Mindfulness, Group Therapy and Psychosis; Training Decreases Anxiety and Depression in Outpatients With a Psychotic Disorder in a Non-Randomized Within Group Comparison
Conditions: Psychosis
Sponsor: University of Minnesota

Title: Mindfulness, Group Therapy and Psychosis; Training Decreases Anxiety and Depression 
 
PI: Joan Lund 
 
IRB: STUDY00005035 
 
ClinicalTrials.gov: NCT04711460 
 
 
Document Date: February 12th, 2019 
 

Study Protocol 
The main investigator and author is a doctoral level licensed clinical psychologist with 
over 20 years of adult outpatient mental health experience, has training in CBT, mindfulness, has 
knowledge of severe and persistent mental illnesses, psychological assessment, crisis 
intervention, individual therapy, group therapy, and has conducted the group therapy for all 
participants.  The author has worked in the outpatient mental health setting at the University of 
MN Medical Center for over 20 years. The study is monocentric and conducted at the UMMC, 
MHealth, Fairview hospital location, Minneapolis, MN. 
The title of the study is:  Mindfulness, Group therapy and Psychosis;  Training Decreases 
Anxiety and Depression in Outpatients with a Psychotic Disorder in a Non-Randomized Within 
Group Comparison. The protocol number is:  STUDY00005035.  The Assurance of Compliance 
number is FWA 00000312 (Fairview Health Systems Research FWA00000325).  The field of 
research is psychology. 
Key words for the study include: mindfulness, psychosis, anxiety, depression, outpatient, 
group therapy, and schizophrenia.   
The rationale for the study is to evaluate the addition of mindfulness as a new therapeutic 
technique.  This is done in an outpatient group therapy program with participants diagnosed with 
a psychotic spectrum disorder, alongside of cognitive behavioral therapy.  This group has been 
under-served in areas of therapeutic techniques, particularly in group therapy.  Although some 
research has been done in this area, in the United Kingdom, it is not regular practice in the USA. 
Results from this study indicate that the addition of mindfulness training to the recommended 
Cognitive Behavioral Therapy training is beneficial to participants. 
Historically, the recommended treatment for psychotic disorders from the National 
Institute of Mental Health (NIMH) has been the use of anti-psychotic medications, individual 
therapy, cognitive behavioral therapy, and psychoeducation (Dickerson & Lehman, 2006; Patel, 
Cherian, Gohil, & Atkinson, 2014; NIMH, 2016a, 2016b). Person-centered care and recovery-
oriented treatment were added in 2014. (Dixon, Holoschitz, & Nossol, 2016). Although 
individual CBT and cognitive behavior therapy for psychosis (CBTp) is recommended by NIMH 
and the National Institute for Care Excellence (NICE, 2008) for patients with a diagnosis of 
psychosis, Chadwick, et al. (2016) noted that access to group CBTp remains poor, and that it 
lacks sufficiently robust evidence of its effectiveness. Chadwick, et al. (2016), argue that CBTp 
is aimed at trying to control psychotic symptoms, whereas person based cognitive therapy 
(PBCT) is aimed at alleviating distress. Chadwick, et al. (2016) noted that PBCT has lasting 
effects on improvements in mood, reductions in depression levels, and behavioral change, and 
that CBTp has not typically found a reduction in depression levels (Birchwood.et al. 2014).  
 
Past research urged caution when using mindfulness with psychosis (Yorston, 2001). 
However, randomized studies using Acceptance and Commitment Therapy (ACT), which 
includes mindfulness training, reported a reduction in relapses for inpatients experiencing 
psychosis, as well as a decrease in hospital re-admissions (Bach, 2002; Guidano & Herbert, 
2006). 

 
With no recommended group therapy for psychosis, or use of mindfulness from either 
NIMH or NICE, Chadwick, Newman-Taylor, and Abba (2005) developed a 10 minute 
mindfulness group-based technique to alleviate the distress associated with psychosis. Their 
research resolved this gap, since it demonstrated that a shorter duration exposure to mindfulness 
was effective in reducing stress, anxiety, and depression (Cavanagh et al., 2013).  
 
Investigations of how people relate to their psychotic experience found that most of the 
distress was from their reaction to the psychosis (Birchwood & Chadwick, 1997; Morrison & 
Wells, 2003). Chadwick and his colleagues introduced the idea that patients were more than their 
psychosis and that the patient’s core self is good (Chadwick, et al., 2005; Chadwick, Hughes, 
Russell, Russell, & Dagnan, 2009). Abba, Chadwick, and Stevenson (2008) noted that those who 
experienced auditory hallucinations were unable to direct and focus their attention. Chadwick et 
al. (2005) and Ratcliffe & Wilkinson (2016) both wrote of how depression accompanies anxiety 
with psychosis, and notably verbal hallucinations. 
 
Part of the recovery process is being able to identify how distressing psychosis events and 
related avoidance behaviors can lead to a relapse (Chadwick 2006). Hayes and Wilson (1994) 
referred to the process as “experiential avoidance,” which occurs when the person avoids a 
distressing situation, and takes steps to change their form, frequency, and context. The process  
results in more avoidant behaviors to manage the experience. Ruminating about the avoided 
situation affects judgment in a negative manner (Hayes, 2004; Hayes, Strosahl, & Wilson, 2012). 
The person becomes more frustrated with this behavior, which limits choices (Morris, 2019). 
Increased anxiety shapes anticipation and perception of psychosis events (Ratcliffe & Wilkinson, 
2016). In response to a psychosis event, a person can get stuck in a habitual pattern that 
maintains their distress and increases the possibility of relapse (Newman-Taylor & Abba, 2019). 
Thus, the reaction to the psychosis event is rumination about how they misperceive the event and 
turn to confrontation.  
 
 The core goal is to create a mindful response to the psychosis event. This response 
enables a person to develop an awareness of the event and begin the process of disengaging from 
it. The person does not resist the psychosis event, but becomes aware of it, and learns to observe, 
accept, and let it go. The process of disengaging from psychosis and developing an open attitude 
towards it is vital when applying mindfulness (Chadwick, 2014).  
Kabat-Zinn (1990, 1994) described mindfulness as a way of focusing attention 
purposefully in the present moment, non-judgmentally; he developed mindfulness-based stress 
reduction (MBSR) to use as a psychiatric intervention. Kabat-Zinn (1994) also developed a 
technique alongside cognitive behavior therapy (CBT) and emphasized that distress and 
suffering result from the mind and not from sensations. Segal, Williams, and Teasdale (2013), 
drawing from Kabat-Zinn’s concepts, wrote about mindfulness based cognitive therapy (MBCT) 
as an independent intervention. A meta-analysis of the two interventions, reported by Baer 
(2003) showed clinical benefits for those who were experiencing pain, stress, anxiety, 

depression, and disordered eating behaviors; mindfulness treatment therefore became an 
accepted intervention.  
The Mindfulness Process 
 
Chadwick adapted techniques from MBSR and MBCT approaches, adding the first 
minute which involves the body scan. All mindfulness practices are guided, with reminders 
every few minutes to re-focus on the mindfulness process and not become lost in reactions to 
psychosis. Homework is encouraged, but not required. Therapeutic process, relationships, and 
group therapy concepts from Yalom and Leszcz (2005) are included in the structure.  
Results and Benefits from the Mindfulness Intervention 
 
Benefits of mindfulness training showed significant improvement in the areas of 
symptom severity, illness insight, functioning, and in the number of hospital admissions (Chien 
& Thompson, 2014). The PBCT process focuses on reducing negative symptoms of affect, 
reducing positive symptoms of psychosis, and on improved functioning and quality of life (Dyga 
& Stupak, 2015).  Langer, Cangus, Salcedo, and Fuentos (2012) found an improvement in the 
ability to respond to stressful internal psychotic symptoms and external events. The PBCT 
approach has been demonstrated to be a powerful technique that reduces the distress associated 
with psychosis (Samson, 2012) and specifically with the distress associated with auditory 
hallucinations (Ratcliffe & Wilkinson, 2016).  
 
Chadwick (2016) noted that the mindfulness training results demonstrated a post-
intervention reduction in the participants’ feeling controlled by their voices. Regarding 
delusions, Ellett (2012, 2013) found improvements in levels of distress, preoccupation, anxiety, 
and depression, and improvements which were maintained at a one-month follow-up, suggesting 
that mindfulness training can impact cognition and affect associated with paranoid beliefs. 
Khoury, Lecomte, Gaudiano, and Paquin (2013) found that mindfulness interventions were 
moderately effective in treating psychosis when used as an adjunct to pharmacotherapy. In sum, 
mindfulness has been beneficial for those suffering from psychosis, as noted by Newman-Taylor 
and Abba (2019), and with adaptations, mindfulness can be safely used with this population. 
 
The study design is monocentric and was conducted at the University of MN Medical 
Center. The scope is retrospective, with matched data in a within-group comparison format.  This 
study was observational in design to accommodate the outpatient clinical setting’s needs.  
Main goal for study 
The aim of the present study was to evaluate the addition of mindfulness, as a new 
technique to be in a group therapy setting with participants who have a psychotic spectrum 
disorder diagnosis. Additional focuses are to evaluate scores on depression and anxiety scales, to 
replicate concepts from Chadwick’s 2005 and 2009 studies, and to determine if participants’ 
responses were from a mindfulness-based response or from an experiential-avoidance response. 
The hypothesis was that depression and anxiety scores would drop as participants applied 
learned skills. Since CBTp alone did not appear to decrease depression, Chadwick (2016) 
believed that mindfulness practices would help alleviate the symptoms of distressing psychosis, 

in particular, it would alleviate symptoms of anxiety and depression, and demonstrate that group-
based CBT with mindfulness is a vital intervention that needs to be incorporated as a treatment 
recommendation.   
Participants referred to the outpatient program, were interviewed by a licensed mental 
health professional and received a diagnosis that included psychosis from the Diagnostic and 
Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). 
The necessary level of care was determined to be outpatient group therapy.   
 
Participants were screened for substance abuse using the CAGE-AID and scores had to 
fall within two or less affirmed questions. Consultation with a licensed addiction and drug 
counselor was obtained for questionable participants, and all agreed to remain sober and comply 
with doctor recommendations. A mental status exam was conducted to determine their ability to 
retain information and apply it. For inclusion, the Columbia Suicide Severity Rating Scale (C-
SSRS) scores needed to be between 1 and 3, which indicates a level of care appropriate for 
outpatient programs.  
 
Upon admission to the outpatient program, participants signed a hospital treatment 
consent and a consent for research.  No recruitment was done for this research.  Participants 
scores on the PHQ-9 and GAD-7 were taken at admission and discharge.  Scores were matched 
for two sets of data to compare participants who received treatment plus mindfulness and those 
who received only treatment for the first experiment.  The second experiment compared scores 
that examined different age groups. 
Mindfulness training was measured on a daily and weekly basis over five to 12 weeks. 
This length of time corresponds to the full duration of the day treatment program. Sessions were 
50 minutes long with 10 minutes of mindfulness practice. Only scores from participants who 
completed a minimum of five weeks were included, which is consistent with the Chadwick 
(2009) study. 
 
Person-Based Cognitive Therapy for Distressing Psychosis by Chadwick (2006) was 
used for treatment conception, but there was not a manual. Five concepts were emphasized. The 
first concept is how the therapist radically collaborates with the client to meet them where they 
are. The second concept includes personal growth. It shows how development occurs through a 
dynamic social and collaborative process within the group explained by Vygotsky’s (1978) zone 
of proximal development, which enhances insight. The third concept demonstrates how the 
mindfulness intervention builds personal development, awareness, teaches a non-judgmental 
stance, and acknowledges that others have distress (Neff, Kirkpatrick, & Rude, 2007). When 
distress is experienced, the participants choose to adopt a mindfulness response rather than the 
experiential avoidance response. 
 
The aim of the present study was to evaluate the effectiveness of providing a new 
technique of mindfulness training in a group therapy format with psychiatric outpatients 
diagnosed with a psychotic disorder. The rationale for mindfulness training and the specific 
practice of focused attention to one’s breath and its rhythm was discussed in relation to the 
participant’s experience of psychotic events. It was expected that mindfulness practices would 

help lower anxiety and depression levels. The PHQ-9 and GAD-7 were used to determine pretest 
and posttest depression and anxiety levels. Scores were derived from participants who received 
mindfulness training plus treatment as usual, and from those who received treatment as usual. 
The results showed that those who received mindfulness training had lowered levels of 
depression and anxiety at posttest. The participants that did not receive mindfulness training had 
a lower level of depression at posttest, but no change in their level of anxiety. 
 
 
The results of the training are encouraging because there has been limited research on the 
use of mindfulness with participants diagnosed with a psychotic disorder due to concerns about 
meditation having the potential to trigger psychosis. However, in the present study, feedback 
from the participants about the group were positive, and they did not find the process to be 
harmful. As more is written about using mindfulness practices with patients diagnosed with a 
psychotic disorder, the idea has become more acceptable; however, access to the treatment 
remains limited. The therapist who led the group had over 20 years of clinical experience using 
mindfulness techniques and CBT, and the groups were conducted in an open, accepting, and 
collaborative manner. This enabled a partnership or alliance to develop with the therapist and 
among the group participants. Therefore, generalization of this practice to other therapists, 
approaches, types of meditation, and participants cannot be assumed.  
 
The pretest-posttest design was used to measure the benefits of mindfulness practice in 
addition to psychiatric care. However, the specific benefits measured were limited to anxiety and 
depressive symptoms. Future research should include other specific symptom-based instruments 
to measure different dimensions of the psychotic experience, as well as examine the transfer of 
mindfulness training and practices from the group to the participant’s daily life. In addition, 
measures such as the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), the 
revised 12-item Cognitive and Affective Mindfulness Scale (CAMS-R; Feldman, Hayes, Kumar, 
Greeson, & Laurenceau, 2007), and the Five Facet Mindfulness Questionnaire (FFMQ; Baer et 
al., 2008) can be used to assess improvements or changes in mindfulness and how mindfulness 
relates to psychosocial functioning in this population. 
The results suggest that the mindfulness training had a statistically significant effect on 
the level of anxiety and depression of the participants, and that lowering anxiety was beneficial 
for those who had auditory hallucinations and paranoia, whose self-reports indicated less 
distress. Participants who completed the mindfulness training reported feeling more confident to 
return to the community since their anxiety and depression levels had decreased. Certainly, a 
decrease in anxiety would be considered improvement in psychological functioning, but it is only 
one aspect of one’s overall functioning, and the intervention was delivered as part of an overall 
treatment program that included a group process. Participants were able to describe openly their 
psychosis experiences during the group therapy, and they would ask for advice from other 
participants about how to manage their psychosis symptoms of voices, images, sensations, and 
paranoia. The effects of the mindfulness training, discussions, and practice may have contributed 
to a change in non-psychotic symptoms as well. In this regard, more rigorous empirical 
investigations are recommended to gain evidence of the effects of mindfulness training on 
different aspects of the psychosocial functioning of patients with a psychotic disorder. 

Statistical Analysis Plan 
Data sets 
The data sets to be analyzed are pre and posttest scores of the PHQ-9 and GAD-7 scores from 
participants in the study who have completed 5 weeks of training in the outpatient mental health 
program. The first experiment measured the Treatment As Usual scores against the Treatment 
plus Mindfulness Training scores.  The second experiment compared the scores of the younger 
adults to the older adults’ scores over the five-week training time. 
Attrition data was collected and presented for each experiment. These include demographics of 
those who did not complete the five weeks of training.  
A second data set was the ranking of the eight Yalom principles with the highest to lowest 
preference for each that described the most important principle learned during the training.  
A third data set ranked the aspects of mindfulness training that were most helpful from highest to 
lowest.   
Analysis Objectives 
The objective was to determine the effect of mindfulness training plus Treatment As Usual 
(TAU) on a group therapy setting for participants diagnosed with a psychosis spectrum disorder. 
The admission and discharge scores were compared to others with a similar diagnosis in group 
therapy that did not receive the mindfulness training but did received treatment as usual. 
Confounding variables include the participant’s response to the therapist, and level of 
comprehension.  Another variable is the individual’s psychotic symptoms and their ability to 
focus during the mindfulness training, since some psychotis symptoms may interfere with 
concentration more than others.  
Analysis sets and population subgroups 
The eligible participants had to have a diagnosis that included psychosis.  The first experiment 
compiled scores to compare TAU to TAU plus mindfulness training. Eligible admission and 
discharge scores were taken from those who completed at least five weeks of treatment. 
Observations were made for males and females, younger and older adults, and different 
ethnicities.  
The second experiment compiled scores to compare younger adults to older adult scores to 
determine if age made a difference to outcome scores.  
End points and covariates 
The scores were collected over 2 years, to ensure a large enough data set. The participants had to 
stay in the program for at least five weeks or longer and practice the mindfulness training. Those 
that did not complete five weeks were observed in the attrition data. Data was collected over 
years to establish two populations.  
Missing values 

Data values that were missing were observed and recorded as the attrition data. This allowed for 
a better depiction of participants’ reasons for not completing the program. This also explained 
the type of barriers to treatment that arose and caused drop-out rates. This is helpful for 
clinicians to understand how effective the treatment can be. The attrition data gives information 
about potential risk factors for participants and can help explain why some participants are not 
successful in the group therapy program.  
Multiplicity 
To reduce multiplicity, a post-hoc test was included in the study.  The Tukey-Kramer Test was 
conducted as a post-hoc test to determine the relevance of the mindfulness training in lowering 
anxiety levels of those diagnosed with psychosis.  Outlying scores were included in the data sets 
to determine if an effect was present in the study. 
 
Statistical Tests 
Experiment 1 and 2 
 
The Generalized Anxiety Disorder 7-item scale (GAD-7; Spitzer, Kroenke, Williams, & 
Lowe, 2006) is a 7-item questionnaire that evaluates levels of anxiety at home, work, and with 
other people. Participants respond to items on a 4-point scale where 0 = “not at all” and 3 = 
“nearly every day.” Item responses are summed to create a total score of anxiety. When used as a 
screening tool, further evaluation for an anxiety disorder is recommended when the score is 10 or 
greater. The measure has been shown to be a valid and reliable measure of anxiety (Terrill, 
Hartoonian, Beier, Salem, & Alschuler, 2015). 
 
The Patient Health Questionnaire-9 (PHQ-9) by Kroenke, Spitzer, & Williams (2001) is a 
9-item screening for major depressive disorder based on DSM-IV criteria. It is rated on a 4-point 
scale where 0 = “not at all” and 3 = “nearly every day” for the past two weeks. Item responses 
are summed to create a total score of depression symptoms. The measure has been shown to be a 
valid and reliable measure of depression (Chiu & Chin, 2018).  
 
The Columbia Suicide Severity Rating Scale (C-SSRS), developed by Posner et al. 
(2011), is a suicidal ideation and behavior rating scale which helps determine passive and active 

suicidal ideation with intent, behaviors, and specific plan. The scale identifies specific behaviors 
indicative of suicide attempts. Questions are phrased in an interview format to determine the 
outcome. It has been shown to be valid and reliable (Mundt et al., 2013). 
 
The CAGE-AID (Brown & Rounds 1995) is a 5-question tool that assesses severity of 
drug and alcohol abuse, and if further assessment needs to be done. If two or more questions are 
affirmative, a complete drug assessment is advised. The measure has been shown to be a valid 
and reliable measure for substance abuse (Leonardson et al., 2005; Dhalla & Kopec, 2007).  
 
 
Results 
Experiment 1. 
A non-standardized, within group comparison was used, since there was open enrollment 
into the program. The use of a T-test for unequal variances compared pre and posttest scores to 
determine the effect of the mindfulness intervention on anxiety and depression. A single-factor 
ANOVA was used to determine differences between the groups. (See Table 4). 
(Table 4)  
 
Two-Tailed T-Test: TAU vs TAU + Mindfulness Training_______________________________ 
(1A and 1B, N=32) 
 
 
 
 
 
Mean  
Mean 
Group Scale  
t-stat t Critical 
P (two tail) 
Pre-test  
Post-test    
SD   _   
1A 
PHQ-9  
1.66 
1.99 
 
p= 0.10 
9.32 
 
6.68 
 
6.4 
1A 
GAD-7 
0.57 
1.99 
 
p= 0.56 
6.25 
 
4.68 
 
5.4 
 
1B 
PHQ-9  
3.18 
1.99 
 
p= 0.002 
12.31  
6.96 
 
7.19 
1B 
GAD-7 
3.02 
1.99 
 
p= 0.003 
10.09  
6.28 
 
5.59 
 
ANOVA:  Single factor test  
SUMMARY GAD-7 
SUMMARY GAD-7 
Groups 
Count Sum Average Variance 
Groups 
Count 
Control 
32 
33 1.03125 22.16028 Control 
6.675907 
Treatment  
32 
127 3.96875 16.86996 Treatment 2.854335 
 

ANOVA 
Source of 
Variation 
SS 
df 
MS 
F 
P-value 
F crit 
Between 
Groups 
138.0625 
1 138.0625 7.074642 0.009938 3.995887 
Within Groups 
1209.938 
62 19.51512 
Total 
1348 
63   
  
  
  
 
To determine the differences between and within groups, a single factor ANOVA was 
conducted. Results indicated that PHQ-9 was not significant with p = 0.119, however, the  
GAD-7 did show statistically significant results with F (1, 62) = 7.0746, p = 0.021.  The GAD-7 
results indicate the impact of the mindfulness treatment upon anxiety levels. Post hoc 
comparison using the Tukey-Kramer Test indicated a statistically significant effect at p<.05 level 
for the treatment group, demonstrating the relevance of the mindfulness training in lowering 
anxiety levels of those diagnosed with psychosis.    
Experiment 2. 
A paired t-test comparing the pre- and posttest means was used to determine the effect of 
the mindfulness intervention on anxiety and depression. All participants completed the PHQ-9 
and the GAD-7 upon admission to the program and at discharge from the program. (see Table 5) 
(Table 5) 
Two-tailed T-Test: Younger vs Older 
 
 
 
 
 
 
 
 
 
Group Scale  
t-stat t Critical 
P (two tail) 
Pre-test  
Post-test  
  SD      
2A 
PHQ-9  
4.90 
2.01 
 
p= 1.47E-05 11.84  
5.11 
 
5.90 
2A 
GAD-7 
3.93 
2.01 
 
p= < 0.001 
9.15 
 
3.96 
 
5.39 
 
 
2B 
PHQ-9  
2.12 
2.01 
 
p= 0.002 
12.34  
8.34 
 
6.9 
2B 
GAD-7 
3.02 
2.01 
 
p= 0.003 
11.42  
7.38 
 
5.13 
 
A single factor ANOVA was conducted to determine the difference between the two 
groups. The PHQ-9 reported F (1, 50) = 2.773, p= 0.102, which indicated there were no 

significant differences between the two groups.  The GAD-7 results were: F (1,50) = 0.569, p = 
0.451, indicated no differences between older or younger participants. 
Discussion 
Experiment 1 
When examining the T-tests from the experiment 1, a significant difference from pre to 
post-test scores was discovered. Group 1A, which received TAU, or CBT, psychoeducation, 
psychotherapy, and standard psychiatric care did not show significant results, however group 1B, 
which received TAU plus mindfulness training showed statistically significant results.   The 1B 
finding demonstrates the importance of the added mindfulness training to lower anxiety scores. 
When comparing within-group and between-group differences, the single factor ANOVA 
indicated a significant reduction in scores on the GAD-7 anxiety scale, but not the PHQ-9 
depression scale. Interestingly, this emphasizes the importance that the training has on mood and 
how it can impact psychosis symptoms. Many participants with paranoia expressed problems 
with underlying anxiety which increased symptoms, such as hallucinations, delusions, and 
paranoia. Mindfulness training lowers anxiety level and allows participants to develop a 
mindfulness response to the psychosis event.  The development enables the participant to 
become aware of the psychosis event and learn to disengage from it. Thus, the mindfulness 
training has importance for the development of a mindful response as opposed to the experiential 
response to distress.  
Experiment 2 
The second experiment examined the effectiveness of mindfulness training for two 
groups: a younger and an older group. The T-Test shows significant results for both PHQ-9 and 
GAD-7 for both groups, which demonstrates how both groups benefitted from the therapy that 

included mindfulness training plus TAU. The single factor ANOVA result was not significant, 
indicating that both groups benefitted equally.  
Participants’ Response to Mindfulness Training 
 
At discharge participants were asked to rank statements about mindfulness training from 
the most to least important. These items asked about staying present; making observations of 
thoughts, feelings, images, actions, and psychosis symptoms; letting go; being non-judgmental; 
understanding triggers; and being able to do reality checks. The participants indicated that 
“staying present” and “noticing, observing, and accepting the thoughts, feelings, images, and 
psychosis symptoms” were the most important. This was followed by being non-judgmental, 
understanding triggers, being able to do reality checks, and letting go. These responses are 
represented in the previously mentioned model by Chadwick et al. (2005), illustrating the 
mindfulness response as compared to the distressing reaction response.    
 
Participants were also asked to rank the benefits of group therapy using Yalom’s 8 
Therapeutic Factors and they ranked them from most to least important. Participants chose the 
following factors: Altruism 24%; Catharsis 16%; Instillation of Hope and Self-Understanding, 
both at 12%;  Group Cohesion, and Learning  both at 8% ; Guidance at 4%.  
 
At the end of the group, participants reported that they learned from peers to let go of 
negative thoughts and feelings and see that the psychosis symptom was from the illness and not 
real.  Participants reported making different choices, trusting themselves, and learned how drugs 
influenced mood and made their paranoia and voices worse. Participants experiencing paranoia 
and delusional thoughts stated the training took time to learn, but once learned they noticed less 
anxiety, lower paranoia levels, and could understood the illness in a different way.  Participants 
stated they could complete daily routines, and ignore psychosis symptoms, with continued 

mindfulness practice at home. They reported being able to disengage from the psychosis, and had  
no adverse effects from the mindfulness training,.  
 
Participants that experienced voices reported benefits by being able to disengage from it, 
understand how their perception was affected by anxiety and depression levels, and could choose 
their reaction to the event in a mindful way or in an experiential avoidance way. After five weeks 
of practicing mindfulness training with the group, they stated that they were less disturbed by the 
symptoms and were able to refocus, so that they could choose their method of response. 
Participants learned how their response to psychosis events affected their relationships with 
family, friends, and the community, and felt more empowered by this understanding. 
General Discussion 
 
The aim of the present study was to evaluate the effectiveness of providing a new 
technique of mindfulness training in a group therapy format with psychiatric outpatients 
diagnosed with a psychotic disorder. The rationale for mindfulness training and the specific 
practice of focused attention to one’s breathing and its rhythm was discussed in relation to the 
participant’s experience of psychotic events. It was expected that mindfulness practices would 
help lower anxiety and depression levels. The PHQ-9 and GAD-7 were used to determine pretest 
and posttest depression and anxiety levels. Three therapy groups received mindfulness training 
plus treatment as usual, and one therapy group received treatment as usual and did not receive 
mindfulness training. The results showed that those who received mindfulness training had 
lowered levels of depression and anxiety at posttest. The group that did not receive mindfulness 
training had a lower level of depression at posttest, but no change in their level of anxiety. 
 
 
The results of the training are encouraging because there has been limited research on the 
use of mindfulness with patients diagnosed with a psychotic disorder due to concerns about 

meditation having the potential to trigger psychosis. However, in the present study, feedback 
from the participants about the group were positive, and they did not find the process to be 
harmful. As more is written about using mindfulness practices with patients diagnosed with a 
psychotic disorder, the idea has become more acceptable; however, access to the treatment 
remains limited. The therapist who led the group had over 20 years of clinical experience using 
mindfulness techniques and CBT, and the groups were conducted in an open, accepting, and 
collaborative manner. This enabled a partnership or alliance to develop with the therapist and 
among the group participants. Therefore, generalization of this practice to other therapists, 
approaches, types of meditation, and participants cannot be assumed.  
 
The pretest-posttest design was used to measure the benefits of mindfulness practice in 
addition to psychiatric care. However, the specific benefits measured were limited to anxiety and 
depressive symptoms. Future research should include other specific symptom-based instruments 
to measure different dimensions of the psychotic experience, as well as examine the transfer of 
mindfulness training and practices from the group to the participant’s daily life. In addition, 
measures such as the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), the 
revised 12-item Cognitive and Affective Mindfulness Scale (CAMS-R; Feldman, Hayes, Kumar, 
Greeson, & Laurenceau, 2007), and the Five Facet Mindfulness Questionnaire (FFMQ; Baer et 
al., 2008) can be used to assess improvements or changes in mindfulness and how mindfulness 
relates to psychosocial functioning in this population. 
The results suggest that the mindfulness training had a statistically significant effect on 
the level of anxiety and depression of the participants, and that lowering anxiety was beneficial 
for those who had auditory hallucinations and paranoia, whose self-reports indicated less 
distress. Participants who completed the mindfulness training reported feeling more confident to 

return to the community since their anxiety and depression levels had decreased. Certainly, a 
decrease in anxiety would be considered improvement in psychological functioning, but it is only 
one aspect of one’s overall functioning, and the intervention was delivered as part of an overall 
treatment program that included a group process. Participants were able to describe openly their 
psychosis experiences during the group therapy, and they would ask for advice from other 
participants about how to manage their psychosis symptoms of voices, images, sensations, and 
paranoia. The effects of the mindfulness training, discussions, and practice may have contributed 
to a change in non-psychotic symptoms as well. In this regard, more rigorous empirical 
investigations are recommended to gain evidence of the effects of mindfulness training on 
different aspects of the psychosocial functioning of patients with a psychotic disorder. 
 
 
References 
 
Abba, N., Chadwick, P., & Stevenson, C. (2008). Responding mindfully to distressing psychosis: 
A grounded theory analysis. Psychotherapy Research, 18(1), 77–87. 
https://doi.org/10.1080/10503300701367992 
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders 
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596  
Bach, P. & Hayes, S. (Oct. 2002) the use of acceptance and commitment therapy to prevent the 
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