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201]

168 Original article

Efficacy of teaching self-management strategies on auditory

hallucinations among schizophrenic patients
Nadia E. Sayied, Zamzam A. Ahmed
Department of Psychiatric Nursing, Faculty of
Nursing, Assiut University, Assiut, Egypt
Correspondence to Zamzam A. Ahmed,
Lecturer of Psychiatric Nursing, Department of
Psychiatric Nursing, Faculty of Nursing, Assiut
University, Assiut, Egypt.
Tel: +20 102 079 9257;
e-mail: zamzam_ooo@yahoo.com
Received 3 May 2017
Accepted 30 May 2017
Egyptian Nursing Journal
2017, 14:168–178
The study aimed to evaluate the effectiveness of teaching self-management
strategies on auditory hallucinations among schizophrenic patients. A
quasiexperimental design (pre–post test design) was utilized in this study. The
study was carried out at Inpatient Unit at Neuropsychiatry and Neurosurgical
Hospital at Assiut University. The study consisted of 30 patients with chronic
schizophrenia. Three tools were used to collect data from this study: tool 1, a
structured interview tool for the sociodemographic and clinical data of patients with
schizophrenia who are suffering from auditory hallucinations; tool 2, phenomenology
scale of hallucinations, which is a semistructured interview and was a modified
version; and tool 3 structured interviewing tool of self-management strategies to
control auditory hallucinations. The study results revealed that there was a statistically
significant difference as regards hallucination and coping strategies of self-
management to control auditory hallucination before and after intervention. On the
basis of the present study it can be concluded that patients can use self-management
strategies to reduce the severity of auditory hallucination and help them to cope and
succeed in dealing with their own illness. In the light of the result of the present study it
is recommended that the psychiatric healthcare provider (psychiatric nurse and/or
psychiatrist) provides accurate information to schizophrenic patients who have
auditory hallucinations about different self-management techniques. Schizophrenic
patients with auditory hallucination should be trained on self-management coping
strategies to control their hallucination.

Keywords:
auditory hallucinations, schizophrenia, self-management
Egypt Nurs J 14:168–178
© 2018 Egyptian Nursing Journal
2090-6021

auditory hallucination is the most common form of

Introduction
hallucination in schizophrenia (Waters, 2010). It is
Auditory hallucinations experienced in psychotic illness
estimated that the prevalence of auditory hallucinations
contribute significantly to distress and disability. Many
among people living with schizophrenia ranges from
patients with schizophrenia in inpatient psychiatric units
64.3 to 83.4% (Thomas et al., 2007).
experience painful auditory hallucinations. Substantial
individual differences in specific characteristics and
Copolov et al. (2004) stated that a number of studies
impact of hallucinations have been shown, and thus
were located concerning the impact of auditory
require careful exploration. Hearing voices is an
hallucinations on the lives of individuals. An
internal experience, and it cannot be directly observed
Australian study on 199 people with a psychotic
(Nayani and David, 1996; Copolov et al., 2004).
disorder reported that people who experience
auditory hallucinations frequently feel depressed. In
These auditory hallucinations often give ‘bad advice’,
addition, Suryani (2006) found that most of the
including commanding patients to harm themselves or
participants (60% of 150 participants) were disturbed
others. If patients have a lack of effective self-management
by the sound of voices to the point of becoming angry,
skills, these voices are especially dangerous, and the only
depressed, and unable to attend to activities of daily
way they can manage them is by obeying them. Buccheri
living. Similarly, a systematic review by Waters (2010)
et al. (2007) stated that hearing voices is an internal
confirmed that people who experience auditory
experience; it cannot be directly observed. Even though
hallucinations were stressed by the intrusive and
from time to time it is accompanied by observable
personal nature of the voices.
behaviors such as addressing a hidden speaker,
investigation of auditory hallucinations essentially relies
on the voice hearer’s reports. This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work
Hallucination is the most common symptom of noncommercially, as long as the author is credited and the new
schizophrenia (Uhlhass and Mishara, 2006) and creations are licensed under the identical terms.

© 2018 Egyptian Nursing Journal | Published by Wolters Kluwer - Medknow DOI: 10.4103/ENJ.ENJ_25_17
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Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients Sayied and Ahmed
A study by Beavan and Read (2010) in New Zealand
explored the effects of the content of hallucinations on
emotional well-being in 154 people. The findings of
the study indicated that there was a correlation between
the content of the voices and participants’ emotional
response. For example, participants who heard negative
content such as being criticized experienced negative
emotions such as feeling distressed.
Singh et al. (2003) reported that people diagnosed with
schizophrenia who experience auditory hallucinations
feel significant stress and discomfort. The often
unabating presence of the voices has led individuals
to develop their own coping strategies. An exploratory
descriptive study in Taiwan by Tsai et al. (2003) asked
200 participants to describe their coping strategies in
managing auditory hallucinations. They found that
most of the participants developed their own distraction
techniques such as ignoring the voices, engaging in
activities, and accepting or arguing with the voices.
Significance
A lot of patients with schizophrenia in inpatient
psychiatric units experience painful auditory
hallucinations. These auditory hallucinations often
include ‘bad advice’ such as commanding patients to
harm themselves or others. These voices are dangerous
if patients lack successful self-management skills and
the only way they can manage them is by obeying them.
Self-management strategies allow individuals to cope
with disease and help them to succeed in dealing
with their own illness. Therefore, we designed and
implemented evidence-based program to teach those
patients how to cope with auditory hallucinations.
Aim
The study was aimed to evaluate the effectiveness of
teaching self-management strategies on auditory
hallucinations among those patients.
Hypothesis
At the end of study we expected the following:
Schizophrenic patient who receive teaching on self-
management strategies will have lower hallucination
and show improvement in coping with hallucination
than that before intervention.
Patients and methods
Research design
First, screening of chronic schizophrenic patients with
complaints of auditory hallucination was carried out.
169
Thereafter, a quasiexperimental design (pre–post test
design) was utilized in this study through the
application of self-management strategies to cope
with auditory hallucinations.
Research setting
The study was carried out at the Inpatient Unit at
Neuropsychiatry and Neurosurgical Hospital at Assiut
University.
Patients
The study sample included 30 patients with chronic
schizophrenia diagnosed according to Diagnostic and
Statistical Manual of Mental Disorders, 5th ed. 60% of
the studied sample was male, with a mean±SD age of
36.2±10.9 years (range: 18–65 years); 36.7% were
illiterate, 36.7% did not have work, and 70% were
married.
Inclusion criteria
Diagnosis of chronic schizophrenia.
Both sexes.
Age from 18 to 65 years.
Exclusion criteria
Mental retardation.
Age less than 18 years or more than 65 years.
Tools of data collection
Tool 1
A structured interview tool was used for the
sociodemographic and clinical data of patients with
schizophrenia suffering from auditory hallucinations.
This tool includes two parts:
(1) Sociodemographic characteristics: It includes age,
sex, marital status, education, and occupation.
(2) This part included clinical data of psychiatric
inpatients, such as diagnosis, length of time
experiencing voices, and hallucination in other
modalities − visual/olfactory/gustatory/tactile.
Tool 2
Phenomenology scale of hallucinations: It is a
semistructured interview. It was developed by Lowe
(1973) and modified by Miller et al. (1993). The
scale measures various parameters of hallucination. It
consists of 11 items, each of which is scored on a four-
point Likert scale from 0 to 4, with zero indicating the
lowest severity and four indicating the highest severity. It
measures various parameters of hallucinations − namely,
extent (frequency, duration, loudness, and beliefs),
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170 Egyptian Nursing Journal, Vol. 14 No. 2, May-August 2017
reorigin of voices, amount of negative content of voices,
degree of negative content of voices, amount of distress,
intensity of distress, disruption, and control. The
hallucination severity score therefore ranged from 0 to
44. This scale was tested for content validity. A jury of
five experts in the psychiatric nursing and medicine field
examined the content and tested for its validity.
Cronbach’s α reliability coefficient of the tool was
reported (r=0.95).
Tool 3
Structured interviewing sheet of self-management
strategies to control auditory hallucinations: It was
developed by Abd El-Hay (2008) and Gaber,
(2013). It consists of three categories:
(1) Physiological category: It includes seven items to
reduce patient’s arousal, such as sleeping, taking
extra medication, lying down, and resting, and
strategies to increase patient’s arousal, such as
listening to music, exercising, smoking cigarettes,
etc.
(2) Cognitive category: It includes eleven items of
acceptance of voices, such as arguing with
voices, accepting and staying with voices
peacefully, doing as the voices say, talking to
voices, asking self to calm down, and reduced
attention to voices, such as ignoring them,
verifying voices, etc.
(3) Behavioral category: It includes seventeen items of
blocking ears, such as watching television, seeking
help from nurse and doctor, talking to others,
praying, singing, going to crowded place,
isolating self, eating, crying, leaving the place,
etc. The participants respond on a four-point
Likert scale (not used=0, did not help=1,
helped to some extent=2, or helped a lot=3).
This scale was tested for content validity by a
jury of five experts in the psychiatric nursing
and medicine field. Categories of this tool
proved to be strongly reliable, physiological
strategy (r=0.88), cognitive strategy (r=0.97),
and behavioral strategy (r=0.86).
Pilot study
A pilot study was carried out before starting data
collection. It was carried out on 10 patients to test
clarity and applicability of the study tools and to
estimate the time needed to collect data. These 10
patients were excluded from the study.
Development of the interaction program
The following steps were carried out to develop the
program.
First stage
(1) Assessment phase:
First, the assessment phase included initiation of
trustful nurse–patient relationship, maintaining
patient safety, and providing supportive teaching
methods for the patients.
Thereafter, the patients were assessed for auditory
hallucination using the Phenomenology scale of
hallucinations and structured interviewing sheet
of self-management strategies to control auditory
hallucinations. On the basis of the assessment
phase, a simple booklet and audiovisual material
were prepared by the investigators. The program
content was revised by a group of experts for
content validity and relevancy based on the
opinion of the experts and results of the pilot
study.
(2) Planning phase:
The planning phase included the program strategy
(time and number of sessions and interaction
methods). The number of sessions was five
sessions per week for 1 h for 2 weeks for each
patient and for the caregiver the number of sessions
was one. The interaction sessions of the program
were conducted at the Inpatient Unit at
Neuropsychiatry and Neurosurgical Hospital at
Assiut University.
Second stage (training stage): content of the program
Session 1: Assessment of voice hearer’s experience and
assessment of patients’ awareness of these symptoms.
Session 2: Teaching the patient and the caregiver
techniques that will help in controlling auditory
hallucinations, such as talking to someone.
Session 3: Teaching the patients to listen to music to
distract themselves from hallucination.
Session 4: Teaching the patients to watch TV or watch
something that moves during hallucination.
Session 5: Teaching the patients and the caregivers the
technique to control hallucination, such as saying stop
and you are not real.
Session 6: Teaching the patients and the caregivers the
technique to control hallucination, such as changing
his or her position and going away.
Session 7: Training the patients to use earplugs to
control hallucination.
Session 8: Teaching the patients relaxation techniques,
such as rest, exercise, or engage in activity.
Session 9: Teaching the patients to doing something
they like to do.
Session 10: Teaching the patients to take prescribed
medication and not stop it abruptly.
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Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients Sayied and Ahmed 171

Evaluation phase: Patients with auditory hallucination Statistical analysis

were assessed immediately after the program
implementation using the phenomenology scale of
hallucinations and structured interviewing sheet of self-
management strategies to control auditory hallucinations.
Third stage: Implementation phase
A total of 10 interaction sessions were conducted for
each group in addition to the preassessment session
(initial interview).
Methods
The program included teaching the patients
self-management strategies to control auditory
hallucinations. The sample was divided into subgroups
for program implementation; each session included
5–6 patients and their caregivers.
The data were tested for normality using the
Anderson–Darling test and for homogeneity variances
before further statistical analysis. Categorical variables
were described using number and percent, whereas
continuous variables were described as mean±SD.
The χ and Fisher exact tests were used to compare
2
categorical variables, whereas to compare between
continuous variables the Paired t-test and analysis
of variance were used. A two-tailed P value less than
0.05 was considered statistically significant. All
analyses were performed with the IBM SPSS 20.0
software (IBM Corp., Released 2011. IBM SPSS
Statistics for Windows, Version 20.0. Armonk, NY:
IBM Corp.).

The questionnaire was filled by the investigator on each Result

occasion as follows:
Before commencing the programs an assessment was
carried out for patients with auditory hallucination.
Thereafter, the questionnaire was administered
immediately after complete implementation of programs.
Table 1 shows the sociodemographic data of the
studied sample. It was revealed that 60% of the
studied sample were male with a mean±SD age of
36.2±10.9 years (range: 18–65 years); 36.7% were
illiterate, 36.7% did not have work, and 70% were
married.

Procedure Table 1 Sociodemographic characteristics of the studied

The program included the following steps: schizophrenic patients (N=30)
Sociodemographic characteristics n (%)

(1) An official permission was granted from Sex

responsible personnel to carry out the study after Male 18 (60.0)
explaining the purpose of the study. Female 12 (40.0)
Age
(2) A sociodemographic data sheet was developed by
Range 18–65
the researcher. Mean±SD 36.2±10.9
(3) The researcher assured voluntary participation and Education
confidentiality to each patient and caregivers who Illiterate 11 (36.7)
agreed to participate. Primary 1 (3.3)
(4) The aim and strategy of the study was explained to the Preparatory 7 (23.3)
patients and their caregivers before data collection. Secondary 9 (30.0)
(5) Patients were assessed before application of the University 2 (6.7)
Occupation
program using the study tools. The interview was
Not working 11 (36.7)
carried out in a special room in inpatient unit. Housewife 10 (33.3)
(6) The patients were chosen after final assessment by Employer 1 (3.3)
the researchers. Worker 8 (26.7)
(7) The program was applied for patients and their Marital status
caregivers who met the inclusion criteria of the Married 21 (70.0)
study. The duration of the program was 5 months Single 8 (26.7)
from October to February. Widow 1 (3.3)

(8) Application of the program included teaching

strategies to control auditory hallucination. Table 2 Clinical characteristics of the studied schizophrenic
(9) Patients were assessed before and immediately patients

after the program implementation using the Duration of illness n (%)

Phenomenology scale of hallucinations and 2 years 9 (30.0)

Structured interviewing sheet of self-management 3 years 9 (30.0)
strategies to control auditory hallucinations. 4 and more years 12 (40.0)
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172 Egyptian Nursing Journal, Vol. 14 No. 2, May-August 2017

Table 3 Auditory hallucination as reported by schizophrenic patients at pre and post-teaching self-management strategies
according to (frequency and duration of hallucination) (N=30)
Auditory hallucination rating scale Pre [n (%)] Post [n (%)] P value
Frequency
Voices not present or present less than once a week 0 (0.0) 1 (3.3) <0.001**
Voices occur for at least once a week 0 (0.0) 16 (53.3)
Voices occur at least once a day 4 (13.3) 12 (40.0)
Voices occur at least once an hour 10 (33.3) 1 (3.3)
Voices occur continuously 16 (53.3) 0 (0.0)
Duration
Voices not present 0 0 (0.0) 1 (3.3) 0.001**
Voices last for a few seconds, fleeting voices 7 (23.3) 23 (76.7)
Voices last for several minutes 18 (60.0) 5 (16.7)
Voices last for at least 1 h 3 (10.0) 1 (3.3)
Voices last for hours at a time 2 (6.7) 0 (0.0)
Location
Voices originate inside head only 12 (40.0) 20 (66.7) 0.017*
Voices outside the head, but close to ears or head 12 (40.0) 10 (33.3)
Voices originate from outside space, away from head only 6 (20.0) 0 (0.0)
Loudness
Voices not present 0 (0.0) 1 (3.3) 0.003**
Quieter than own voice, whisper 2 (6.7) 14 (46.7)
About the same loudness as own voice 26 (86.7) 14 (46.7)
Louder than own voice 2 (6.7) 1 (3.3)
Believe reorigin of the voice
Voices not present 0 (0.0) 4 (13.3) 0.001**
Believes voices to be solely internally generated and related to self 12 (40.0) 21 (70.0)
Holds a <50% conviction that voices originate from external causes 7 (23.3) 5 (16.7)
Holds 50% or more conviction (but <100%) that voices originate from external cause 9 (30.0) 0 (0.0)
Believes voices are solely due to external causes (100% conviction) 63 2 (6.7) 0 (0.0)
Amount of negative content of voice
No unpleasant content 26.7 (8) 20.0 (6) <0.001**
Occasional unpleasant content 56.7 (17) 6.7 (2)
Minority of voice content is unpleasant or negative (<50%) 10.0 (3) 10.0 (3)
Majority of voice content unpleasant or negative (>50%) 3.3 (1) 63.3 (19)
All voice content is unpleasant or negative 3.3 (1) 0.0 (0)
Degree of negative content
Not unpleasant or negative 30.0 (9) 20.0 (6) <0.001**
Some degree of negative content, but not personal comments relating to self or family 43.3 (13) 13.3 (4)
Personal verbal abuse, comments on behavior 20.0 (6) 0.0 (0)
Personal verbal abuse relating to self-concept 3.3 (1) 13.3 (4)
Personal threats to self 3.3 (1) 53.3 (16)
Amount of distress
Voices not distressing at all 30.0 (9) 23.3 (7) <0.001**
Voices occasionally distressing, majority not distressing 70.0 (21) 13.3 (4)
Equal amounts of distressing and nondistressing voices 0.0 (0) 46.7 (14)
Majority of voices distressing, minority not distressing 0.0 (0) 16.7 (5)
Intensity of distress
Voices not distressing at all 30.0 (9) 23.3 (7) <0.001**
Voices slightly distressing 60.0 (18) 3.3 (1)
Voices are distressing to a moderate degree 10.0 (3) 6.7 (2)
Voices are very distressing, although the patients could feel worse 0.0 (0) 30.0 (9)
Voices are extremely distressing, feel the worst he/she could possibly feel 0.0 (0) 36.7 (11)
No disruption to life 20.0 (6) 13.3 (4) <0.001**
Voices cause minimal amount of disruption to life 60.0 (18) 10.0 (3)
Voices cause moderate amount of disruption to life 20.0 (6) 6.7 (2)
Voices cause severe disruption to life 0.0 (0) 46.7 (14)
Voices cause complete disruption of daily life requiring hospitalization 0.0 (0) 23.3 (7)

(Continued )
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Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients Sayied and Ahmed
Table 3 (Continued)
Auditory hallucination rating scale
Control
Patients believe they can have control over their voices
Patients believe they can have some control over the voices on the majority of occasions
Patients believe they can have some control over their voices approximately half of the time
Patients believe they can have some control over their voices but only occasionally
Patient has no control over when the voices occur and cannot dismiss or bring them on at all
Total score of auditory hallucination rating scale
**Significant.
Figure 1
The comparison between pre and postprogram in relation to self-
management strategies as a total score of coping mechanism.
Table 2 presents the clinical data of the studied sample.
This table shows the duration of illness. There were
40% of patients with auditory hallucination for more
than 4 years.
Table 3 presents auditory hallucination as reported by
schizophrenic patients before and after teaching self-
management strategies. It was found that there were
statistically significant differences before and after
intervention in most items of auditory hallucination
rating scale (P=0.001). Before intervention, as regards
frequency of the voices, in the majority of the sample
(53.3%) voices were heard continuously, but after
intervention the voices were heard only once a week
(53.3%). In relation to duration of the voices, 60% of
the studied sample revealed that voices lasted for
several minutes, but after intervention 76.7% of the
studied sample said that voices lasted for a few
seconds. According to the location of voices, 40%
of the studied sample said that the voice came from
inside the head; similarly, 40% of them said that the
voice came from outside. In relation to negative
content in the majority of the sample (63.3%) the
content of the voices were unpleasant or negative
before intervention but after intervention 56.7% of
them reported occasional unpleasant content. As
regards control of voices, 76.7% of them had no
control over the voices, but after intervention 50%
of them believe they can have some control over the
voices.
173
Pre [n (%)] Post [n (%)] P value
20.0 (6) 13.3 (4) <0.001**
50.0 (15) 10.0 (3)
23.3 (7) 0.0 (0)
6.7 (2) 0.0 (0)
0.0 (0) 76.7 (23)
26.7±91 12.2±4.3 <0.001**
Table 4 presents comparison between pretest and post-test
self-management strategies in the studied sample. It was
found that there were statistically significant differences
between preprogram and postprogram cognitive,
behavioral, and physiological strategies in the studied
sample (P=0.001). The studied sample showed
improvement and used some coping mechanism for
stopping hallucination effectively. The studied sample
used behavioral techniques for coping and stopping
hallucination in relation to physiological techniques:
before program 76.7% did not use sleep but after
program it helped 50% to some extent; and before
program 86.7% did not use the technique of listening to
music to cope but after program 60% of them listened to
music, which helped them to cope to some extent. As
regards cognitive techniques, 86.7% did not use the
technique of talking with voices after intervention. 100%
of patients did not shout to the voice but after intervention
50% of them shouted to the voice. In relation to behavioral
techniques such as covering the ear or placing cotton, 100%
of the studied sample did not use this technique but after
intervention 66.7% of them covered their ear and reported
that it helped a lot. As regards watching TV with loud
voices 100% of them did not use, but after program it
helped a lot. As regards leaving the place, 100% of patients
did not use but after program 53.3% of patients adopted it
and reported that it helped a lot.
Figure 1 presents comparison between total score of
coping mechanism before and after intervention using
self-management strategies to control auditory hallu
cinations. This figure revealed that the patients showed
improvement in controlling auditory hallucination after
program than that before program. These results indicate
that this program helps the patient’s to cope and succeed in
dealing with their own illness and used self-management
strategies as a way for managing voices.
Discussion
Auditory hallucinations have traditionally been associated
with a diagnosis of schizophrenia and are one of the most
debilitating symptoms of schizophrenia. Despite the
development of new psychotropic medications, a
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174 Egyptian Nursing Journal, Vol. 14 No. 2, May-August 2017

Table 4 Self-management strategies (physiological coping according to (sleep, ask for medication, listening to music and rest)
as reported by schizophrenic patients before and after intervention (N=30)
Self-management strategies Pre [n (%)] Post [n (%)] P value
Physiological techniques
Sleep
Not used 23 (76.7) 3 (10.0) <0.001**
Did not help 5 (16.7) 11 (36.7)
Helped to some extent 1 (3.3) 15 (50.0)
Helped a lot 1 (3.3) 1 (3.3)
Ask doctor for medication
Not used 22 (73.3) 5 (16.7) <0.001**
Did not help 7 (23.3) 8 (26.7)
Helped to some extent 1 (3.3) 16 (53.3)
Helped a lot 0 (0.0) 1 (3.3)
Listening to music
Not used 26 (86.7) 5 (16.7) <0.001**
Did not help 3 (10.0) 6 (20.0)
Helped to some extent 1 (3.3) 18 (60.0)
Helped a lot 0 (0.0) 1 (3.3)
Rest and sleep
Not used 23 (76.7) 2 (6.7) <0.001**
Did not help 4 (13.3) 8 (26.7)
Helped to some extent 3 (10.0) 17 (56.7)
Helped a lot 0 (0.0) 3 (10.0)
Smoking
Not used 21 (70.0) 11 (36.7) 0.006**
Did not help 1 (3.3) 9 (30.0)
Helped to some extent 6 (20.0) 10 (33.3)
Helped a lot 2 (6.7) 0 (0.0)
Play sport
Not used 27 (90.0) 9 (30.0) <0.001**
Did not help 0 (0.0) 11 (36.7)
Helped to some extent 2 (6.7) 9 (30.0)
Helped a lot 1 (3.3) 1 (3.3)
Walking
Not used 26 (86.7) 3 (10.0) <0.001**
Did not help 1 (3.3) 12 (40.0)
Helped to some extent 2 (6.7) 11 (36.7)
Helped a lot 1 (3.3) 4 (13.3)
Cognitive technique
Talking with voices <0.001**
Not used 7 (23.3) 26 (86.7)
Did not help 0 (0.0) 1 (3.3)
Helped to some extent 15 (50.0) 3 (10.0)
Helped a lot 8 (26.7) 0 (0.0)
Listening to voices
Not used 11 (36.7) 30 (100.0) <0.001**
Did not help 2 (6.7) 0 (0.0)
Helped to some extent 13 (43.3) 0 (0.0)
Helped a lot 4 (13.3) 0 (0.0)
Choice to listening to voices
Not used 4 (13.3) 27 (90.0) <0.001**
Did not help 0 (0.0) 1 (3.3)
Helped to some extent 13 (43.3) 2 (6.7)
Helped a lot 13 (43.3) 0 (0.0)
Calming himself
Not used 28 (93.3) 11 (36.7) <0.001**
Did not help 1 (3.3) 16 (53.3)
Helped to some extent 0 (0.0) 3 (10.0)
(Continued )
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Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients Sayied and Ahmed 175

Table4 (Continued)
Self-management strategies Pre [n (%)] Post [n (%)] P value

Helped a lot 1 (3.3) 0 (0.0)

Ignoring the voice
Not used 29 (96.7) 3 (10.0) <0.001**
Did not help 0 (0.0) 20 (66.7)
Helped to some extent 0 (0.0) 6 (20.0)
Helped a lot 1 (3.3) 1 (3.3)
Say to himself this voice not real
Not used 30 (100.0) 0 (0.0) <0.001**
Did not help 0 (0.0) 4 (13.3)
Helped to some extent 0 (0.0) 26 (86.7)
Helped a lot 0 (0.0) 0 (0.0)
Shouting to the voice
Not used 30 (100.0) 0 (0.0) <0.001**
Did not help 0 (0.0) 15 (50.0)
Helped to some extent 0 (0.0) 14 (46.7)
Helped a lot 0 (0.0) 1 (3.3)
Say to the voice to stop and go away
Not used 29 (96.7) 0 (0.0) <0.001**
Did not help 1 (3.3) 3 (10.0)
Helped to some extent 0 (0.0) 21 (70.0)
Helped a lot 0 (0.0) 6 (20.0)
Reading with loud voice
Not used 30 (100.0) 4 (13.3) <0.001**
Did not help 0 (0.0) 16 (53.3)
Helped to some extent 0 (0.0) 9 (30.0)
Helped a lot 0 (0.0) 1 (3.3)
Thinking other things
Not used 30 (100.0) 0 (0.0) <0.001**
Did not help 0 (0.0) 22 (73.3)
Helped to some extent 0 (0.0) 6 (20.0)
Helped a lot 0 (0.0) 2 (6.7)
Repeating sentences or numbers with loud voice
Not used 30 (100.0) 1 (3.3) <0.001**
Did not help 0 (0.0) 22 (73.3)
Helped to some extent 0 (0.0) 5 (16.7)
Helped a lot 0 (0.0) 2 (6.7)
Behavioral techniques
Cover my ear put cotton in my ears
Not used 30 (100.0) 0 (0.0) <0.001**
Did not help 0 (0.0) 1 (3.3)
Helped to some extent 0 (0.0) 9 (30.0)
Helped a lot 0 (0.0) 20 (66.7)
Watching TV with loud voice
Not used 30 (100.0) 1 (3.3) <0.001**
Did not help 0 (0.0) 0 (0.0)
Helped to some extent 0 (0.0) 8 (26.7)
Helped a lot 0 (0.0) 21 (70.0)
Seek help from doctor or nurse
Not used 28 (93.3) 4 (13.3) <0.001**
Did not help 2 (6.7) 0 (0.0)
Helped to some extent 0 (0.0) 9 (30.0)
Helped a lot 0 (0.0) 17 (56.7)
Isolation
Not used 25 (83.3) 26 (86.7) 0.670
Did not help 0 (0.0) 1 (3.3)
Helped to some extent 3 (10.0) 2 (6.7)
Helped a lot 2 (6.7) 1 (3.3)
(Continued )
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176 Egyptian Nursing Journal, Vol. 14 No. 2, May-August 2017

Table4 (Continued)
Self-management strategies Pre [n (%)] Post [n (%)] P value

Praying
Not used 30 (100.0) 9 (30.0) <0.001**
Did not help 0 (0.0) 13 (43.3)
Helped to some extent 0 (0.0) 7 (23.3)
Helped a lot 0 (0.0) 1 (3.3)
Singing
Not used 30 (100.0) 16 (53.3) <0.001**
Did not help 0 (0.0) 10 (33.3)
Helped to some extent 0 (0.0) 3 (10.0)
Helped a lot 0 (0.0) 1 (3.3)
Go to crowded place
Not used 30 (100.0) 5 (16.7) <0.001**
Did not help 0 (0.0) 4 (13.3)
Helped to some extent 0 (0.0) 10 (33.3)
Helped a lot 0 (0.0) 11 (36.7)
Paint
Not used 29 (96.7) 0 (0.0) <0.001**
Did not help 1 (3.3) 3 (10)
Helped to some extent 0 (0.0) 21 (70)
Helped a lot 0 (0.0) 6 (20)
Eat
Not used 30 (100.0) 28 (93.3) 0.355
Did not help 0 (0.0) 1 (3.3)
Helped to some extent 0 (0.0) 0 (0.0)
Helped a lot 0 (0.0) 1 (3.3)
Cry
Not used 29 (96.7) 28 (93.3) 0.221
Did not help 0 (0.0) 2 (6.7)
Helped to some extent 0 (0.0) 0 (0.0)
Helped a lot 1 (3.3) 0 (0.0)
Hurt onesel
Not used 27 (90.0) 28 (93.3) 0.503
Did not help 1 (3.3) 0 (0.0)
Helped to some extent 0 (0.0) 1 (3.3)
Helped a lot 2 (6.7) 1 (3.3)
Play cards
Not used 28 (93.3) 26 (86.7) 0.355
Did not help 2 (6.7) 2 (6.7)
Helped to some extent 0 (0.0) 0 (0.0)
Helped a lot 0 (0.0) 2 (6.7)
Talk to someone
Not used 28 (93.3) 1 (3.3) <0.001**
Did not help 0 (0.0) 1 (3.3)
Helped to some extent 0 (0.0) 14 (46.7)
Helped a lot 2 (6.7) 14 (46.7)
Perform task
Not used 30 (100.0) 2 (6.7) <0.001**
Did not help 0 (0.0) 6 (20.0)
Helped to some extent 0 (0.0) 12 (40.0)
Helped a lot 0 (0.0) 10 (33.3)
Leave the place
Not used 30 (100.0) 0 (0.0) <0.001**
Did not help 0 (0.0) 0 (0.0)
Helped to some extent 0 (0.0) 14 (46.7)
Helped a lot 0 (0.0) 16 (53.3)
Change ones posture
Not used 29 (96.7) 1 (3.3) <0.001**
(Continued )
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Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients Sayied and Ahmed
Table4 (Continued)
Self-management strategies Pre [n (%)]
Did not help
Helped to some extent 1 (3.3)
Helped a lot 0 (0.0)
Do as the voice says
Not used 10 (33.3)
Did not help 1 (3.3)
Helped to some extent 4 (13.3)
Helped a lot 15 (50.0)
**Mean significance.
significant number of people with schizophrenia continue
to suffer from auditory hallucinations. Auditory
hallucinations experienced in psychotic illness
contribute significantly to distress and disability. People
with schizophrenia not only have the ability to make
decisions about taking medicine but also have a great
capacity to manage psychotic symptoms [Frederick, 2000;
Marks et al. (2005)]. The present study was conducted to
identify self-management strategies to control auditory
hallucinations among patients with chronic
schizophrenia.
The present study illustrated that more than half of the
studied sample had a frequency of auditory
hallucinations of once/day or more continuously.
These findings are consistent with El Ashry and
Hassan Abdel Al (2015), who reported that more
than two-thirds of the studied sample (65.0%) had a
frequency of auditory hallucinations once/day or more.
Moreover, Kelkar (2002) noted that hallucinations are
directly responsible for profound dysfunction in all
aspects of daily life. In addition, Brown (2008)
indicated that a large majority of individuals
experiencing auditory hallucinations reported the
frequency as several times per day. Concerning the
location of voices, David (2004) also reported that
hallucination was defined as sensory experience that
occurs in the absence of corresponding external
stimulation of the relevant sensory organ and has a
sufficient sense of reality to resemble a veridical
perception, over which the one does not feel one has
direct and voluntary control. This may be due to, one is
that nurses are still afraid to talk openly to people about
hearing voices. A second reason may be that nurses do
not know about the strategies that could be used to help
those patients to control auditory hallucination.
The current study results revealed that less than half of
the studied sample had voices coming from outside the
patient’s body. Similarly, less than half of the patients
in the studied sample had voice inside the head that
was real to them. This result is partially supported by
177
Post [n (%)] P value
15 (50.0)
14 (46.7)
30 (100.0) <0.001**
0 (0.0)
0 (0.0)
0 (0.0)
Cottam et al. (2011) and Gaber (2013), who reported
that patients hear voices in the head. This finding was
supported by El Ashry and Hassan Abdel Al (2015),
who found that, as regards location of voices, 53.3% of
the studied patients had voices coming from outside
the patient’s body. This may be due to patient’s
conviction of the reality of heard voices, or it may
be due to patients beliefs about the origin of the
voices − that is, if a person believes that the voices
come from existing independent beings of some
type (e.g. God, devils, evil spirits, invisible people,
or dead relatives). This is in agreement with Shepherd
et al. (2010), who concluded that patients with
schizophrenia often perceive hallucinated voices/
sounds as being located in the external auditory
space. In this respect, Duffy (2006) reported that
some patients reported that when voices start they
take specific posture and speak with voices. This may
probably be attributed to the fact that all voices were
perceived to be omnipotent by the hearer.
The finding of the present study illustrated that the
majority of patients in the studied sample showed
improvement and used some self-management
strategies for stopping hallucination effectively
(physiological, cognitive, and behavioral techniques).
This result is in agreement with Abd El-Hay (2008),
who reported that the majority of the studied sample
used behavioral and physiological strategies as coping
strategies. In addition, El Ashry and Hassan Abdel Al
(2015) reported that the studied patients used different
forms of self-management strategies (e.g. physiological,
cognitive, and/or behavioral) to deal with auditory
hallucinations, such as ‘sleep’ as a way for managing
voices. Moreover, Hayashi et al. (2007) and Wong
(2008) indicated that a large number of patients use
‘falling asleep’ as a way for managing voices and they
reported that it is a completely successful technique.
Moreover, Zou et al. (2013) reported that the most
commonly used strategy to deal with persistent
symptoms by Chinese patients was ignoring them.
[Downloaded free from http://www.enj.eg.net on Sunday, June 10, 2018, IP: 36.81.177.201]
178 Egyptian Nursing Journal, Vol. 14 No. 2, May-August 2017
However, this finding is contradictory to the study by
Beck and Rector (2003), who stated that more
than half of the people who experience voices are
not successful in their efforts to escape or ignore the
voices. The present study revealed that there
were statistically significant differences between
behavioral, cognitive, and physiological strategies
and hallucination rating scale, which means
that increased use of behavioral self-management
techniques is associated with increased use of
cognitive physiological self-management strategies.
The greater the use of self-management strategies
the better the control of auditory hallucination. This
result is congruent with El Ashry and Hassan
Abdel Al (2015), who found that there was
statistically significant difference between behavioral
self-management strategies and a cognitive self-
management strategies, which means that, when there
is increased use of behavioral self-management
strategies, it is accompanied by increased use of
cognitive self-management strategies and vice versa.
Conclusion
On the basis of the results of the present study it can be
concluded that patients can use self-management
strategies to reduce the severity of auditory
hallucination and help them to cope and succeed in
dealing with their own illness.
Recommendation
In the light of the result of the present study, the
following were recommended:
(1) Psychiatric healthcare provider (psychiatric nurse
and/or psychiatrist) should provide accurate
information to schizophrenic patients who have
auditory hallucinations about different self-
management techniques.
(2) Schizophrenic patients with auditory hallucination
should be trained on self-management coping
strategies to help them in controlling their
hallucination.
Limitation
Decreased chronic schizophrenic patients flow.
Some patients were aggressive due to response to
auditory hallucinations.
Strength
Most of the patients responded to teaching self-
management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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