University of Ghana http://ugspace.ug.edu.gh uwivtnsiTY or Oman* l i o n a n v RC553. A84 B44 bite C.l n-»711Q4 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh UNDERSTANDING PATIENTS’ BELIEFS ABOUT VOICES (AUDITORY HALLUCINATIONS) AND PATIENTS’ ADOPTED COPING STRATEGIES B Y EVELYN BENTIL THIS THESIS IS SUBM ITTED TO THE UNIVERSITY OF GHANA. LEGON IN PARTIAL FULFILMENT OF THE REQUIREM ENT FOR T ill AW A RD OF M. PHIL DEGREE IN “PSYCHOLOGY" UNIVERSITY OF GHANA LEGON, 2003 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that, except for references to other people's works which have been duly cited, this work is the result of my own research and that this thesis has neither in whole nor in part been presented for another degree. Signature:.. !?. \........... Date:... L| EVELYN BENTIL (STUDENT) Signature:..................... Date:............................ PROF S A DANQUAH (SUPERVISOR) Signature:............. Date:...................... PROF JYOPOKU (SUPERVISOR) II http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT PAGE Acknowledgment............................................................................................... V1i Dedication........................................................................................................ vii* List of Acronyms................................................................................................ ix Abstract.............................................................................. x CHAPTER ONE (INTRODUCTION) 1.1 Schizophrenia.............................................................................................1 1.2 Symptoms of Schizophrenia......................................................................4 1.3 Hallucinations............................................................................................6 1.4 Culture and Auditory Hallucinations.........................................................9 i 1.5 Prevalence of Schizophrenia and Hallucination......................................10 1.6 Are Hallucinations Always Psychiatric?................................................12 1.7 Auditory Hallucinations.........................................................................14 1.8 The Diagnosis of Auditory Hallucinations..............................................18 1.9 Auditory Hallucinations, Stress And Ways of coping............................ 21 1.10 Beliefs And Hallucinations..................................................................... 25 i 1.11 Gender and Coping Strategies................................................................ 30 1.12 Aim.................................................. 30 1.13 Goals of the Study.................................................................................. 31 1.14 Definitions.............................................................................................. 31 1.15 Statement of the problem........................................................................ 33 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO (LITERATURE REVIEW) 2.1 The Domain of the Review........................................... 35 2.2 Theoretical framework................................................................................. 35 2.3 Coping Strategies Frequently Used By Patients.......................................... 38 2.4 Coping Techniques Studied By Professionals And Effectiveness.............. 40 2.5 Cross-Cultural Differences In Coping Strategies.........................................48 2.6 Clinical Explanations For Effectiveness Of Techniques.............................49 2.7 Literature On Studies Done Using The GAF Scale.....................................50 2.8 Literature On Studies That Have Been Done Using The Ways Of Coping Technique..................................................................................................... 52 2.9 Literature Reviewed On Beliefs About Mental Illness................................56 2.10 Research Done On Sex And Gender.......................................................58 2.11 Limitations Of These Methodologies......................................................60 £ 2.12 Summary Of Main Types Of Coping Strategies.....................................61 2.13 Rationale For This Study.........................................................................61 2.14 Hypotheses...............................................................................................62 • b tCHAPTER THREE (METHODOLOGY) 3.1 Population And Sample........................................ j * a : ......................... 63 3.2 Instruments Used..................................................................................... 63 3.3 The Design And Procedure....................... 70.... ^ 3.4 Scoring Of Data....................................................................................... 72 iv http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR (RESULTS) , 4.1 Global Assessment Of Functioning (GAF) Scale...................................73 4.2 Summary Of Results................................................................................ 80 CHAPTER FIVE (DISCUSSION) 5.1 Summary and Conclusion........................................................................ 94 5.2 Limitations Of The Study........................................................................97 5.3 Recommendations...................................................................................97 Bibliography.................................................... ;...............................................98 Appendix 1. Consent form......................................................................................... 110 2. Screening question................................................................................. I l l 3. G A F Scoring Sheet..............................................................................112 4. G A F Scale...........................................................................................113 5. W O C Checklist................. 116 6. Cognitive Assessment Questionnaire...................................................120 LIST OF TABLES AND FIGURES Figure 2.1 (The coping process)....................................................................... 39 Table 3.1 (descriptive characteristics of the sample).........................................63 Table 4.1 (GAF Score)...................................................................................... 75 Table A 1 (Level of education)........................................................................ 122 Table A2 (Occupation) ..................................................................................122 Table A3 (Religion)..........................................................................................122 Table A4 (Gender And Type Of Coping)........................................................ 123 Table A5 (Gender And Level Of Coping)....................................................... 123 Table A6 (Gender And Other Ways Of Coping With Voices)........................123 Table A7 (Age And Type Of Coping)............................................................. 124 Table A8 (Age And Level Of Coping)............................................................ 124 Table A9 (Age And Other Ways Of Coping).................................................. 124 Table A10 (Age And Powerful Nature Of Voice)...................................:.......125 Table A11 (Intention Of Voices And Level Of Education)............................125 Table A12 (Repetitive Nature Of Voices And Affective Response Of Subjects)...........................................................................................................125 Table A13 (Affective Response And Intention Of Voices)............................126 Table A14 (Affective Response And Antecedent Events)..............................126 University of Ghana http://ugspace.ug.edu.gh vi http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh A C K N O W LED G EM EN TS For every good work done, the first appreciation must go to God. I therefore thank the Most High God for His help throughout my second-degree programme. I also gratefully acknowledge analytical inputs to this study by my supervisors: Prof. SA Danquah and Prof. J Y Opoku. I am grateful to Mr Domfeh of the School of Administration and Evangelist Ekow Dadzie of the Full Bible Church who helped me with the printing of this work. May the Good God bless you. Special acknowledgements also goes to the staff, the trainee nurses who helped me with data collect and patients (who participated in the study) at Accra psychiatric Hospital and Pantang Psychiatric Hospital. vii http://ugspace.ug.edu.gh University” of Ghana http://ugspace.ug.edu.gh I DEDICATION I dedicate this thesis to the Most High God, My Family at Cape Coast and to my children yet to be born. http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh LIST OF ACRONYMS G A F - Global Assessment of Functioning Scale W O C - Ways of Coping Checklist D S M - Diagnostic and statistical manual ix http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh ABSTRACT The purpose of this study was to obtain information regarding the understanding of the schizophrenic patients’ beliefs about voices (auditory hallucinations) and their adopted coping strategies. The Ways of Coping Checklist, a Semi-Structured Questionnaire and the Global Assessment of Functioning Scale were used to explore the beliefs patients suffering from schizophrenia have about auditory hallucinations and the ways of coping patients adopt to cope with auditory hallucinations. The participants were in­ patients with clinical diagnoses of schizophrenia. The results indicated that there were significant differences between men and women in the strategies adopted in coping with auditory hallucination. Further, the young and old did not differ in the coping strategies they have adopted for coping with auditory hallucinations; and also beliefs about the intention of the voice affected one's affective response to auditory hallucinations. The results revealed that most patients’ suffering from auditory hallucinations believe that auditory hallucinations have supernatural causes. Ways of coping with auditory hallucinations varied from praying to taking medication. http://ugspace.ug.edu.gh C H A PTE R ONE INTRO DUCTIO N 1.1 SCHIZOPHRENIA Schizophrenia is the label given to a group of psychotic symptoms in which deterioration of functioning is accompanied by severe distortion of thought, perception, mood, bizarre behaviour and social withdrawal (Bootsin, Acocella, & Alloy 1993). In other words, schizophrenia may be defined as a severe disorder characterised by impaired social, emotional, cognitive and perceptual functioning. The basis of schizophrenia is a splitting within thinking and feeling themselves, between internal and external perception, a loosening in the association of ideas, which leads to a deep distance of both thought and feeling and thus a disorder of the whole personality. In fact, the term schizophrenia comes from the Latin word ‘schizo' meaning split and ‘phrenia' meaning mind. The individual’s mind is split from reality and thought patterns become fragmented. Schizophrenia and multiple personality disorder (called split personality) are different. Schizophrenia involves the split of one’s personality from reality not the co-existence of several personalities within one individual (as in split personality). Schizophrenia can be caused by genetic, biological, environmental or socio­ cultural factors (Bootsin, Acocella, & Alloy 1993). A. Genetic factors: If one has a relative with schizophrenia, what are the chances that one'will develop schizophrenia? It depends on how closely you are related. As genetic similarity increases, so does your risk of becoming schizophrenic. University of Ghana http://ugspace.ug.edu.gh http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh An identical twin of a person with schizophrenia has a 46% chance of developing the disorder. A fraternal twin, 14%; a sibling, 10% and an unrelated individual in the general population, 1% (Gottesman & Shields, 1982). The precise nature of the genetic influence is unknown. B. Neurobiological factors: Many neuroscientists believe that imbalances in brain metabolism, a malfunctioning dopamine system and distorted cerebral blood flow, cause schizophrenia (Cromwell & Snyder, 1993). Imaging techniques, for example, Positron Emission Tomography (PET) scan clearly shows deficits in brain metabolism. It has been reported that persons with schizophrenia produce too much of the neurotransmitter dopamine (Cromwell & Snyder, 1993). Persons suffering from schizophrenia also have a reduced blood flow in the prefrontal cortex (Weinberger, Berman, & Zee, 1986). For example when scientists monitored the brains of persons with schizophrenia as they performed a sorting task, the blood did not adequately flow into the prefrontal region' where much of advanced thinking takes place (Weinberger, Berman, & Zee, 1986). C. Environmental factors Schizophrenia does not occur in an environmental vacuum. Some researchers e.g: (Goldstein, 1986) believe that environmental factors are important in schizophrenia. Others e.g. (Gottesman & Shields, 1982) 2 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh believe that genetic factors outweigh environmental factors. Stress is the environmental factor given the most attention in understanding schizophrenia. The diathesis-stress view argues that a combination of environmental stress and biogenetic disposition can cause schizophrenia (Meehl, 1962). A defective gene make-up only produces schizophrenia when the individual lives in a stressful environment. Advocates of the diathesis-stress view emphasise the importance of stress reduction and family support as part of treating schizophrenia (Meehl, 1962). D. Socio-cultural factors Disorders of thinking and emotions are common in schizophrenia within all cultures but the type and incidence of schizophrenic disorders may vary from culture to culture (Carson, Butcher & Coleman, 1988). One of the most puzzling studies evaluating cultural factors reported that the admission to mental health facilities for schizophrenia is very high for Irish Catholics in the Republic of Ireland (Torrey, 1980) but not among Irish Catholics living elsewhere (Murphy, 1978). Rates of schizophrenia may also vary for different groups within the same culture. For example, one study revealed that Blacks had higher rates of schizophrenia than Whites in both U.S. and Great Britain (Bagley, 1984). Blacks had significantly greater number of life crises than Whites and that may have precipitated schizophrenic episodes. In addition, African-Americans and African-British who became schizophrenic had higher aspirations to succeed than those who did not 3 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh become schizophrenic. One explanation may be that Blacks’ efforts to became assimilated into, and achieve parity within a mainstream society that is oppressively racist creates considerable stress. It seems that poverty and the living conditions it engenders are much more likely to be associated with schizophrenia than ethnicity. 1.2 SYMPTOMS OF SCHIZOPHRENIA Symptoms of schizophrenia can be divided into positive and negative symptoms (Kurt Schneider 1939). There are also other symptoms, which are neither positive nor negative. These terms, positive and negative symptoms, have slipped into the language of contemporary psychiatry with comparative ease. Negative symptoms consist of behavioural deficits such as avolition, alogia, anhedonia and flat affects (Davison & Neale, 1989): i. Avolition refers to the situation whereby patients lose interest in daily routine activities. At times, personal hygiene is not observed. ii. Alogia is a negative thought disorder. Here the amount of speech is greatly reduced and the patient's speech is with little information. Some patients may not respond to questions at all or take a long time before they do so. iii. Anhedonia refers to an inability to experience pleasure especially in things that once gave the patient pleasure. iv. Flat Affect: A patient with flat affect may answer in a flat toneless voice 4 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh when spoken to. The patient may stare vacantly, the muscles of the face flaccid and the eyes lifeless (Davison & Neale, 1989). Positive symptoms. consist of excesses such as delusions, bizarre behaviour and hallucinations. i. Delusions may be defined as irrational beliefs that a person will defend with great vigour despite overwhelming evidence that they have no basis in reality. There are delusions of control. That is, the belief that some external force such as radar, a television or a creature from outer space is manipulating the person. In Africa, a person with delusions of control may belief that he or she is being controlled by witchcraft or his or her dead mother, and so on. There are also delusions of grandeur, which is the belief that one is an especially important or powerful person. People ," with schizophrenia sometimes have delusions of persecution - the belief that one is being plotted against or oppressed by others. ii. Bizarre behaviour is also a positive symptom of schizophrenia. This behaviour includes habits like hoarding food, collecting garbage and talking to one’s self. iii. Other positive symptoms include somatic passivity, thought insertion, thought broadcasting, thought withdrawal and hallucinations. Somatic passivity is when the person is passive to things around him or her. Thought insertion is when the person believes that outside thoughts are inserted into his or her head. Thought broadcasting is when the person 5 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh believes that his or her thoughts are being broadcast to people around him or her. When the person feels that some of his or her thoughts are being withdrawn from his or her head, it is described as thought withdrawal (Davison & Neale, 1989). Hallucinations will be discussed in detail later on, in this thesis. Other symptoms, which do not fall under the positive-negative scheme, include catatonic excitement, catatonic immobility, waxy flexibility and inappropriate affect. i. Catatonic Excitement: A patient with catatonic excitement may behave in the same way that a manic patient does. He or she will get excited about things that should not excite him/her under normal conditions. A schizophrenic patient with catatonic immobility adopts unusual and seemingly uncomfortable postures for long periods of time. For example, he or she may stand on one leg all day long. Some catatonic patients may have waxy flexibility. Here the patient's limb can be moved into strange positions and maintained for long periods of time. ii. Inappropriate Affect: Patients who laugh on hearing bad news like the death of a relative and get angry on being complimented are said to be having inappropriate affect (Davison & Neale, 1989). 1.3 HALLUCINATIONS Added to the perceptual problems in schizophrenia is the fact that schizophrenic patients perceive things that are not there. Most schizophrenics report difficulties in attending to what is happening around them. Most schizophrenics are not aware 6 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh of what is happening around them. In addition, most of them remark that their surroundings are not as they used to be and everything appears flat and colourless (Falloon & Talbot 1981). The most dramatic distortions are called hallucinations and this is a positive symptom of schizophrenia. The word hallucination is derived from the Latin word ‘alucinatio’, which means to talk idly or to wander mentally. In the 16th century, it was used to refer to ghosts and spirits walking by night (Sarbib & Juhasz, 1975). A perceptual experience in the absence of relevant stimulation is hallucination. Hallucinations can also be defined as perceptions in any sensory modality without relevant and adequate external stimuli (Bootsin, Acocella & Alloy 1993). Hallucinations may be in the form of hearing voices (auditory hallucination) or seeing images (visual hallucination). It can also be tactile hallucinations (crawling things such as bugs, felt on the skin along with uncanny sensations), gustatory (in connection with the taste), somatic (to do with the body) and olfactory hallucinations (smelling odours), Among these forms of hallucinations, auditory hallucinations are the most frequent, followed by visual hallucinations and then hallucinations of the other senses (Ludwig 1986). Hallucinations occur spontaneously and most people with schizophrenia are unsure whether their hallucinations are real or imagined (Frith & Done, 1988). This is because hallucinations result from the failure of the cognitive mechanism [which assists us to distinguish between experiences generated by the mind and 7 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh experiences induced by external stimuli, (Bental, 1990).] Severely psychotic patients are in fact convinced that their hallucinations are perceptions of objectively real events (Frith & Done 1988). These voices are sometimes persistent. Moreover, they may have a threatening or obscene nature or represent some outside evil power over which the patients feel they have no control. At other times, the same voices may be regarded as good and pleasant companions. Some patients are so pre-occupied with and reactive to the voices that social reintegration is hampered. Various reviews of schizophrenia research published in the 1960s and 1970s (DeWolf, 1974; Higgins, 1969; Neale and Cromwell, 1970; Payne, 1973) were in agreement that patients with a good premorbid history differed in their style of attention deployment from patients with a poor premorbid history (process schizophrenics). Reactives were more attentive to external stimulation, risked excessive input and stimulus flooding. Process schizophrenics were described as insensitive to external stimulation and as such vulnerable to the dangers of attentional withdrawal and autism. Most patients (64%) consider external factors to be responsible for their voices (Jenner, Van & Wiersma, 1998). In a study of auditory hallucinations, (Heilbrun & Blum, 1984), psychiatric patients were asked to judge the localisation from which words were spoken within the experimental room and without assistance of visual cues. Process hallucinators revealed a serious deficit in spatial localisation 8 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh of auditory cues, suggesting that they would have a special problem in dis- confirming the perception of a voice thought to be addressing them from somewhere in their surroundings. Their lack of spatial localisation ability was interpreted to be a result of their withdrawal of attention from outside stimulation. Reactive hallucinators were not impaired on the spatial-location task relative to patient control subjects (Heilbrun & Blum, 1984). The problem of dis-confirming the faulty perception of a voice in the case of reactive hallucinators was treated in an investigation of how patients assign meaning to stimuli (Heilbrun & Blum, 1984). Heilbrun and Blum, (1984) found out that reactives with a history of auditory hallucinations were more intolerant of ambiguity, being quick to assign meaning to unclearly spoken words. A second measure suggested that they also were disinclined to search for alternative meaning once they had settled on an interpretation. Process hallucination and non­ hallucinating control subjects did not show these cognitive characteristics. It was suggested that reactives would be vulnerable to misinterpretation because of the premature interpretation of ‘thought’ as a voice, and less capable of correcting this error because they are less inclined to consider alternatives (Heilbrun, Diller, Fleming, & Slade, 1986). 1.4 CULTURE AND AUDITORY HALLUCINATIONS Culture appears to moderate the occurrence, quality and frequency of hallucinations. Third world cultural groups - partly Africans, West Indians, and 9 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh Saudi Arabians - .hallucinate (hear voices) more than those in industrialised societies do (Ndetei & Vadher, 1984). Within the U.S., Blacks and Hispanics report more auditory hallucinations than Whites, which tends to lead to a higher risk of misdiagnosis in the direction of psychopathology (Mukher-jee, 1983). But specific studies of the effect of culture on hallucinations have either lacked an accurate contemporary population base (Field, 1968; Sikanartey & Eaton, 1984) or have not involved active case - finding within the general population under investigation (Sikanartey & Eston, 1984). Gender differences are not apparent from the literature. 1.5 PREVALENCE OF SCHIZOPHRENIA AND HALLUCINATIONS There are reports that the prevalence of schizophrenia is constant with respect to time and place (Ben-Toyim, & Cushnie J.M. 1986). Torrey (1980) has proposed that schizophrenia is a disease of industrialised society, thus reviving an argument that has been alive for at least 150 years (Burrows, 1828; Maudsley 1879; Morison, 1824). Torrey (1980) has also used contemporary fieldwork studies to examine geographical variations in the prevalence of schizophrenia, and has identified a relative failure of schizophrenia to penetrate to the more remote parts of certain developing countries such as Papua New Guinea. Murphy (1984) has also said of schizophrenia that “with some notable exceptions such as the rural Irish, its 10 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh prevalence is higher in more civilised societies than in more primitive ones.” If schizophrenia is less common in non-industrialised settings, it could be said that people who are genetically predisposed to schizophrenia are more likely to break down when they are subject to the stress of modem industrialised society. Schizophrenia has been repeatedly identified in various parts of Africa by both clinical methods (German, 1972) and structured interviews (Orley and Wing, 1979; World Health Organisation 1973). However, as has been stated earlier on, specific studies of prevalence have lacked an accurate contemporary population base (Field 1968, Sikanartey & Eaton 1984). Ben-Tovim and Cushier (1986) reported one- year prevalence of schizophrenia amongst individual’s aged 15 years or older living in six villages in a remote area of Botswana. All cases were diagnosed independently by two experienced psychiatrists following the ICD 9. DSM IE criteria was also applied separately. Accurate contemporary population estimates of the villages were available. The age-adjusted prevalence of schizophrenia was 5.3 per 1000 in terms of I.CD 9 or 4.3 per 1000 in terms of DSM III, which has an upper age limit for onset of 45 years. These figures are well within the range generally reported for industrialized communities. Remote village life in Botswana appears to offer no protection against the development of schizophrenia. Various estimates suggest that 1/8 to 2/3 of the normal population have had hallucination while awake (Coleman, 1984; Parish, 1994; Posey & Losch, 1983). l l http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh 1.6 ARE HALLUCINATIONS ALWAYS PSYCHIATRIC? Experiencing auditory hallucinations does not mean that one is a mental case. According to Bauman (1999), one lady heard “The Star Spangled Banner” (US anthem) playing over and over in her head. Actually, according to one medical report, the National Anthem is often heard by those who experience auditory hallucinations. This report went on to say that there is nothing wrong with these people mentally. In other words, the occurrence of hallucinations may not necessarily be related to psychopathology though it is considered to be a common sign of psychosis by all leading psychiatric textbooks. One source of evidence that normal people hallucinate in their everyday course of events comes from studies in which people are simply asked whether they have had this kind of experience in their lifetimes (Posey & Losch, 1983). Slade and Bental's (1988) review of this evidence begins with an early report by Sidgewick (1894) in which interviews with several thousand men and women revealed that about 10% had hallucinated at least once in their lifetime. West (1948) in another large-scale study, concluded that over 14% of his normal sample had ever engaged in hallucinatory behaviour. Two studies on normal subjects reported by Mckellar (1968) confirmed hallucination rates of 10% and 25%. Health professionals for example, are used to interpreting hallucinations within a psychodynamic, biological, or psychopharmacological frame of reference (Kaplan & Sadock, 1985). Hence, hearing voices is supposed to be accompanied by other psychiatric signs or symptoms for it to be seen as clinically significant. But auditory 12 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh hallucinations are perceived as a sign of mental illness by the psychiatric profession and both'patients and lay people accept it as such. The society for Natural Medicine is a group that interprets voices as the wandering spirits of the deceased (Murphy 1984). Jehovah Witnesses also consider voices as demons speaking. Pre-school children may experience hallucinations as part of their normal development (Posey & Losch 1983). Clinical observation of children has revealed the presence of hallucinations in 3 - 6 year old children as they communicate with imaginary companions (Bender, 1970). Although Despert (1984) earlier had failed to uncover evidence of hallucinations in children 2 - 5 years of age. Al-Issa (1995) point out that normal waking imagery is distinguished from the occurrence and content of schizophrenic hallucinations by the control that the normal individual can exert in the former case. Schriere and Libow (1986) found out that those 2 - 5 year-old children experiencing hallucinations do so when uniformly bright and independent. For both normal and psychiatric populations, hallucinations may serve an adaptive function. Benjamin’s (1989) study of 30 individuals with mental illness reported an integrated interpersonally coherent and complementary relationship with then- auditory hallucinations. 13 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh 1.7 AUDITORY HALLUCINATIONS Auditory hallucinations are characteristic of mental impression of sensory vividness, occurring without external stimulus. Auditory hallucinations are the most prevalent form of hallucination in schizophrenia which is usually experienced as voices. Typically, voices may ridicule the person or order the person to commit antisocial acts. The auditory hallucinations may be abusive, give orders, forbid them to do things or even be obscene. Sometimes it is a reassuring or complimentary voice and is therefore listened to and welcomed. Hallucinations seem to result in part from an impaired ability to discriminate self from non-self- generated events, linked to a sense of lack of control over this experience. Patients often seem to suffer less from the experience of auditory hallucinations ‘per se ’ than from lack of control of that experience (Romme & Escher, 1989). For example, they may be worried about whether to follow the advice of the voices, to set limits to them, to listen without becoming absorbed to them or drifting away from surrounding events. Auditory hallucinations may sound (vaguely, and at times not so vaguely) like tunes, music or voices. Often they sound "fuzzy" or indistinct. In a case study, one lady from USA described hers as, "like the wind blowing, but with a musical quality, as if someone off in the distance was singing without words." Another lady said, "I've never heard a tune that I could identify. It sounds more like an orchestra warming up." Another woman described hers thus; "When I am in a real quiet 14 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh room I hear this humming in my head like someone is humming a song but can't keep a tune." And a man described his as, "some song that sounds for all the world." Neuroleptics do not have any effect on the voices although they reduce the anxiety provoked by them. For example, a 30 year old woman who was examined by Romme & Escher, (1989) had auditory hallucination dominating her life. Neuroleptics had no effect on the voices but it reduced her mental awareness. One third of ex-patients continue to experience false perceptions, usually "voices" or auditory hallucinations after treatment. These may recur from time to time and may be difficult to ignore. Families find the return of this key symptom distressing. It is important to remember that it is usually sporadic and does not herald a new breakdown. Sometimes the command of the voices is compelling and calls for action. The psychiatric patient may answer the voices, returning abuse for abuse. This tendency to reply can be very upsetting to the uninformed witness - a relation, bystander, e t c . Ex-patients can be taught, in time, to ignore the voice, to develop strategies of not listening to it. Above all, they can learn not to act on the voice, to dismiss it as a "figment of their imagination," (Romme and Escher 1989). The attitude of patients to their experience varies. Patients newly ill may be very t distressed, some may claim that a radio or an automatic radiation or spirits of one kind or another is behind the voices (Meehl, P.E. 1986). Others are bewildered and depressed. Many researchers view auditory hallucinations as a form of inner 15 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh speech (Cutting, 1989). Electromyography (EMG) and other evidence suggest that they are sub-vocalisations, which reflect patients’ disordered thoughts projected into other imagined speakers (Bicks & Kinsboume, 1987). Prototypic auditory hallucinations, that of being addressed by a voice, is considered to be a misrepresentation of a person’s own lexical thought (Horowitz, 1975). Patients may thus generate their own ‘voices’ and be able to control them more than clinicians realise (Persaud, 1995). Auditory hallucinations are very real experience to those who hear them. In a case study, one woman commented to her husband after they arrived at their hotel that she had really enjoyed the music on the plane trip. Her husband replied, “there was no music on the plane.” On the return trip, she again heard the music and nudged her husband. He listened and replied, “Nope! No music!” (Bauman, 1999). Auditory hallucinations come in all varieties (Bauman, 1999). One lady reported, “I get Red Barber calling the game, I can’t distinguish the words - but I’m sure that’s who is talking.” A man describing his said, “I had real life sounds like a jet aeroplane taking off, or someone talking to me, or classical music.” One lady noted that when she was a young girl and flying with her Dad in small planes, she would hear music. She described it, “The music was a full choir, rather like the Mormon Tabernacle Choir, and when I was very young, I though it was angels singing.” (Bauman, 1999). 16 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh Romme and Escher (1989) put auditory hallucinations into three phases considering the process of learning to cope. These are the startling phase, phase of organisation and stabilising phase. i. The startling phase: Here most people who have auditory hallucinations report that it began quiet suddenly at a moment they well remembered. This is usually a startling and anxiety provoking experience. ii. Phase of organisation: This is the phase whereby the patient goes through a process of selection and communication with the voices. Some people get angry with the voice and later they find ways of coping with the auditory hallucinations like ignoring the voices, setting limits to them, selective listening, the use of distraction and many others. iii.Stabilisation Phase: Here people who learned to cope with voices developed a kind of balance. They accept it as part of themselves and part of life (Romme, Honig, Nourthom, & Escher, 1992, pp 209 - 216). Auditory hallucinations can come from a variety of causes. The main cause is hearing losses. When people become hard of hearing/deaf after having good hearing, their brains feel the loss of auditory input and seem to make up for this lack on their own. This seems to be particularly noticeable when it is very quiet and/or when one is very tired. Another common cause of auditory hallucinations is taking various medications and drugs. One lady reported about one of her medications that “makes music in 17 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh my deaf ear.” A man taking several medications explained, “recently, I was about to take a nap when I heard the national anthem being played. I went into the next room and asked my wife if they were playing it on the Television. No! Well, I continued to hear it for a period of time. Then all of a sudden it went to ‘Amazing Grace.’ Now, it is a repetitive three or four notes.” (Bauman, 1990). Beliefs about aetiology are also related to culture rather than profession (Wahass & Kent, 1997). Wahass & Kent, (1997), reported that UK staff were more likely to believe that brain damage, bad childhood experience, environmental factors, and stressful life events could have etiological significance. In addition, UK psychologists were more likely to believe that there could be a genetic component than did Saudi Arabian psychologists. Thus, UK staff were willing to entertain a wider range of possible aetiologies than Saudi Arabian staff (Wahass & Kent, 1997). In other words, psychologists and psychiatrists within a culture tend to agree with each other. 1.8 THE DIAGNOSIS OF AUDITORY HALLUCINATIONS Comparisons of mental health staff of UK and Saudi Arabia revealed cultural differences in influencing diagnoses based on auditory hallucinations (Wahass & Kent, 1997). Most psychiatrists and psychologists believed that when one experienced auditory hallucinations, schizophrenia was a possible diagnosis and also the majority in both cultures believed that hallucinations could be due to drug and alcohol abuse. Few believed a diagnosis of neurosis or personality disorder 18 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh was appropriate. However more of the studies in the U K than Saudi Arabian staff believed that a general diagnosis of psychosis could be appropriate and more of the UK staff believed that a psychiatric diagnosis is not required. It is important to note that UK staff tended to agree with each other, as did Saudi Arabian staff. Thus, a psychologist’s cultural background influences diagnosis based on auditory hallucinations. In other words, psychiatrists and psychologists are influenced by their cultural backgrounds when they are making a diagnosis of auditory hallucinations. In general, the aim of psychiatric treatment is to bring the patient back into reality with anti-psychotic medication, social therapies, and sometimes psycho-dynamic therapy. The treatment of auditory hallucinations has been based on a medical model with the assumption that there is a causal biological deficit of some kind, which underlines the symptoms (Wahass & Kent, 1997). As a result, several anti­ psychotic medications have been developed and used in attempt to control the frequency and intensity of the hallucinations. Advances in neuroleptic medication have led to significant improvement in the management of psychotic symptoms (Falloon & Talbot, 1981). But then many patients continue to experience auditory hallucinations despite the use of anti-psychotic medication (Barrow, Clough & Tarrier, 1992; Falloon & Talbot, 1981; Mclnnis & Mark, 1990). Patients may gain more control over persistent auditory hallucinations with a ‘non-distraction’ than with a 'removal’ tactics (Persaud & Marks, 1995). They can learn that their experiences are self-generated, like their thoughts and have no external auditory 19 http://ugspace.ug.edu.gh source. This approach resembles prolonged exposure therapy used to promote control over obsessive rumination (Duggan, 1993). On a portable cassette player, patients listen to their own-recorded voice describing their anxiety-generating thoughts for an hour or more daily and were encouraged to induce these thoughts in order to get used to them. An obstacle to applying this technique to auditory hallucinations is that psychotic patients seem to have less understanding than obsessives as to whether their experiences are generated internally or externally. Slade (1976) used systematic desensitisation for auditory hallucinations, but the hierarchy was imagined plus live exposure to stressful cues, which evoked the hallucination themselves. Several trials have shown Cognitive-Behavioural Therapy to be an effective means of reducing persistent auditory hallucinations among patients with schizophrenia (Haddock, Slade 1995). These interventions have been developed as result of (a) theoretical developments in the understanding of psychosis (Bental, Haddocjk & Slade, 1994), (b) a recognition that symptoms are not controlled in up to 50% of patients and (c) a need to reduce unwanted side effects. But these have involved individual, fairly long-term protocols (such as 20 sessions over 6 months) administered by highly trained therapists (Bental, Haddock & Slade, 1994). Examples of cognitive behavioural therapies which have been used to treat auditory hallucinations are, coping enhancement strategies (Tarrier, Harwoo, Yusopoff, Beckett, & Baker, 1990), Family Therapy (Tarrier, 1991: Mari & University of Ghana http://ugspace.ug.edu.gh 20 http://ugspace.ug.edu.gh Streiner 1994) and focusing strategies, (Bental, Hadduck & Slade 1993: Morrison 1994). These have achieved good clinical results. Other methods for dealing with persistent voices include headphone therapy (Hustig, Tran, Haafher, & Miller 1990), coping with hearing voices (Romme, Honig, Nourthom, & Escher 1992) and language therapy (Hoffman & Satel, 1993). 1.9 AUDITORY HALLUCINATIONS. STRESS AND WAYS OF COPING Empirical evidence suggests that auditory hallucinations can be distressing (Garety & Hemley, 1987). Apart from the distressing nature of the experience itself, there is evidence that such symptoms may depress social function and in some cases underpin the formation of delusion (Wallace, 1984). The question is, to what extent are auditory hallucinations stressful? Do some people cope better than others do? What then is defined as stress? According to Canadian endocrinologist Hans Selye (1907-1982), stress is the physiological response of the body to physical and psychological demands (stressors). Stressors include noise, crowding, a bad relationship and many others. Each one of these experiences may be stressful to some people but not to others. In the same way, auditory hallucination is stressful to some people but not to others. How one perceives a potential stressor substantially determines whether one will experience stress. Also, the impact of any potentially stressful event is substantially influenced by how a person copes with it. Coping is the process of managing demands that are appraised as taxing or exceeding the resources of the University of Ghana http://ugspace.ug.edu.gh 21 http://ugspace.ug.edu.gh person (Lazarus & Folkman, 1984). The question of importance here is “how do auditory hallucinators perceive the voices they hear and how do they cope with the voices?” This will be the main focus of this study. ( Coping with stress has much in common with the 'serenity prayer' of Reinhold Niebuhr that asks God for the wisdom to know the difference between what one can change and what one cannot (Sdorow, 1993). Most hallucinators spontaneously try ways of coping with voices such as distraction, seeking company and using alcohol (Falloon & Tallbot, 1981). It is unclear whether these strategies are specific to hallucinations and whether their success is due to amelioration of the hallucination or reduction of distress. According to Folkman, Lazarus et al., (1979), two types of coping can be distingu ished . These are problem solving efforts and emotion-focused coping. Problem solving efforts are attempts to do something constructive about the stressful conditions. For example, harming, threatening or challenging a stress event. Emotion-focused coping involves efforts to regulate the emotional consequences of the stressful events. Sometimes problem solving efforts and emotional regulations work together. An individual will use a wide variety of specific coping strategies in managing a single stressful event. Some will be problem-focused and others will be oriented towards emotional regulation. Which coping response will be used and what their effects are depends in large part on the nature of the stressor itself and the problems that are imposed by the particular University of Ghana http://ugspace.ug.edu.gh 22 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh setting within which the event has arisen. Subsequent research has suggested that coping strategies may be more varied than the simple distinction between problem-focused coping and emotion-focused coping strategies (e.g., Fleishmann, 1984). In another study by Folkman, Lazarus et al., (1986), 85 married Californian couples were interviewed once a month for 6 months about their most stressful event of the previous week, and coping was assessed using the Ways of Coping Instruments. Eight distinct coping strategies emerged in this study. These were as follows: Confrontative coping which characterised aggressive efforts to change the situation. The second one was seeking social support. Seeking social support characterised efforts to obtain emotional comfort and information from others. The next was Planful problem solving which described deliberate problem-focused coping dimension identified earlier. These three factors most clearly relate to the problem-focused coping dimension identified earlier. The next were more focused on the regulation of emotion like self-control which was used to describe efforts to regulate one's feeling. (For example, "I tried to keep my feelings to myself'). Distancing was also one of the coping strategies discovered, this described efforts to detach one’s self from the stressful situation (e.g. “I didn't let it get to me. I refused to think about it too much.”). Positive reappraisal also characterised efforts to find positive meaning in the experience by focusing on personal growth (e.g. "I came out of the experience 23 http://ugspace.ug.edu.gh better than I went in.”)- Accenting responsibility which is acknowledging one's role in the problem (e.g. “I criticised or lectured myself.”). And also escape/avoidance describing wishful thinking (e.g. “I wished that the situation would go away.”) [Folkman, Lazarus et al., 1986]. Studies have shown that about five coping strategies are specific to auditory hallucinations. Among these are: i. Distraction: Distraction could be by physical means (taking a shower, jogging, breathing exercises, watching a pleasant video) or by more abstract means [drawing a cloak around yourself in your mind, meditation, yoga (Romme, Noorthoom and Escher 1989)]. ii. Ignoring: Patients using this coping strategy refuse to obey the instruction of the voices. This is very difficult in the beginning. But later their control over the voice increases (Romme, Noorthoom and Escher 1989). iii. Focusing: A book published by Johns Hopkins university press discusses several methods to control hallucinations, including focusing on them instead of trying to ignore them. This may be as simple as saying the word “Stop” until the hallucination goes away. Some of the things that patients do to cope is engaging the hallucinations and taking the hallucinations' advice. The book also recommends taking personal responsibility for the hallucinations [(instead of attributing them to an outside source) and counter-stimulation (reading something out aloud) University of Ghana http://ugspace.ug.edu.gh 24 http://ugspace.ug.edu.gh (Romme, Noorthoom and Escher 1989)]. / iv. Selective listening: Patients using this strategy select the positive from the negative voices and they also control voices. They ignore the negative voices but listen to the positive ones (Romme, Noorthoom and Escher 1989). v. Setting limits: Patients using this strategy allow the voices to control them only at certain times and not at other times. They report that with time, the voices operate within the limits spelt out for them (Romme, Noorthoom and Escher 1989). 1.10 BELIEFS AND HALLUCINATIONS Beliefs may be defined as one's sets of expectations about the world. According to previous studies (Chadwick & Birchwood, 1994; Fowler and Morley, 1989), the last decade has seen an increase in sophisticated psychological intervention such as cognitive techniques for psychiatric symptoms, using coping techniques and belief modification. Encouraging research has focused on patients' beliefs about their hearing of voices, that is auditory hallucinations. Chadwick and Birchwood (1994) used a cognitive model to develop an understanding of voices and the affective and behavioural responses to them. They have postulated that a mediating factor between the voice experienced and distress is a person's beliefs about his voices. They then examined the voice hearer's beliefs and attribution about their voices. They identified three major themes, which characterised the voices of 26 people: University of Ghana http://ugspace.ug.edu.gh 25 http://ugspace.ug.edu.gh i. The voices’ omnipotence, ii. The voices’ intent to do harm or good (malevolence or benevolence), iii. And the reaction to the voices in terms of engagement, resistance or indifference (Romme & Escher 1989). t Wahass and Kent (1997) reported that beliefs about aetiology among health professionals were related to culture. They realised that UK psychologists and psychiatrists were more likely to believe in the genetic component of auditory hallucinations. Saudi Arabian psychologists and psychiatrists believed that brain damage, bad childhood experience, environmental factors and stressful life event cause auditory hallucinations. In a study by Romme, Noorthoom and Escher (1989), 13 subjects reported that the voices they heard stimulated them. “They are friends, guides and tutors.” And in this group, 7 of the subjects felt themselves to be paranormally gifted and described themselves as ‘clairaudient’ (Romme, Noorthoom and Escher 1989, pp 209-216). Literature on African beliefs regarding the cause of mental illness has focused on the magical and the religious (Jahoda 1961). However, some beliefs about mental illness among Africans include natural causes like bad diet, bad blood, the use of narcotic drugs and so on. .A close observation of Africa and its society reveals that religion is a dominating factor of African culture just as it is the determining factor University of Ghana http://ugspace.ug.edu.gh 26 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh of African life. To the African, religion is life and life religion. Idowu (1960) said that Africans are “a people who in all things are religious. The mentally ill is viewed as somebody who possesses or is possessed by evil spirit and for that reason it is considered a disgrace in some quarters of our society to have a mental patient in the family since that would spoil the family image (Bagleyl984). Hence, in Ghana for example, people hesitate when they have to marry from families with a history of mental illness. The belief that illness was inflicted by a supernatural power or by an angry deity as a punishment for sin was widespread among the people of the ancient world. In other words, the beliefs are not only typical of the 20th century Ghanaian but also people of other African countries as well as those who lived in the 18th and 19th centuries in Europe (Torrey, 1980). In the middle ages magical beliefs and practices were common. Witches and werewolves were accused of bewitching their neighbours or neighbour’s animals or cause the death of infants, and producing miscarriages. They were further accused of producing impotence in a bridegroom, causing blights, and raising tempests. African traditional healers believe the cause of illness is “wrong doing or doing something bad.” A person may get an illness from the evil spirit of his own family like the witches in the family and it is believed that gods punish witches when they do evil and they do so not by killing them but by making them suffer. A cheated person can also consult a god to punish the cheat. Hence the cheat will suffer. 27 http://ugspace.ug.edu.gh Also, envious evil people, can cause the downfall of a person. Another cause of illness is when a child bom with the help of a god grows to become a rebellious adult, and refuses to keep close contacts with the god and also treats the god in question with contempt. (‘Rebellious adult’ because most gods expect such children to worship them and observe their statutes carefully). If such a child does anything contrary to that, he/she is seen as a rebellious person and he will incur the wrath of the gods. Only pacification can help treat this individual. Others see the causes of illness as natural (Jahoda, 1961). G hanaians believe in a Supreme Being who sends rain and other good things but is believed to be responsible for epidemics and plagues, famines and death. G hanaians also believe that this powerful God has created other lesser gods, who have been endowed with supernatural powers and so, can bless, kill, heal illnesses or cause affliction (Sikanartey & Eaton, 1984). Foster (1961) outlined some of the etiological factors held by the Ghanaian society on mental illness are enumerated. Put in his words, “illness of any sort was never considered as the result of pathological change. The supernatural powers were invariably invoked as the causative factor in mental illness. Spirits, witchcraft, juju, infringement of taboos, the evil eye, failure to perform customary rites, were all regarded as etiological factors,” (Foster, 1961 pp 138). It is the contention of the Yoruba of Nigeria that mental illness is caused by some University of Ghana http://ugspace.ug.edu.gh 28 http://ugspace.ug.edu.gh supernatural forces, witchcraft, malignant magic or juju, drugs, blood in the head, and cosmic forces such as the sun and dry season as well as hereditary. They are of the opinion that worms are normal and necessary inhabitants of the human body and that there are both good and bad worms. In their opinion, the good worms help in the digestion of food while the bad ones cause sickness and death. Thus, depending on which part of the body the bad worms are located, a particular illness is caused. For example, they believe that 'Soporo' (a spirit of small pox) can cause mental illness. In the case of mental illness, when 'Soporo' heats the blood, the worms that normally reside in the blood are driven in to the brain by the excessive heat. And it is believed that worms in the brain can cause madness. The Yorubas believe also that each person has his/her own destined life pattern fixed by a contract he/she makes before he/she is bom and that if willingly or unwillingly, he/she departs from this,-the results may be mental or emotional illness (Tooth 1950). Shona, the dominant ethnic group of Zimbabwe identifies some four general causes of mental illness, which are: i. Spirits such as ancestral spirits which have been angered for some reason, ii. A witch who has cast a spell, iii. Certain ghosts, iv. Natural causes.' They also believe that the cause of mental disturbances may be, guilty conscience University of Ghana http://ugspace.ug.edu.gh 29 http://ugspace.ug.edu.gh such as might occur if one stole something or had committed adultery, strain and worry if one’s material desires were excessive and has not been able to satisfy all and improper development of the brain (Jahoda, 1961). To the Hebrews, those who grossly disobeyed God?s commandments and violated his ordinance were threatened with death, madness and some kind of sickness. Moses’ warning in the Old Testament that the people will go mad if they disobeyed God is an example of that. This passage can be found in the book of Deuteronomy, Chapter 28, verses 15-28. 1.11 GENDER AND COPING STRATEGIES Gender is among the most important categories in human social life. The dichotomy between female and male is of crucial relevance to virtually every domain of human experience (Bern, 1981; Huston, 1983; Ruble and Ruble, 1982). All known cultures associate men and women with different sets of characteristic features and with different sets of behavioural expectations (Williams & Best, 1990). If males and females differ in certain aspects of life then they can also differ in the ways of coping they adopt to cope with auditory hallucinations. 1.12 AIM The aim of this study is to explore the coping strategies patients with auditory hallucinations adopt to cope with their condition. University of Ghana http://ugspace.ug.edu.gh i 30 http://ugspace.ug.edu.gh 1.13 GOAL OF THE STUDY The goal of this study is to examine the coping strategies of patients who suffer from auditory hallucinations. 1.14 DEFINITIONS i. BELIEFS Beliefs have been defined as assumptions about the probability that an object exits. Therefore the object that is believed to exist is ascribed some attributes. For example, most people believe that there is God and this God is described as omnipotent, omniscient, omnipresent. Beliefs influence a person’s behaviour because of their cognitive nature. ii. VOICES (AUDITORY HALLUCINATIONS-) Auditory hallucinations (voices) has been defined by Chadwick & Birchwood, (1994) as the hearing of voices. They are mental impressions of sensory vividness, occurring without external stimulus. Auditory hallucinations are a characteristic of psychosis. They can be prototypic auditory hallucinations (that of being addressed by a voice). This is considered to be a misrepresentation of the person’s own lexical thoughts (Horowitz, 1975). They can be abusive, they can argue with the patient, accuse the patient of something the patient most likely has not done, and command the patient to do things outside his will or pass a comment about the University of Ghana http://ugspace.ug.edu.gh http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh patient. Auditory hallucinations can be put into two categories. These are process auditory hallucinations and reactive auditory hallucinations. Most patients respond to these voices. This is quite distressing because no one else hears the voices except the patient. Most patients seen talking to themselves are responding to voices (auditory hallucinations) they have heard. They (the patients) believe the voices are real and their inability to discriminate between actual voices and invented ones is what brings about the inappropriate behaviour of a patient talking to himself or herself. Romme, Noorthoom and Escher (1989) defined auditory hallucinations as a disorder of perception which people describe as being located in the external world (ego-dystonic) and which has the same qualities as normal perceptions, that is, is vivid and solid, in the absence of any actual sensory stimulus. iii. COPING Coping is the process of managing demands that are appraised as taxing or exceeding the resources of the person. The process of coping is complex and entails many variations in the prelim inary sample. Coping must be successful. And coping success entails reaching some sort of peaceful accommodation and acceptance of the voice as “part of me” (Romme, Escher et al., 1989). 32 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh 1.15 STATEMENT OF THE PROBLEM People believe that mental illness is a moral problem rather than pathological as in the case of diseases like cancer and bronchitis. In the 18th century in Europe, the mentally ill were locked up in jails, workhouses and mad houses; insanity was attributed to sin and the activities of the devil, the retention of bodily excretion, poor diets and lack of sleep. In view of this, ignorance, superstition and moral condemnation dominated the treatment of the mentally ill in Europe. In Ghana over the years, treatment for the mentally ill has had its problems. Few mentally ill are sent to the psychiatric hospitals first for treatment. Instead, they are often taken to the herbalists, traditional and other spiritual healers as in Europe of the 1800’s therefore treatment is characterised by fear, superstition and condemnation. In fact, this is not to say that certain institutions have not helped in treating the mental ill. Traditional healers like the herbalists and some spiritual churches have helped in treating the mentally ill. According to Jahoda (1961), were it not for extensive preliminary screening, by traditional methods, mental hospitals would be overwhelmed by a flood of cases with whom they would not possibly be able to deal with. In other words, traditional healers provide care to a large number of patients. . In this study, it is hoped that some of the beliefs about mental illness would be 33 http://ugspace.ug.edu.gh examined. Certain questions will also be addressed. For example, “How do schizophrenics cope with this problem of persisted auditory hallucinations? Do they respond to it, ignore it or distract their attention from the auditory hallucinations by concentrating on other things?” These are some of the questions that this research seeks to answer. University of Ghana http://ugspace.ug.edu.gh 34 http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 THE DOMAIN OF THE REVIEW Attempts to control hallucinations by behavioural strategies, distractive tasks, cognitive behavioural approaches and so on have been fruitful (Romme and Escher 1989). Others have also used other coping strategies like praying, fasting and meditation to cope with auditory hallucinations. Literature was reviewed in these areas. Also, literature was reviewed on subjects' beliefs about the phenomena of auditory hallucinations. The literature reviewed also focused on cross-cultural studies done on coping with auditory hallucinations like the study by Wahass and Kent, (1997). It was found out that no study had so far been done on coping with auditory hallucinations in Ghana. 2.2 THEORETICAL FRAMEWORK 1. GREEN’S THEORY Green (1963) did a lot of research into auditory hallucinations. And he came out with a theory. He did observe schizophrenic patients wearing earplugs of their own accord and he used this method experimentally with patients. His theory states that schizophrenics suffer from defective information transfer between cerebral hemispheres and this defect interferes with speech comprehension. Schizophrenics with left hemisphere speech representation are significantly better at understanding speech presented to the right ear than to the left (Green 1978). Wearing an earplug in the left ear leads to significant increased levels of speech comprehension compared with binaural listening. In cases of right hemisphere University of Ghana http://ugspace.ug.edu.gh 35 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh speech, the reverse is the case that is wearing earplug in the right ear leads to significant decreased levels of speech comprehension. To Green, voices are sub­ vocalisations and so any verbalisation aloud or silent should be incompatible with auditory hallucinations. Therefore, Green’s patients were taught to say, “stop” and to name things in the immediate environment whenever they start hearing voices. The emphasis is on loudness and speed of naming. This is later extended into a variety of settings in which the patient is taught to say stop and name things relevant to the ongoing activity and continuing that activity after the last thing named. At this stage stop and naming is done silently: 2. HYPNOSIS. SUGGESTIBILITY. AND HALLUCINATIONS Despite the questions that have been raised regarding the nature of hypnosis and the quality of hallucination that is supposedly induced, there is evidence that hallucinatory experience can be generated by suggestion within the trance (Barber, 1970; Wagstaff, 1983). Rosenthal and Meele (1952) had their hypnotised subjects examine grey cards while suggesting that the cards were of another colour. A second grey card followed the first with instructions to name the colour. These instructions elicited responses in which the negative afterimage of the original suggested colour was reported just as if that colour had actually been seen. The involuntary afterimage response corresponded to the suggested sensory experience as if it had really occurred. Brady and Levitt (1964, 1966) also obtained results indicating that an involuntary response can be made to occur under hypnosis given a suggested perceptual experience. Subjects were told that they were viewing a 36 http://ugspace.ug.edu.gh rotating drum on which . alternating black and white strips were painted paralleled to the axis of rotation. Viewing actual movement ordinarily produces nystagmus. This type of involuntary eye movement was observed among those given the hypnotic suggestion that rotation was occurring, but only when the subjects described the movement perceptions as especially real. Barber & Calverley (1964) and Spanos and Barber, (1968) pre-tested their subjects for suggestibility prior to hypnosis. They were asked to hear a record playing “White Christmas” or they see a cat, each in the absence of the actual stimuli. A surprising number reported hearing the music or seeing the animal during the base-rate procedures, yet hypnotic induction further increases subjects’ response to the auditory and visual suggestion above base levels. The Spanos and Barber’s (1968) study included added instructions to an extra group of subjects from whom honest responses were demanded. Hypnotic induction did not result in an increase in auditory hallucination beyond base level for this group, but false perception of the visual stimulus remained above baseline. The limitations of hypnotic suggestion were revealed in a study by Thome (1967) who found that a hypnotised group failed to differ in capability for hallucination a song from a group receiving simple instruction without hypnosis. 3. COPING PROCESS The coping process is' a process described by coping strategy researchers which says that when one perceives a stressful event, that person will have to appraise or interpret the event as stressful and thus will need some form of strategy to cope University of Ghana http://ugspace.ug.edu.gh 37 http://ugspace.ug.edu.gh with it which can be either emotion focused or problem focused. The purpose of these strategies is to reduce the negative impact of the stress and to help the person maintain an emotional equilibrium. The choice of the coping strategy depends on some factors, for example the person’s personality will influence the choice of a particular coping strategy. If the coping strategy chosen is effective the person will resume his or her normal duties other wise it will lead to psychological distress. This is illustrated in figure 2.1. 2.3 COPING STRATEGIES FREQUENTLY USED BY PATIENTS In an early effort to examine coping strategies comprehensively, Folkman and Lazarus (1980) enrolled 100 adults men and women in a 12-month study of stress, coping and emotions. Respondents were interviewed monthly about their most stressful experiences and they completed a 68-item checklist called “Ways of Coping” to indicate the thoughts and actions they had used in dealing with these stressful encounters. Respondents reported using both problem-focused and emotion-focused coping in 98% of their stressful experiences, suggesting both types of stressful events. Work related problems most commonly led people to attempt problem-focused coping efforts such as taking direct attention or seeking help from others. On the other hand, health problems were an event that led to more emotion-focused coping, (Folkman & Lazarus, 1980). University of Ghana http://ugspace.ug.edu.gh 38 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh FIG UR E 2.1 THE CO PING PROCESS External Resource or impediments Other personality factors that influence selection of coping responses and strategies Internal Resources or impediments (Source: Cohen & Lazarus, 1979; Hamburg & Adams, 1967; Lazarus & Folkman 1984; Moos, 1988; Taylor, 1983) 39 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh Romme and Escher (1992) developed a questionnaire comprising 30 open ended items and were sent to 450 people aged 15 and above years with chronic hallucinations of hearing voices who had responded to a request on Television. Of the 173 subjects who were suitable for the study, 115 reported an inability to cope with voices. This suggests the distressing nature of voices. Ninety-seven (97) of the subjects were .in psychiatric care and copers were less often in apparent psychiatric care than non-copers were. Four coping strategies were apparent. These were distraction, ignoring the voice, selective listening to them and setting limits on their influence. Subjects reported that the most fruitful strategy was to listen to the voices selectively (Romme and Escher, 1989). 2.4 COPING TECHNIQUES STUDIED BY PROFESSIONALS AND THEIR EFFECTIVENESS There have been a number of reports of attempts to control hallucinations by behavioural strategies but the results have been variable and not firmly based on theory (Marzailler & Birchwood, 1981). Hustig, Tran, Haftier and Miller (1990), examined the effects of relaxing and stimulating audio-tapes on the frequencies and characteristics of auditory hallucinations in 9 subjects (22 - 57 years) with persistent auditory hallucinations. All subjects were diagnosed with schizophrenia. The subjects had to rate the effects of the music on 9-point scales for seven conservative m ornings. Overall, neither the relaxing nor the stimulating tapes influenced the frequency of auditory hallucination. However, three subjects reported significant reductions of http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh frequencies individually. Listening to both the relaxing and the stimulating audio­ tapes reduced the amount of distress caused by the auditory hallucinations. The effect of the relaxing audio-tape was somewhat greater in this. With this study, the music was not able to reduce the frequencies of the auditory hallucinations but it was able to help them cope with their hallucinations by reducing the distress it created in them. One can conclude that distraction can help subjects cope with their hallucinations. Green (1989) investigated the effects of several behavioural conditions of 17 schizophrenic inpatients who experienced frequent auditory hallucinations. Five experimental conditions were selected based on predictions of their effects on sub­ vocalisations like opening the mouth, biting the tip of the tongue, softly humming a single tone, raising the eyebrow and making a fist. Using ANOVA, it was realised that humming reduced the amount of time that subjects reported hallucinations. Humming can be said to be a distractive task. If this is able to reduce the frequency of hallucinations, then humming can help people cope with their hallucinations and hence an effective method. Green (1978) and Green et al., (1983), reported evidence suggestive of poor inter- hemispheric transfer of complex manual and auditory information in schizophrenics, and this has been replicated (Carr 1980; Hatta, Yamamoto, & Kawabata, 1984). Poof interhemispheric transfer may not be a secondary (e.g. drug induced) phenomenon (Myslobodsky, Mintz, & Tomer 1983), as sim ilar 41 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh results of poor inter-hemispheric transfer of complex manual and auditory information have been found in high-risk samples (Hallett & Green 1983). Green’s theory is consistent with previous observation of sub-vocal speech and movement of vocal musculature, concomitant with reports of voices (Erickson and Gusstafson 1968; Gould 1948; Inouye and Shimizo 1970; McGuigon 1966). A patient with schizophrenia whose severe level of auditory hallucinations had proved refractory to neuroleptic medication, participated in two treatment methods derived from Green’s theory that hallucinations represent verbal activity in the non-dominant hemisphere. Voice activity was markedly reduced in frequency and severity over a six-month period and led to general improvements in interpersonal functioning. There- was evidence for independent and additive effects of the two techniques (Hallett & Green 1983). Green and Preston (1980) reported that the content of amplified sub-vocal speech in one schizophrenic patient corresponded to the patients’ self-reports of his voices, which were schneriderian in character. [Kurt Schneider first introduced the concept of first rank symptoms of schizophrenia in 1939. His concept was named after him (schneriderian first rank symptoms of schizophrenia)]. These sym p tom s include; hallucinations (which may be auditory, visual, tactile, gustatory, or somatic) thought broadcast, feelings of paranoia, inappropriate behaviour, and so on. According to Mellor (1970), hallucination is found in only 72% of schizophrenic patients but their use as operational criteria for the diagnosis of 42 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh schizophrenia has become world-wide to the extent that patients are sometimes erroneously diagnosed as being schizophrenic despite the presence of an organic or toxic pathology (like benzodiazepine withdrawal) Roberts, and Vass, (1985). A further study (Green et al., 1980) reported the success of a technique where auditory input is reduced using an earplug and the patient is taught to name things in his immediate environment at the onset of the voices. The choice of side for the earplug is determined by the results of an auditory comprehension (transfer) test. This technique could reduce the distress caused by auditory hallucinations, hence making the patient able to cope with auditory hallucinations. An additional result of the use of earplugs in some patients is a decrease in hallucinations. Green and Preston (1980) reported patients diagnosed with schizophrenia wearing earplugs of their own accord and Green (1978) used this method experimentally with patients, determining the choice of side for the earplug by the headphones test described in his paper. Various other strategies were employed to disrupt hallucinatory experience. According to his theory, if voices are sub-vocalisation (a view not universally accepted) any verbalisation, aloud or silent should be incompatible with auditory hallucinations. Therefore, whenever hallucinations occur, patients are taught to say “stop” and to name things in immediate environment, the emphasis being on loudness and speed of nam ing. This is later extended into a variety of settings in which the patient is taught to say stop and name things relevant to the on going activity, continuing that activity after 43 http://ugspace.ug.edu.gh the last thing named. At this stage saying stop and naming the object is done silently. James (1983) conducted an experimental treatment of two people with auditory hallucinations. One was a 39 year old man and the other, a 20 year old woman who had been diagnosed with acute schizophrenia. Their auditory hallucinations resisted neuroleptic drugs. They were treated with earplugs in the left ear to test Green's (1978) suggestions that schizophrenics suffer from defective information transfer between the cerebral hemispheres. Both subjects improved. The male subject spontaneously changed the plug to his right ear after reductions in his hallucinations when the plug was in the left ear. Improvements continued, but at a slower rate. The female also experienced a decrease in hallucinations, but at a slower rate when she was asked to transfer the plug to her right ear. Results weakened one of the key points of the non-dominant hemisphere theory. In a case reported by Chiu (1994), a 34-year-old woman with schizophrenia, whose auditory and visual hallucinations were resistant to medication was treated with two behavioural techniques derived from W.P. Green's reports (1978). The results showed that for auditory hallucinations, reducing the external auditory input to the non-dominant hemisphere by using an ear plug in the opposite ear was a very effective treatment where as visio-verbal activity (naming objects and reading) was insignificant for visual hallucinations. University of Ghana http://ugspace.ug.edu.gh 44 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh Khan, Clark and Oyebode (1988) reported a case of a 72-year-old female with unilateral auditory hallucinations related to deafness on the same side. This woman's auditory hallucinations disappeared when she used a hearing aid. Definitely a hearing aid would enable her hear properly and this has a way of creating some kind of distraction as compared to not hearing at all. Done, Frith and Owen (1986) investigated the efficacy of wearing an earplug in a 42 year old male diagnosed with (chronic) schizophrenic with persistent neuroleptic resistant auditory hallucinations. Significant reductions in the frequencies and volumes of the voices during both day and night were detected when the plug was in the dominant ear only. After three months the subject ceased to be suicidal or depressed and had become optimistic about the future and somewhat ambitious. Here, the earplug made the subject concentrate on a particular information and this helped the subject remove his attention from the auditory hallucinations. If the earplug was able to help these clients, then one can conclude one more time that concentration on other tasks instead of the voices helps patients cope with the voices they hear. Slade and Bental (1988) reported a useful review of the evidence relating hallucinations to schizophrenia. They conducted 15 studies, which considered the breakdown of schizophrenic patients experiencing the various types of hallucinations. Auditory hallucinations was found in about 60% of the schizophrenics on average range (25%-94%) and visual hallucinations in 39% 45 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh overall range (4%-72%); auditory hallucinations always prevailed in frequencies over visual hallucinations. Fewer studies reported on other modalities. Based on those that did include such reports, 40% of the schizophrenics experienced tactile hallucinations, with gustatory (18%), olfactory (17%) and somatic sensations (4%) observed less frequently. Posey & Losch, (1983) found evidence for the fact that auditory hallucinations may not necessary be psychiatric from their 357 college subjects, based on interviews and the Minnesota Multiphasic Personality Inventory (MMPI) results. They found out that some people believed that the occurrence of auditory hallucinations was not necessarily believed to be a psychiatric symptom. Posey and Losch (1983) also reported that the most common auditory hallucinations were hearing a voice calling one’s name aloud when alone (36%), hearing one’s own thought as if they were spoken aloud (39%), and 5% of the students revealed that they held conversations with these voices. Slade and Bental’s (1985) own research programme identified from 14% to 18% of two samples of college students who confirmed that they had heard their own thoughts as spoken voices. Despite the methodological limitations of these studies of normal people and questions regarding the equivalence of their self-reported experiences and schizophrenic hallucinations, it is difficult, given these percentages, to escape the conclusion that true hallucinations do occur among normal individuals. An experiment was conducted by Bick and Kinsboume (1987) to test the hypothesis that “auditory hallucinations may be projections of schizophrenic 46 http://ugspace.ug.edu.gh patients’ verbal thoughts, sub-vocalised due to deficient cerebral cortical inhibition.” The basic manoeuvre of the experiment was to attempt to obstruct the hypothesised sub-vocalisation by requiring the hallucinating individual to open his or her mouth, which makes sub-vocalisations impossible. Bicks and Kinsboume (1987) studied two groups of subjects (18 schizophrenic inpatients and 21 normal controls). Bicks and Kinsboume (1987) used two control manoeuvres in addition to the mouth opening: 1. Closing the eyes tightly and 2. Making a tight fist. The experimenters stated that the 3 manoeuvres were requested in a random order, counterbalanced across subjects for the schizophrenic subjects, and while this statement was not repeated with respect to the normal subjects. Presumably it was applied to them as well. Bicks and Kinsboume informed their subjects before the instruction of the manoeuvres that they would later be asked to state if their voices got worse, stayed the same or went away. Such disclosure greatly magnified the possibility that the result would be largely a function of the demand characteristics of the experiment. This possibility was further increased by the facts that two of the three manoeuvres were relatively remote from the speaking - hearing axis. Consistent with this finding, Erickson and Gusstafson (1968) suggested (based on two case studies) that humming or gargling could help patients control voices. University of Ghana http://ugspace.ug.edu.gh 47 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh Allen, Halperin and Friend (1985) explored the effectiveness of combining removal and diversion tactics in the treatment of auditory hallucinations in a 29- year-old single woman with schizophrenia. Results showed that in controlled conditions, removal and diversion tactics effectively complemented each other in that diversions reduced the frequency and removal reduced the duration of auditory hallucinations. Data suggests that in uncontrolled real life conditions, diversion but not removal tactics may be effectively employed in controlling auditory hallucinations. This study suggests the efficiency of diversion in helping patients deal with their auditory hallucinations in uncontrolled situations. Removal tactics may be a good coping strategy but it works only in controlled situations. Birchwood (1986) examined a case on the effect of occluding auditory input directly in a severely hallucinating patient suffering from schizophrenia. It was found out that the patient improved dramatically. 2.5 CROSS-CULTURAL DIFFERENCES IN COPING STRATEGIES Research on coping has been largely confined to the United States. There is as yet no agreed-upon classification of coping behaviours. For example, Gurim, Veroff & Feld, 1960; Veroff, Kulka & Douvan, 1981), distinguish ‘active from passive’ coping methods, Folkman and Lazarus (1980, 1985) distinguish ‘problem-focused’ from ‘emotion-focused’ coping methods, and Billings & Moos, 1981; Holahan & Moos, 1987), distinguish between ‘active-behavioural’, ‘active-cognitive’ and 48 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh ‘avoidance’ methods. A study by Wahass and Ken (1997) showed that there were cultural differences in coping with auditory hallucinations. In this study, 70 patients with schizophrenia from Saudi Arabia and the United Kingdom who reported auditory hallucinations were interviewed to explore the ways in which they coped with their voices and sounds. Patients from both cultures had several coping mechanisms. These varied between cultures. The majority of Saudi Arabian patients used strategies associated with their religion whereas United Kingdom patients were more likely to use distraction or physiologically-based approaches. The majority of patients were slightly or not at all confident about the effectiveness of their coping strategies. Comparisons of Western and Non-western cultural reactions to hallucinatory experiences are of particular interest because of the widespread association in the west between hallucination and psychiatric illness. Much emphasis in the western societies, for example, is placed on the precipitating conditions of hallucinations (Al-Issa, 1976) where the mere occurrence of the event is likely to prompt a pejorative response. In contrast, while non-western societies do not necessarily welcome such experiences, their concern is generally focused on content and not on the occurrence of the phenomenon. 2.6 CLINICAL EXPLANATIONS FOR EFFECTIVENESS OF TECHNIQUES If listening to both the relaxing and the stimulating audio-tapes reduced the amount of distress caused by the auditory hallucinations then distraction can be said to be 49 http://ugspace.ug.edu.gh very effective in reducing the distress caused by auditory hallucinations. According to Green's (1978) theory voices are sub-vocalisation and so any verbalisation, aloud or silent is incompatible with auditory hallucinations. Therefore, whenever hallucinations occur, patients are taught to say stop and to name things in the immediate environment, the emphasis being on loudness and speed of naming and this is what interferes with the phenomenon of auditory hallucinations thus, reducing the frequency of auditory hallucinations. Clinical observation shows that for auditory hallucinations, reducing the external auditory input to the non-dominant hemisphere by using an ear-plug in the opposite ear was a very effective treatment for auditory hallucinations. It reduces the frequency of auditory hallucinations. It is believed that auditory hallucinations results from poor inter-hemispheric transfer and so auditory inputs should only be through the dominant hemisphere alone instead of both hemispheres. Ear-plugs are effective because the auditory inputs are introduced to only one ear (the dominant ear). Also the distractive nature of humming Helped clients to cope with their auditory hallucination. It takes their attention off the voices. 2.7 LITERATURE ON STUDIES DONE USING THE GAF SCALE A lot of studies have been done using the GAF Scale. A wide range of subjects have been administered the GAF Scale. Propst, Paris and Rosberger (1994) used University of Ghana http://ugspace.ug.edu.gh 50 http://ugspace.ug.edu.gh the GAF Scale in their article on outcome in short-term psychotherapy. They investigated the effects of clinical diagnosis, functional level, and therapist experience. The therapists included psychiatrists, psychiatry residents, family practice residents, and medical students. GAF Scale scores and the Global severity Index (GSI) of the SCL-90 were used to rate subjects at baseline after therapy, and 6 month follow up. Client satisfaction was assessed. All the subjects improved significantly. Neither therapist type, diagnostic category (adjustment, mood anxiety, or personality disorders), nor their interaction was related to outcome GAF Scores or to the GSI. Irrespective of their baseline symptom severity subjects improved significantly. Increased functioning and decrease in symptom severity were highly related to client satisfaction while the number of therapy sessions attended was modestly related to outcome and patient satisfaction. This is one of the ways in which the GAF Scale has been used. In another article by O’Connor, and Herrman, (1993), the GAF Scale was used to define a range of disability levels. In this article, they assessed components of disability in 41 patients (aged 23-61yrs) diagnosed with DSM III R residual schizophrenia who were undergoing hospital and community rehabilitation programmes. A range of disability levels was defined with the GAF Scale. Most of the subjects had poor results on frontal lobe testing, persistent positive symptoms and high levels of emotion distress. Results suggest that rehabilitation programmes could be more focused if patients were assessed not only for their overall level of functional disability but also for the level of treatment resistant University of Ghana http://ugspace.ug.edu.gh 51 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh positive symptoms, frontal lobe impairment and the amount and type of emotional distress and insight. 2.8 LITERATURE ON STUDIES THAT HAVE BEEN DONE USING THE WAYS OF COPING TECHNIQUE Some studies have been done on the impact of these strategies. Frank, Umlauf, Wonderlick, Askansasi, Buckelew and Elliot (1987) used the scale to identify two subgroups of an SCI population by cluster analysis. They found out that cluster 1 had higher levels of depression and psychological distress and used all coping strategies to a greater extent than cluster 2. The general pattern of use of coping strategies was similar for both clusters. The most used coping strategies were using wishful thinking and problem-focused, the least used was self-blame. Reidy, Caplan and Shawaary (1991) administered the Ways of Coping Questionnaire to 54 newly injured spinal cord patients. Depression was found to have a strong positive correlation with the use of escape - avoidance coping strategies. Positive affective states were positively associated with distancing, seeking social support, positive reappraisal and planful problem solving. Those used least were acceptance of responsibility and escape - avoidance. However, Carver, Schiere & Weintraub (1989), have argued that the distinction between problem-focused and emotion-focused coping is too simple. There are indications that studies using this instrument have found responses from several factors rather than just two (problem focus and emotion focus). Aldwin, Folkman, Schaefer, Coyme & Lazarus (1980) involved factors, which can themselves, be 52 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh inversely correlated with one another (Scheire, Weintraub and Carver 1986). Malt (1992), used the Ways of Coping Questionnaire with 2 adult males * hospitalised following accidental injury and found that the most commonly reported coping efforts involved passive - acceptance or mental avoidance, given that avoidance behaviour is central to both psycho-dynamic and conditioning models of trauma response (Horowitz 1986; Keane, Zimmerling & Caddell, 1985). Studies show that emotion-focused coping is used more in encounters holding little possibility for change (Folkman & Lazarus, 1950). In an article by Atkinson and Violati (1993), The WOC Questionnaire was administered to 149 undergraduates coping with saddening life events. Subjects were made to collect data over a ten-week period using logbooks. The results were factor analysed and this indicated that the WOC Questionnaire Escape-avoidance item lost its uni-demensionlity and loaded on to two distinct factors: Cognitive Avoidance and physiological Escape-avoidance. However, items on the self­ control Scale lost their coherence and did not load meaningfully on any factor. A study by Wykes (1999) was undertaken with the aim to evaluate a shorter, group-based (and therefore less expensive) variant of the approach. Twenty-one patients participated in seven group sessions in which the goals were to share information about “voices,” learn about psychosis and hallucinations, develop effective coping strategies, and raise self-esteem. The patients’ mean age was 40 53 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh years, with a mean illness duration of 14 years. Three-fourths had auditory hallucinations every day, and three-fourths said these "severely disrupted" their lives. Moderate depression and anxiety plus low self-esteem characterised the group. Compared with a waiting-list control group, the treated patients showed an increase in insight and self-esteem and in the number and effectiveness of coping strategies. There was "a strong trend" toward improvement in auditory hallucination scores that was maintained at follow-up one month later. In particular, the acquisition of active coping strategies led to an increase in the sense of mastery. In addition, a reduction in the “power” of voices was associated with reductions in levels of distress. Improvements in psychopathology were similar to those seen with conventional, individual Cognitive-Behavioural Therapy. In addition, the group format appeared to have particular benefits. Patients were generally happy to attend, and several expressed appreciation at the opportunity to exchange coping ideas with others. “I’m not alone anymore,” one patient was reported to have said. The WOC Questionnaire has also been used in finding out the ways women with eating disorders cope with the disorder. Troop, Holbrey, Trowler and Treasure (1994) investigated coping strategies used with a current, self-nominated problem in 24 subjects (1 8 -4 5 years) with anorexia nervosa and 66 subjects (aged 1 7 -4 3 years) with bulimia nervosa. The control group were 30 undergraduate female students aged 20-34 years. Subjects completed the Beck Depression Inventory, measures of eating disorder symptoms and social class, and the revised WOC Questionnaire. Anorexia nervosa and bulimia nervosa subjects used more http://ugspace.ug.edu.gh avoidance than controls. Problem-focused coping was lower and self-blame was higher for psychological problems than for general and relationship problems and psychological problems were nominated more frequently by anorexia nervosa and bulimia nervosa than by controls. Teaching coping strategies especially to bulimia nervosa patients may be a useful component of treatment for eating disorders. Burley and Kim (1994) examined relationships among gender, coping, and anticipated work-family conflict for 136 female and 120 male university students. Subjects completed an inter-role conflict scale and a dual employed coping scale. Results indicated significant differences between the sexes with respect to anticipated work-family conflict as well as with respect to expected use of coping strategies to manage anticipated work-family conflict. Contrary to expectation, coping strategies did not mediate the relationship between gender and work-family conflict. In another study, Bentelspacher, Chitran and Binte-Abdul-Rahmaan (1994) examined cultural variations in the coping and adaptation process among 30 Chinese, Malay and Indian families caring for a relative with schizophrenic illness. Primary care givers were interviewed about the effects of patient behaviours on the family and the use of helpful coping techniques or informal and formal community support system. Eighteen (18) subjects reported that negative schizophrenic behaviours caused distress, and 17 subjects reported that the patient’s illness had adversely affected their household. Chinese subjects experienced approximately University of Ghana http://ugspace.ug.edu.gh 55 http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh twice as many adverse effects as did Malay and Indian subjects. Malay families were least adversely affected, because they tended to use more helpful coping strategies and relied on informal support networks. Indian families also used helpful coping strategies and did not use either informal or formal support networks. Other measures of coping are also available. Stone and Neale (1984) developed a measure of daily coping designed for use in longitudinal studies to see how coping changes on a day-to-day basis over time. There is also, another one by Carver, Scheier and Weintraub (1989). The selection of a particular use of coping strategies depends on a variety of internal and external resources. These factors are called moderators of the stress experience because they influence how stressful an experience will be and coping strategies an individual will bring to bear on the stressful experience. Internal resources or impediments consist of coping styles and other personality factors. External resources or impediments include money and time, social support and other life stressors that may be occurring simultaneously with the stressful event. Figure 2.1 represents the coping process. 2.9 LITERATURE REVIEWED ON BELIEFS ABOUT MENTAL ILLNESS In a case study of mental illness in Ghana, Jahoda (1961) found out that