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 xivList of Contributors xviAcknowledgements xixForeword: Acceptance, Mindfulness and Psychotic Disorders: Creating a New Place to Begin xx1 Introduction to Mindfulness and Acceptance-based Therapies for Psychosis 1Joseph E. Oliver, Candice Joseph, Majella Byrne, Louise C. Johns and Eric M. J. Morris1.1 Introduction to Psychosis 11.2 Interventions 21.2.1 Cognitive Behavioural Therapy 21.2.2 Developments in CBT: Contextual Approaches 31.2.3 Acceptance and Commitment Therapy 41.2.3.1 Open 51.2.3.2 Aware 61.2.3.3 Active 61.2.4 Mindfulness and Person-based Cognitive Therapy for Psychosis 71.3 Conclusion 82 Theory on Voices 12Fran Shawyer, Neil Thomas, Eric M. J. Morris and John Farhall2.1 Phenomenology 122.2 Mechanisms and Origins of Hearing Voices 132.3 Meaning Given to Voice Experience 142.4 Responses to Voices 152.4.1 Resistance 162.4.2 Engagement 172.5 Implications for the Role of Acceptance and Mindfulness in Voices 183 Emotional Processing and Metacognitive Awareness for Persecutory Delusions 33Claire Hepworth, Helen Startup and Daniel Freeman3.1 Introduction 333.2 Persecutory Delusions 333.3 Improving Treatments for Persecutory Delusions 343.4 Development of the Intervention 353.5 The EPMA Intervention 383.6 The EPMA Pilot Study 403.7 Case Study 413.8 Conclusion 424 Clinical Assessment and Assessment Measures 47John Farhall, Fran Shawyer, Neil Thomas and Eric M. J. Morris4.1 Introduction 474.2 Clinical Assessment 474.2.1 Overview 474.2.1.1 Aims and Scope 474.2.1.2 General Principles 484.2.2 Structure and Methods of Assessment 494.2.2.1 Assessment Interwoven with Interventions 494.2.2.2 Use of Assessment Instruments 494.2.2.3 Role of Self-monitoring in Assessment 494.2.2.4 Goal Setting 504.2.3 A Guide to Clinical Assessment 514.2.3.1 The Problems Experienced by the Client 514.2.3.2 Understanding the Client 524.2.4 Assessing and Addressing Potential Barriers to and Risks Arising from Therapy 524.3 Assessment Measures 544.3.1 Issues in the Use of Self-report Measures 554.3.2 Mindfulness Measures 554.3.3 Measures of ACT Processes and Constructs 574.3.3.1 Acceptance and Action Questionnaire 574.3.3.2 The Voices Acceptance & Action Scale 584.3.3.3 Believability of Symptoms 584.3.3.4 Additional Measures 594.4 Conclusion 605 Acceptance and Commitment Therapy Case Formulation 64Patty Bach5.1 Introduction 645.2 Case Study 645.2.1 Avoidance 665.2.2 Cognitive Fusion 675.2.3 Attachment to Content 675.2.4 Weak Self-knowledge, Dominating Concept of the Past or Feared Future 685.2.5 Lack of Values Clarity 685.2.6 Persistent Inaction, Impulsivity or Avoidance 695.3 Case Formulation using the Inflexahex Model 705.4 Conclusion 736 Engaging People with Psychosis in Acceptance and Commitment Therapy and Mindfulness 76Brandon A. Gaudiano and Andrew M. Busch6.1 Introduction 766.1.1 Treatment Adherence and Engagement in Psychosis 766.2 Acceptance and Commitment Therapy 776.3 Functional Analytic Psychotherapy 786.4 Acceptance-based Methods and Techniques for Improving Engagement 796.4.1 Workability 816.4.2 Values Clarification 816.4.3 Acceptance and Mindfulness 826.4.4 Committed Action 836.4.5 The Therapeutic Relationship 846.5 Special Contexts and Issues 856.5.1 ACT Made Even Simpler 856.5.2 Involuntary Admission and Lack of Insight 866.5.3 Other Cognitive Behavioural Approaches for Psychosis 866.5.3.1 Traditional CBT 866.5.3.2 Motivational Interviewing 876.6 Case Study 886.6.1 Early Sessions (1–5) 886.6.2 Mid-treatment Sessions (6–15) 896.6.3 Late-treatment Sessions (16–20) 896.7 Conclusion 907 Acceptance and Commitment Therapy for Voices 95Neil Thomas, Eric M. J. Morris, Fran Shawyer and John Farhall7.1 Introduction 957.2 Formulating how Voices are a Problem 957.3 Overall Considerations in Conducting ACT with Voices 967.3.1 Sequence of Therapy 987.3.2 Acceptance: Letting Go of Struggle with Voices 987.3.2.1 Discussing Responses to Voices 987.3.2.2 Letting Go of Struggle 997.3.3 Defusion 1007.3.4 Mindfulness: Present Moment and Self as Observer 1017.3.5 Willingness: Values and Committed Action 1037.4 Case Study 1047.4.1 Current Mental-health Problems 1047.4.2 Mental-health History 1057.4.3 Relevant Background 1057.4.4 Assessment and Formulation 1057.4.5 ACT Case Formulation 1067.4.6 The ACT Approach 1067.4.6.1 Initial Phase (Sessions 1–3) 1077.4.6.2 Mid-therapy (Sessions 4 − 7) 1077.4.6.3 End Sessions (Sessions 8 − 10) 1087.4.7 Outcomes 1087.4.7.1 Psychotic Symptoms 1087.4.7.2 Depression and Anxiety 1097.4.7.3 Valued Action, Quality of Life and Social Functioning 1097.4.7.4 Changes in Mindfulness towards Voices and Thoughts 1097.4.8 Discussion 1108 Acceptance and Commitment Therapy for Delusions 112José Manuel García Montes, Marino Pérez Álvarez and Salvador Perona Garcelán8.1 Introduction 1128.2 Delusions as Ways of Making Contact with Experience 1128.2.1 Delusions as Active Forms of Experiential Avoidance 1138.3 Intervention with ACT 1158.3.1 Create a State of Creative Hopelessness 1158.3.2 Clarify and Strengthen the Patient’s Values 1178.3.3 Suggest the Possibility that the Problem is Control 1208.3.4 Create a Distance from Language 1228.3.5 Help Create a Transcendental Sense of Self 1238.3.6 Developing Willingness 1248.4 Conclusion 1259 Acceptance and Commitment Therapy for Emotional Dysfunction following Psychosis 129Ross White9.1 Introduction 1299.2 Understanding Emotional Dysfunction following Psychosis 1299.3 Emotional Dysfunction and Experiential Avoidance 1309.4 An ACT Conceptualisation of Emotional Dysfunction following Psychosis 1319.5 Treating Emotional Dysfunction following Psychosis 1329.5.1 Socialising the Individual to the ACT Model 1339.5.2 Assessment and Formulation 1339.5.2.1 Suffering List 1359.5.2.2 Attempts to Solve Suffering 1369.5.2.3 Valued Life Direction 1369.5.2.4 Valued Action 1389.5.3 Beyond Formulation: Progressing with the ACT Intervention 1389.5.3.1 Showing Up to Distress 1399.5.3.2 Defusion 1399.5.3.3 Mindful Acceptance 1409.5.3.4 Worries about Psychosis Recurring 1419.5.4 Moving Beyond the ACT Intervention 1419.6 Conclusion 14210 Person-based Cognitive Therapy for Distressing Psychosis 146Lyn Ellett10.1 Introduction 14610.2 Zone of Proximal Development 14610.2.1 Overview of the Zones of Proximal Development 14710.2.1.1 Symptomatic Meaning 14710.2.1.2 Relationship with Internal Experience 14810.2.1.3 Schemata 14810.2.1.4 Symbolic Self 14910.2.1.5 Radical Collaboration (RC) 14910.2.1.6 Acceptance 14910.2.1.7 Metacognitive Insights 15010.3 Case Formulation in PBCT 15010.3.1 Symptomatic Meaning: ABC Formulation 15010.3.2 Relationship with Internal Experience: Mindfulness-based Formulation of Distress 15110.3.3 Negative and Positive Self-schema 15210.4 Experiential Methods of Change 15310.4.1 Symptomatic Meaning 15310.4.1.1 Goodness of Fit (‘Evidence’) and Generating Alternative Symptomatic Meaning 15310.4.1.2 Behavioural Experiments 15610.4.1.3 Accepting Fixity 15610.4.2 Relationship with Internal Experience 15610.4.2.1 Rationale and Preparation for Mindfulness Practice 15610.4.2.2 Overview of Mindfulness Meditation 15610.4.2.3 Specific Adaptations of Mindfulness Practice 15710.4.3 Working with Schemata 15710.4.3.1 Two-chair Method 15710.4.4 Symbolic Self 15810.5 Conclusion 15911 Spirituality: A New Way into Understanding Psychosis 160Isabel Clarke11.1 Introduction 16011.2 Repositioning Psychosis and Spirituality: Recognition of the Two Ways of Knowing 16111.3 Research Basis 16211.4 Spirituality and Mental Health 16211.5 Clinical Approach: The Therapeutic Alliance 16411.5.1 The What is Real and What is Not Approach 16411.5.2 Schizotypy and ‘Unshared Reality’ 16511.5.3 From Conceptualisation to Coping Strategies 16611.5.4 Role of Mindfulness 16711.6 Psychosis as a Spiritual Crisis 16812 The Service User Experience of Acceptance and Commitment Therapy and Person-based Cognitive Therapy 172Joseph E. Oliver, Mark Hayward, Helena B. McGuinessand Clara Strauss12.1 Introduction 17212.2 An Overview of Service User Involvement 17212.3 The Importance of a Service User Perspective in Informing ACT and PBCT for Psychosis 17412.4 A Service User Perspective on the Experience of ACT for Psychosis 17512.4.1 Background 17612.4.2 The Therapy 17812.4.3 How the Therapy Helped 17812.4.4 Conclusion 17912.4.4.1 How I Felt before ACT Therapy 17912.4.4.2 How I Feel after ACT Therapy 18012.5 Summary of Qualitative Findings from PBCT Groups on Participant Experiences of Mindfulness Practice and What was Learned from these Studies 18012.5.1 Acceptance of Voices 18112.5.2 Development of Sense of Self beyond Voices 18212.5.2.1 Relating to Voices 18412.5.2.2 Relating to Self 18512.5.2.3 Relating to Others 18612.5.3 The Value and Challenges of Seeking Service User Views 18812.6 Conclusion 18813 Acceptance and Commitment Therapy for First-episode Psychosis 190Joseph E. Oliver and Eric M. J. Morris13.1 Introduction 19013.2 Recovery from a First Episode of Psychosis 19113.2.1 At-risk Mental States 19213.3 Using ACT to Enhance Recovery from a First Episode of Psychosis 19213.3.1 Assessment and Formulation 19213.3.2 Being Aware and Present 19413.3.3 Opening Up 19513.3.4 Being Active 19713.4 ACT in Different Modalities 19813.4.1 Group Work 19813.4.2 Working with Families and Carers 19913.5 Case Study 20013.6 Conclusion 20314 Acceptance and Commitment Therapy for Psychosis in Acute Psychiatric Admission Settings 206Gordon Mitchell and Amy McArthur14.1 Introduction 20614.2 Acute Psychosis and ACT Interventions 20614.3 ACT in the Acute Psychiatric Admission Ward 20914.4 Case Study 20914.5 Convergence of Mindfulness/Metacognitive-basedCognitive Therapy Approaches 21414.6 Reflections on Developing Systemic Applications of ACT 21514.7 Conclusion 21615 Developing Acceptance and Commitment Therapy for Psychosis as a Group-based Intervention 219Amy McArthur, Gordon Mitchell and Louise C. Johns15.1 Introduction 21915.2 A Six-session ACT-for-Psychosis Group Protocol 22115.2.1 Session 1: Introducing the ACT Approach and Exploring the Workability of Current Strategies for Managing Distress 22215.2.1.1 The Matrix 22215.2.1.2 Between-session Task 22315.2.2 Session 2: Exploring the Impact of the Struggle for Control and Introducing Willingness as an Alternative 22315.2.2.1 Between-session Task 22515.2.3 Session 3: Identifying Personal Valued Directions 22515.2.3.1 The Ripple Exercise 22515.2.3.2 Between-session Task 22715.2.4 Session 4: Moving in Valued Directions 22715.2.4.1 The Passengers-on-the-Bus Exercise 22815.2.4.2 Between-session Task 22915.2.5 Session 5: Continuing to Develop Self-as-Context and Willingness to Move towards Values 22915.2.5.1 Between-session Task 23015.2.6 Session 6: Summarising the Themes of the Course and Reviewing Experiences of the Work 23015.2.7 Optional Follow-up Session 23015.3 Case Study 23115.4 Reflections on the Experience of Developing and Delivering the Groups 23315.5 Other Protocols 23415.5.1 ACT for Life Group 23515.6 Conclusion 23716 Group Person-based Cognitive Therapy for Distressing Psychosis 240Clara Strauss and Mark Hayward16.1 Introduction 24016.2 Person-based Cognitive Therapy 24016.2.1 Group PBCT 24216.3 The Importance of the Group Process in PBCT 24216.4 Facilitating a PBCT Group 24316.4.1 Inclusion Criteria 24316.4.2 The 12-week Programme 24316.4.3 Mindfulness Practice in PBCT 24416.4.4 Cognitive Therapy in PBCT 24716.4.4.1 Session 2 24716.4.4.2 Session 3 24716.4.4.3 Session 4 24816.4.4.4 Session 5 24916.4.4.5 Session 6 24916.4.4.6 Session 7 24916.4.4.7 Session 8 25016.4.4.8 Session 9 25116.4.4.9 Session 10 25116.4.4.10 Session 11 25116.4.4.11 Session 12 25216.5 PBCT: An Integrated Model 25216.6 Group PBCT: The Evidence 25316.7 Conclusion 254Appendix A Chessboard Metaphor 256Appendix B Leaves-on-the-Stream Metaphor 257Appendix C Passengers-on-the-Bus Metaphor 259Appendix D Person-in-the-Hole Metaphor 261Appendix E Polygraph Metaphor 262Appendix F See the Wood for the Trees (And Other Helpful Advice for Living Life) 263Appendix G Skiing Metaphor 270Appendix H Tug-of-War-with-the-Monster Metaphor 271Index 272