CNE

Earn Contact Hours

Integrating Anxiety Reduction into an Existing

Self-Management of Auditory Hallucinations Course
Robin K. Buccheri, PhD, RN, MHNP, FAAN; Louise Nigh Trygstad, PhD, RN, CNS;
Martha D. Buffum, PhD, RN, PMHCNS-BC; Dau-shen Ju, PhD; and Glenna A. Dowling, PhD, RN, FAAN

T
ABSTRACT he purpose of developing the
High levels of anxiety were found to interfere with voice hearers’ ability to current authors’ 12-Session
Behavioral Management of
benefit from a 10-Session Behavioral Management of Auditory Hallucina- Anxiety and Auditory Hallucinations
tions Course. The 10-session course was revised, adding anxiety reduction Course was to integrate additional
strategies to the first four classes and reinforcing those strategies in the anxiety reduction content and strat-
egies into the widely disseminated
remaining eight classes. A multi-site study (N = 27) used repeated mea-
evidence-based 10-session course. The
sures to determine whether the new 12-session course would significantly new version front loads the course with
reduce anxiety. Ten course leaders were trained and taught the course six four sessions of anxiety management
and reinforces content throughout the
times at three different outpatient mental health sites. Three measures of
remaining eight classes that teaches
anxiety were used. The 12-session course was found to significantly reduce strategies to manage auditory halluci-
anxiety after the first four classes with further reduction at the end of the nations (AH).
course. Eighty-eight percent of course participants reported the course The original 10-session course
was designed to teach AH symptom
was moderately to extremely helpful. They also reported that being in a self-management to individuals with
group with others with similar symptoms was valuable. Course leaders schizophrenia. The authors and other
reported learning about the prevalence and importance of treating voice course leaders frequently noted that
some clients were too anxious to stay
hearers’ anxiety. [Journal of Psychosocial Nursing and Mental Health Ser- in class or complete the course. Data
vices, 55(5), 29-39.] analysis from the 10-session course

Journal of Psychosocial Nursing • Vol. 55, No. 5, 2017 29

(N = 62) demonstrated that those
with the highest levels of anxiety were
more likely to drop out or have fewer
positive outcomes at the end of the
course (Buccheri, Buffum, & Trygstad,
2015).
High levels of anxiety in individuals
with schizophrenia have been related
to an increase in psychotic symptoms
over time (Docherty et al., 2011). This
finding may explain why some individ-
uals with schizophrenia have difficulty
Teaching anxiety self-management strategies in
the beginning of the course could reduce anxiety
in course participants and lead to improved
outcomes.
remaining in a classroom and partici-
pating in learning activities. Teaching
anxiety self-management strategies
in the beginning of the course could
reduce anxiety in course participants
and lead to improved outcomes.
STUDY OBJECTIVE
The primary objective of the cur-
rent study was to determine whether
initial and continued focus on anxiety
reduction in this 12-Session Behav-
ioral Management of Anxiety and
Auditory Hallucinations Course would
result in significantly reduced anxiety
in course participants from baseline to
the fourth class and be sustained to the
end of the course.
BACKGROUND
Summary of Past Work
The 10-Session Behavioral Man-
agement of Auditory Hallucinations
Course was recognized by the Amer-
ican Psychiatric Nurses Association
as Best Treatment of Schizophrenia
in a Behavioral Health Care Pro-
gram (Buccheri & Trygstad, 1999).
The 10-session course significantly
reduces negative characteristics of
AH (i.e., frequency, self-control,
30
clarity, tone, distractibility, and dis-
tress), anxiety, and depression with
some sustainability up to 12 months
(Buccheri et al., 2004). These results
were published in a pilot study (Buc-
cheri, Trygstad, Kanas, Waldron,
& Dowling, 1996) with 12-month
follow up (Buccheri, Trygstad, Kanas,
& Dowling, 1997) and a multi-site
intervention study (Trygstad et al.,
2002) with 12-month follow up
(Buccheri et al., 2004). A reduction
also occurred in commands to harm
self or others after attendance at the
10-session course (Buccheri, Tryg-
stad, & Dowling, 2007).
Disseminating the 10-session course
in two multi-site studies revealed
that 60% of course participants had
improved their AH intensity scores
(Buffum et al., 2009) and 66% of
course participants reported improve-
ment in unpleasant voices (Buffum,
Buccheri, Trygstad, & Dowling,
2014). Further, 96% of course partici-
pants reported course helpfulness and
85% felt better able to communicate
with staff about their AH. These were
findings with 32 and 33 course partici-
pants, respectively.
Scott, Webb, and Rowse (2015)
conducted a meta-analysis of
24 studies that evaluated self-help
efficacy interventions for psychosis.
Studies by Trygstad et al. (2002), Buc-
cheri et al. (2004), and Buccheri et al.
(2007) were included in this review
along with a study that replicated their
work (Kanungpairn, Sitthimongkol,
Wattanapailin, & Klainin, 2007).
These four studies were the only ones
in the meta-analysis that were statis-
tically significant. Scott et al. (2015)
concluded that several factors influ-
ence treatment effects, including the
complexity of the intervention (i.e.,
including a variety of strategies), the
amount of face-to-face contact time
with those supporting the interven-
tion, and the professional guidance of
the intervention with patients/clients.
All factors are present in the current
authors’ evidence-based 10-session
course; professionals teach the course
to clients in weekly face-to-face ses-
sions that last 1 to 1.5 hours and
include 10 behavioral strategies (and
practice within the session) for man-
aging distress from AH.
Lack of Improvement in Some Course
Participants
Although anxiety has been known
to worsen psychosis (Docherty et al.,
2011), it has been recently hypoth-
esized that anxiety can trigger AH
(Ratcliffe & Wilkinson, 2016). Yet,
self-management of AH symptoms
in the presence of anxiety has been
minimally studied. This frequent and
common symptom of anxiety may
be related to lack of improvement
in some 10-session course partici-
pants. Approximately 36% to 40% of
course participants in two dissemina-
tion studies of the 10-session course
reported no improvement in AH
intensity (Buffum et al., 2009; Buffum
et al., 2014).
Review of Relevant Evidence
Prevalence of Comorbid Anxiety in
Schizophrenia. Comorbid anxiety dis-
orders are highly prevalent among
individuals with schizophrenia
(Achim et al., 2011; Young et al.,
2013). Achim et al. (2011) performed
a systematic review of 52 studies and
found that 38.3% of patients with
schizophrenia reported at least one
type of anxiety disorder. They calcu-
lated pooled prevalence rates for spe-
cific anxiety disorders among patients
with schizophrenia and reported 12%
for obsessive–compulsive disorders,
15% for social phobia, 11% for gener-
alized anxiety disorder, 10% for panic
disorders, and 12% for posttraumatic
Copyright © SLACK Incorporated
stress disorders. Young et al. (2013)
examined the prevalence of comorbid
anxiety disorders in patients with
schizophrenia (n = 174) and schizoaf-
fective disorder (n = 153) and reported
anxiety prevalence rates of 17% for
schizophrenia and 30% for schizoaf-
fective disorders.
Untreated anxiety is associated
with poorer treatment outcomes in
schizophrenia (Braga, Reynolds, &
Siris, 2013). Comorbid anxiety often
goes untreated in patients with schizo-
phrenia; it can negatively affect treat-
ment outcomes and quality of life
and is associated with higher rates of
relapse and suicide attempts (Vrbová
et al., 2013). Achim et al. (2011) rec-
ommend that clinicians identify anx-
iety as a treatment target for patients
with schizophrenia.
Evidence-Based Strategies for Anx-
iety Reduction. Three strategies were
chosen for incorporation into the
12-session course based on expert
opinion, evidence to support effec-
tiveness in reducing anxiety, and feasi-
bility for easily teaching course leaders
and course participants. These anxiety
management strategies were: (a) pro-
gressive muscle relaxation, (b) mindful
breathing while sitting and walking,
and (c) replacing anxious thoughts
with healthy thoughts.
Progressive muscle relaxation. Progres-
sive muscle relaxation was first reported
in 1939 by Jacobson. Vancampfort et al.
(2012) conducted a systematic review
of randomized controlled trials (RCTs)
to evaluate the effectiveness of progres-
sive muscle relaxation in patients with
schizophrenia. The review included
three RCTs (Chen et al., 2009; Geor-
giev et al., 2012; Vancampfort et al.,
2011). The three RCTs represented
146 patients with schizophrenia. Van-
campfort et al. (2012) reported no
adverse effects of progressive muscle
relaxation and significantly improved
state anxiety. A conclusion was that
progressive muscle relaxation can safely
reduce state anxiety in individuals with
schizophrenia.
Mindful breathing while sitting and
walking. Mindfulness programs are
Journal of Psychosocial Nursing • Vol. 55, No. 5, 2017
often based on a two-component con-
ceptual model: (a) self-regulation
of attention—to focus on current
experiences, and (b) orientation to
experience—meeting those current
experiences with openness and curi-
osity (Bishop et al., 2004). Group
mindfulness programs have been taught
to patients with psychotic symptoms
(e.g., AH) and found to be feasible and
related to clinical improvement (Abba,
Chadwick, & Stevenson, 2008; Brown,
Davis, LaRococo, & Strasburger, 2010;
Chadwick et al., 2016; Chadwick,
Taylor, & Abba, 2005; Davis, Stras-
burger, & Brown, 2007). Chadwick et
al. (2005) taught six group sessions of
mindfulness of the breath to 10 patients
with distressing psychosis and reported
clinical improvement.
Replacing anxious thoughts with
healthy thoughts. Cognitive–behavioral
therapy (CBT) was found to improve
symptoms of anxiety in patients with
schizophrenia (Naeem, Kingdon, &
Turkington, 2006). Replacing anx-
ious thoughts with healthy thoughts is
derived from cognitive restructuring—
a component of cognitive–behavioral
group therapy (CBGT) (Heimberg &
Barlow, 1991). Cognitive restructuring
comprises four steps: (a) identification
of automatic thoughts, (b) identifica-
tion of cognitive distortions in auto-
matic thoughts, (c) rational disagree-
ment with automatic thoughts, and
(d) development of rational rebuttal
to automatic thoughts. Cognitive
restructuring is often complemented
by two other components of CBGT
(i.e., role playing and homework).
Evidence for Practice of Anxiety
Reduction Strategies. At-home prac-
tice of anxiety reduction strategies is
the bridge between classroom learning
and use in everyday life. CBT inter-
ventions that include practice out-
side of class help clients improve up
to 60% more than those in treatment
without at-home practice (Granhome,
McQuaid, & Holden, 2016).
Research Questions
The following research questions
were the focus for the current study:
1. What are course participant
mean anxiety scores at baseline,
Class 4, and Class 12?
2. Is there a significant change in
course participant mean anxiety scores
from baseline to Class 4 and from base-
line to Class 12?
3. What is the optimal clinical tool
(i.e., Anxiety Rating Scale, Tension-
Anxiety subscale of the Profile of
Mood States, or Zung Self-Rating
Anxiety Scale) for measuring anxiety
in the 12-session course (i.e., feasi-
bility, ease of use, and access)?
4. What are course participants’
ratings of course helpfulness in man-
aging their anxiety?
5. How many course participants
report each strategy (i.e., mindful
breathing, progressive relaxation,
and replacing negative thoughts with
healthy thoughts) as helpful in man-
aging their anxiety?
6. What were course leader per-
ceptions of: (a) what they themselves
learned, (b) the most and least helpful
aspects of the 12-session course for
course participants, (c) obstacles to
conducting the course, and (d) sugges-
tions for future course leaders?
METHOD
Design and Settings
This investigation is a multi-site
intervention study using repeated
measures over 12 weeks. The study
was conducted at three outpatient
mental health settings: one Veterans
Affairs setting in the Midwest (con-
ducted three courses) and two com-
munity settings in the West (one set-
ting conducted two courses, the other
conducted one course).
Sample
Course Leaders. The sample com-
prised 10 course leaders and co-leaders
at three sites. All course leaders were
mental health professionals with expe-
rience facilitating groups or teaching
psychosocial educational classes to
individuals with schizophrenia who
experience AH.
Course Participants. Course leaders at
all three sites recruited their own course
31
 l age 18 years or older;
TABLE 1 l informed of the investigational
LIST OF 12-SESSION CLASSES (60- TO 90-MINUTE WEEKLY nature of the study and gave written
CLASSES) informed consent in accordance with
Classes 1-4 focus on anxiety symptom management through interactive institutional guidelines;
l diagnosis of schizophrenia or
discussions, behavioral management strategies, cognitive strategies, and
strategy practice both in-class and at home through individual practice records schizoaffective disorder based on the
(IPRs/homework). Diagnostic and Statistical Manual of
Mental Disorders-TR fourth edition
Class 1 Interactive discussion. Defining anxiety, symptoms experienced,
(DSM-IV TR; American Psychiatric
triggering situations, actions that improve or worsen anxiety.
Association, 2000). (The study began
Mindful breathing practice. Assignment: IPR/homework
in 2009 when the DSM-IV TR was
Class 2 Discussion about impact of anxiety and excessive caffeine current. The researchers maintained
consumption on well-being. Ends with a progressive relaxation its use throughout the study to ensure
exercise. Assignment: IPR/homework consistency.);
Class 3 Practice replacing negative thoughts with healthy thoughts. l self-report of having AHs for at

Assignment: IPR/homework least the past 3 months;

l self-report of a desire to learn
Class 4 Positive emotions, continue practicing replacing negative thoughts
with healthy thoughts. Assignment: IPR/homework new strategies to manage anxiety and
AHs;
Classes 5-12 are the evidence-based behavioral strategies from the 10-session
l proficient in reading and writing
course. Anxiety content and practice opportunities from Classes 1-4 are
English;
reinforced in each of these eight classes.
l receive mental health care at the
Class 5 Symptom self-awareness. specific mental health facility; and
l agree to conform to study proce-
Class 6 Talking with someone. dures.
Exclusion criteria for course par-
Class 7 Listening to music/radio with or without earphones. ticipants included:
l unwilling or unable to provide

Class 8 Watching television or something that moves. informed consent; and

l acutely psychotic that behavior

Class 9 Saying “Stop!”; ignoring the voices; not doing what the voices say would be disruptive in the course ses-
to do; using an earplug. sions.
Class 10 Keeping busy with an enjoyable activity or helping others.
Procedures
The institutional review boards
Class 11 Practicing communication related to taking medication and not at the University of San Francisco
using drugs and alcohol. and each participating clinical site
Class 12 A summary class where participants complete instruments, receive approved the research before any study
two lists of strategies, and receive a certificate of achievement. procedures began. Informed consent
was obtained from all site principal
investigators, course leaders and
co-leaders, and course participants.
All consents were stored with respect
participants from those receiving care 12-session course. Repeating the course to privacy and security according to
at their outpatient mental health facili- may help achieve better understanding institutional regulations. Those who
ties. Course participant recruitment and more success with symptom self- signed the consent forms were entered
flyers were posted in the treatment area management. Inclusion of repeaters into the study and began study proce-
and course leaders distributed them to was also reported by Chadwick et al. dures.
eligible clients. Twenty-seven mental (2005) in their study of the effect of Course leaders received the Treat-
health clients met eligibility criteria, mindful breathing group training on ment Manual: Guidelines for Teaching
signed consent forms, and completed clinical functioning of patients with the 12-Session Behavioral Management
the course. distressing psychotic symptoms. of Anxiety and Auditory Hallucina-
Some course participants had previ- Inclusion criteria for course partici- tions Course (Buccheri et al., 2015), a
ously completed the 10-session and/or pants was: training DVD, a relaxation CD, instru-

32 Copyright © SLACK Incorporated

 TABLE 2
DATA COLLECTION POINTS
Week
Tool/Form 0 1 2 3 4 5 6 7 8 9 10 11 12
Zung SAS X X X
ARS X X X X X
T-A POMS X X X
IPR X X X X X X X X X X X
Course Participant X
Feedback Form
Course Leader X
Feedback Form

Note. SAS = Self-Rating Anxiety Scale; ARS = Anxiety Rating Scale; T-A POMS = Tension-Anxiety subscale of the Profile of Mood States; IPR = individual
practice records (homework).

ments, and individual practice records
(IPRs)/homework. Details about the
12-session course are outlined in the
treatment manual. Researchers pro-
vided 1.5 hours of training in-person
at the two local community sites and
by telephone at one geographically
distant site. The teleconferencing
method demonstrated success for
staff and patient outcomes in two
prior dissemination studies where the
researchers taught course leaders to
teach the 10-session course (Buffum
et al., 2009; Buffum et al., 2014).
Training included a detailed review
of the treatment manual that includes
all instructions for the study; how to
teach the course; scripts for each of
the 12-session classes; and all instru-
ments, IPRs (referred to interchange-
ably as homework), and feedback
forms for course leaders and patient
participants. Based on each course
leader’s needs, researchers provided
ongoing phone calls, e-mail communi-
cation, or both.
Intervention
Course Description. The inter-
vention involved attendance at a
12-Session Behavioral Management
of Anxiety and Auditory Hallucina-
tions Course with the first four classes
focused on anxiety reduction followed
by eight classes focused on learning
how to manage AH with reinforce-
ment of anxiety reduction strategies.
A summary of the content taught in
each of the 12 classes is depicted in
Table 1 and a summary of data collec-
tion points for instruments is shown in
Table 2.
Anxiety management. To teach
self-management of anxiety, course
participants were first involved in an
interactive discussion about anxiety,
personal symptoms, triggering situa-
tions, and strategies for improvement.
They then learned and practiced
mindful breathing, progressive relax-
ation, and replacing anxious thoughts
with healthy thoughts. Participants
were given IPRs (homework) to
complete at home and return the fol-
lowing week. To reinforce what was
learned in the first four classes, partic-
ipants practiced one of the three anx-
iety reduction strategies in Classes 5
through 12.
Auditory hallucinations management.
To teach behavioral management of
AH, participants were first taught
symptom self-awareness followed by
other behavioral strategies to manage
their AH. The IPRs that were distrib-
uted each week focused on strategies
to manage AH with anxiety reduction
reinforcement as described above.
Instruments
Anxiety Measures. Three measures
of anxiety were used, allowing psy-
chometric evaluation for selecting an
optimal tool in future studies.
Tension-Anxiety subscale of the
Profile of Mood States (T-A POMS).
The T-A POMS comprises nine
items that measure anxiety/tension
(i.e., tense, shaky, on edge, panicky,
relaxed [reverse scored], uneasy, rest-
less, nervous, anxious) (McNair, Lorr,
& Droppleman, 1992). Responses are
on a 5-point Likert-type intensity
scale ranging from 0 (not at all) to
4 (extremely). The total score ranges
between 0 and 36, with a higher total
score indicating more anxiety/tension.
Originally developed with Veterans
receiving outpatient mental health
treatment, the POMS has been used
extensively with a variety of indi-
viduals with and without physical
and mental illnesses (McNair et al.,
1992). This tool was used successfully
in the authors’ past research (Buccheri
et al., 2004) and was deemed feasible
for the current study based on testing
with a small group of residents in a
setting for individuals with chronic
mental disabilities. Psychometrically
valid, the T-A POMS has reported
internal reliability coefficients of
0.90 and 0.92 and test–retest reli-

Journal of Psychosocial Nursing • Vol. 55, No. 5, 2017 33

 TABLE 3
MEAN ANXIETY SCORES AT BASELINE, AFTER FOUR ANXIETY REDUCTION CLASSES, AND END OF
12-SESSION COURSE
Mean (SD), [Range] (n)
Anxiety Measure Baseline After Four Classes End of Course
T-A POMSa 14.63 (8.67), [1 to 31] (27) 11.67 (8.08), [0 to 28] (24) 11.00 (8.13), [0 to 36] (25)
Zung SAS Index Scoreb 50.62 (10.68), [33 to 84] (26) 50.04 (9.7), [33 to 71] (25) 48.27 (9.93), [25 to 71] (26)
ARS c
3.26 (2.52), [0 to 8] (26) 2.54 (2.26), [0 to 9] (24) 1.92 (2.04), [0 to 8] (24)

Note. T-A POMS = Tension-Anxiety subscale of the Profile of Mood States; SAS = Self-Rating Anxiety Scale; ARS = Anxiety Rating Scale.
a
Total score ranges between 0 and 36, with higher scores indicating more anxiety/tension.
b
Total score ranges between 25 and 100, with <45 = within normal range; 45 to 59 = minimal to moderate anxiety, 60 to 74 = marked to severe
anxiety, and ≥75 = most extreme anxiety.
c
Total score ranges from 0 = no anxiety to 10 = extreme anxiety.

ability pretreatment of 0.70 (McNair
et al., 1992). The researchers began
the study in 2009 when the POMS
was current and before the Profile of
Mood States, second edition (Heu-
chert & McNair, 2012), was released.
The researchers maintained use of the
POMS throughout the study to ensure
consistency.
Zung Self-Rating Anxiety Scale
(Zung SAS). The Zung SAS com-
prises 20 statements with Likert-type
responses within a specified time range
(i.e., “during the past week including
today”), and responses range from 1
to 4: 1= a little of the time, 2 = some
of the time, 3 = good part of the time, or
4 = most of the time, with five items
reverse scored (Zung, 1971). Content
includes cognitive, autonomic, motor,
and central nervous system symp-
toms. A total raw score is translated to
Anxiety Index scores ranging from 25
to 100 with a guide to clinical inter-
pretation: <45 = within normal range;
45 to 59 = minimal to moderate anxiety;
60 to 74 = marked to severe anxiety;
and ≥75 = most extreme anxiety. Zung
(1971) reported reliability in individ-
uals with schizophrenia.
Anxiety Rating Scale (ARS). The
ARS was investigator-developed by
the current first three authors (R.K.B.,
L.N.T., M.D.B.) to determine utility
and feasibility for self-rated anxiety in
individuals with schizophrenia. The
scale is similar to the Numeric Pain
Scale (0-10), which has been widely
accepted as the standard for self-rated
pain. Using one item to rate anxiety,
the scale ranges from 0 (no anxiety) to
10 (extreme anxiety). Feasibility and
clinical utility were established based
on ease of use for course leaders to
administer and course participants to
understand and complete. To estab-
lish reliability, the ARS was analyzed
for correlation with the T-A POMS
and Zung SAS, and these findings are
described under Research Question 3
below.
Individual Practice Records (Home-
work). IPRs were developed by the
researchers to assist participants in
applying strategies in a structured
manner that they learned in class for
managing their anxiety. These IPRs
are handed out during Classes 1-11
and are due at the beginning of the
following class.
Feedback Forms
Two feedback forms were developed
and used to collect data.
Course Leader Feedback Form. This
form comprises 15 items about course
leaders’ experiences teaching the
course with some optional write-in
responses. Course leaders completed
the feedback form after Class 12. The
researchers participated in summa-
rizing the emergent topics from the
course leader feedback forms.
Course Participant Feedback Form.
This form comprises nine questions,
including rankings of helpfulness of
the course and each strategy, whether
they would recommend the course to
others, and whether they feel better
able to communicate with staff about
command hallucinations (if experi-
enced). Participants completed their
forms during Class 12. Forms were
analyzed for frequencies.
RESULTS
Demographics
Ten course leaders taught the
12-session course for a total of six
times at three sites. Course leader
and co-leader disciplines included
combinations of psychology, nursing,
and psychiatry. Of the 27 course par-
ticipants, 81% were male (n = 22)
and 19% were female (n = 5); all were
diagnosed with either schizophrenia
or schizoaffective disorder. Demo-
graphic items for course participants
were intentionally limited to minimize
respondent burden.
Research Question 1
Mean anxiety scores and standard
deviations were calculated for the
three anxiety measures used in the cur-

34 Copyright © SLACK Incorporated

 TABLE 4
CHANGE IN MEAN ANXIETY SCORES FROM BASELINE TO AFTER FOUR ANXIETY REDUCTION CLASSES
Mean (SD) (n)
Anxiety Measure Baseline After Four Classes t Test (p Value), df
T-A POMSa 14.24 (9.04) (21) 11.86 (7.16) (21) 2.216 (<0.038), 20
Zung SAS Index Score b
50.10 (11.48) (21) 49.48 (10.11) (21) 0.265 (<0.794), 20
ARS c
3.36 (2.77) (22) 2.68 (2.30) (22) 1.767 ( 0.092), 21

Note. T-A POMS = Tension-Anxiety subscale of the Profile of Mood States; SAS = Self-Rating Anxiety Scale; ARS = Anxiety Rating Scale.
a
Total score ranges between 0 and 36, with higher scores indicating more anxiety/tension.
b
Total score ranges between 25 and 100, with <45 = within normal range; 45 to 59 = minimal to moderate anxiety, 60 to 74 = marked to severe
anxiety, and ≥75 = most extreme anxiety.
c
Total score ranges from 0 = no anxiety to 10 = extreme anxiety.

TABLE 5
CHANGE IN MEAN ANXIETY SCORES FROM BASELINE TO END OF 12-SESSION COURSE
Mean (SD) (n)
Anxiety Measure Baseline End of Course t Test (p Value), df
T-A POMS a
14.04 (8.86) (21) 10.92 (8.29) (24) 2.823 (<0.01), 23
Zung SAS Index Score b
49.39 (10.35) (23) 48.26 (10.50) (23) 0.451 (<0.656), 22
ARSc 3.32 (2.78) (22) 1.86 (1.98) (22) 2.492 (<0.021), 21

Note. T-A POMS = Tension-Anxiety subscale of the Profile of Mood States; SAS = Self-Rating Anxiety Scale; ARS = Anxiety Rating Scale.
a
Total score ranges between 0 and 36, with higher scores indicating more anxiety/tension.
b
Total score ranges between 25 and 100, with <45 = within normal range; 45 to 59 = minimal to moderate anxiety, 60 to 74 = marked to severe
anxiety, and ≥75 = most extreme anxiety.
c
Total score ranges from 0 = no anxiety to 10 = extreme anxiety.

rent study: (a) T-A POMS, (b) Zung
SAS, and (c) ARS. Zung SAS scores
were converted to Anxiety Index
scores. Means, standard deviations,
and score ranges are shown in Table 3.
Research Question 2
To examine the change in mean
scores for each of the three measures
of anxiety, t tests were calculated. The
results of these analyses are displayed
in Table 4 and Table 5.
Research Question 3
The correlations among all three
anxiety measures at baseline (when
anxiety scores were highest) were sig-
nificant and include: ARS and Zung
SAS, p < 0.006; ARS and T-A POMS,
p < 0.000; and T-A POMS and Zung
SAS, p < 0.001. At the end of the
course at 12 weeks, only the ARS and
T-A POMS were significantly corre-
lated (p = 0.001).
The T-A POMS is proprietary,
costly, and has been recently replaced
with the POMS 2, which requires
online data entry and scoring by
Multi-Health Systems Incorporated
(Heuchert & McNair, 2012). There
is no cost for the Zung SAS, yet cal-
culations are required to convert raw
scores to Anxiety Index scores, it was
inconsistent over time in measuring
anxiety, and was insignificantly corre-
lated with the other scales at Week 12.
The ARS showed consistent measure-
ment of anxiety, significant correla-
tion with the T-A POMS at two time
points, is cost-free, easy to use with
only one item, requires no tallying,
and is understandable for course par-
ticipants.
Research Question 4
Course participants’ ratings of
course helpfulness were measured
with a Likert-type item on the Course
Participant Feedback Form admin-
istered during Class 12. The item
asks: “How helpful has attending this
course been to your learning how to
manage your anxiety?” There are five
possible responses to the question:

Journal of Psychosocial Nursing • Vol. 55, No. 5, 2017 35

 TABLE 6
RATINGS OF COURSE
HELPFULNESS FOR PATIENT
PARTICIPANTSa (N = 26)
Rating n (%)
Not at all helpful 0 (0)
Minimally helpful 3 (11.5)
Moderately helpful 7 (26.9)
Very helpful 11 (42.3)
Extremely helpful 5 (19.2)
a
One participant did not provide a
rating.
(a) not at all helpful, (b) minimally
helpful, (c) moderately helpful, (d) very
helpful, and (e) extremely helpful.
The frequencies of answers for each
response are displayed in Table 6.
The mean course participant rating
for course helpfulness in managing
anxiety was 3.69 (SD = 0.93) (n = 26),
indicating that the 12-session course
was moderately helpful to very helpful
for anxiety reduction in the average
course participant.
Research Question 5
Course participants’ ratings of the
helpfulness of strategies to manage
their anxiety were measured with a
Likert-type item on the Course Par-
ticipant Feedback Form administered
during Class 12. The item asks, “Please
circle each of the strategies that are
helpful to you in managing your anx-
iety.” The frequencies and percentages
were calculated for each strategy and
are shown in Table 7.
Research Question 6
What they themselves learned.
Course leaders said that after teaching
the course, their practice improved
in working with patients with AH. A
PhD leader with 30 years’ experience
said he learned the high prevalence of
anxiety symptoms among this popu-
lation and the importance of anxiety
management in helping individuals
with schizophrenia.
36
TABLE 7
RATINGS OF ANXIETY REDUCTION STRATEGY HELPFULNESS FOR
PATIENT PARTICIPANTS
Strategy
Mindful breathing
Progressive relaxation
Changing anxious thoughts to
healthy thoughts
The most and least helpful aspects of
the 12-session course for course partici-
pants. There was extensive feedback
about the most helpful aspects of the
course for participants. The 12-session
course protocol offered participants
the opportunity to increase awareness
about how anxiety intensified their
AH. Participants also benefitted from
the discussion about how AH trig-
gered negative self-talk, which in turn
heightened their anxiety.
Several participants found it
helpful to be in a group with others
who heard voices and chose to repeat
the course. They shared how iso-
lating it is to experience symptoms
of schizophrenia and how difficult it
was for others without AH to relate to
them. They also learned new ways to
cope from those who had successfully
managed their symptoms. There was
an increased sense of optimism when
they finished the course. Participants
showed an improved understanding of
their illness and ways to manage symp-
toms, increased awareness of available
social support, and improved trust of
health care providers.
The strategies participants learned
in Classes 1 through 4 (anxiety man-
agement) laid the foundational skills
for increased self-awareness and disen-
gagement with voices. One participant
had previously had significant per-
sonal and legal consequences because
of his AH. He had solely depended
on pharmaceutical treatment with
hope for eliminating symptoms, but
grew increasingly impatient with the
lack of efficacy. Because of this course,
n (%)
Helpful Not Helpful
20 (74.1) 7 (25.9)
14 (51.9) 13 (48.1)
8 (47.1) 9 (52.9)
he learned to identify his AH and
negative thoughts, and the relation-
ship between his AH and childhood
trauma. This realization enabled his
consideration of and engagement in
individual psychotherapy, from which
he benefitted greatly. Shortly after-
ward, he wrote to the Medical Center
Director about the success of his treat-
ment and his gratitude for the care he
received.
According to course leaders’ feed-
back, the least helpful aspects of the
course for participants included mul-
tiple instruments that required class
time to complete and resulted in
a faster pace of the classes. Conse-
quently, course participants had less
class time for discussion and question–
answer communication.
Course leaders’ obstacles to con-
ducting the course. Three major obsta-
cles to conducting the course included:
irregular attendance, IPR completion,
and excessive content and measures
per class that limited valued discus-
sion time. Irregular attendance was
often related to course participants’
lack of transportation, inclement
weather, and illness. IPR completion
was inconsistent. Explanation and
completion of measures took away
from class time.
Suggestions for future course leaders.
To improve likelihood of success,
course leaders suggested identifying
and planning for anticipated chal-
lenges (e.g., patient transportation,
staff illness). Another suggestion was
to allow more time at the beginning
of each class to discuss course partici-
Copyright © SLACK Incorporated
pants’ experiences practicing assigned
strategies from the previous week.
DISCUSSION
The 12-session course significantly
reduced anxiety after the first four
classes with further reduction achieved
at the end of the course. Several fac-
tors may have contributed to the effec-
tiveness of the course. First, an anxiety
reduction content expert collaborated
in the design of the first four classes.
Second, training sessions were pro-
vided for all course leaders using the
highly structured treatment manual,
instruments, and IPRs; research pro-
tocol; and timeline for data submis-
sion. Third, strategy practice in class
and at home provided reinforcement
and real-life application.
The ARS and T-A POMS are
optimal for different reasons. The
ARS is simple to understand, based on
the familiar 1-10 Numeric Pain Scale,
...Popularity of the course grew once the course
became evidence-based practice and leaders could
customize applicability to their own settings.
free, and requires no scoring. The T-A
POMS is a stronger research tool with
reported reliability and validity but
costly to purchase and complicated
to score. The ARS and T-A POMS
were highly correlated in the current
study. For the same patients, Zung
SAS Anxiety Index scores did not
reflect significant improvement and
were not correlated with the ARS and
T-A POMS. Hence, for clinical use,
the ARS would be the preferred tool
for anxiety screening that requires the
least burden.
Study findings indicated that the
12-session course was moderately to
very helpful for course participants.
All participants found a useful strategy
to manage their anxiety and no one
Journal of Psychosocial Nursing • Vol. 55, No. 5, 2017
strategy was universally useful. The
benefit of teaching multiple strate-
gies has been demonstrated previously
(Buccheri et al., 2007; Buccheri et al.,
1996; Scott et al., 2015; Trygstad et
al., 2002).
Course leaders reported that
teaching the course helped them
learn the importance of anxiety man-
agement in this population. They
reported improving their knowledge
about the language of AH, skills for
communicating with voice hearers,
and strategies for anxiety reduction
and AH symptom management.
One of the most helpful aspects
of the course for course participants
was being in a group with individuals
with similar issues and sharing expe-
riences. Course participants reported
that the value of being in a group
was in helping others, being helped,
and a sense of not being alone. These
benefits were consistent with Conn,
Algase, Rawl, Zerwic, and Wyman
(2010) who reported that partici-
pant responses to an intervention go
beyond the outcome measures. The
least helpful aspects of the course for
course participants were completing
multiple instruments that resulted in
rushed classes and insufficient discus-
sion time.
Course leader perceptions of obsta-
cles to teaching the course involved
the complex nature of conducting
research in clinical settings. Likely,
reducing the number of tools, data
collection frequency, and addressing
anticipated obstacles could help future
research endeavors. Feeling pressured
to complete requirements while main-
taining clinically beneficial groups
presents challenges to course leaders
for motivating course participants and
maintaining attendance. As noted in
the current authors’ past work with
the 10-session course, popularity of the
course grew once the course became
evidence-based practice and leaders
could customize applicability to their
own settings.
LIMITATIONS
The small sample with a majority of
male course participants limits the gen-
eralizability of the findings. Expecting
clinicians to apply for and receive insti-
tutional review board (IRB) approval
was unrealistic. Few clinicians were
able to complete the IRB process. The
lengthy research approval process lim-
ited the number of settings to those
with clinicians with previous research
approval experience or a mentor to help
them learn the process.
Multiple tools administered at mul-
tiple times were overly burdensome to
course leaders and participants. Incon-
sistent completion of instruments by
course participants may have been
related to their being asked to complete
multiple instruments. Unfortunately,
these incompletions resulted in incon-
sistent sample sizes in the analyses. A
larger sample with fewer instruments
would be ideal for diminishing instru-
ment burden and expanding generaliz-
ability of findings.
Another limitation of the current
study is the number of t tests calculated,
which increases the risk of Type I errors.
A larger study with a control group
would allow for analysis of variance to
be calculated with less risk of Type I
errors.
IMPLICATIONS FOR NURSING
PRACTICE
The findings from the current study
provide evidence that individuals with
schizophrenia and schizoaffective dis-
orders who hear voices and want to
learn new strategies to manage their
anxiety benefit from this 12-session
course. The authors successfully inte-
grated anxiety management into the
existing 10-session course and tested
37

its effectiveness; this work provides
evidence for the clinical utility of the
12-session course.
Nurses are optimally situated to
provide leadership to a variety of
mental health disciplines as they work
together to implement and evaluate
this 12-session course in their setting.
Nurses contribute a unique perspec-
tive in their collaboration with other
disciplines. An important part of this
perspective is nurses’ understanding
of the importance of evidence-based
symptom management. Nurses can
serve as evidence-based practice
champions in their settings by begin-
ning the dialogue about the impor-
tance of evidence-based treatment
for AH, sharing this article with their
leaders and colleagues, and having
discussions about whether there is a
need for teaching this course and what
would be needed for implementation.
CONCLUSION
Four classes that focus on teaching
anxiety reduction strategies were inte-
grated into the 12-Session Behavioral
Management of Anxiety and Auditory
Hallucinations Course. These anxiety
reduction classes became the first four
classes taught in the course. The purpose
of adding anxiety reduction content
into the course was to help participants
reduce anxiety, remain in the course,
and optimize their course benefits. The
current study demonstrated that adding
these classes significantly reduced course
participants’ anxiety after the first four
classes and their anxiety remained
reduced at the end of the course.
The current study found that
psychiatric–mental health nurses and
other licensed mental health staff from
a variety of disciplines can success-
fully teach this evidence-based course.
Psychiatric–mental health nurses can
facilitate a discussion with staff and
administrators about whether this course
could benefit their clients who experi-
ence distressing AH. Using a journal
club format for discussion after staff read
the current article (as well as others on
the reference list) can promote consid-
38
eration about whether the course might
help meet the needs of clients with AH.
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Dr. Buccheri is Professor, and Dr. Trygstad
is Professor Emerita, School of Nursing and
Health Professions, University of San Fran-
cisco, San Francisco; Dr. Buffum is WOC Nurse
Researcher, San Francisco Veterans Affairs
Health Care System, and Clinical Professor,
Department of Community Health Systems,
School of Nursing, and Dr. Dowling is Pro-
fessor, Department of Physiological Nursing,
University of California, San Francisco, Cali-
fornia; and Dr. Ju is Psychologist, Mental
Health Service Line, Iowa City Veterans Affairs
Health Care System, Iowa City, Iowa.
The authors have disclosed no potential
conflicts of interest, financial, or otherwise.
This project was funded by a grant from
the University of San Francisco Faculty
Development Funds. This material is the result
of work supported with resources and the use
of facilities at Marin and Sonoma Buckelew
Programs, the San Francisco Veterans Affairs
Health Care System, San Francisco, California,
and Iowa City Veterans Affairs Health Care
System, Iowa City, Iowa.
This article is dedicated to voice hearers
who experience high levels of anxiety. The
authors acknowledge Monica Elden, MFT,
for her expertise on anxiety reduction and
for helping develop the classes that focus on
reducing anxiety for voice hearers.
The authors wish to promote adoption of
this course by mental health professionals
worldwide. To learn more about implementing
this course, please contact Robin Buccheri by
e-mail at buccherir@usfca.edu. Certificates of
completion and continuing education credits
are offered for implementing this course and
evaluating the outcomes.
Address correspondence to Robin K.
Buccheri, PhD, RN, MHNP, FAAN, 2577 Las
Gallinas Avenue, San Rafael, CA 94903; e-mail:
buccherir@usfca.edu.
Received: February 9, 2017
Accepted: March 22, 2017
doi:10.3928/02793695-20170420-04
39
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permission.