory hallucinations. British Medical Journal, 302,
Falloon, I.R.H., & Talbot, R.E. (1981). Persistent auditory hallucina-
327.
tions: Coping mechanisms and implications for management.
O’Sullivan, K. (1994). Dimensions of coping with auditory hallucina-
Psychological Medicine, 11, 329-339.
tions. Journal of Mental Health, 3, 351-361.
Feder, R. (1982). Auditory hallucinations treated by radio head-
Romme, M.A.J., & Escher, A.D.M.A.C. (1989). Hearing voices. Schizo-
phones. American Journal of Psychiatry, 139, 1188-1190.
phrenia Bulletin, 15, 209-217.
Fenton, W.S., McGlashan, T.H., Victor, B.J., & Blyler, C.R. (1997).
Symptoms, subtype and suicidality in patients with schizophrenia Rutner, I.T., & Bugle, C. (1969). An experimental procedure for the
spectrum disorders. American Journal of Psychiatry, 154, 199- modification of psychotic behavior. Journal of Consulting and
204. Clinical Psychology, 33, 651-653.
Fenton, W.S., & Scholler, N.R. (2000). Editors’ introduction: Evidence- Shergill, S.S., Murray, R.N., & McGuire, P.K. (1998). Auditory hallu-
based psychosocial treatment for schizophrenia. Schizophrenia cinations: A review of psychological treatment. Schizophrenia
Bulletin, 26, 1-3. Research, 32, 137-150.
Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mini-mental Slade, P.A. (1972). Case histories and shorter communications: The
state: A practical method for grading the cognitive state of patients effects of systematic desensitisation on auditory hallucinations.
for the clinician. Journal of Psychiatric Research, 12, 189-198. Behaviour Research and Therapy, 10, 85-91.
Frederick, J., & Cotanch, P. (1995). Self-help techniques for auditory Slade, P.A. (1974). The external control of auditory hallucinations: An
hallucinations in schizophrenia. Issues in Mental Health Nursing, information theory analysis. British Journal of Social and Clinical
16, 213-224. Psychology, 12, 73-79.
Frederick, J.A., & Killeen, M.R. (1998). Instruments of assessment of Tarrier, N. (1987). An investigation of residual psychotic symptoms in
auditory hallucinations. Archives of Psychiatric Nursing, 12, 255- discharged schizophrenic patients. British Journal of Clinical
263. Psychology, 26, 141-143.
Haddock, G., Bentall, R.P., & Slade, P.D. (1993). Psychological treat- Turner, S.M., Hersen, M., & Bellack, A.S. (1977). Effects of
ment of chronic auditory hallucinations: Two case studies. Be- social disruption, stimulus interference, and aversive condi-
havioral and Cognitive Psychotherapy, 21, 335-346. tioning on auditory hallucinations. Behavior Modification, 1,
Hustig, H.H., & Hafner, R.J. (1990). Persistent auditory hallucinations 249-259.
and their relationship to delusions and mood. Journal of Nervous UCSF Symptom Management Faculty Group. (1995). A model for
and Mental Disease, 178, 264-267. symptom management. Image: The Journal of Nursing Scholar-
Hustig, H.H., Tran, D.B., Hafner, R.J., & Miller, R.J. (1990). The effect ship, 26, 272-276.
of headphone music on persistent auditory hallucinations. Behav- Yalom, I.D. (1985). The theory and practice of group psychotherapy
ioural Psychotherapy, 18, 273-281. (3rd ed.). New York: Basic Books.

June 2002 APNA Web site: www.apna.org 91


Downloaded from jap.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016