Archives of Psychiatric Nursing 35 (2021) 141–152

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Archives of Psychiatric Nursing

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EFFECT OF APPLYING “ACCEPTANCE AND COMMITMENT THERAPY” ON

AUDITORY HALLUCINATIONS AMONG PATIENTS
WITH SCHIZOPHRENIA
Ayman Mohamed Nasr El Ashry, Assistant Lecturer *, Samia Mohamed Abd El Dayem, Professor,
Fatma Hussien Ramadan, Professor
Psychiatric Nursing and Mental Health Department, Faculty of Nursing, Alexandria University, Egypt

A R T I C L E I N F O A B S T R A C T

Keywords: Experiencing persistent auditory hallucinations may contribute to unproductive struggle and interference with
Acceptance and commitment therapy valued living among patients with schizophrenia. Acceptance and commitment therapy (ACT) represents a new
Auditory hallucinations generation of behavior therapies that proposes active acceptance and achievement of worthwhile goals despite
Schizophrenia
experiencing auditory hallucinations. Utilization of acceptance commitment therapy may assist in reducing
auditory hallucinations and may increase patient’s feeling of control. Aim: Determine the effect of applying
acceptance and commitment therapy on auditory hallucinations among patients with schizophrenia. Setting: The
study was conducted at El-Maamoura Hospital for Psychiatric Medicine in Alexandria, Egypt. Subjects: A random
sample of 70 male inpatients with schizophrenia was selected and divided equally into a study and a control
groups (35 patients in each group). Both groups were matched as much as possible in relation to socio- de­
mographic and clinical data. Tools: Psychotic Symptom Rating Scales (PSYRATS-AHs) and Voices Acceptance
and Action Scale (VAAS). A quasi-experimental research design was utilized in this study. Results: Significant
differences were found between the study and control groups immediately post and after 3 months of ACT on
baseline PSYRATS& VAAS scores. Conclusion: ACT offers a promising new treatment for auditory hallucination
among patients with schizophrenia. A significant improvement in auditory hallucination was found in the study
group immediately after implementing ACT and after 3 months. As well as a decrement in re hospitalization rate
and improvement in drug compliance for the study group compares to control one. Recommendations: ACT
should be integrated in psychiatric treatment and nursing interventions of inpatients with schizophrenia who
experiencing auditory hallucination.

Introduction may differ significantly in their phenomenology as they are originated

Hallucinations are one of the main positive symptoms and a char­
acteristic feature of patients with schizophrenia (American Psychiatric
Association, 2013). The most common type of hallucinations experi­
enced by these patients is auditory hallucinations with a prevalence
measured at 70% and about 35% of those patients are persisting to
antipsychotic medications (Galletly et al., 2016). Although, antipsy­
chotic medications are a cornerstone in the treatment of schizophrenia,
the frequency of auditory hallucinations is persisting; leaving the pa­
tients disabled, and is one of the best predictors of re-hospitalization (De
PickFer et al., 2017; McGregor et al., 2018). Auditory hallucinations
from inside or outside the head. They are distinguished from the pa­
tient’s own thoughts by possessing an auditory quality that is often not
regulated by the patients who experience auditory hallucinations
(Hofmann, 2008). They may take the form of commanding, comment­
ing, and conversing. It is reported that about 30% of patients with
schizophrenia have command auditory hallucinations that are more
distressing than commenting ones that may predispose the patients to a
greater risk of suicides and homicides (Elkis & Buckley, 2016; Pandar­
akalam, 2016).
Experiencing persistent auditory hallucinations may lead to unpro­
ductive combat and conflict with valued living through three different

* Corresponding author.
E-mail addresses: Ayman.el-ashry@alexu.edu.eg, aymanmohammed2010@yahoo.com (A.M.N. El Ashry), Sm_dayem@yahoo.com (S.M. Abd El Dayem), fatma_
ramadan45@yahoo.com (F.H. Ramadan).

https://doi.org/10.1016/j.apnu.2021.01.003
Received 1 September 2020; Received in revised form 2 January 2021; Accepted 16 January 2021
Available online 29 January 2021
0883-9417/© 2021 Elsevier Inc. All rights reserved.
A.M.N. El Ashry et al.
aspects. The first aspect of the hallucinatory perception is being intru­
sive and salient. Voices are attentive; they are invasive and difficult to
remove and can be experienced as a feeling of madness particularly
meaningful and salient personally (Chadwick et al., 1996). Thus, voices
can draw a person’s attention away from the precious living, and can
become a source of frustration and anxiety, often leading to attempts to
avoid or control them. The second aspect is the verbal content of the
hallucinatory experience that potentiates cognitive fusion, which means
that the human predisposition to become engaged with thoughts, feel­
ings, and memories of the mind because of a strong belief in their literal
content. Particularly, voices may often include emotional content such
as critique, threats, warnings, and dangerous commands that are
responsible for that fusion (Morris et al., 2013). The third and final
element of voice experience is its interpersonal quality. Patients are
often drawn into responding to the hallucinatory encounter as if they
were being approached by someone else. Patients often assign identities
and intentions to their voices, view them like others that exist in external
reality, and possess great power (Chadwick & Birchwood, 1994). In
recent years, several interventions have emerged within the behavior
and cognitive therapy traditions to help patients with schizophrenia to
accept their auditory hallucinations and to defuse from internal sources
of distress (Strauss et al., 2015; White et al., 2011). Acceptance and
Commitment Therapy (ACT) is one of those interventions, which were
used firstly on patients who suffered from schizophrenia with auditory
hallucinations (Shawyer et al., 2012; Thomas et al., 2014).
Acceptance and Commitment Therapy (ACT) is a third wave cogni­
tive behavioral therapy that focuses on changing the patient’s rela­
tionship with voices, rather than the voices themselves. It can reduce the
influence of the symptoms especially auditory hallucinations and help
the patients to focus more on valued actions (Pérez-Álvarez et al., 2008).
ACT focuses on the workability of the patient’s behavior, with greater
flexibility and more response options (Morris et al., 2014). For example,
through acceptance work of ACT, a patient who typically responds to
auditory hallucinations with social isolation and arguing with them may
develop a wide range of behavioral responses to hearing voices such as
going out of the house, having a conversation with another person,
deliberately noticing the acoustic properties of the voices, or engaging in
a valued activity (Bach et al., 2006).
Acceptance and commitment therapy (ACT) focuses on increasing
psychological flexibility by using mindfulness and noticing skills and
helping people to engage in values-based actions, and to reduce the
processes of experiential avoidance and cognitive fusion that trigger the
negative emotional states and limit the functioning of persons (Hayes
et al., 2012). ACT facilitates a shift in emphasis for clients, from focusing
on trying to control internal events to focusing more on behavior change
processes that can lead to positive outcomes (Levin et al., 2012). This
approach is achieved basically through the use of experiential exercises
(e.g., meditation) and didactic metaphors, and is presented in the
context of values clarification, goal setting, and overt behavior change
strategies. Patients are taught to letting go of the struggle of usual
control strategies in dealing with the voices to control unpleasant pri­
vate experiences. Therefore, they are accepting the presence of dis­
tressing symptoms while learning to notice nonjudgmentally the
occurrence of thoughts, feelings, and sensations without assuming that
they are literally “true”. Acceptance does not imply “giving in” to
symptoms but instead recognizes that thoughts are products of mental
events rather than the self (Hayes et al., 1999).
The utilization of ACT in psychiatric care may assist in reducing the
detrimental effect of auditory hallucinations and may increase the pa­
tient’s feeling of control. It may help the patient to be more effectively
disengaged attention from these salient aspects of hallucinatory expe­
rience and break associated habitual behavioral responses. Several re­
searchers described how ACT can be applied in a clinical setting in the
treatment of auditory hallucinations, it is revealed that the patient was
able to develop new and more functional self-regulatory processing
pathways, which in turn lead to increased perceived control over his/her
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Archives of Psychiatric Nursing 35 (2021) 141–152
symptoms and significantly improve his daily functioning (Bach &
Hayes, 2002; Martínez et al., 2008 & Shawyer et al., 2012). Despite the
beneficial effects of applying ACT on auditory hallucination among
patients with schizophrenia, little researches are found to investigate its
effectiveness. In Egypt, the effect of ACT on auditory hallucination has
not been yet investigated among patients with schizophrenia. Therefore,
this study was conducted to investigate the effect of applying ACT on
auditory hallucination in patients with schizophrenia. ACT may
contribute toward the development of effective nursing interventions to
manage auditory hallucination. Also, it could develop further consid­
eration of effective treatment and rehabilitation strategies to improve
the patient’s quality of life. Research hypothesis: Patients with schizo­
phrenia who receive acceptance and commitment therapy will exhibit
improvement in the different aspects of auditory hallucinations than
those who are treated as usual.
The current study
Setting
The present study was carried out in the inpatient wards at El-
Maamoura Hospital for Psychiatric Medicine in Alexandria, Egypt. The
hospital is affiliated to the Ministry of Health and Population. It is
composed of 12 wards for psychotic patients with a total capacity of 948
beds. The hospital includes an outpatient clinic for psychiatric and
substance-dependent patients. The number of inpatients with psychotic
disorders in El-Maamoura Hospital ranges from 700 to 750. Patients
with schizophrenia are representing about 500 patients with 68% of the
total number of inpatients with psychotic disorders (230 male patients
and 270 female patients) based on the statistical report of El-Maamoura
Hospital for Psychiatric Medicine in 2018.
Subjects
Seventy male patients with schizophrenia were selected in this study.
They were divided randomly equally into a study and a control group.
The patients selected in this study were diagnosed with schizophrenia
with no co-morbidity, having auditory hallucinations as recorded in
their charts, and patients currently admit having them, able to
communicate coherently and relevantly, and the duration of illness
didn’t exceed 5 years, and they were able to read and write. As showed
in the CONSORT flow diagram (Fig. 1), participants were selected from
an inpatient unit (N = 209) for applying Acceptance and Commitment
Therapy (ACT) over 15 months. The number of patients excluded from
the total eligible number (N = 139), 73 patients with schizophrenia were
not meeting the inclusion criteria, 33 refused to participate in ACT, 18
patients were discharged before completing the six ACT sessions, and 15
patients were in unstable mental state like risk issues, unreliable
attendance, and poor engagement with sessions. All participants in the
study and control groups were treated as usual (TAU); the selected pa­
tients for the study group participated in six ACT sessions. The imme­
diately post-treatment measurements were completed by all study and
control groups (N = 70). Most of the studied participants attended the
post-three months’ survey (35 participants’ form the study group, and
29 participants attended from control one with 6 participants missing).
Tools of the study
Three tools were used to collect the data of this study:
Tool I: Socio-demographic and clinical data structured interview
schedule for patients with schizophrenia
This tool was developed by the researcher to elicit socio-
demographic data of patients with schizophrenia as age, marital sta­
tus, occupation, level of education, and living status. In addition, clinical
data as the duration of illness, number of admissions, duration of current
hospitalization, and type of medication.
A.M.N. El Ashry et al. Archives of Psychiatric Nursing 35 (2021) 141–152

Total number screened for eligibility to participate (N=209)

Excluded (N=139)
Not meeting inclusion criteria (N=73)
Enrollment Refused to participate (N=33)
Discharged before finishing ACT sessions
(N=18)
Unstable mental state a (N=15)

Participants assigned (N=70)

Allocation

Selected to study group (N=35) Selected to control group (N=35)

Selected for ACT and TAU (N=35). TAU (N=35 patients)
Complete 6 sessions of ACT (N=35)

Follow-Up

Patients participated at immediately post Patients participated at immediately post

intervention (N=35) intervention (N=35)
Complete data 35 patients Complete data 35 patients
Data analyzed 35 patients Data analyzed 35 patients

Analysis

Patients participated at final post three Patients participated at final post three
months follow up intervention (N=35) months follow up intervention (N=29)
Massing patients (N= 0) Missing Patients (N=6)
Data analyzed (N=35) Data analyzed (N=35)

a.Unstable mental state: risk issues, unreliable attendance and poor engagement with sessions.
ACT: Acceptance and Commitment Therapy
TAU: Treatment As Usual

Fig. 1. CONsolidated Standards of Reporting Trials (CONSORT).

Tool II: Psychotic Symptom Rating Scales (PSYRATS-AH)
The PSYRATS was developed by Haddock et al. (1999). It consists of
17 items divided into two subscales designed to rate auditory halluci­
nations and delusions. In this study, only the auditory hallucination
subscale (PSYRATS-AH) was used. The auditory hallucination subscale
measures various dimensions of auditory hallucinations through 11
items divided into three subscales. The first subscale is for physical
characteristics of auditory hallucination, which is composed of 4 items
that assess the frequency, duration, location, and loudness of voices. The
second subscale is for emotional characteristics of auditory hallucina­
tion (4 items) that assesses the amount and degree of negative content
and amount and intensity of distress. The third subscale is for cognitive
characteristics of auditory hallucination (3 items) that assesses beliefs
about origin, disruption; and controllability. The PSYRATS-AH was
rated on a five-point Likert scale ranging from 0 (not endorsing the item)
to 4 (fully endorsing the item). With a total score range from 0 to 44. The
PSYRATS-AH has been found to have high inter-rater reliability (0.99–1)
and test-retest reliability (r = 0.70) (Drake et al., 2007).
Tool III: Voices Acceptance and Action Scale (VAAS)
Voices Acceptance and Action Scale (VAAS) was developed by
Shawyer et al. (2007). It is a self-report scale used to measure two
constructs: (a) acceptance of having the experience of auditory hallu­
cinations and (b) action, the ability to act autonomously. VAAS was
consists of 31-items rated on a 5-point Likert scale ranging from strongly
disagree (0) to strongly agree (4). There are 16 items representing
acceptance of the voices with the total score ranging from 0 to 64. Also,
15 items for measuring the autonomous act related to voices with a scale
total score ranging from 0 to 60. VAAS consists of 5 subscales repre­
senting acceptance and actions toward voices, section A1 representing
acceptance attitude toward general voices besides section A2 which
representing autonomous actions toward general voices. On the other
hand, section B1 measured beliefs about actions related to command
voices, section B2 representing acceptance attitudes toward command
voices, and finally, section B3 measured autonomous actions toward
command voices. Voices Acceptance and Action Scale and its subscales
demonstrate adequate internal consistency with a Cronbach’s α ranged
between 0.76 and 0.90 for subscales, and high test-retest reliability
ranging from 0.72 to 0.82 for total scale (Ratcliff et al., 2011; Shawyer
et al., 2008).
Method
Administrative steps
Official written permission from the director of EL-Maamoura Hos­
pital for Psychiatric Medicine in Alexandria, Egypt was obtained for
conducting the study.
Preparation and planning phase
The socio-demographic and clinical data structured interview
schedule was developed by the researcher. Tools II Psychotic Symptom
Rating Scales (PSYRATS-AH) and Tool III Voices Acceptance and Action
Scale (VAAS) were translated into the Arabic language. A jury of 5

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A.M.N. El Ashry et al.
experts in the field of psychiatric nursing has assessed the translation of
tools I and II, as well as their content validity, and the necessary mod­
ifications were done accordingly.
Pilot study
Before conducting the actual study, a pilot study was carried out on
15 patients with schizophrenia to assess and ensure the clarity and
applicability of the study tools and identify any obstacles and problems
that may hinder data collection, and modifications were done accord­
ingly. Accordingly, the study tools were clear, understood, and easily
applicable. The subjects of the pilot study were excluded from the actual
study. The content of ACT sessions was translated into the Arabic lan­
guage with some modifications to fit the Egyptian society. Then, a pilot
study was carried out on 3 patients with schizophrenia; they were also
excluded from the actual study. Then, the content and the results of each
session of the pilot study were revised and approved by the supervisors,
and making necessary required modifications.
Test of reliability
The test-retest reliability was done for the two study tools (voices
acceptance and action scale (VAAS) and Psychotic Symptom Rating
Scales- auditory hallucination (PSYRATS-AH) on fifteen patients with
schizophrenia taking into consideration the inclusion criteria. Non-
parametric statistical test Cronbach alpha was used which is a version
of the “r” correlation coefficient test (Pearson’s test); at a level of sig­
nificance (p ≤ 0.07). The test-retest, reliability for Tool I (Psychotic
Symptom Rating Scales- Auditory Hallucination) (PSYRATS-AH) was
reflected a significant correlation of 0.70. As well as, tool II (Voices
Acceptance and Action Scale (VAAS) showed high level of significant;
VAAS (acceptance subscale) =0.70, VAAS (action subscale) =0.830, and
VAAS (total) =0.844.
Actual study
The actual study was conducted during the period from 15th of
March 2018 to the end of April 2019.
Selection of the subjects
All psychotic male patients’ wards were ranked by simple random­
ization and the first two randomized selected wards were chosen for the
study group of data collection. The second two-selected wards were
assigned for the control group and were similarly chosen from both
wards until the required number was obtained. Both groups were
matched as much as possible concerning socio-demographic and clinical
data characteristics.
Implementation of acceptance and commitment therapy (ACT) sessions
The researcher developed a psycho-educational module of Accep­
tance and commitment therapy (ACT) based on the guidelines and ap­
plications developed by Hayes et al. (1999), Bach and Hayes (2002), and
Morris et al. (2013) on patients with psychosis. The researcher was
undergoing a period of training on Acceptance and Commitment Ther­
apy (ACT) through online academic training at Association for Contex­
tual Behavioral Science (ACBS) for 8 weeks with 16 credits hours’
certificate by Harris (2015). Before embarking on the actual study, the
researcher passed through independent teaching about acceptance and
commitment therapy under the direction, guidance, and supervision of
the thesis supervisors. This included a discussion of the theoretical
foundation of ACT as well as the accuracy and appropriateness of the
exercises used and needed for each session. The therapy consisted of six
sessions, each session of acceptance and commitment therapy was
developed based on general and specific objectives. An expert professor
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Archives of Psychiatric Nursing 35 (2021) 141–152
in the nursing education field revised the ACT sessions’ overall objec­
tives and the specific ones. The overall objectives of each session and the
content of the sessions were translated into Arabic. The researcher
explained the objectives of ACT sessions and their time schedule to the
psychiatrists in each hospital ward in order to gain their support for
completing the ACT process without abrupt cessation because of the
premature discharge of the patients. The teaching materials used in
acceptance and commitment therapy were slide pictures, metaphoric
videos, and metaphoric role-play. As well as simulations, providing
corrective feedback, images for homework. All these teaching materials
have been prepared by the researcher and revised by professors in
psychiatric nursing and mental health.
The selected patients were then exposed to the pretesting using tools
of PSYRATS-AH, VAAS, and socio-demographic and clinical data tools
by interviewing each patient on an individual basis. The interview time
was 30–45 min, three days/week. Also, the researcher met the selected
patients in a quiet room or in the garden, or in the rehabilitation center
in the hospital. (See Table 8).
Evaluation of the effectiveness of acceptance and commitment therapy
The post-assessment survey was done by using tools of PSYRATS-AH
and VAAS on each of the study (35 patients) and control groups (35
patients) after finishing ACT sessions within 4 to 7 days to assess the
efficacy of the therapy on the experience of the voices. Besides, a post-
three months test at an outpatient clinic was done again by using tools
of PSYRATS-AH and VAAS on the studied group to assess the efficacy of
therapy on the voices after patients were discharged. Also, to assess the
effect of ACT on re-hospitalization rate and drug compliance.
Ethical considerations
Study procedures were revised and approved by the ethical com­
mittee of the faculty of nursing, Alexandria University (code: 692/2017)
and the Human Rights Protection Committee of the General Secretariat
of Mental Health, Ministry of Health and Population in Cairo (code.
660/2017). Informed written consent was obtained from each patient in
the study after an explanation of the objectives’ of the therapy. The
patient’s privacy and anonymity were maintained. Data confidentiality
was assured. The patient’s right to refuse to participate in the study or
withdraw at any time was emphasized.
Statistical analysis
Data were coded and fed to statistical software IBM SPSS version 20.
Following data entry, checking and verification processes were carried
out to avoid any errors during data entry.
Descriptive statistics
Descriptive statistics were conducted for clinical and demographic
characteristics and the Chi-square test was used to detect the baseline
difference between both groups. Statistical analysis was done using an
acceptance error of 0.05. A P-value less than or equal to 0.05 was
considered to be statistically significant.
The mean with standard deviation was used for the numeric data for
the study tools Voices Acceptance and Action Scale (VAAS) and Psy­
chotic Symptoms Rating Scales (PSYRATS- AH) to describe the fre­
quency of each category for categorical data.
Analysis of numeric data
The distribution of quantitative variables was tested for normality
using the Kolmogorov-Smirnov test. The test result revealed that the
data were normally distributed, parametric tests were used. An inde­
pendent sample t-test was used.
A.M.N. El Ashry et al. Archives of Psychiatric Nursing 35 (2021) 141–152

Results respectively). According to their clinical data, it can be noticed that

atypical antipsychotics were the most frequently prescribed drugs for
Table 1 shows that the age of the studied patients ranged between 20 the study and control groups (68.6% and 71.4% respectively). Mixed
and 35 years with mean age 27.69 ± 2.76 years, and more than half atypical and typical antipsychotic medications were prescribed for 20%
(54.3%) and nearly two thirds (65.7%) of both the study and control of the study group compared to 25.7% of the control group. Concerning
groups aged between 25 to less than 30 years. Concerning patient’s the type of voices, it can be observed that more than two-thirds of the
working status, nearly two-thirds of the study group and the majority of study and control groups reported having malevolent voices (80% and
the control groups were unemployed (65.7% and 80% respectively). 85.7% respectively), and the rest of both groups have mixed types
Regarding the educational level, about three-quarters of the study and (malevolent and benevolent voices).
control groups had secondary education (74.3% and 77.1% respec­ From this table, it is observed that there is no statistically significant
tively). Patients who were single representing 74.3% and 85.7% for the difference was found in relation to all socio-demographic characteristics
study and control groups respectively. Concerning the patient’s living between the study and control groups, which reflects that both groups
situation, 71.4% of the patients of the study, and 85.7% of control are matched.
groups were living with their parents or siblings. About more than three- Table 2 showed that for the study group who participated in ACT
quarters of the study group had enough financial income, in comparison sessions there is a decrease in all items of Psychotic Symptom Rating
to 60% for the control group. More than three-quarters of both the study Scale- AH means scores and each subscale at immediately post-
and control groups were living in urban areas (85.7% and 77.1% intervention and slightly increasing of mean scores after three months
intervention. The total mean scores of (PSYRATS-AH) showed remarked
decrement in the mean score of total items immediately after applying
Table 1 therapy (18.77 ± 3.15) than pre-intervention (31.88 ± 4.35) and almost
Distribution of the studied patients with schizophrenia who experienced audi­ stability of mean score at post three months (19.80 ± 5.56).On the other
tory hallucinations according to their socio-demographic and clinical data hand, for the control group, the table showed that the total (PSYRATS-
characteristics.
AH) mean score decreased from (32.48 ± 4.69) at pre-intervention to
Socio-demographic and clinical Study Control χ2 P* (24.34 ± 5.04) immediately post and remarkable increment again to
characteristics. group (N group (N 32.44 ± 6.12 post three months after patients discharge from the
= 35) = 35)
hospital.
N % N % Table 3 showed that there is an increase in the mean scores of all
Age of the patient (years) VAAS subscales in the study group who participated in ACT sessions at
▪ 20- 11 31.4 7 20 1.27 0.530 pre, immediately after an assessment, and even stability of mean score at
▪ 25- 19 54.3 23 65.7
post three months after patients discharge from the hospital. The total
▪ 30–35 5 14.3 5 14.3
Min-Max 21–32 years
means score of VAAS was increased from 31.97at pre interventions to
Mean ± SD 27.69 ± 2.76 years 103.63 immediately after the session finished and to 103.17 at post three
months. Whereas, there is a slight increase in the mean scores of all
Working status
▪ Unemployed 23 65.7 28 80 4.29 0.368 VAAS subscales for the control group, the total mean score of VAAS was
▪ Employed 2 5.7 2 5.7 increased immediately after(29.71)than pre-intervention (17.74)and
▪ Student 2 5.7 0 0 decreasing at post three months 19.72 than immediately after the
▪ Handcraft 4 11.4 4 11.4 intervention.
▪ private worker 4 11.4 1 2.9
Table 4 showed that there is an increase in the mean differences of
Level of education the total psychotic symptom rating scales between pre and immediately
Read & write 0 0 1 2.9 2.41 0.491
▪
post-intervention for the study group (− 4.92) more than the control
▪ Basic education 4 11.4 5 14.3
▪ Secondary education 26 74.3 27 77.1 group, and that difference was found a strong statistically significant (t
▪ University education 5 14.3 2 5.7 = − 4.47, p = 0.000). The total Psychotic Symptom Rating Scale mean
difference between pre and post-three months intervention was
Marital status
▪ Single 26 74.3 30 85.7 1.714 0.424 increased with − 11.99 for the study group more than the control group
▪ Married 4 11.4 3 8.6 and that difference was found a strong statistically significant (t =
▪ Divorced 5 14.3 2 5.7 − 8.54, p = 0.000). As well as, physical characteristics subscale, cogni­
Living situation tive characteristics subscale, and emotional characteristics subscale
▪ Alone 6 17.2 2 5.7 2.59 0.273 mean differences between pre and post-three months intervention be­
▪ With wife 4 11.4 3 8.6 tween study and control groups was and a strong statistically significant
▪ With parents or siblings 25 71.4 30 85.7
difference was found. Finally, the table showed that total Psychotic
Financial income Symptom Rating Scales (PSYRATS-AH) mean difference between
▪ Not enough 8 22.9 14 40 2.386 0.122 immediately post and post three months intervention of the control
▪ Enough 27 77.1 21 60
group was more than study group with 7.07 with a strong statistically
place of residency significant difference(t = 4.52, p = 0.000).
▪ Urban 30 85.7 27 77.1 0.850 0.356
Table 5 showed that there is a remarkable increase in the mean
▪ Rural 5 14.3 8 22.9
difference between pre and immediately post-intervention of VAAS and
Type of voice its subscales for the study group more than the control group. The mean
▪ Benevolent 0 0 0 0 0.40 0.526
difference between pre and immediately post-intervention between both
▪ Malevolent 28 80 30 85.7
▪ Mixed (malevolent and 7 20 5 14.3 groups relating to the total Voices Acceptance and Action Scale (VAAS)
benevolent) was 59.69 and there is a strong statistically significant difference found
Type of medications
(t = 20.02, p = 0.000). Also, the table showed that there is a remarkable
▪ Atypical antipsychotics 24 68.6 25 71.4 4.96 0.175 increase in the mean differences for the study group more than control
▪ Typical antipsychotics 4 11.4 1 2.9 one between pre and post-three months intervention of VAAS and each
▪ Mixed typical and atypical 7 20 9 25.7 subscale with a strong statistical significance. The total Voices Accep­
X2: Pearson Chi-square test. tance and Action Scale (VAAS) mean difference between pre and post-
*
No significant difference if P > 0.05. three months intervention between both groups was 69.22with a

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A.M.N. El Ashry et al. Archives of Psychiatric Nursing 35 (2021) 141–152

Table 2
Description of mean scores and standard deviations of Psychotic Symptoms Rating Scales –AH (PSYRATS-AH) for the study and control groups at pre, immediately
post, and post three months.
Study group Control group

Psychotic Symptoms Rating Scales-AHa Pretest (N Immediately post (N Post three months Pretest (N Immediately post (N Post three months
= 35) = 35) (N = 35) = 35) = 35) (N = 29)b

M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD

Physical Frequency 2.91 ± 0.51 1.94 ± 0.48 2.40 ± 0.74 3.20 ± 0.47 2.43 ± 0.61 3.10 ± 0.62
characteristics Duration 2.63 ± 0.59 1.77 ± 0.43 2.17 ± 0.66 2.51 ± 0.51 2.03 ± 0.62 2.93 ± 0.46
Location 2.20 ± 0.21 1.43 ± 0.89 1.40 ± 0.95 1.77 ± 0.97 1.31 ± 0.68 2.21 ± 1.01
Loudness 2.49 ± 0.89 1.26 ± 0.44 1.97 ± 0.75 2.69 ± 0.72 1.69 ± 0.63 2.52 ± 0.69
Total score subscale 10.23 ± 6.40 ± 1.29 7.94 ± 2.29 10.17 ± 7.46 ± 1.77 10.76 ± 2.03
1.93 1.71
Emotional Amount of negative content 3.37 ± 0.69 2.37 ± 0.88 2.66 ± 0.97 2.11 ± 1.11 1.34 ± 0.68 2.31 ± 1.07
characteristics of voices
Degree of negative content 3.31 ± 0.99 2.46 ± 0.95 2.17 ± 0.62 3.49 ± 0.66 3.17 ± 0.75 3.62 ± 0.56
Amount of distress 3.06 ± 0.77 1.63 ± 0.65 1.83 ± 0.82 3.31 ± 0.96 2.20 ± 0.68 3.17 ± 1.04
Intensity of distress 3.11 ± 0.53 1.51 ± 0.61 1.37 ± 0.59 3.34 ± 0.59 2.86 ± 0.85 3.59 ± 0.50
Total score subscale 12.86 ± 7.97 ± 2.49 8.03 ± 2.29 12.25 ± 9.57 ± 2.38 12.69 ± 2.43
2.25 2.45
Cognitive Beliefs re-origin of voices 2.17 ± 1.22 1.31 ± 0.58 1.14 ± 0.43 3.29 ± 0.67 2.26 ± 0.74 3.07 ± 0.75
characteristics Disruption to life caused by 3.14 ± 0.36 1.69 ± 0.83 1.31 ± 0.72 3.14 ± 0.36 2.51 ± 0.74 2.83 ± 1.04
voices
Controllability of voices 3.49 ± 0.56 1.40 ± 0.55 1.37 ± 0.73 3.63 ± 0.55 2.54 ± 0.66 3.10 ± 0.0.67
Total score subscale 8.80 ± 1.64 4.40 ± 1.24 3.82 ± 1.62 10.06 ± 7.31 ± 1.61 9.00 ± 2.42
1.41
Total score 31.89 ± 18.77 ± 3.15 19.80 ± 5.56 32.54 ± 24.34 ± 5.04 32.44 ± 6.12
4.35 4.69
a
Increase of mean score of (PSYRATS-AH) means more severe voices.
b
6 patients missing.

Table 3
Description of mean scores and standard deviations of Voices Acceptance and Action Scale (VAAS) for the study and control groups at pre, immediately post, and post
three months interventions.
Study group Control group

Voices Acceptance and Action Scale (VAAS) and subscalea Pre test Immediately post Post three Pre test Immediately post Post three
N = 35 N = 35 months N = 35 N = 35 months
N = 35 N = 29b

M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD

Section A1 (Acceptance attitude toward general voices) 8.54 ± 4.40 31.08 ± 2.32 31.05 ± 3.97 4.37 ± 2.96 7.714 ± 3.86 4.65 ± 4.05
Section A2 (autonomous actions toward general voices) 3.11 ± 1.27 9.60 ± 1.38 9.54 ± 1.82 1.40 ± 0.94 2.62 ± 1.30 1.55 ± 1.50
Section B1 (beliefs about actions related to command 10.54 ± 2.72 27.06 ± 2.09 27.34 ± 3.84 7.28 ± 3.94 10.17 ± 2.84 7.51 ± 4.03
voices)
Section B2 (acceptance attitude toward command voices) 6.85 ± 2.49 23.60 ± 2.00 23.37 ± 3.16 3.71 ± 1.72 6.25 ± 2.30 4.55 ± 3.04
Section B3 (autonomous actions toward command voices) 2.91 ± 1.29 12.28 ± 1.40 11.85 ± 2.70 0.971 ± 0.92 2.94 ± 1.30 1.44 ± 1.18
Total score of VAAS 31.97 ± 10.48 103.63 ± 7.35 103.17 ± 14.55 17.74 ± 8.51 29.71 ± 9.79 19.72 ± 12.78
a
Increasing of mean score of VAAS subscales means more acceptance attitudes.
b
6 patients missing.

strongly statistically significant difference (t = 18.12, p = 0.000). As
well as, it can be seen from the table that the mean differences between
immediately post and post three months intervention of the total VAAS
decreased to − 9.53for total Voices Acceptance and Action Scale and
there is a strong statistically significant difference found(t = 2.65, p =
0.010).
Table 6 shows that the majority of the study group of patients with
schizophrenia were compliant with their medications after three months
of intervention (88.6%), comparing to around a quarter of the control
group (25.7%) and there is highly statistically significant differences
were found between both groups. According to re-hospitalization after
discharge from the hospital during three months period, the majority of
the study group (88.6%) was not readmitted to the hospital during three
months of discharge, as compared to more than one-third of the control
group (37.1%), and the difference between both groups was found high
statistical significance.
Table 7 shows that the majority of the study group of patients with
schizophrenia was very highly satisfied with all sessions of acceptance
and commitment therapy with 62.8% and a mean score of 3.60 for
acceptance and willingness session. As well, cognitive defusion session
also shows very high satisfaction with 60% and a mean score of 3.54. In
addition, the patients were very high satisfied equally for both sessions
of contacting with the present moments and values direction with
57.2%.
Discussion
The present study findings showed that more than three-quarters of
the studied patients experienced hearing malevolent voices while the
rest experienced mixed voices (malevolent and benevolent). Those pa­
tients who experienced malevolent voices in the present study reported
having bad, criticizing, cursing, commanding with threatening and
intimidating voices thus make the patients invoke resistance toward
these voices all of the time. From the patients’ perspective, such resis­
tance is considered one of the usual ways of dysfunctional coping with
these voices, which is perceived by the majority of the studied patients
as inefficient and perplexing, this may explain why most of the studied
patients were willingly participating in ACT sessions.

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Table 4
Comparison between mean differences of Psychotic Symptom Rating Scales –Auditory Hallucinations among study and control groups between pretest and imme­
diately post, pretest and post three months interventions, and between immediately post and post three months interventions.
Psychotic Symptom Rating Mean differences comparison between pretest Mean differences comparison between pretest Mean differences comparison between
Scales (PYSRATS-AH) and immediately post test and post three months test immediately posttest and post three months

MD1 MD2 MD3 t Sig MD4 MD5 MD6 t Sig MD7 MD8 MD9 t Sig

Total Psychotic Symptom − 13.12 − 8.20 − 4.92 4.47 0.000* − 12.09 − 0.10 − 11.99 8.54 0.000* 1.03 8.10 7.07 4.52 0.000*
Rating Scales
Physical characteristics − 3.83 − 2.71 − 1.12 2.79 0.007* − 2.29 0.59 − 1.70 4.82 0.000* 1.54 3.30 1.76 2.61 0.011*
Cognitive characteristics − 4.40 − 2.75 − 1.65 4.48 0.000* − 4.98 − 1.06 − 3.92 8.89 0.000* − 0.58 1.69 1.11 4.97 0.000*
Emotional characteristics − 4.89 − 2.68 − 2.21 3.32 0.001* − 4.83 0.44 − 4.39 7.39 0.000* 0.06 3.12 3.06 3.57 0.001*

MD1 Mean difference between pre and immediately post of study group.
MD2 Mean difference between pre and immediately post of control group.
MD3 Mean difference between pre and immediately post between both groups.
MD4 Mean difference between pre and post three months of study group.
MD5 Mean difference between pre and post three months of control group.
MD6 Mean difference between pre and post three months for both groups.
MD7 Mean difference between post immediately and post three months of study group.
MD8Mean difference between post immediately and post three months of control group.
MD9 Mean difference between post immediately and post three months for both groups.
*
p value is significant at ≤0.05.

Table 5
Comparison between mean differences of Voices Acceptance and Action Scale (VAAS)among study and control groups between pretest and immediately post, pretest
and post three months interventions, and between immediately post and post three months interventions.
Voices Acceptance and Action Mean differences comparison between pretest Mean differences comparison between Mean differences comparison between
Scale (VAAS) and immediately post test pretest and post three months test immediately posttest and post three months

MD1 MD2 MD3 t Sig MD4 MD5 MD6 t Sig MD7 MD8 MD9 t Sig

Total Voices Acceptance and 71.66 11.97 59.69 20.02 0.000* 71.20 1.98 69.22 18.12 0.000* − 0.46 − 9.99 − 9.53 2.65 0.010*
Action Scale (VAAS)
Section A1 (Acceptance 22.54 3.34 19.20 17.12 0.000* 22.51 0.28 22.23 17.74 0.000* − 0.05 − 1.06 − 1.01 2.62 0.011*
attitudes toward general
voices)
Section A2 (Autonomous 6.49 1.22 5.27 11.99 0.000* 6.43 0.15 6.28 13.38 0.000* − 0.06 − 1.07 − 1.01 2.04 0.046*
actions toward general
voices)
Section B1 (Beliefs about 16.52 2.89 13.63 16.89 0.000* 16.80 0.23 16.57 14.52 0.000* 0.24 − 2.66 − 2.42 2.81 0.006*
actions related to command
voices)
Section B2 (Acceptance 16.75 2.54 14.21 14.19 0.000* 16.52 0.84 15.68 17.99 0.000* − 0.23 − 1.70 − 1.47 1.79 0.078
attitudes toward command
voices)
Section B3 (Autonomous 9.37 1.97 7.40 19.81 0.000* 8.94 0.47 8.47 14.72 0.000* − 0.43 − 1.50 − 1.07 1.48 0.144
actions toward command
voices)

MD1 Mean difference between pre and immediately post of study group.
MD2 Mean difference between pre and immediately post of control group.
MD3 Mean difference between pre and immediately post between both groups.
MD4 Mean difference between pre and post three months of study group.
MD5 Mean difference between pre and post three months of control group.
MD6 Mean difference between pre and post three months for both groups.
MD7 Mean difference between post immediately and post three months of study group.
MD8Mean difference between post immediately and post three months of control group.
MD9 Mean difference between post immediately and post three months for both groups.
*
p value is significant at ≤0.05.

These results were congruent with a study done by El Ashry and
Abdel Al (2015) in Egypt who found that the majority of the patients
reported experiencing frequent auditory hallucinations, which are
abusive, critical, and accusing the patients of horrible things that evoked
negative interpretations and negative affect.
The current study results showed an improvement in all aspects of
auditory hallucination after implementing ACT, The severity of the
mean scores of all auditory hallucinations characteristics was decreased
among the patients in the study group who participated in the ACT as
compared to the patients in the control group who Treated As Usual
(TAU) and a higher statistical significant mean difference was found
between the study and control groups at immediately post and post three
months of the therapy. These results are attributed to the effect of ACT
activities and processes that enlarge the patient’s psychological flexi­
bility in dealing with auditory hallucination. In ACT sessions, the stud­
ied patients were practiced to adopt the stance of a mindful observer of
voice experience and foster an attitude of willingness to experience
voices while pursuing valued action. ACT promotes the patient’s will­
power and self-control along the ACT process by letting go of coping
practices and embracing the self as a context, not as content in reacting
to voices instead of resistance and struggle with auditory hallucinations
(Tonarelli & Pasillas, 2016).
The results of the current study showed that the patients with
schizophrenia who participated in ACT sessions reported having less

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Table 6
Distribution of the studied patients with schizophrenia who experienced auditory hallucinations according to their clinical data characteristics post three months after
session application.
Clinical data characteristics Study groups (N = 35) Control group (N = 29) χ2 P

N % N %

Compliance with medication after ACT 28.77 0.00*

▪ Yes 31 88.6 9 25.7
▪ No 4 11.4 20 83.2
▪ Missed 0 0 6 17.1
Re-hospitalized after 3 months from discharge 19.83 0.00*
▪ Yes 4 11.4 22 62.9
▪ No 31 88.6 13 37.1

X2: Pearson Chi-square.

*
Significant difference if P ≤ 0.05.

Table 7
Description of satisfaction level about session’s activities for patients with schizophrenia who experienced persisting auditory hallucinations.
Patient satisfaction about session application Low satisfaction High satisfaction Very high satisfaction M ± SD

N Percent N Percent N Percent

Developing acceptance and willingness 1 2.9% 12 34.3% 22 62.8% 3.60 ± 0.55

cognitive defusion 2 5.7% 12 34.3% 21 60% 3.54 ± 0.61
Getting contact with the present moment 1 2.8% 14 40% 20 57.2% 3.54 ± 0.56
Identify the conceptualized self from self as context 0 0% 19 54.3% 16 45.7% 3.46 ± 0.51
Defining valued direction 2 5.7% 13 37.1% 20 57.2% 3.51 ± 0.61
Building patterns of committed action 2 5.7% 14 40% 19 54.3% 3.49 ± 0.61

physical characteristics of the auditory hallucinations, as most of the
studied patients reported having less frequent voices to be once per day,
with less duration that lasted for minutes. Also, the loudness of the
voices was decreased to be whispering instead of having shouting ones.
The improvement in the physical aspect of the auditory hallucination in
the current study can be attributed to the workability effect of ACT that
is used by the patients as a guide to coping with auditory hallucinations.
In this respect, the patients were practiced to set SMART goals based on
their deeply inherited value and they were motivated to engage in
committed action.
Moreover, drug compliance is one of the SMART goals that are
chosen by the patients in the ACT process, which was found to be
consistent with the value of being healthy to handle one’s jobs and in
turn was committed as an action in ACT session and homework. The
drug compliance and re-hospitalization rate were reassessed after three
months of implementing ACT to validate the chosen goal. Accordingly,
the current study showed that compliance with medications after
participating in ACT interventions after three months was improved in
the study group with 88.6% as compared to 25.7 of the control group
with a highly statistically significant difference. Besides, the current
study results showed that 11.4% of the patients in the study group who
received ACT intervention were re-hospitalized comparing to 62.9% of
the control group with a highly statistically significant difference. In this
perspective, a study done by Bach and Hayes (2002) found that ACT
resulted in a 50% reduction in re-hospitalization among patients with
schizophrenia as compared to the control group who received treatment
as usual.
Regarding the cognitive characteristics of auditory hallucinations,
the results of the present study found that the studied patients who
participated in ACT showed improvement in all dimensions of cognitive
characteristics including beliefs about origins of the voices, disruption to
life caused by the voices, and controllability of the voices on the pa­
tients. The present study showed a highly statistically significant dif­
ference with an effect size of 79.29% in the cognitive characteristics of
auditory hallucination between the study and control groups in the post
immediately and after three months. Conversely, no significant
improvement was found among the patients in the TAU group. These
results are attributed to the effect of ACT activities like defusion and
present moment exercises that target auditory hallucinations by moti­
vating the patients to respond to auditory hallucinations and their
related feelings, thoughts, and emotions as just events in the mind,
rather than literal content and help the patients to develop a mindful
acceptance perspective toward them. This intervention would be helpful
particularly when patients are struggling or persisting with efforts to
control those internal experiences that lead to problems in everyday
living. Also, the development of awareness of present-moment experi­
ence with a compassionate, non-judgmental stance was an important
attribution for such improvement in cognitive characteristics of auditory
hallucinations.
Furthermore, using mindfulness attention exercises toward internal
experiences like voices and external experiences perceived by the pa­
tients with five senses helped the patient to accept willingly the verbal
content of auditory hallucinations, physical feelings, and emotions in
more flexible ways. Furthermore, self as a context exercise in ACT ses­
sions may develop new metacognitive abilities as the patients able to
notice the voices and related thoughts in their head, recognize these
voices as their own, and notice and identify their feelings.
Incongruent with the decrement in the cognitive characteristics of
the voices in the current study, a study was done by Morris (2012)
investigated the relationships between psychological flexibility and
distress, disability, and behavioral responses to voices experiences. He
found that patients who practice nonjudgmental acceptance by using
ACT with voices reported having less appraisals of voice omnipotence
(the power of the voice). In other words, they accepted their voices
without engaging judgmentally with them, and in turn, the chance of
appraising voices as powerful and controlling was reduced.
Concerning the emotional characteristics of auditory hallucinations,
the studied patients who participated in ACT sessions exhibited an
improvement in the emotional domain of the voices with a highly sig­
nificant statistical mean difference between the study and control
groups after implementing ACT. It is worth noting that the studied pa­
tients in the current study reported having less distressing voices and
less negative content voices than the control one. This may be attributed
to the efficacy of mindfulness or present moment exercises on an

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Table 8
Acceptance and commitment therapy sessions in details.
General objectives of acceptance and commitment therapy (ACT) sessions:
The patient will be able to:
• Accept auditory hallucinations as they occurred without judging or avoiding them, and letting go of the internal struggle with the experienced voices.
• Build patterns of valued committed actions despite contrary voices and their related thoughts and emotions.
Session Specific objectives
Session (1) • Explore auditory hallucinations experiences in detail to identify
General objectives: various explanatory forms of psychological inflexibility.
• Apply unworkable response of auditory hallucinations
• Develop acceptance and experiences on psychological inflexibility model.
willingness. • Explore ways of coping with auditory hallucination experiences
• Undermine experiential control that used to avoid and get rid of thoughts and feelings triggered
by AHs (the usual emotional control agenda).
• Identify the negative effect of the control agenda which was used
as a coping response with auditory hallucinations
• Control of the voices is the problem, not the solution.
• Letting go of the struggle with the usual control agenda as a
response for coping with AHs.
• See experiential willingness as an alternative to experiential
control.
Session(2) • Notice what is present in the external environment to expand
General objective: attention, build patients’ resilience, and engaging fully in
whatever doing.
• Get in contact with the present • Notice and describe what presents internally like; auditory
moment hallucinations experience and related thoughts, feelings, and
physical sensations as it occurred without judgment
• Notice and describe sources of distraction and avoidance that
used as a response to auditory hallucinations and make him away
from being here and now
Session (3) • Identify and aware of the sources of cognitive fusion that are
General objectives: triggered by the verbal content of auditory hallucinations.
• Link between sources of fusion that are triggered by verbal
• Undermine sources of cognitive content of auditory hallucinations and unworkable actions that
fusion make him moving away from valued life actions.
• Accept voices by defusing from the • Identify and observe the verbal content of auditory
verbal content of the auditory hallucinations as what they are nothing more than bits of
hallucination language or words.
• Make a distance between the verbal content of AHs and the
patient, so verbal content of AHs can be responded to in terms of
their workability toward the patient values
Session (4) • Observe and describe the experience of auditory hallucinations
General objective: and its related thoughts, feelings, and urges that were probably
changed with time and situations.
• Distinguish the conceptualized self • Encourage the patient to make contact with a sense of self that is
from self as a context. continuous, safe, and consistent and from which he can observe
and accept the experience of AHs.
• Reinforce the meaning that the patient was not his voice or
triggered thoughts and feelings but these phenomena change
constantly and were a peripheral aspect of his personality.
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Archives of Psychiatric Nursing 35 (2021) 141–152
Content and processes
• The researcher introduced himself to the patient
• Inform the patient with program objectives, content, and set the
rules of the therapy.
• The researcher demonstrates the essential components of ACT that
leading to psychological flexibility for dealing with auditory
hallucinations experiences (be here and now, accepting and do
what matters to him)
• Assess and develop a detailed understanding of voice experience,
including basic information on voice phenomenology.
• Encourage the patient to the link between the responses related to
the voices phenomenology and psychological inflexibility
components.
• The researcher motivates the patient to explore the usual emotional
control agenda that he used as a response to voices, and their effect
on his life.
• Confront the patient about the usual emotional control agenda that
was used as a response to the voices that is largely responsible for
his problems (confronting agenda)
• The researcher used the choice point model to illustrate that
meaning and to focus on acceptance as a helper for workable coping
with voices.
• Introduce the meaning of creative hopelessness about the usual
emotional control agenda
• The researcher empowers the patient to let go of the struggle with
voices and use willingness as an alternative, which was illustrated
by simulating tug-of-war with the monster metaphor and by
showing a video for the bad guest metaphor.
• Homework was practicing willingness and acceptance exercise
after the session by using the tug of war with monster images.
• The researcher helped the patient to contact with the present
moment to develop psychological flexibility to deal with auditory
hallucinations by involving the mindfulness skills
• The researcher was Practicing the dropping anchor exercise with
the patient
• The researcher encouraged the patient to use the language of
noticing like saying “I’m noticing that…” when referring to
behavior that changed because of internal experiences of the voices
or any thoughts and emotions raised during the session.
• The researcher used the metaphor river of thoughts by showing a
video to make the patient watch the voice experiences came and go
from an observer perspective (Mindfulness exercises).
• If voices did not arise within a session, the researcher played quiet
recorded speech to provide an analogous stimulus.
• Homework: the metaphor river of thoughts will be applied on a
paper worksheet.
• The researcher revised the choice point model to illustrate the link
between sources of fusion triggered by verbal content of AHs and its
effect on making away moves from the life that the patient wants to
be.
• The researcher trained the patient to make a distance between the
verbal content of voices and himself to decrease its influence on
behaviors by practicing distancing exercises to create a separation
between him and the conceptualized self of voice experience:
Naming patient mind exercise, milk milk milk exercise, selling your
voices and thoughts exercise and I am having the voice that)
• In addition, “taking your mind for a Walk” was acted by the
researcher and the patient to confirm the message of distancing
from voice verbal content and that acted in the hospital garden.
• Homework: the patient repeated all distance exercises “I am having
the thought that ……” and “naming your mind”.
• The researcher helped the patient to understand the different
qualities of self-conceptualization by just noticing voices and
negative thoughts on different occasions.
• The researcher drew the patient’s attention to the distinction
between the negative thoughts or voices that arises, and the self
who observes those thoughts or voices.
• The researcher asked the patient to visualize their thoughts and
feeling and voices content on leaves floating down a stream, and
just noticing them drifting without trying to stop or control them
(continued on next page)
A.M.N. El Ashry et al. Archives of Psychiatric Nursing 35 (2021) 141–152

Table 8 (continued )
General objectives of acceptance and commitment therapy (ACT) sessions:
The patient will be able to:

• Accept auditory hallucinations as they occurred without judging or avoiding them, and letting go of the internal struggle with the experienced voices.
• Build patterns of valued committed actions despite contrary voices and their related thoughts and emotions.

Session Specific objectives Content and processes

Therefore, the patient was acted more effectively guided by the and that was used by leaves on the stream metaphor by showing a
chosen values. video.
• The researcher built and highlighted the distinction between
products and contents of self-evaluations versus the self that eval­
uates. That was explained by using the chessboard metaphor in
which the researcher played chess with the patient and using chess
pieces and board to apply the difference between thoughts and self.
• Homework: worksheet paper for leaves on the stream metaphor
was practiced by the patient to validate the concepts of self as a
context and self as a content
Session (5) • Define his value domains that give meaning to his life. • The researcher discussed with the patient how past attempts of
General objective: • Differ between value and goal response to voices affecting and interfering with the attainments of
• Define and identify specific goals that align with the chosen his goals and subsequently his values.
• Define valued directions values • The researcher helped the patient to explore possible values that
• Identify potential barriers to following through with valued- give meaning to his life
based living and explore ways of overcoming those barriers. • The researcher used a bull’s eye worksheet to help the patient to
clarify and categorizing his values to provide a rationale for why he
was intentionally dropping avoidance and control coping agenda
with the voices and move into ACT components of his life.
• The researcher explained to the patient the difference between
value and goal by using the compass metaphor to explain what is
the function of the value concerning goals
• The researcher focused on the discrepancies between his valued
area and his daily actions because of the voices.
• The researcher helped the patient to set a SMART goal by using a
worksheet based on the chosen value from the bull’s eye and to take
actions based on his value not based on the voice experience.
• Homework to the patient included one of the selected values from
the bull’s eye worksheet and specified goals that were consistent
with their chosen value.
Session(6) • Define and set goals that are consistent with his values. • The researcher focused on values that are determined by using the
General objective: • Identify barriers that hinder goal completion. bully’s eye.
• Willing to commit actions to a meaningful life goal direction • The researcher has chosen one of the value domains from the
• Build and develop pattern of even with the presence of uncomfortable voices and related bully’s eye and starts to set an action plan for it.
committed action thoughts and feelings. • The patient listed 10 specific activities (for examples; making some
• Utilize all six core processes involved in the ACT model to physical exercises, praying, talking with other patients, and
overcome those barriers. practicing mindful walking in the hospital garden) that are relevant
to his short-term goals that are consistent with the chosen value and
put them in order of how difficult they are to make them.
• The researcher continued to identify the potential difficulties and
barriers that might stand in the way of achieving his goals, and how
he dealt with those barriers when they arise.
• The researcher showed a video and worksheet of Passengers-on-
the-Bus Metaphor to convince the patient to have the willingness to
keep committed to the action plans even in the presence of barriers.
• Taking your voice for a walk is an exercise that is acted again by the
researcher and the patient to clarify committed actions in the face
of voice activities.
• Finally, the patient’s feedbacks were obtained about ACT sessions

affective domain, which was practiced by the studied patients in ACT
sessions.
There is a beneficial biological effect of using mindfulness exercises
in the ACT as proved recently by several cross-sectional anatomical MRI
studies, which found that patients who experienced mindfulness inter­
vention exhibited hippocampus and the right anterior insula activation
(Hölzel et al., 2011; Lutz et al., 2008). Moreover, metaphors in the ACT
can affect positively the cognition and emotional experience and be­
haviors of the individuals and considered reflection, remembrance,
consideration, and insight. This effect is shown in the Egyptian Muslim
culture in the Holy Qur’an by using proverbs that may come in the
Qur’an in the sense of metaphors. The most important benefit of using
metaphors in the Qur’an is bringing what is meant to the mind and
visualizing it in a perceptible image, to be fixed in the minds. They bring
the picture closer, bring attention, and relive the illusion of the mind.
Among the purposes of metaphors in the Qur’an is the remembrance; the
Almighty said: {We have struck people in this Qur’an from every
example that they may remember} Al-Zumar 27, and The Almighty said:
{And God will give proverbs to people so that they may remember}
Ibrahim 25, or used as a representation: a metaphor of an intangible
tangibly, and imagined scenes to be in things formative. The Almighty
said: {Like those who spend their money for the sake of God, like a pill
that grows seven spikes in every single hundredth of his love, and God
doubles for whomever He wills, and God is All-Knowing} Al-Baqarah 26.
Accordingly, Gaudiano (2004) found that applying ACT for psychiatric
inpatients with psychotic symptoms revealed a decrement in auditory
hallucinations associated distress with 38% more than the control group
as compared to Bach and Hayes (2002) who reported that patients with
psychosis who participated in ACT reported a lower degree of voices
associated distress with 50% as compared to control group and both of

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study.
The results of the current study revealed a highly significant increase
in the mean score of all acceptance attitudes and autonomous actions
toward voice experiences by using VAAS, the results showed that the
stability of the mean score of VAAS in post three months follow-up re­
flects the perseverance of positive ACT outcomes. Such improvements
could be justified by the activation of the normalizing and accepting
attitudes toward the patients’ experiences of auditory hallucinations as
an integral aspect of the ACT competencies.
Consistent with these results, a study was done by Tsai and Chen
(2005) who assessed self-care symptom management strategies for
auditory hallucinations among patients with schizophrenia, found that
the patients who used acceptance and staying with voices peacefully
were considered to be effective self-management strategies in dealing
with voices and can be developed by the patients themselves. Moreover,
Gaudiano and Herbert (2006) and Gaudiano et al. (2010) found that the
hospitalized patients with schizophrenia who intervened with ACT re­
ported greater improvement in decreasing the distressing level of
auditory hallucination. They also found that patients who participated
in ACT sessions reported that their relationship with their auditory
hallucination has been changed as the majority of the patients respon­
ded differently to their voices by being more accepting and act more
autonomously.
Regarding the effect of ACT on commanding hallucination, the re­
sults of the present study revealed that there is an increase in the level of
acceptance and autonomous actions related to the command voices at
immediately post and post three months measurement and that
increasing was found a highly statistically significant for beliefs about
actions related to command voices, for acceptance attitudes toward
command voice, and for autonomous actions toward command voices.
The current study showed also that the more acceptances of the voices as
measured by VAAS indicated the more the patients able to act autono­
mously without engagement or resistance with voices. These results
were supported by a study done by Shawyer et al. (2007) who found that
acceptance of the voices as measured by VAAS in patients with schizo­
phrenia who experiencing commanding auditory hallucination was
associated with less harmful compliance, lower levels of depression, and
increasing satisfaction with the general activities of life and feeling able
to function in society. Regarding satisfaction level toward ACT sessions,
the decrement effect of ACT sessions on all aspects of auditory halluci­
nations was reflected with a very high satisfaction level to the patients’
response in every session activities as described in results.
Conclusively, the current study findings suggest a new clinical cul­
ture to deal with auditory hallucinations. It showed that the application
of ACT in the psychiatric hospital could affect positively the way of
coping with auditory hallucinations among patients with schizophrenia.
Therefore, it is mandatory to integrate ACT practices into psychiatry and
psychiatric nursing interventions to empower the patients with schizo­
phrenia to be resilient with the diversity of auditory hallucinatory ex­
periences and to grow and improve the quality of their lives.
Conclusion and recommendations
Based on the results of the study it can be concluded that acceptance
and commitment therapy (ACT) can be successful in decreasing the
severity of all aspects of auditory hallucinations for patients with
schizophrenia especially in relation to voices related distress. Also, it is
very promising in changing patient’s responses toward voice experi­
ences instead of engagement to benevolent voices and resistance to
malevolent voices to acceptance attitude and independent autonomous
actions that make the patients’ lives more valued and more satisfied. As
well as, acceptance and commitment therapy can be very effective in
decreasing the re-hospitalization rate for three months after discharge
than patients who are treated as usual in the hospital.
151
Archives of Psychiatric Nursing 35 (2021) 141–152
Implication of the study
Acceptance and commitment therapy was used firstly in the Egyptian
culture, especially for the patients who experience auditory hallucina­
tions with schizophrenia, this study showed the feasibility of using ACT
among Arab culture.
Limitations of the study
- The high rate of turnover during the conduction of the ACT sessions
leads to the loss of some patients who were discharged before the
termination of the therapy.
- Although some of the selected patients admitted having auditory
hallucinations, they refused to participate in the ACT because of the
benevolence content of their voices.
Fund
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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