Acceptance and Commitment Therapy and Mindfulness for Psychosis

Eric M. J. Morris is a chartered consultant clinical psychologist and the psychology lead for early intervention for psychosis at the South London and Maudsley NHS Foundation Trust, UK. Eric has been practising Acceptance and Commitment Therapy (ACT) for more than ten years, and researches mindfulness and acceptance interventions for psychosis at the Institute of Psychiatry, King’s College London. Eric is a highly experienced trainer and supervisor in contextual cognitive behavioural therapies. Louise C. Johns is a chartered consultant clinical psychologist and coordinator of a specialist clinical service at the Maudsley Hospital, London, UK, offering psychological interventions for outpatients with psychosis. She is also an honorary lecturer at the Institute of Psychiatry, King’s College London. Since qualifying as a clinical psychologist in 1998, she has worked in a clinical and research capacity in the field of psychosis. She has published over 50 articles on psychosis, covering development and psychopathology of symptoms, and cognitive behavioural treatments. She has led on the first UK funded studies to evaluate ACT for psychosis in group settings. Joseph E. Oliver is a clinical psychologist currently working in an early intervention programme for psychosis in South London, UK. He is also co-director of Contextual Consulting, an ACT based consultancy, offering contextual-CBT training, supervision and therapy. In addition to teaching and research supervision at King’s College London’s Institute of Psychiatry, he has active research interests in the use of ACT for psychosis, in group contexts and in its potential to enhance workplace well-being.

About the Editors xiv List of Contributors xvi

Acknowledgements xix

Foreword: Acceptance, Mindfulness and Psychotic Disorders: Creating a New Place to Begin xx

1 Introduction to Mindfulness and Acceptance-based Therapies for Psychosis 1
Joseph E. Oliver, Candice Joseph, Majella Byrne, Louise C. Johns and Eric M. J. Morris

1.1 Introduction to Psychosis 1

1.2 Interventions 2

1.2.1 Cognitive Behavioural Therapy 2

1.2.2 Developments in CBT: Contextual Approaches 3

1.2.3 Acceptance and Commitment Therapy 4

1.2.4 Mindfulness and Person-based Cognitive Therapy for Psychosis 7

1.3 Conclusion 8

2 Theory on Voices 12
Fran Shawyer, Neil Thomas, Eric M. J. Morris and John Farhall

2.1 Phenomenology 12

2.2 Mechanisms and Origins of Hearing Voices 13

2.3 Meaning Given to Voice Experience 14

2.4 Responses to Voices 15

2.4.1 Resistance 16

2.4.2 Engagement 17

2.5 Implications for the Role of Acceptance and Mindfulness in Voices 18

3 Emotional Processing and Metacognitive Awareness for Persecutory Delusions 33
Claire Hepworth, Helen Startup and Daniel Freeman

3.1 Introduction 33

3.2 Persecutory Delusions 33

3.3 Improving Treatments for Persecutory Delusions 34

3.4 Development of the Intervention 35

3.5 The EPMA Intervention 38

3.6 The EPMA Pilot Study 40

3.7 Case Study 41

3.8 Conclusion 42

4 Clinical Assessment and Assessment Measures 47
John Farhall, Fran Shawyer, Neil Thomas and Eric M. J. Morris

4.1 Introduction 47

4.2 Clinical Assessment 47

4.2.1 Overview 47

4.2.2 Structure and Methods of Assessment 49

4.2.3 A Guide to Clinical Assessment 51

4.2.4 Assessing and Addressing Potential Barriers to and Risks Arising from Therapy 52

4.3 Assessment Measures 54

4.3.1 Issues in the Use of Self-report Measures 55

4.3.2 Mindfulness Measures 55

4.3.3 Measures of ACT Processes and Constructs 57

4.4 Conclusion 60

5 Acceptance and Commitment Therapy Case Formulation 64
Patty Bach

5.1 Introduction 64

5.2 Case Study 64

5.2.1 Avoidance 66

5.2.2 Cognitive Fusion 67

5.2.3 Attachment to Content 67

5.2.4 Weak Self-knowledge, Dominating Concept of the Past or Feared Future 68

5.2.5 Lack of Values Clarity 68

5.2.6 Persistent Inaction, Impulsivity or Avoidance 69

5.3 Case Formulation using the Inflexahex Model 70

5.4 Conclusion 73

6 Engaging People with Psychosis in Acceptance and Commitment Therapy and Mindfulness 76
Brandon A. Gaudiano and Andrew M. Busch

6.1 Introduction 76

6.1.1 Treatment Adherence and Engagement in Psychosis 76

6.2 Acceptance and Commitment Therapy 77

6.3 Functional Analytic Psychotherapy 78

6.4 Acceptance-based Methods and Techniques for Improving Engagement 79

6.4.1 Workability 81

6.4.2 Values Clarification 81

6.4.3 Acceptance and Mindfulness 82

6.4.4 Committed Action 83

6.4.5 The Therapeutic Relationship 84

6.5 Special Contexts and Issues 85

6.5.1 ACT Made Even Simpler 85

6.5.2 Involuntary Admission and Lack of Insight 86

6.5.3 Other Cognitive Behavioural Approaches for Psychosis 86

6.6 Case Study 88

6.6.1 Early Sessions (1–5) 88

6.6.2 Mid-treatment Sessions (6–15) 89

6.6.3 Late-treatment Sessions (16–20) 89

6.7 Conclusion 90

7 Acceptance and Commitment Therapy for Voices 95
Neil Thomas, Eric M. J. Morris, Fran Shawyer and John Farhall

7.1 Introduction 95

7.2 Formulating how Voices are a Problem 95

7.3 Overall Considerations in Conducting ACT with Voices 96

7.3.1 Sequence of Therapy 98

7.3.2 Acceptance: Letting Go of Struggle with Voices 98

7.3.3 Defusion 100

7.3.4 Mindfulness: Present Moment and Self as Observer 101

7.3.5 Willingness: Values and Committed Action 103

7.4 Case Study 104

7.4.1 Current Mental-health Problems 104

7.4.2 Mental-health History 105

7.4.3 Relevant Background 105

7.4.4 Assessment and Formulation 105

7.4.5 ACT Case Formulation 106

7.4.6 The ACT Approach 106

7.4.7 Outcomes 108

7.4.8 Discussion 110

8 Acceptance and Commitment Therapy for Delusions 112
José Manuel García Montes, Marino Pérez Álvarez and Salvador Perona Garcelán

8.1 Introduction 112

8.2 Delusions as Ways of Making Contact with Experience 112

8.2.1 Delusions as Active Forms of Experiential Avoidance 113

8.3 Intervention with ACT 115

8.3.1 Create a State of Creative Hopelessness 115

8.3.2 Clarify and Strengthen the Patient’s Values 117

8.3.3 Suggest the Possibility that the Problem is Control 120

8.3.4 Create a Distance from Language 122

8.3.5 Help Create a Transcendental Sense of Self 123

8.3.6 Developing Willingness 124

8.4 Conclusion 125

9 Acceptance and Commitment Therapy for Emotional Dysfunction following Psychosis 129
Ross White

9.1 Introduction 129

9.2 Understanding Emotional Dysfunction following Psychosis 129

9.3 Emotional Dysfunction and Experiential Avoidance 130

9.4 An ACT Conceptualisation of Emotional Dysfunction following Psychosis 131

9.5 Treating Emotional Dysfunction following Psychosis 132

9.5.1 Socialising the Individual to the ACT Model 133

9.5.2 Assessment and Formulation 133

9.5.3 Beyond Formulation: Progressing with the ACT Intervention 138

9.5.4 Moving Beyond the ACT Intervention 141

9.6 Conclusion 142

10 Person-based Cognitive Therapy for Distressing Psychosis 146
Lyn Ellett

10.1 Introduction 146

10.2 Zone of Proximal Development 146

10.2.1 Overview of the Zones of Proximal Development 147

10.3 Case Formulation in PBCT 150

10.3.1 Symptomatic Meaning: ABC Formulation 150

10.3.2 Relationship with Internal Experience: Mindfulness-based Formulation of Distress 151

10.3.3 Negative and Positive Self-schema 152

10.4 Experiential Methods of Change 153

10.4.1 Symptomatic Meaning 153

10.4.2 Relationship with Internal Experience 156

10.4.3 Working with Schemata 157

10.4.4 Symbolic Self 158

10.5 Conclusion 159

11 Spirituality: A New Way into Understanding Psychosis 160
Isabel Clarke

11.1 Introduction 160

11.2 Repositioning Psychosis and Spirituality: Recognition of the Two Ways of Knowing 161

11.3 Research Basis 162

11.4 Spirituality and Mental Health 162

11.5 Clinical Approach: The Therapeutic Alliance 164

11.5.1 The What is Real and What is Not Approach 164

11.5.2 Schizotypy and ‘Unshared Reality’ 165

11.5.3 From Conceptualisation to Coping Strategies 166

11.5.4 Role of Mindfulness 167

11.6 Psychosis as a Spiritual Crisis 168

12 The Service User Experience of Acceptance and Commitment Therapy and Person-based Cognitive Therapy 172
Joseph E. Oliver, Mark Hayward, Helena B. McGuiness and Clara Strauss

12.1 Introduction 172

12.2 An Overview of Service User Involvement 172

12.3 The Importance of a Service User Perspective in Informing ACT and PBCT for Psychosis 174

12.4 A Service User Perspective on the Experience of ACT for Psychosis 175

12.4.1 Background 176

12.4.2 The Therapy 178

12.4.3 How the Therapy Helped 178

12.4.4 Conclusion 179

12.5 Summary of Qualitative Findings from PBCT Groups on Participant Experiences of Mindfulness Practice and What was Learned from these Studies 180

12.5.1 Acceptance of Voices 181

12.5.2 Development of Sense of Self beyond Voices 182

12.5.3 The Value and Challenges of Seeking Service User Views 188

12.6 Conclusion 188

13 Acceptance and Commitment Therapy for First-episode Psychosis 190
Joseph E. Oliver and Eric M. J. Morris

13.1 Introduction 190

13.2 Recovery from a First Episode of Psychosis 191

13.2.1 At-risk Mental States 192

13.3 Using ACT to Enhance Recovery from a First Episode of Psychosis 192

13.3.1 Assessment and Formulation 192

13.3.2 Being Aware and Present 194

13.3.3 Opening Up 195

13.3.4 Being Active 197

13.4 ACT in Different Modalities 198

13.4.1 Group Work 198

13.4.2 Working with Families and Carers 199

13.5 Case Study 200

13.6 Conclusion 203

14 Acceptance and Commitment Therapy for Psychosis in Acute Psychiatric Admission Settings 206
Gordon Mitchell and Amy McArthur

14.1 Introduction 206

14.2 Acute Psychosis and ACT Interventions 206

14.3 ACT in the Acute Psychiatric Admission Ward 209

14.4 Case Study 209

14.5 Convergence of Mindfulness/Metacognitive-based Cognitive Therapy Approaches 214

14.6 Reflections on Developing Systemic Applications of ACT 215

14.7 Conclusion 216

15 Developing Acceptance and Commitment Therapy for Psychosis as a Group-based Intervention 219
Amy McArthur, Gordon Mitchell and Louise C. Johns

15.1 Introduction 219

15.2 A Six-session ACT-for-Psychosis Group Protocol 221

15.2.1 Session 1: Introducing the ACT Approach and Exploring the Workability of Current Strategies for Managing Distress 222

15.2.2 Session 2: Exploring the Impact of the Struggle for Control and Introducing Willingness as an Alternative 223

15.2.3 Session 3: Identifying Personal Valued Directions 225

15.2.4 Session 4: Moving in Valued Directions 227

15.2.5 Session 5: Continuing to Develop Self-as-Context and Willingness to Move towards Values 229

15.2.6 Session 6: Summarising the Themes of the Course and Reviewing Experiences of the Work 230

15.2.7 Optional Follow-up Session 230

15.3 Case Study 231

15.4 Reflections on the Experience of Developing and Delivering the Groups 233

15.5 Other Protocols 234

15.5.1 ACT for Life Group 235

15.6 Conclusion 237

16 Group Person-based Cognitive Therapy for Distressing Psychosis 240
Clara Strauss and Mark Hayward

16.1 Introduction 240

16.2 Person-based Cognitive Therapy 240

16.2.1 Group PBCT 242

16.3 The Importance of the Group Process in PBCT 242

16.4 Facilitating a PBCT Group 243

16.4.1 Inclusion Criteria 243

16.4.2 The 12-week Programme 243

16.4.3 Mindfulness Practice in PBCT 244

16.4.4 Cognitive Therapy in PBCT 247

16.5 PBCT: An Integrated Model 252

16.6 Group PBCT: The Evidence 253

16.7 Conclusion 254

Appendix A Chessboard Metaphor 256

Appendix B Leaves-on-the-Stream Metaphor 257

Appendix C Passengers-on-the-Bus Metaphor 259

Appendix D Person-in-the-Hole Metaphor 261

Appendix E Polygraph Metaphor 262

Appendix F See the Wood for the Trees (And Other Helpful Advice for Living Life) 263

Appendix G Skiing Metaphor 270

Appendix H Tug-of-War-with-the-Monster Metaphor 271

Index 272