الفهرس 
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Abstract
Schizophrenia is a persistent and severe mental condition that affects about 7 to 8 individuals out of 1,000 worldwide populations. According to the World Health Organization in 2016, it is ranked among the top 10 causes of disability in developed countries worldwide. Schizophrenia is characterized by perturbation of the thoughts, perceptions, attitudes and emotions of the patient. Hallucinations are one of the main positive symptoms of schizophrenia, occurring in around 90 percent of all schizophrenia patients. The most common type of hallucinations experienced by these patients is auditory hallucinations with a prevalence measured at 70% and persistence about 35% of those patients. Although antipsychotic medications are a cornerstone in the treatment of schizophrenia, the frequency of auditory hallucinations is persisting and leaving the patients disabled.
In recent years, several interventions have emerged within the behavior and cognitive therapy traditions to help patients with schizophrenia to accept their auditory hallucinations and to defuse from internal sources of distress. Acceptance and commitment therapy (ACT) is one of those interventions which were used firstly on patients who suffered from schizophrenia and particularly auditory hallucinations. Acceptance and commitment therapy is a third wave cognitive behavioral therapy that focuses on changing the patient’s relationship with voices, rather than the voices themselves. It can reduce the influence of the symptoms especially auditory hallucinations and help the patients to focus more on valued actions. ACT focuses on the workability of the patient’s behavior with greater flexibility and more response options.
Acceptance and commitment therapy (ACT) was developed by Hayes et al (2004) and Hayes et al (2012) to provide a more adaptive alternative response to both engagement and resistance toward auditory hallucinations. It involves two main sets of skills. Firstly, non-judgmental awareness which deliberately observes voices as they occur without judging them as good or bad and without reacting to them. Secondly, disengagement (detachment) from the literal meaning of the content of voices and associated appraisals that is, distinguishing the actual experience (sounds/words) from what it represents (literal reality) like meaning of seeing things the way they really are.
In mental health care settings, nurses have a significant role in supporting physical, mental and social care of patients with schizophrenia. They are found to be particularly appropriate for introducing and conducting ACT because of having a close bond and trustful relationship with their patients. They can implement ACT to resolve the major barriers in managing auditory hallucination. Despite the beneficial effects of applying ACT on auditory hallucination among patients with schizophrenia, little researches are found to investigate its effectiveness. Up to the researcher’s knowledge, the effect of ACT on auditory hallucination has not been yet investigated among patients with schizophrenia in Egypt. Therefore, this study will be conducted to investigate the effect of applying ACT on auditory hallucinations among patients with schizophrenia in Egyptian culture.
The current study was conducted at inpatients wards of Al-Maamoura hospital of psychiatric medicine, in Alexandria. Seventy patients were recruited and divided into two groups, a study and a control group (35 patients for each group). The following inclusion criteria were considered: Diagnosed with schizophrenia with no co-morbidity, having auditory hallucinations as recorded in the patients’ charts, currently admit having auditory hallucination, able to communicate coherently and relevantly, only male patients were recruited to decrease interfering variables, with duration of illness wasn’t be more than 5 years, and able to read and write. A number of 70 attended the immediately posttest while 64 patients were attended post three months interventions with 6 patients missing from control group.
The following tools were used for data collection
Tool I: Psychotic Symptom Rating Scales -Auditory hallucination (PSYRATS-AH) was used to measures various dimensions of auditory hallucinations through 11 items divided into three subscales and developed by Haddock et al (1999). First subscale is for physical characteristics of auditory hallucination which consists of 4 items that assess frequency, duration, location, and loudness of voices. Second subscale is for emotional characteristics of auditory hallucination (4 items) that assesses amount and degree of negative content and amount and intensity of distress. The third subscale is for cognitive characteristics of auditory hallucination (3 items) that assesses beliefs about origin, disruption; and controllability. The PSYRATS-AH was rated on a five point likert scale ranging from 0 (not endorsing the item) to 4 (fully endorsing the item).
Tool II: Voices Acceptance and Action Scale (VAAS) was developed by Shawyer et al (2008). It is a self-report scale used to measure two constructs: (a) acceptance of having the experience of auditory hallucinations and (b) action, the ability to act autonomously. It consists of 31-items rated on a 5-point likert scale ranging from strongly disagree (0) to strongly agree (4). VAAS was consisted of 5 subscales representing acceptance and actions toward voices, section A1 representing acceptance attitude toward general voices besides section A2 which representing autonomous actions toward general voices . On the other hand, section B1 measured beliefs about actions related to command voices, section B2 representing acceptance attitudes toward command voices and finally section B3 measured autonomous actions toward command voices.
Tool III: Socio-demographic and clinical data structured interview schedule was used to elicit socio-demographic data of patients with schizophrenia as age, marital status, occupation, level of education, and living status. In addition, clinical data as duration of illness, number of admission, duration of current hospitalization and type of medication.
• The Psychotic Symptom Rating Scales (PSYRATS-AH) and Voices Acceptance and Action Scale (VAAS) were translated into Arabic language and back translated into English. The content validity was examined by a jury of 5 experts in the field of psychiatric nursing.
• Before conducting the actual study, a pilot study was carried out on 15 patients with schizophrenia in order to assess and ensure the clarity and applicability of the study tools, and identify any obstacles and problems that may hinder data collection and modifications were done accordingly. Results of the pilot study proved that the study tools were clear, understood, and easily applicable. The test-retest reliability was done for the two study tools (voices acceptance and action scale (VAAS) and Psychotic Symptom Rating Scales- auditory hallucination (PSYRATS-AH) on fifteen patients with schizophrenia taking into consideration the inclusion criteria, with a time laps of two weeks in between using Pearson Chi-Square. They proved to be reliable. Cronbach’s alpha also demonstrated high internal consistency for both tools. The subjects of the pilot study were excluded from the actual study.
• The content of ACT sessions was translated into Arabic language with some modifications to fit the Egyptian society. Then, a pilot study was carried out on 3 patients with schizophrenia during the ACT sessions development by the researcher in order to assess and ensure the clarity and applicability of acceptance and commitment therapy sessions, and identify any obstacles and problems that may hinder the researcher during data collection. The three subjects of the pilot study were excluded also from the actual study.
• Acceptance and commitment therapy sessions was based on guidelines and applications developed by Hayes et al (1999), Bach & Hayes S (2002) and Morris et al (2013) on patients with schizophrenia.
• The researcher was undergoing a period of training on Acceptance and Commitment Therapy (ACT) through online academic training at Association for Contextual Behavioral Science (ACBS) for 8 weeks with certified 16 credits hours (Harris R, 2015).
• The therapy consisted of six sessions, each session of acceptance and commitment therapy was developed based on general and specific objectives. The teaching materials used in acceptance and commitment therapy were: slide pictures, metaphoric videos, and metaphoric role plays. As well as simulations, and homework assignment.
• The researcher attended the inpatient hospital setting three days/week to apply ACT sessions
• Each session of the ACT intervention was taken between one hour to one and half; that time increased or decreased according to the content of session and the response of the patients.
The field work in the present study was implemented in three phases:
• The actual study was conducted during the period between 15th of Mars 2018 to the end of May 2019. It went through three phases:
Phase 1: selection of the subjects:
• All psychotic male patients’ wards were ranked by simple randomization and the first two selected ward was picked from a pool from 1 to 5 for the study group of data collection and the second two-selected wards were assigned for the control group. Both groups were matched as much as possible in relation to socio- demographic and clinical data characteristics.
• In the first two selected wards, all patients’ medical charts were reviewed to identify those who met the inclusion criteria. The process was repeated till the required number was obtained.
• Each recruited patient in the study and control groups were underwent the usual hospital routine care or (TAU) treated as usual, as well as ACT sessions were carried out for the study group only.
Phase II: implementation of acceptance and commitment therapy (ACT) sessions:
• The researcher then provided detailed information to the recruited patients in relation to number of sessions, length and frequently of each session, general goals of ACT model and specific objectives of every session, and the importance of homework that should be done between sessions.
• The researcher and the recruited patients were working together to practice the ACT skills and metaphors to achieve the sessions objectives throughout the therapy, different audio-visual materials (videos, images).
• Summary of important steps and concepts of every session was discussed by the researcher at the end of each session and also at the beginning of the next one.
• Throughout the sessions, the researcher was always keen to keep the recruited patients motivated and active participant, this was done through continuous positive reinforcement (i.e. in the form of reward as positive comments and candy…..etc.)
Phase III: evaluation of the effectiveness of acceptance and commitment therapy:
• The post test was done immediately after ACT sessions completed for both groups by using tools I and II to assess efficacy of therapy on auditory hallucinations after patients discharged.
The following are the main results obtained from the study:
• The age of the majority of both the study and control groups ranged between 25-30 years (54.3% and 65.7% respectively) with mean age 27.69 ±2.76 years for both groups.
• Nearly two thirds of the study group and the majority of the control groups were unemployed (65.7% and 80% respectively).
• About three quarter of the study and control groups had secondary education (74.3% and 77.1% respectively).
• Patients who were single representing 74.3% and 85.7% for the study and control groups respectively.
• It was found that 40% of the study group and 54.3% of the control group had five years duration of illness with mean duration of illness 4.11± 0.99 years.
• Atypical antipsychotics were the most frequent prescribed drugs for the study and control groups (68.6% and 71.4 % respectively).
• Around half of the study and control groups abused cigarettes and hashish (57.1% and 45.7% respectively).
• The current study showed that the mean differences between pre and immediately post interventions of the study group is increasing more than control group for the total psychotic symptom rating scales at immediately with -4.97 and is increasing again after three months from intervention with (-12.06), and those differences between both groups were found strong statistically significant between pre and immediately post intervention (t=-4.47, p=0.000) and between pre and post three months intervention (t = -8.54, p=0.000).
• By using repeated ANOVA test, the current study showed that the mean score of the study group for the total psychotic symptoms rating scales -AH is 31.88 at pre intervention, decreasing to 18.77 at immediately post and to 19.80 at post three months, that decreasing in the mean score was found highly statistically significant (p=0.000) with effect size 78.08% , while the mean difference of total score of PSYRARS-AH between two periods of time at pre and immediately post was highly significant (P1=0.000), also between pre and post three months was highly significant (P2=0.000). But, between the period of immediately post and post three months was found insignificant (P3=0.250).
• The current study showed that, there is a remarkable increasing in the mean differences between pre and immediately post intervention of VAAS and its subscales for the study group more than control group. The mean difference between pre and immediately post intervention for both groups relating to total Voices Acceptance and Action Scale (VAAS) was 59.69 with a strongly statistically significant difference (t=20.024, p=0.000). as well as, the mean differences between study and control groups at pre and post three months intervention of VAAS was 69.60 with a strong statistically significance difference (t=18.12, p=0.000)
• By using repeated ANOVA test, the current study showed that the mean score of total VAAS is 31.97 at pre intervention, 103.63 at immediately post and 103.17 at post three months, that increasing in the mean scores were found highly statistically significant (t=485.57& P=0.000) with effect size 93.46% , while the mean difference of total score of VAAS between two period of time at pre and immediately post was highly significant (P1=0.000), between pre and post three months was highly significant (P2=0.000), whereas, between the period of immediately post and post three months, it was found insignificant (P3=0.841).
• The majority of patients with schizophrenia in the study group were found to be compliant with their medications after three months of intervention (88.6%), in comparing to around quarter of control group (25.7%) and there is a highly statistically significant different were found between both group ( χ2=28.77, P=0.00).
• According to re-hospitalization after discharge from the hospital in three months period, the majority of the study group 88.6% were not readmitted to hospital during three months of discharge, in comparing to more than one third (37.1%) of the control group, that difference between both groups was found a highly statistically significant (χ2=19.83, P=0.00).
According the study results, the main recommendations are:
• Psychiatric hospitals should support the application of acceptance commitment therapy as an integral component in the hospital routine care of patients with schizophrenia who experienced auditory hallucination.
• Develop workshops for psychiatric nurses and psychiatrists on applying ACT for patients with schizophrenia.
• Further studies are needed to assess the values of patients with schizophrenia and assess how they affect on patient’s quality of life.
• Further studies are needed to assess the effect of ACT application on patients with schizophrenia who have delusions and other psychotic disorders as mood disorders as well as with addiction.
• Family caregivers of patients with schizophrenia should be trained on ACT to overcome burnout and decrease emotional burden of caring psychotic family member.
• Further studies are needed to investigate the effect of ACT on /metacognitive functions, clinical insight, self-esteem, emotional regulation, and quality of life among patients with schizophrenia.
• Integrating ACT application into theoretical and practical educational programs in psychiatric nursing and medicine.
• Replication of the present study more extensively for longer period on a larger sample; including female patients to ensure proper generalization.