Journal of the American Psychiatric Nurses Association

Behavioral Management of Persistent

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

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

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

Research supported by grants from University of San Fran-

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

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 Journal of the American Psychiatric Nurses Association
P eople with schizophrenia continue to report persis-
tent auditory hallucinations, or “voices,” despite rig-
orous pharmacologic treatment and the introduction of
new psychotropic medications (Carter, Mackinnon, & Co-
polov, 1996). Even after inpatient treatment, Miller (1996)
found that 56% of patients reported persistent hallucina-
tions. Persistent auditory hallucinations are one of the two
most bothersome symptoms reported by persons with
schizophrenia, with up to 98% experiencing related ad-
verse effects including heightened anxiety, depression,
suicide, homicide, substance abuse, inappropriate behav-
ior, and social withdrawal (American Psychiatric Associa-
tion, 1997; Betempts & Ragiel, 1994; Carter, et al.; Freder-
ick & Killeen, 1998). This persistence of symptoms de-
spite treatment clearly indicates a need for adjuncts to
pharmacologic therapy in the clinical management of
persistent auditory hallucinations.
PURPOSE
The overall purpose of this multi-site intervention study
was to examine the short and long term effects of a
10-week course in which behavior management strate-
gies were taught to participants with schizophrenia who
experienced persistent auditory hallucinations. The pri-
mary aim was to examine the effects of teaching behavior
management strategies in a group setting on seven char-
acteristics of auditory hallucinations (i.e., frequency, loud-
ness, self-control, clarity, tone, distractibility, and distress).
Secondary aims included examination of mood states
(i.e., level of anxiety and depression). This study built on
the previous work of the principal investigators in which
participants who attended a similar course showed symp-
tom improvement immediately postcourse and at quar-
Oakland Veterans Administration Outpatient Mental
Health Clinic in Oakland, California.
Susan Hippe, RN, NP, MS, is a nurse practitioner at Cas-
cadia Behavioral Healthcare in Portland, Oregon.
Merrie J. Kaas, RN, CS, DNSc, is an associate professor at
the School of Nursing, University of Minnesota in Minne-
apolis, Minnesota.
Cheryl Covert, RN, CS, MS, is a clinical nurse specialist at
Minneapolis Veterans Administration Medical Center in
Minneapolis, Minnesota.
Patrice Hebert, RN, MSN, is a psychiatric clinical nurse
specialist at Associates in Psychiatry and Psychology in
Rochester, Minnesota.
Reprint requests: Robin Buccheri, RN, DNSc, School of
Nursing, University of San Francisco, 2130 Fulton Street,
San Francisco, CA 94117.
Copyright © 2002 by the American Psychiatric Nurses
Association.
1078-3903/2002/$35.00 ⫹ 0 66/1/125223
doi:10.1067/mpn.2002.125223
June 2002
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Trygstad et al.
terly intervals over a year (Buccheri, Trygstad, Kanas,
Waldren, & Dowling, 1996; Buccheri, Trygstad, Kanas, &
Dowling, 1997). This article presents immediate postint-
ervention effects of the 10-week course. Participants were
followed for 1 year after completion of the intervention,
and these long-term effects will be reported in a future
publication.
BACKGROUND
The University of California San Francisco (UCSF)
Symptom Management Faculty Group (1995) developed
a conceptual model of symptom management that guided
this study and other related work. This preliminary, yet
comprehensive, model of symptom management has
three primary dimensions: the symptom experience,
symptom-management strategies, and symptom out-
comes. Key assumptions underlying the model are that
effective symptom management begins and ends with an
assessment of the symptom from the client’s perspective,
requires a partnership between the client and health care
providers, and goes beyond the prescription of medica-
tions to include a variety of interventions.
Most patients are able to find techniques
that decrease their symptoms, and in some
cases, complete relief is achieved (Carter et
al., 1996).
Behavior Strategies in Managing Auditory
Hallucinations
A growing body of literature suggests that behavior
strategies can be effective in managing auditory halluci-
nations. Behavior management strategies (e.g., self-mon-
itoring, watching television, listening to music with ear-
phones, or talking with someone) (Corrigan & Storzbach,
1993; Margo, Hemsley, & Slade, 1981; Nelson, Thrasher, &
Barnes, 1991) combined with antipsychotic medications
(Breier & Strauss, 1983; Lehman, Thompson, Dixon, &
Scott, 1995) are the most widely used and described
treatments for assisting people with schizophrenia to man-
age the symptoms of persistent auditory hallucinations.
At least seven published reports describe more than
70 patient-initiated techniques for dealing with audi-
tory hallucinations (Breier & Strauss, 1983; Carr 1988;
Falloon & Talbot, 1981; Frederick & Cotanch, 1995;
O’Sullivan, 1994; Romme & Escher, 1989; Tarrier,
1987). Most patients are able to find techniques that
decrease their symptoms, and in some cases, complete
relief is achieved (Carter et al., 1996). Case studies of
therapist-teaching behavior management strategies
(Allen, Halperin, & Friend, 1985; Alford & Turner, 1976;
Feder, 1982; Slade, 1972; Turner, Hersen, & Bellack,
1977) led to more rigorous research, which examined
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Trygstad et al. Journal of the American Psychiatric Nurses Association
teaching a few strategies to small numbers of patients
(Buccheri et al., 1996; Buccheri et al., 1997; Margo et
al., 1981; Nelson et al., 1991). These studies consis-
tently demonstrate symptom improvement; however,
the degree of improvement and individual responses to
specific strategies varies widely.
Characteristics of Auditory Hallucinations
The characteristics of auditory hallucinations are often
used as outcome variables or indicators of symptom im-
provement to assess the effectiveness of behavior inter-
ventions (Allen et al., 1985; Bentall, Haddock, & Slade,
1994; Buccheri et al., 1996; Collins, Cull, & Sireling, 1989;
Margo et al., 1981; Nelson et al., 1991; Turner et al., 1977).
A review of the literature (27 studies) by Shergill, Murray,
and McGuire (1998) found that psychological treatment of
auditory hallucinations often leads to a decrease in dis-
tress and an increased sense of control, but not a reduc-
tion in the frequency of auditory hallucinations.
Anxiety and Depression
Persons with schizophrenia have high rates of comor-
bidity for anxiety and depression (Kendler, Gallagher,
Abelson, & Kessler, 1996). Morbidity is increased regard-
less of whether the affective disturbance is at a symptom
or disorder level (American Psychiatric Association, 1997).
Affective disorder is strongly correlated with suicide,
which is the leading cause of premature death in persons
with schizophrenia (Conwell, Cholette, & Duberstein,
1998; Fenton, McGlashan, Victor, & Blyler, 1997). This risk
is significant, with 9% to 24% of persons with schizophre-
nia committing suicide (Conwell et al.).
Hustig and Hafner (1990) reported that patients who
experienced more intrusive and distressing hallucinations
were more anxious and depressed than patients with less
intrusive and distressing hallucinations. They suggested
that further work be done to alter the mood of people
who experience persistent auditory hallucinations and
called for researchers to study the effects of strategies that
decrease anxiety and depression on auditory hallucina-
tions. Buccheri et al. (1996) and Buccheri et al. (1997)
taught behavior management strategies in a 12-week
course that incorporated a support-group format and re-
laxation exercises specifically designed to target anxiety
and depression. This intervention resulted in clinical im-
provement in anxiety and depression from preinterven-
tion assessment to postintervention assessment and
throughout the entire 12 month follow-up period.
Group Format in Treating Psychotic Symptoms
Carter et al. (1996) suggested “an approach that intro-
duces patients to a range of strategies, encourages exper-
imentation and monitors outcomes” (p. 164). Experiment-
ing with a wide array of strategies and learning from the
experiences of self and others are best accomplished in a
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group setting with people who have similar experiences.
Possible benefits from group participation include sup-
port, universality, and installation of hope (Yalom, 1985).
Kanas (1919) described group treatment for patients with
schizophrenia as particu- larly appropriate to achieve the
benefits discussed by Yalom and to help clients improve
interpersonal relationships and learn to cope with psy-
chotic symptoms. Participants in the Buccheri et al. study
(1996) described benefits similar to those described by
Kanas and Yalom. These benefits included: universality
(“I’m not the only one”); validation of their own experi-
ence, such as the circumstances regarding the onset of
auditory hallucinations; an opportunity to learn about
auditory hallucinations and how others manage them,
such as whether to answer the voices in public; an op-
portunity to be a role model and/or find a role model; and
encouragement and hope from observing other members
of the group who experienced a decrease in some dis-
tressing characteristics of auditory hallucinations.
Possible benefits from group participation
include support, universality, and installation
of hope (Yalom, 1985).
In summary, this review of the literature highlights the
pervasiveness of persistent auditory hallucinations in per-
sons with schizophrenia and the benefits that behavior
management strategies can have on symptom severity.
However, research on the comparative effectiveness of
specific behavior strategies and effective measurement of
specific outcome variables is limited and inconsistent.
METHODS
Design
This study employed a quasi-experimental, repeated
measures design.
Sample
A nonprobability sample of people with schizophrenia
who were experiencing persistent auditory hallucinations
was used. Subjects were recruited for 10 groups in nine
different outpatient settings. The sample consisted of 72
subjects whose diagnosis of schizophrenia had been con-
firmed by a board-certified psychiatrist using Diagnostic
and Statistical Manual of Mental Disorders, fourth edition
(American Psychiatric Association, 1994) criteria. Subjects
underwent screening by the investigators and met the
following inclusion criteria: reported having persistent
auditory hallucinations for at least 10 minutes a day for the
past 3 months; reported a desire to learn new strategies to
manage their auditory hallucinations; were taking stable
doses of antipsychotic medication for at least 4 weeks
before entry into the study; were able to read and write in
Vol. 8, No. 3
 Journal of the American Psychiatric Nurses Association
English; and did not have a severe cognitive deficit as
defined by a score of ⬎24 on the Mini-Mental Status Exam
(Folstein, Folstein, & McHugh, 1975). All patients with
severe substance abuse were excluded from the study.
Ten subjects were dropped from the study when they did
not adhere to the protocol; the final sample size was 62.
The mean age of participants was 44.1 years with a
range of 23 to 72 years. The mean age of onset of voices
was 24.8 years with a range of 1 to 47 years. Participants
had, on average, heard voices for approximately 20 years.
Of the 62 study participants, 72.6% (n ⫽ 45) were male
and 27.4% (n ⫽ 17) female. The gender bias towards
males was influenced by the study sites. Four of the 10
groups were in Veterans Administration facilities. These
four groups were nearly all male. Ethnicity is also reflec-
tive of the data collection sites; 8 of the 10 sites were in
urban areas in Northern California. Participants were 71%
(n ⫽ 44) Caucasian, 14.5% (n ⫽ 9) African American,
4.8% (n ⫽ 3) Latino, 6.5% (n ⫽ 4) Chinese, and 2.8% (n ⫽
2) other. The majority of participants (62.9%, n ⫽ 39)
were single, while 17.7% (n ⫽ 11) were married, and
19.4% (n ⫽ 12) were widowed or divorced. About one
third (32.2%, n ⫽ 20) had some paid or volunteer em-
ployment, whereas approximately two-thirds (67.7%, n ⫽
42) had no employment or volunteer work.
Measurement and Instrumentation
Characteristics of Auditory Hallucinations. The
Characteristics of Auditory Hallucinations Questionnaire
(CAHQ) is a seven item instrument compiled by the in-
vestigators. The CAHQ asks participants to rate the char-
acteristics of their auditory hallucinations during the past
24 hours. Four items (clarity, tone, distractibility, loud-
ness) were adapted from items developed by Hustig and
Hafner (1990); three items (frequency, self-control, and
distress) were drawn from the literature review (Allen et
al., 1995; Breier & Strauss, 1983; Chadwick & Birchwood,
1994; Hustig, Tran, Hafner, & Miller, 1990; Shergill, Mur-
ray, & McGuire, 1998; Slade, 1974). Similar to the Hustig
and Hafner diary, the CAHQ uses a Likert-type scale
ranging from 1 to 5. Hustig and Hafner report adequate
reliability (.74) based on test-retest correlations.
Clarity. Clarity is a characteristic of auditory hallu-
cinations that describes to what degree the voices are
either clear or muddled (Hustig & Hafner, 1990). As
auditory hallucinations improve, voices become more
mumbled and easier to ignore (Buccheri et al., 1996).
Participants rated the clarity of their voices as very
mumbled, moderately mumbled, sometimes mum-
bled—sometimes clear, moderately clear, or very clear.
Tone. Tone is a characteristic of auditory hallucinations
that relates to whether the voices are perceived as com-
forting or distressing. This characteristic of auditory hallu-
cinations has been labeled differently by various research-
ers. Hustig and Hafner (1990) described distressing voices
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Trygstad et al.
as the opposite of comforting voices. Participants rated
their auditory hallucinations as very comforting, moder-
ately comforting, sometimes comforting—sometimes dis-
tressing, moderately distressing, or very distressing.
Distractibility. Distractibility is a characteristic of au-
ditory hallucinations that describes the person’s ability to
ignore the voices and focus on something else (e.g.,
talking with someone or watching television). Behavior
strategies that require “holding or focusing of attention”
seem to provide some relief to those who hear distressing
voices (Buccheri, et al., 1996; Carter et al., 1996; Frederick
& Cotanch, 1995; Tarrier, 1987). Participants rated their
auditory hallucinations as very easy to ignore, minimally
distracting, moderately distracting, very distracting, or
unable to pay attention to anything else.
Loudness. Loudness is a characteristic of auditory hal-
lucinations that describes the volume of the voices. Hustig
and Hafner (1990) asked participants to record the loud-
ness of their auditory hallucinations on a 5-point Likert-
type item with responses ranging from very loud to very
quiet. For this study, this characteristic was modified to
include terms frequently used by clients (Buccheri et al.,
1996; Buccheri et al., 1997). Participants rated the loud-
ness as whispering, could hardly hear, speaking softly,
normal speaking tone, speaking loudly, or shouting.
Frequency. Frequency is a characteristic of auditory
hallucinations that refers to how often the voices are
heard. This characteristic has been used as an outcome
measure in many studies but has yielded mixed results,
especially when examining grouped versus individual
data. For example, Hustig et al. (1990) examined the
effects of listening to two different audiotapes (relaxing
and arousing) on the frequency of hearing voices for 10
subjects. They found that listening to either of the tapes
did not affect frequency of voices for the group means
but was effective for three persons. Buccheri et al.
(1996) and Buccheri et al. (1997) found similar results
with a sample of 12. Participants rated their auditory
hallucinations as only once or twice, sometimes, half the
time, very often, or constantly.
Self-control. Self-control is the person’s ability to
decrease or stop the voices. Kanfer (1971) developed a
model of self-control which had three phases: self-
monitoring, self-evaluation, and self-reinforcement.
Breier and Strauss (1983) operationally defined the
three phases of Kanfer’s model of self-control— detec-
tion of behavior, evaluation of the behavior, use of a
strategy to control the behavior—and then tested the
model with a small sample of psychiatric patients. The
researchers found that some people were able to con-
trol their psychotic symptoms. In this study, partici-
pants rated their level of self-control over their auditory
hallucinations as totally in control, pretty much in con-
trol, a little in control, very little in control, and not in
control at all.
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Trygstad et al. Journal of the American Psychiatric Nurses Association
Distress. Distress is the degree of suffering that the
person experiences in response to hearing voices. Dis-
tress and being bothered, worried, and upset are words
used to describe this experience. Carter et al. (1996)
reported that 81% of subjects were worried or upset by
their hallucinations. Participants rated their level of
distress as not distressed, minimally distressed, moder-
ately distressed, very distressed, or extremely distressed.
Symptom Management Notebook
Participants were also given a Symptom Manage-
ment Notebook to help teach self-monitoring. Com-
pleting the notebook served to remind subjects to prac-
tice the strategies twice a day.
Anxiety
The Tension-Anxiety subscale of the Profile of Mood
States (POMS) (McNair, Lorr, & Droppleman, 1992)
consists of nine items and is measured on a 5-point
Likert scale, ranging from 0 not at all, to 4 extremely. A
higher score is indicative of more anxiety/tension.
Lower mean scores indicate less anxiety. The POMS
has been used with a variety of physically and mentally
ill patients and healthy persons. Internal reliability for
the tension-anxiety subscale is ⬎.90, and test-retest
reliability pretreatment is .70 (McNair et al.).
Depression
The Beck Depression Inventory, second edition (BDI-
II) (Beck, Steer, & Brown, 1998) is a 21-item self-report
instrument that assesses the presence and degree of de-
pressive symptoms in adults and is scored on a 4-point
scale. Two of the items assess possible suicide risk.
Higher scores indicate higher levels of depression. The
BDI-II builds on 35 years of psychometric data from the
first two versions of the Beck Depression Inventory. The
initial psychometric data for the BDI-II are from a sample
of 500 psychiatric outpatients with a variety of diagnoses.
Reliability measures include internal consistency (coeffi-
cient alpha ⫽ .92) and test-retest stability (correlation
⫽.93, p ⬍ .001). Validity measures include content valid-
ity and construct validity (Beck et al., 1996).
STUDY PROTOCOL
The study took place in three phases: preinterven-
tion assessment, intervention (10-week course), and
postintervention assessment.
Preintervention Assessment
The preintervention assessment occurred in group
meetings. Participants completed the CAHQ, the Ten-
sion-Anxiety subscale of the POMS, and the BDI-II.
Intervention: The 10-week Course
The 10-week course was taught in a structured group
format designed to foster safe interactions among partic-
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ipants and to stress the value of each person’s experience.
Course facilitators were nurses with experience with pa-
tients with schizophrenia and with group facilitation
skills; most had Master’s or Doctoral degrees. In each
class, participants were taught and practiced one behav-
ioral strategy. The following strategies were taught in the
course: self-monitoring, talking with someone, listening
to music with or without earphones, watching television,
saying “stop”/ignoring what the voices say to do, using an
ear plug, relaxation techniques, keeping busy with an
enjoyable activity and/or helping others, and practicing
communication related to taking medication and not us-
ing drugs and alcohol.
In each class, participants were taught and
practiced one behavior strategy.
The structure of each weekly class was as follows:
● Participants completed the CAHQ while course facili-
tators collected the Symptom Management Notebook
from the previous week (5 minutes).
● Course facilitators asked each participant to describe his
or her experience with the strategy of the past week.
Participants could respond to course facilitators or one
another with questions or comments (15 minutes).
● Course facilitators taught the new strategy for the week
and why and how it might be helpful. Participants asked
questions and made comments as desired (10 minutes).
● The new strategy was practiced by all individuals in the
course including the course facilitators. Questions, com-
ments, and experiences were discussed (15 minutes).
● Symptom Management Notebooks for the next week
were distributed (5 minutes).
The investigators developed a manual for the 10-week
course to clarify class structure and climate and to ensure
consistency across courses and between facilitators. Con-
sistency was needed both in the delivery of the interven-
tion and in data collection. The investigators met or talked
with each course facilitator before implementation of the
course and reviewed the manual, data collection proce-
dures, and instrument administration. The investigators
maintained regular telephone contact with course facili-
tators to answer questions and to ensure consistency
across data collection sites.
Post-Intervention Assessment
At the conclusion of the course (last class session),
participants completed the CAHQ, the tension-anxiety
subscale of the POMS, and BDI-II.
RESULTS
It was expected that subjects who attended the be-
havior-management strategy classes for auditory hallu-
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 Journal of the American Psychiatric Nurses Association Trygstad et al.

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

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

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Trygstad et al. Journal of the American Psychiatric Nurses Association
using a convenience sample and a one-group design,
including only participants who were stable on medi-
cation in an outpatient setting and focusing on short-
term effects of the intervention. The investigators are
currently analyzing longitudinal follow-up data to as-
sess the long-term effects of this intervention.
This study demonstrates that clients can learn and
use behavior strategies to manage their auditory hallu-
cinations. This study also illustrates that a group setting
is a particularly useful venue in which to have clients
learn new strategies. In a group setting, clients see that
they are not alone, that is, that others suffer from the
same symptoms. Participants were encouraged when
they saw others finding strategies that worked for them.
By teaching the strategies in a group, clients are given
the chance to practice and discuss the effectiveness of
new strategies with others who have experience man-
aging their auditory hallucinations.
The investigators are currently examining which be-
havior strategies are effective for participants with spe-
cific characteristic profiles. This may allow us to answer
the question posed by Fenton and Schooler (2000)
“What works best for whom?” (p. 2). For example, are
earplugs more effective in left-handed versus right-
handed persons, or are headphones more effective
when voices are heard outside the head versus inside
the head? The results of these analyses could provide
specific strategies for participants with certain charac-
teristics rather than having them try to practice all of the
strategies.
The researchers are also exploring the characteristics
of those participants who improved, stayed the same,
or declined on each measure. This will allow answers
to questions such as: Did participants who had heard
voices longer show the most improvement in the char-
acteristics of their hallucinations after attending the
10-week course? Did participants who heard voices
inside their head report no change in their anxiety and
depression whereas those who heard voices outside
their head report less anxiety and depression after
attending the 10-week course?
Teaching behavior management of persistent
auditory hallucinations to clients who wish to
learn has minimal risks and could be easily
incorporated into existing outpatient
programs.
IMPLICATIONS FOR NURSING PRACTICE
The intervention tested in this study, group teaching
of behavior strategies to manage auditory hallucina-
tions, combines education, skills training, and support.
This low cost, low-tech intervention could be incorpo-
rated into the practice of psychiatric nurses or other
90 APNA Web site: www.apna.org
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mental health professionals who have group training
and experience facilitating groups with people who
have schizophrenia. Teaching behavior management
of persistent auditory hallucinations to clients who
wish to learn has minimal risks and could be easily
incorporated into existing outpatient programs.
The results of this study show that people who suffer
from auditory hallucinations can significantly benefit
from learning behavior management strategies. Hope-
fully, this intervention will become widely available to
those who are tormented by auditory hallucinations.
“When an effective psychosocial intervention is avail-
able to remedy a disabling aspect of schizophrenia,
just as when a better medication is available, its appli-
cation should help define the current standard of care”
(Fenton & Scholler, 2000, p. 3).
SUMMARY
The purpose of this multi-site study was to examine
the short-term effects of a 10-week course on seven
characteristics of auditory hallucinations (i.e., fre-
quency, loudness, self-control, clarity, tone, distractibil-
ity, and distress), anxiety, and depression. All except
one were significantly reduced. Medication-resistant
auditory hallucinations are pervasive in persons with
schizophrenia. The results from this study contribute to
the body of knowledge and the scientific basis for
nursing practice for persons with schizophrenia who
have persistent auditory hallucinations. Teaching be-
havior strategies in a class setting that combines edu-
cation, skills training, and support was effective, low
cost, and had minimal risks.
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