Mindfulness
DOI 10.1007/s12671-016-0617-6
ORIGINAL PAPER
Mindfulness as a Mediator Between the Relational Style
with Voices and Negative Affect
Salvador Perona-Garcelán 1,2 & Juan F. Rodríguez-Testal 2 & Cristina Senín-Calderón 3 &
Miguel Ruiz-Veguilla 1 & Mark Hayward 4
# Springer Science+Business Media New York 2016
Abstract Recent studies have established associations be-
tween relating to voices and distress. However, the potential
influence of mindfulness on this relationship has received little
attention. This study was designed to explore the extent to
which associations between relating to voices and distress
are mediated by mindfulness. A cross-sectional study was
conducted to explore the associations between these variables.
A sample of 62 patients with psychotic disorder were given
the Voices and You Scale (VAY) to measure the relational
style with the voices, the Mindfulness and Awareness Scale
(MAAS) to measure the capability of mindfulness, and the
Beck Anxiety Inventory (BAI) and Beck Depression
Inventory-II (BDI-II) to measure anxiety and depression, re-
spectively. The results showed a negative association between
a dysfunctional style of relating to the voices and mindfulness.
It was also found from simple mediation analysis that the
mindfulness variable negatively mediated the dysfunctional
relational style with voices and distress. Mindfulness is a var-
iable that can mediate the effect of relating style upon voices
and distress and should be a target of therapeutic intervention.
Keywords Relational style with voices . Mindfulness .
Auditory hallucinations . Negative affect . Psychosis
* Salvador Perona-Garcelán
sperona@us.es
1
Virgen del Rocío Outpatient Mental Hospital, Andalusian
Health-Care Service, University Hospital Virgen del Rocío, Avda.
Jerez, s/n, 41013 Seville, Spain
2
Personality, Evaluation and Psychological Treatment Department,
University of Seville, Seville, Spain
3
Department of Psychology, University of Cadiz, Cadiz, Spain
4
Department of Psychology, University of Sussex, Brighton, UK
Introduction
Auditory verbal hallucinations or voices are a type of psycho-
logical experience that has received great interest from mental
health researchers in recent years. Such diverse aspects of its
phenomenology as failure of self-recognition, difficulty in
controlling private events, and perceptual and emotional qual-
ities of voices have been studied (Waters et al. 2012). Several
different models have also been developed to explain the phe-
nomenology of voice hearing: some theories propose that
voices are a product of cognitive biases provoked by problems
in monitoring the source, discriminating reality, or cognitive
dissonance; other theories suggest they are the product of cog-
nitive deficits caused by problems in self-monitoring of own
thoughts or a combination of cognitive deficit and biases (see
Aleman and LarØi 2008).
An aspect of the phenomenology of voice hearing that has
received recent attention is the person’s relationship with the
voices. The person is not passive to the Bperception^ of his/her
voices but reacts to them cognitively, emotionally, and behav-
iorally. Often, the person tries to turn away from voices and
avoid contact with them because of the stress they cause;
however, sometimes, the person turns toward voices and en-
ters into reciprocal interactions with them, in a manner that
could be considered relational in nature (see Hayward et al.
2011, for a review).
Birtchnell’s (2002) relating theory is one of the interper-
sonal frameworks that have informed understandings of
voices within relational frameworks. Relating theory sug-
gests that social relations occur between two axes, one of
power and the other of proximity. The power axis describes
the influence that one has over the other, and proximity
describes the distance between two individuals, and there-
fore, the degree of closeness. In the context of distress,
voices are typically perceived to relate dysfunctionally by
 Mindfulness

dominating and intruding upon the person, with the person Method
responding by seeking distance or becoming dependent
(Hayward et al. 2008; León-Palacios et al. 2015; Sorrell Participants
et al. 2010; Vaughan and Fowler 2004).
Curiosity has been expressed about whether the relation- Sixty-two patients with auditory verbal hallucinations and a
ship between the dysfunctional relational style with the voices psychiatric diagnosis in the ICD-10 (World Health
and distress is direct or mediated by other factors. Sorrell et al. Organization 1992) who were being cared for in the Virgen
(2010) found indirect evidence from partial correlations that del Rocío Hospital Mental Health Clinical Management Unit
beliefs about the voices mediated associations between the (Seville) participated in this study. Criteria for inclusion were
relational style and distress, and these findings were corrobo- a score on the PANSS (Kay et al. 1988) hallucinations item of
rated by León-Palacios et al. (2015) using multiple mediation three points or higher, age from 18 to 65, speak fluent Spanish,
analysis. In a further study, Perona-Garcelán et al. (2016b) and have voluntarily agreed to participate in the study.
found that public self-focused attention was partially mediat- Reasons for exclusion from the study were having a history
ing associations between relational style and anxiety. of brain damage, suffering from a psychotic disorder caused
A further variable that could potentially be exerting a me- by use of toxic substances, and at the moment of evaluation
diating influence is mindfulness—the ability to intentionally showing abuse and dependence on alcohol or other toxic sub-
bring awareness to present-moment experience without judg- stances. Table 1 shows the sample demographic and clinical
ing that experience (Kabat-Zinn 1994). Mindfulness-based characteristics.
interventions assist hearers to notice voice comments and to
locate attention elsewhere, if they choose, and have reported
Procedure
beneficial effects upon voice distress and depression (e.g.,
Chadwick et al. 2016).
The self-report questionnaires were administered by three
However, few studies have explored the spontaneous capa-
clinical psychologists who had previously been trained in
bility of mindfulness (or mindfulness as trait) in persons with
their administration. Prior to participation, all participants
psychosis without prior training. Chadwick et al. (2007) found
had provided their written informed consent, and their
that in individuals with psychosis, mindfulness correlated neg-
atively with negative affect, voice distress, and resistance to
them and beliefs about malevolence and omnipotence. Morris Table 1 Demographic and clinical characteristics
et al. (2014) found a negative correlation between mindfulness Characteristics N ( %) MEAN (SD)
and depression, anxiety, and emotional and behavioral resis-
tance to voices in individuals with psychosis. Other studies Gender
have also found a negative correlation between mindfulness Men 39 (63 %)
and proneness to hallucinations in healthy subjects (Perona- Women 23 (37 %)
Garcelán et al. 2014a) and between mindfulness and voice Age 38.3 (10.27)
distress and severity of voices in individuals with psychosis Marital status
(Escudero-Pérez et al. 2016; Úbeda-Gómez et al. 2015). Single 47 (76 %)
Collectively, these studies suggest that spontaneous mindful- Separated 8 (13 %)
ness abilities may be a protective or buffering factor for dis- Married 7 (11 %)
tress caused by the voices. Employment status
Considering the positive association found between rela- Disabled 28 (45 %)
tional style with the voices and distress on one hand and on the Unemployed 28 (45 %)
other the negative association of the spontaneous abilities of Protected job 3 (5 %)
mindfulness and distress, the purpose of this study was to Student 3 (5 %)
examine the relationship between a dysfunctional relational Diagnoses
style with voices and mindfulness, and the impact of these Schizophrenia 53 (85.5 %)
two variables on voice distress. Our hypotheses were as fol- Schizoaffective 6 (9.7 %)
lows: (1) the style of dysfunctional relating with voices (the Unspecified nonorganic psychosis 3 (4.8 %)
perceived dominance and intrusiveness of the voice on one PANSS hallucinations 5 (0.88)
hand and distance and dependence of the hearer on the other) Age when disorder began (in years) 24.13 (7.88)
will be negatively associated with the mindfulness variable. Total years of disorder development 15 (9.75)
(2) The association between the dysfunctional style of relating Years with voices from disorder onset 12 (10.09)
with voices and voice distress/negative affect will be mediated Number of admissions to hospital 2.19 (2.76)
negatively by mindfulness.
Mindfulness
clinical and demographic data were collected. The scales
were given in the following order: VAY, MAAS, BAI,
and BDI-II. All the patients were prescribed medication at
the time of being interviewed.
Measures
Voice and You (VAY, Hayward et al. 2008). This scale mea-
sures the interrelationship between the person who hears
voices and his/her predominant voice. For this study, we used
the 23-item Spanish version of the scale by Perona-Garcelán
et al. (2016a), which is divided into 4 subscales: Bvoice dom-
inance^ (7 items), Bvoice intrusiveness^ (4 items), Bhearer dis-
tance^ (5 items), and Bhearer dependence^ (7 items). Each
item is answered on a four-point Likert-type scale. This ver-
sion has adequate psychometric properties, and the
Cronbach’s alpha in this study varied from 0.74 to 0.85 for
the four subscales.
Mindful Attention Awareness Scale (MAAS, Brown and
Ryan 2003). The Spanish version by Soler et al. (2012) was
used. It is a 15-item self-report scale scored on a Likert scale of
1 to 6. It is based on the single-factor conception of full aware-
ness that evaluates the dispositional capacity of awareness or
attention to the experience of the present moment in daily life.
The Cronbach’s alpha for this scale is 0.89.
The Beck Anxiety Inventory (BAI, Beck and Steer 1993).
This scale is comprised of 21 questions concerning emotions
during the past week, expressed as common symptoms of
anxiety. Each question is rated on a four-point Likert scale.
We used the Spanish version by Sanz and Navarro (2003).
The Cronbach’s alpha for this scale is 0.92.
The Beck Depression Inventory-II (BDI-II, Beck et al.
1996). This scale was designed to measure levels of intensity,
severity, and depth of depression in patients with a psychiatric
diagnosis. It is composed of 21 questions, all of which are
constructed to provide a means of assessing a specific symp-
tom common among persons suffering from depression on a
four-point Likert scale. In this study, we used the Spanish
version by Sanz et al. (2003). The Cronbach’s alpha found
for this scale in this study was 0.94.
Data Analyses
A Pearson’s correlation analysis was conducted of the VAY
and MAAS subscales to test the first hypothesis, and a simple
mediation analysis was conducted to test the second hypoth-
esis. For the mediation analysis, two models were estimated,
one for each dependent variable, in which the VAY subscales
were the independent variables, the mediating variable was
the score on the MAAS scale, and the dependent variables
were the scores on the BAI and BDI-II. PROCESS (version
2.13.2) by Hayes (2013) for SPSS was used for the above,
with a 95 % CI and 5000 bootstrap samples to estimate the
significance of the mediator. Indirect effects were considered
significant when the corrected bias and accelerated confidence
interval did not include zero.
Results
Table 2 shows the Pearson’s correlations for the variables of
interest for testing our hypotheses: the VAY subscales, the
MAAS subscales, and the two negative affect subscales
(BAI and BDI-II). Significant negative correlations were
found between the MAAS and the four VAY subscales.
Positive correlations were evident between the VAY subscales
and the two negative affect scales (BAI and BDI-II).
Table 3 shows the results of the simple mediation analyses
carried out to test our second hypothesis. All the indirect ef-
fects were significant, showing that the relationship between
relational style and negative affect was not direct but was
negatively mediated by the mindfulness variable. In both the
BAI [R2 = 0.46, F (5, 56) = 9.7, p < 0.001] and the BDI-II
[R2 = 0.42, F(5, 56) = 8.2, p < 0.001], the mediating relation-
ship with each of the VAY subscales was full, except the
dominance subscale which was partial. Although the total
effects (c) on mediation of the MAAS between the VAY in-
trusiveness, dependence, and distance subscales on one hand
and negative affect (BAI and BDI-II) on the other were not
significant, significant total effects are not necessary for infer-
ring significant mediation effects (Preacher and Hayes 2008).
Discussion
This study explored the relationship between mindfulness and
auditory verbal hallucinations (voices). Studies to date have
focused upon the relationship between mindfulness and vari-
ous aspects of experiencing voices, such as severity and dis-
tress caused by the voices, proneness to hallucinations, nega-
tive affect (anxiety and depression), beliefs about the voices,
and behavioral and emotional resistance to the voices. This
study explored the relationship between mindfulness and
dysfunctional relational styles with voices, based on the
hypothesis proposed by Hayward et al. (2013) in which
mindfulness-based intervention can help patients to disengage
from their voices by changing the relationship with them, and
experience less distress as a consequence.
With regard to the first hypothesis, it was found that the
mindfulness variable correlated negatively with the four VAY
subscales. That is, higher levels of mindfulness were associ-
ated with less dysfunctional relationships with the voices, in
which they are perceived as less dominating and intrusive, and
the person is shown to be less dependent and distant from
them. This result is coherent with the few related studies de-
scribed above, in which other variables related to
 Mindfulness

Table 2 Means, standard

deviations, and correlations of MEAN 1 2 3 4 5 6 7
VAY, MAAS, BAI, and BDI-II (SD)
subscales
1. VAY Dominance 11.46 (6.7) 1
2. VAY 5.56 (3.6) 0.61*** 1
Intrusiveness
3. VAY Dependence 5.39 (4.6) 0.13 0.46*** 1
4. VAY Distance 8.40 (4.4) 0.80*** 0.40** −0.03 1
5. MAAS 53.18 (17.5) −0.49*** −0.37** −0.33** −0.29* 1
6. BAI 26.32 (14.7) 0.58*** 0.42*** 0.13 0.34** −0.55*** 1
7. BDI-II 25.58 (15.7) 0.59*** 0.39** 0.04 0.38** −0.47*** 0.60*** 1

N = 62
VAY Voices and You, MAAS Mindfulness Attention and Awareness Scale, BAI Beck Anxiety Inventory, BDI-II
Beck Depression Inventory-II
*p < 0.05; **p < 0.01; ***p < 0.001

hallucinations (such as severity, level of emotional distress,
beliefs about voices, etc.) were also found to be negatively
associated with mindfulness (Chadwick et al. 2007;
Escudero-Pérez et al. 2016; Morris et al. 2014; Perona-
Garcelán et al. 2014a; Úbeda-Gómez et al. 2015).
Furthermore, a negative correlation was also found between
mindfulness and negative affect in patients with psychosis.
Thus, the participants in this study who scored highest in
mindfulness showed the lowest levels of anxiety and depres-
sion and vice versa; the participants with lower scores in
mindfulness had higher levels in anxiety and depression.
The second hypothesis in this study explored the possibility
that associations between the relational style with voices and
negative affect were negatively mediated by mindfulness. The
results have offered some support for this hypothesis: those
subjects who had a more dysfunctional relationship with their
voices had lower levels of mindfulness, and these lower levels
of mindfulness were also associated with high negative affect.
Specifically, when the voices are very intrusive, the person
distances himself from them or maintains a relationship of
close dependence; mediation by mindfulness is full. That is,
the direct effect between these relational styles and negative
affect are no longer statistically significant when the mindful-
ness variable forms part of the regression equation. These
results also allow us to speculate that an improvement in the
relationship with the voices could diminish the stress associ-
ated with them by increasing mindfulness. However, when the
relationship with the voices is based on their domination over
the person, the mediation of mindfulness is only partial. This
result enables us to suggest that there could be two ways for a
relationship based on dominance of the voices causing distress
in the person: one direct, that is, the dominance itself is

Table 3 Summary of the simple mediation model in which the dependent variables are the scores on the BAI and BDI-II, the independent variables are
the VAY subscales, and the mediating variable is MAAS

Independent Mediating Dependent Effect of X on M Effect of M on Y Direct Indirect effect Total effect
Variable variable variable controlling for X effect bootstrap

X M Y a b c’ a×b 95 % CI c

BAI −1.27*** −0.29** 1.25* 0.38* (0.11 to 0.76) 1.75**

VAY dominance MAAS BDI-II −1.27*** −0.25* 1.37* 0.31* (0.04 to 0.69) 1.78**
BAI −1.78** −0.29** 0.45 0.52* (0.12 to 1.21) 0.34
VAY MAAS
intrusiveness
BDI-II −1.78** −0.25* 0.44 0.44* (0.07 to 1.13) 0,34
VAY BAI −1.26** −0.29** −0.41 0.37* (0.03 to 1.06) −0.10
dependence MAAS BDI-II −1.26** −0.25* −0.62 0.31* (0.02 to 1.00) −0.36
BAI −1.14* −0.29** −0.88 0.34* (0.08 to 0.78) −1.01
VAY distance MAAS BDI-II −1.14* −0.25* −0.74 0.28* (0.05 to 0.71) −0.92

The data are expressed in non-standardized β coefficients based on 5000 bootstraps. N = 62

a effect of VAY on MAAS, b effect of MAAS on BAI and BDI-II scores, c’ direct effect, a × b indirect effect, c total effect, CI confidence interval
*p < 0.05; **p < 0.01; ***p < 0.001
Mindfulness
sufficiently distressing, and the other indirect, which would be
caused by the decrease in mindfulness. Probably, this partial
mediation by mindfulness between the dominant relational
style and negative effect is related to the value of the correla-
tions found, that is, the correlations between the VAY domi-
nance and negative effect are higher than between the other
types of relational styles (VAY intrusiveness, VAY distance
and VAY dependence) and negative affect (see Table 2).
In view of all of the above, what mechanisms are acting in
the relationship between mindfulness and the style of relating
with the voices? Strauss et al. (2015), based on the qualitative
studies done to study the effectiveness of mindfulness inter-
ventions, suggested three potential processes of change that
could affect the relationship with the voices: (1) reorientation
of attention, (2) decentering, and (3) acceptance of voices.
Along this same line, some studies have found that mindful-
ness is associated negatively with self-focused attention (pri-
vate and public) in healthy subjects highly prone to hallucina-
tions and in patients with psychosis (Perona-Garcelán et al.
2014b; Úbeda-Gómez et al. 2015). Self-focused attention is a
very inflexible, ruminating attentional style strongly concen-
trating on oneself. It is plausible that it is easier for a person
with naturally high levels of mindfulness, or trained to devel-
op this attentional ability, to change to a more flexible atten-
tional style, less evaluative and ruminating, centering on
things that are happening in the here and now. So, all those
private events such as intrusive thoughts and voices are less
distressing when one is able to distance oneself more easily
than when one does not have this ability. This possibility is
consistent with the finding that mindfulness mediates nega-
tively between self-focused attention and hallucination prone-
ness (Perona-Garcelán et al. 2014b).
Furthermore, other studies have found that individuals with
voices show higher levels of absorption and imaginative in-
volvement than those without voices (Perona-Garcelán et al.
2008, 2012). Tellegen and Atkinson (1974; pp. 268) defined
absorption as Ba disposition for having episodes of ‘total’ at-
tention that fully engage one’s representational (i.e., perceptu-
al, enactive, imaginative, and ideational) resources,^ so that
individuals with high levels of absorption enter an altered state
of consciousness. Based on the results found in our study, it
may be speculated that individuals who interact with their
voices intensely and frequently do so under the influence of
very intense states of absorption. Therefore, if the person
shows natural mindfulness skills on one hand, he would be
less vulnerable to suffering from episodes of voices, and on
the other, suffer less from the associated distress.
The clinical contributions of this study concern the need to
value the natural ability (or trait) for mindfulness in patients
with voices. Where this ability is lacking, intervention could
be targeted at teaching mindfulness skills—and recently re-
ported evidence for the effectiveness of a mindfulness-based
group intervention for voices offers encouragement in this
respect (Chadwick et al. 2016). On the other hand, it would
be of interest to design interventions in such a way that the
purpose of the mindfulness techniques is not only becoming
fully aware of the emotional experience related to the voices
but also teaching persons to notice what they do, think, or feel
while relating to the voices, creating the potential to choose a
more functional relational response that may reduce distress.
Adding mindfulness techniques to relationally based therapies
(e.g., relating therapy [Hayward et al. 2009]; avatar therapy
[Leff et al. 2014]) might be productive in this respect.
This study has a number of limitations. Firstly, we used a
correlational design and could not establish causal relation-
ships among the variables studied. Therefore, our theoretical
conclusions should be interpreted with caution, and they are
only presented as proposals for suggesting new problems and
hypotheses for the design of future research. Secondly, the
small size of the sample used could reduce the statistical pow-
er of our results. Finally, an exhaustive evaluation was not
made of previous patient experience with mindfulness tech-
niques. It would be desirable for future studies to control for
this variable or study the relationship between mindfulness
and style of relating with the voices by comparing persons
with and without experience in mindfulness techniques.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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