Is it the symptom or the relation to it? Investigating potential mediators of change in acceptance and commitment therapy for psychosis

Mobile App-Assisted Parent Training Intervention for Behavioral Problems in Children With Autism Spectrum Disorder: Pilot Randomized Controlled Trial

BACKGROUND

In children with autism spectrum disorder (ASD), problem behaviors play a dysfunctional role, causing as much difficulty with daily living and adjustment as the core symptoms. If such behaviors are not effectively addressed, they can result in physical, economic, and psychological issues not only for the individual but also for family members.

OBJECTIVE

We aimed to develop and evaluate the feasibility of a mobile app-assisted parent training program for reducing problem behaviors in children with ASD.

METHODS

This open-label, single-center, randomized controlled trial was conducted among parents of children with ASD aged 36-84 months. Participants were recruited from the Department of Psychiatry at Seoul National University Hospital. Participants were randomly assigned (1:1) by a blinded researcher. Randomization was performed using a stratified block randomization (with a block size of 4). Parents in the intervention group completed the mobile app-assisted parent training program at home over a 12-week period. They continued to receive their usual nondrug treatment in addition to the mobile app-assisted parent training program. The control group continued to receive their usual nonpharmaceutical treatment for 12 weeks without receiving the parent training program intervention. The primary outcome measure was the median change in the Korean Child Behavior Checklist (K-CBCL) scores from before to after the intervention. Lower scores on the K-CBCL indicated a decrease in overall problem behavior.

RESULTS

Between November 9, 2022, and December 8, 2022, 64 participants were enrolled. Overall, 42 children (intervention group median age: 49, IQR 41-52.5 months; control group median age: 49, IQR 42-58 months) of the participants joined the program. The intervention group included 20 (48%) participants and the control group included 22 (52%) participants. In the intervention group, the K-CBCL total scores showed a decrease after the intervention, with a median difference of -0.5 (95% CI -4.5 to 3). Pervasive developmental disorder scores also showed a decrease, with a median difference of -2.1 (95% CI -8.5 to 2.5). However, there was no significant difference in Clinical Global Impression-Severity of Illness scores after the intervention for both the control and intervention groups. Scores on the Korean version of the Social Communication Questionnaire showed a further decrease after the intervention in the intervention group (median difference -2, 95% CI -4 to 1). Caregivers' stress evaluated using the Korean Parenting Stress Index Fourth Edition-Short Form did not show any significant differences between the control and intervention groups. There were no adverse events related to study participation.

CONCLUSIONS

The findings demonstrated the feasibility of using mobile devices for evidence-based parent training to reduce problem behaviors in children with ASD. Mobile devices' accessibility and flexibility may provide a viable alternative for offering early intervention for problem behaviors in children with ASD.

TRIAL REGISTRATION

CRIS KCT0007841; https://cris.nih.go.kr/cris/search/detailSearch.do?&seq=23112.

Targeting metacognitive change mechanisms in acute inpatients with psychotic symptoms: feasibility and acceptability of a modularized group intervention

Emerging evidence suggests the usefulness of psychological interventions targeting metacognitive change mechanisms in patients experiencing psychosis. Although many of these patients are treated in acute psychiatric contexts, only few studies have adapted such interventions for acute inpatient settings. The present study aimed to assess the feasibility, acceptability, and preliminary clinical outcomes of a novel modularized group intervention focusing on different aspects of metacognitive change mechanisms. In particular, the intervention aims to reduce patients' acute symptoms by enhancing cognitive insight and to relieve distress via cognitive defusion (i.e. coping). A sample of 37 participants with acute psychosis received up to nine sessions of the intervention. Baseline and post-intervention assessments were conducted for general psychopathology, psychotic symptoms, global functioning, and symptom distress. Measures of change mechanisms were assessed before and after the respective treatment module. Participants' experiences were explored in feedback questionnaires and interviews. Recruitment, retention, and attendance rate met the pre-set feasibility benchmark of 80%. The intervention was well received by participants, who emphasised the group's clear structure, positive atmosphere, and helpful contents. Response rates were high and linear mixed models revealed significant medium-to-large time effects on all clinical outcomes. As expected, increase in hypothesised change mechanisms cognitive insight and decrease in cognitive fusion was found. However, the uncontrolled design limits interpreting clinical effects. The study provides evidence that an intervention based on a metacognitive model is feasible and acceptable for acute inpatients with psychosis. Positive results on clinical outcomes and change mechanisms warrant further exploration in a randomized controlled trial.

Ultra-brief acceptance & commitment therapy for inpatients with psychosis - a single-case experimental design investigating processes of change

People with primary psychosis are among the most seen in inpatient psychiatry. Treatment guidelines recommend both pharmacological and psychological treatments. However, psychological treatments are not routinely offered in many settings. There is also a lack of research on psychological treatments for this vulnerable population in the inpatient setting. The first aim of the current study was to examine treatment effects of a brief form of Acceptance and Commitment Therapy on outcomes valued by the treatment recipients. The second aim was to explore hypothetical processes of change in relation to outcomes over time. Three people with primary psychosis were treated for two to four sessions. A replicated single-case experimental design with multiple baselines across subjects (Clinical Trials registration number ID NCT04704973) was employed to examine treatment effects. The Personal Questionnaire (PQ) was used as primary outcome, symptom believability and preoccupation as proposed processes of change. Data were analyzed using visual inspection, calculation of Tau-U values, and cross-lagged correlation. All participants improved significantly on PQ and the symptom preoccupation measure. Two improved significantly on the symptom believability measure. Cross-lagged correlation analyses showed no clear mediation. Change in proposed processes of change and primary outcome predominantly happened concomitantly, although patterns of results reflected individual differences.

Acceptance and commitment therapy for psychosis: Current status, lingering questions and future directions

PURPOSE

Acceptance and Commitment Therapy for psychosis (ACTp) is a contextual behavioural intervention that promotes psychological flexibility by fostering active acceptance, cognitive defusion, values construction and committed action to enhance well-being and recovery. Multiple studies have shown that ACTp is acceptable and efficacious, but questions remain as to its distinction from similar approaches and the conditions under which it would be implemented most effectively.

METHODS

We present the current evidence for processes and outcomes of ACTp and summarise the qualitative findings of experiences of service users in ACT programmes. We compare ACTp with other cognitive behavioural therapies and mindfulness-informed interventions for psychosis.

RESULTS

Acceptance and commitment therapy for psychosis is promising as a pragmatic, process-driven intervention model. Further efforts are needed to investigate psychological flexibility in the context of psychosis with observational, experimental and intervention studies that will inform model scope and treatment refinement. Additionally, implementation research is the necessary next step, including how support persons can be trained in ACTp. Lower intensity and technology-assisted approaches have the potential to reduce barriers to accessing ACTp and extend impact.

CONCLUSIONS

Over the last 20 years, ACTp has demonstrated meaningful effects in individual and group formats in a range of settings, targeting outcomes such as rehospitalisation, depression, psychotic symptom distress and impact. Future work should focus on how best to integrate ACTp with other current evidence-based interventions for psychosis.

Trait Mindfulness in Psychotic Disorders: Dimensions Predicting Symptoms, Cognition, and Functional Outcome

Mindfulness-based treatments are efficacious for psychotic disorders (PD). However, which components of mindfulness (i.e., attentive monitoring and nonjudgmental acceptance) are most relevant treatment targets is unclear. Further, there is a dearth of literature examining clinical correlates of mindfulness in people with PD. The present study aimed to examine group differences and clinical correlates of mindfulness in people with PD. We hypothesized that PD would report lower monitoring and acceptance than CN and that mindfulness components would be associated with symptoms including dysfunctional beliefs, alexithymia, neurocognitive ability, positive symptoms, and mood symptoms. Groups included individuals with PD (n = 54) and nonpsychiatric controls (n = 55). Participants completed self-report measures of mindfulness and related constructs and clinical interviews of symptoms. Results of ANOVA models indicated that global mindfulness was lower in PD relative to CN, with greatest differences evident for acceptance in the affective psychosis group. Regression models found that greater monitoring was associated with improved neurocognitive performance, while acceptance was associated with lower defeatist beliefs, alexithymia, and depression/anxiety symptoms. Results highlight the importance of targeting acceptance in the psychosocial treatment of PDs, especially for those with mood symptoms.

Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach

Background

Treatment guidelines for psychosis recommend offering psychotherapy already in the acute illness phase. However, there is a lack of available interventions adapted to the specific needs and key change mechanisms of inpatients experiencing severe symptoms and crisis. In this article we outline the scientific development process of a needs-oriented and mechanism-based group intervention for acute psychiatric inpatients with psychosis (MEBASp).

Methods

To guide our intervention design, we used Intervention Mapping (IM), a six-step framework for developing evidence-based health interventions that consisted of an extensive literature review, an in-depth problem definition and needs analysis, the modeling of change mechanisms and outcomes and the production of an intervention prototype.

Results

Our low-threshold modularized group intervention consists of nine stand-alone sessions (two per week) within three modules and targets different aspects of metacognitive and social change mechanisms. Module I and II aim to reduce acute symptoms by fostering cognitive insight, Module III focuses on reducing distress via cognitive defusion. Therapy contents are adapted from existing metacognitive treatments such as the Metacognitive Training and presented in a destigmatizing, simply understandable and experience-oriented way.

Conclusion

MEBASp is currently evaluated in a single-arm feasibility trial. Using a systematic and rigorous development methodology and providing a detailed description of the development steps demonstrated to be invaluable in improving the intervention's scientific foundation, validity, and replicability for similar research.

"Accept voices©" group intervention for the management of auditory verbal hallucinations-results at 6 and 12 months

"The Accept Voices© is a useful intervention for the management and acceptance of auditory verbal hallucinations in people with schizophrenia. This study aims at determining if the clinical effects remained at six- and 12-month follow-ups. Results show that participants (N = 22) maintained a decrease in auditory hallucinations, at the six and 12 months follow ups for severity and acceptance of Voices, anxiety and depression. Accept Voices© shows promise as a potential treatment for people with schizophrenia struggling with Voices.

Effectiveness of Acceptance and Commitment Therapy on the Positive and Negative Symptoms and Emotion Regulation of Patients with Schizophrenia Spectrum Disorders: A Single-case Clinical Trial Study

Background: The literature suggests the increasing application of acceptance and commitment therapy (ACT) for people with schizophrenia spectrum disorders (SSD). Objectives: This study aimed to determine the effectiveness of ACT on the positive and negative symptoms and emotion regulation of patients with SSD. Methods: The experimental design of the current study was an AB (baseline and intervention phases) along with the follow-up phase, in addition to Treatment-As-Usual (TAU), ACT sessions were held for the participants. Among the 20 participants who had inclusion criteria to the study, five participant (three men and two women in the age range of 32 - 43 years) were randomly allocated to participate in the intervention through drawing and evaluated using the Positive and Negative Syndrome Scale (PANSS) and Difficulties in Emotion Regulation Scale (DERS) in three phases of baseline, intervention, and follow-up. For data analysis, non-overlapping indices and Cohen's d effect size were measured, and visual diagrams were plotted for interpretation. Results: The present results showed that the effect sizes of psychotic symptoms in the first to fifth participants were 1.7, 1.9, 0.6, 4, and 1.4, respectively in the intervention phase relative to the baseline; the effect size was only large for the fourth participant. Also, the effect sizes of emotion regulation in the first to fifth participants were 0.8, 1.6, 1.5, 1.2, and 2.7, respectively; the effect size was only large for the fifth participant. Conclusions: The results of data analysis showed that ACT is effective in reducing psychotic symptoms and improving emotion regulation. The effect size of ACT was the largest for the fourth participant; medium for the first, second, and fifth participants; and small for the third participant.

The Relation between Negative Automatic Thoughts and Psychological Inflexibility in Schizophrenia

Background: Schizophrenia is one of the most severe disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) spectrum. Negative automatic thoughts (NAT), cognitive fusion (CF), and experiential avoidance (EA), as part of psychological inflexibility (PI), can be considered important dysfunctional cognitive processes in schizophrenia. Methods: In the present study, two samples were included: a target group consisting of 41 people with schizophrenia (23 females; aged 44.98 ± 11.74), and a control group consisting of 40 individuals with end-stage chronic kidney disease (CKD) (27 males; aged 60.38 ± 9.14). Results: Differences were found between the two groups, with patients with schizophrenia showing an increased frequency of NAT, as well as higher levels of CF and EA (psychological inflexibility), compared to the control group. NAT were the mediator in the relation between the schizophrenia diagnosis and CF, as well as EA. Conclusion: Individuals with schizophrenia present a specific dysfunctional pattern of cognitive functioning, in which negative automatic thoughts represent a distinctive pathway to cognitive fusion and experiential avoidance.

Acceptance and Commitment Therapy for Patients with a First Psychotic Episode

The search for the most effective methods of therapy for mental disorders is a priority for modern psychiatry. An approach to the early diagnostics and rehabilitation of patients experiencing psychotic episodes for the first time is proposed in the present article. The proposed approach is based on the combination of drug therapy and acceptance and commitment therapy (ACT) characterized by the development of the patient's psychological flexibility, rather than controlling the disease symptoms. The article describes the main processes of the ACT model: acceptance, cognitive defusion, contact with the present moment, understanding of the inner world, awareness of significant values, and the regulation of purposeful behaviour for the implementation of these values. Recommendations for different stages of treatment were also developed by specialists of the First Psychotic Episode Clinic at the Mental Health Clinic No.1 named after N.A. Alexeev. The psychological rehabilitation of patients with the use of ACT in the case of psychotic disorders with both negative and positive symptoms was elaborated. The application of acceptance and commitment therapy in the early diagnostics and treatment of patients experiencing a first psychotic episode results in fewer readmissions and improved psychosocial functioning in both inpatient and outpatient care.

Effectiveness of Acceptance and Commitment Therapy for Patients with Psychosis Being Monitored at a Community Mental Health Center: A Six-Month Follow-up Study

OBJECTIVE

This study aimed to examine the long-term efficacy of a short-term acceptance and commitment therapy-based (ACT) group psychotherapy on patients with psychosis in a community mental health center (CMHC).

METHODS

A total of 6 group-based ACT sessions were applied to 16 people diagnosed with psychotic disorders who met the inclusion criteria. They were evaluated at the start of, end of, and 6 months after the therapy using the acceptance and action questionnaire, the psychotic symptom rating scales, and the quality-of-life scale.

RESULTS

At the end of the 6 session group therapy and 6-month follow-up, a statistically significant decrease was found in patients' psychotic symptoms and experiential avoidance as well as a statistically significant increase in their quality of life (P < .001).

CONCLUSION

According to the results, ACT can be said to be an effective method for managing psychotic symptoms, reducing experiential avoidance, and improving the quality of life in patients diagnosed with psychotic disorders in CMHCs.

EFFECT OF APPLYING "ACCEPTANCE AND COMMITMENT THERAPY" ON AUDITORY HALLUCINATIONS AMONG PATIENTS WITH SCHIZOPHRENIA

Experiencing persistent auditory hallucinations may contribute to unproductive struggle and interference with valued living among patients with schizophrenia. Acceptance and commitment therapy (ACT) represents a new generation of behavior therapies that proposes active acceptance and achievement of worthwhile goals despite experiencing auditory hallucinations. Utilization of acceptance commitment therapy may assist in reducing auditory hallucinations and may increase patient's feeling of control.

AIM

Determine the effect of applying acceptance and commitment therapy on auditory hallucinations among patients with schizophrenia.

SETTING

The study was conducted at El-Maamoura Hospital for Psychiatric Medicine in Alexandria, Egypt.

SUBJECTS

A random sample of 70 male inpatients with schizophrenia was selected and divided equally into a study and a control groups (35 patients in each group). Both groups were matched as much as possible in relation to socio- demographic and clinical data. Tools: Psychotic Symptom Rating Scales (PSYRATS-AHs) and Voices Acceptance and Action Scale (VAAS). A quasi-experimental research design was utilized in this study.

RESULTS

Significant differences were found between the study and control groups immediately post and after 3 months of ACT on baseline PSYRATS& VAAS scores.

CONCLUSION

ACT offers a promising new treatment for auditory hallucination among patients with schizophrenia. A significant improvement in auditory hallucination was found in the study group immediately after implementing ACT and after 3 months. As well as a decrement in re hospitalization rate and improvement in drug compliance for the study group compares to control one.

RECOMMENDATIONS

ACT should be integrated in psychiatric treatment and nursing interventions of inpatients with schizophrenia who experiencing auditory hallucination.

A systematic review and meta-analysis of cognitive behavioural informed psychological interventions for psychiatric inpatients with psychosis

Psychological interventions such as Cognitive Behavioural Therapy for psychosis (CBTp) are recommended by the National Institute of Health and Care Excellence (NICE) for delivery in the acute phase of people's mental health difficulties. However, the effectiveness of cognitive behavioural informed psychological therapies for psychiatric inpatients is unknown. The aim of this review is to examine the type, quality and efficacy of cognitive behavioural informed psychological interventions for psychiatric inpatients experiencing psychosis. A systematic review and meta-analysis was conducted of randomised controlled trials examining the efficacy of cognitive behavioural informed psychological interventions offered to acute psychiatric inpatients with psychosis on primary (positive symptoms) and secondary outcomes of interest. A total of 23 studies were identified reporting on 18 trials of interventions such as CBTp, Acceptance and Commitment Therapy (ACT) and Metacognitive Therapy (MCT). Cognitive behavioural informed psychological interventions were found not be effective in reducing positive symptoms (primary outcome) at post-therapy and at follow-up but when a one study removed analysis was conducted a positive effect was found at both time points. In regard to secondary outcomes, cognitive behavioural informed psychological interventions demonstrated a significant favourable effect on negative symptoms (post-therapy), total symptoms (post-therapy and follow-up), functioning (post-therapy and follow-up) and readmission (follow-up). These psychological interventions may have potential to be effective for those admitted to psychiatric inpatient care and in acute crisis. However, findings are equivocal with evidence that these interventions have effect on some symptom measures but not others. Further examination of inpatient adapted cognitive behavioural informed psychological interventions is required.

Cognitive Fusion Mediates the Impact of Attachment Imagery on Paranoia and Anxiety

Background

Paranoia, in both clinical and non-clinical groups, is characterised by unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but little is known about the mechanisms of change. Cognitive fusion describes the extent to which we can ‘step back’ from compelling beliefs, to observe these as mental events, and is implicated in psychopathology cross-diagnostically.

Aims

This study extends previous research demonstrating the impact of attachment imagery on paranoia and anxiety to determine whether cognitive fusion mediates these relationships.

Method

We utilised a randomized experimental design and recruited an analogue sample with high levels of non-clinical paranoia to test the impact of imagery and the role of cognitive fusion.

Results

Secure attachment imagery resulted in reduced paranoia and anxiety compared to threat/insecure imagery. Cognitive fusion mediated the relationships between imagery and paranoia, and imagery and anxiety.

Conclusions

Secure attachment imagery is effective in reducing paranoia and anxiety and operates via cognitive fusion. In clinical practice, these interventions should seek to facilitate the ability to ‘step back’ from compelling threat beliefs, in order to be most beneficial.

[Acceptance of "voices" in people with or without psychiatric disorders: Francophone validation of the 9-item VAAS scale]

OBJECTIVES

Hearing voices is a common experience for people with schizophrenia. Perceived voices are in most cases a source of great distress for patients. This experience also exists in the general population and is considered as "non-clinical". Much research has focused on the psychological and neuropsychological mechanisms behind the emergence of voices. With regard to voice persistence factors, the acceptance of the voice-hearing phenomenon is still relatively unexplored. In addition, there are few standardized tools that specifically assess this dimension of voice experience. The Voices Acceptance and Actions Scale (VAAS) is the only validated tool to address voice acceptance in individuals with schizophrenia. However, to date, there is no French version. The objective of this research was to validate the VAAS in a French speaking population.

METHOD

Our sample consisted of individuals with schizophrenia (N=65) and voice hearers from the general population (N=321). For the clinical population, individuals with schizophrenia and auditory hallucinations were assessed using the VAAS scale in its two abbreviated versions (9 and 12 items). In order to validate the measure in French, we administered psychopathology scales (BPRS) and voice belief scales (BAVQ-R) for convergent and divergent validity. For the non-clinical population, we administered the VAAS scale online (via LimeSurvey), accompanied by a brief sociodemographic questionnaire (age, sex, country of origin, existence of medical or psychological follow-up).

RESULTS

The psychometric properties of the VAAS scale were satisfactory and similar to the original English-language tool for both versions, with a slight advantage for the one with 9-items. The convergent validity measured with the BAVQ-R scale, and the divergent one measured with the BPRS depression subscale, were found to be satisfactory. In addition, the re-test performed 6 weeks after the first test (N=30) was satisfactory for both scales, with a Pearson correlation index greater than 70 (r=0.70; P<0.001 for the VAAS 9 items) and (r=0.79; P<0.001 for the 12 item version). In individuals with schizophrenia (clinical population), the level of voice acceptance was low and strongly correlated with depression. This point seems to corroborate the current data in the field suggesting that voice hearing in this population is associated with significant distress and has a significant impact on their lives. Conversely, the level of acceptance obtained from the non-clinical population was much higher, reflecting a higher level of acceptance in this population. People from the non-clinical population seemed to accept and experience their voices with less distress than people from the clinical population in this study.

CONCLUSION

To date, a paucity of studies have investigated the acceptance of auditory hallucinations. Our results support the psychometric validity of the French version of the VAAS, particularly the 9-item version. Furthermore, our study supports the need to continue studying voice acceptance, as it appears to be strongly linked to depression in people with psychiatric disorders such as schizophrenia. In addition, our study is novel in that it also explored, with a standardized tool, the level of voice acceptance in a non-clinical population and found people to be more accepting of the voices they hear and better at living with them. These data provide new evidence to better understand the links between the level of acceptance of voices, their experiences, and depression. Clinically, it seems essential to conduct more systematic and regular evaluations of the level of voice acceptance in those hearing voices. Finally, in terms of rehabilitation, voice acceptance can become a therapeutic target in order to improve the psychological and behavioral functioning of the person.

Mindfulness Mediates the Effect of a Psychological Online Intervention for Psychosis on Self-Reported Hallucinations: A Secondary Analysis of Voice Hearers From the EviBaS Trial

BACKGROUND

Psychological online interventions (POIs) could represent a promising approach to narrow the treatment gap in psychosis but it remains unclear whether improving mindfulness functions as a mechanism of change in POIs. For the present study, we examined if mindfulness mediates the effect of a comprehensive POI on distressing (auditory) hallucinations.

METHODS

We conducted a secondary analysis on voice hearers (n = 55) from a randomized controlled trial evaluating a POI for psychosis (EviBaS; trial registration NCT02974400, clinicaltrials.gov). The POI includes a module on mindfulness and we only considered POI participants in our analyses who completed the mindfulness module (n = 16).

RESULTS

Participants who completed the mindfulness module reported higher mindfulness (p = 0.015) and lower hallucinations (p = 0.001) at post assessment, compared to controls, but there was no effect on distress by voices (p = 0.598). Mindfulness mediated the POI's effect on hallucinations (b = -1.618, LLCI = -3.747, ULCI = -0.054) but not on distress by voices (b = -0.057, LLCI = -0.640, ULCI = 0.915).

LIMITATIONS AND DISCUSSION

Completion of the mindfulness module was not randomized. Hence, we cannot draw causal inferences. Even if we assumed causality, it remains unclear which contents of the POI could have resulted in increased mindfulness and reduced hallucinations, as participants completed other modules as well. In addition, confounding variables could explain the mediation and the sample size was small. Nonetheless, the overall pattern of results indicates that the POI is likely to improve mindfulness, and that increased mindfulness could partially explain the POI's efficacy.

Efficacy of Acceptance and Commitment Therapy in Daily Life (ACT-DL) in early psychosis: study protocol for a multi-centre randomized controlled trial

Background

Psychotic experiences, social functioning and general psychopathology are important targets for early intervention in individuals with Ultra-High-Risk state (UHR) and a first-episode psychosis (FEP). Acceptance and Commitment Therapy (ACT) is a promising, next-generation Cognitive Behavioural Therapy (CBT) that aims to modify these targets, but evidence on sustainable change and its underlying mechanisms in individuals’ daily lives remains limited. The aim of the INTERACT study is to investigate the efficacy of a novel ecological momentary intervention, Acceptance and Commitment Therapy in Daily Life (ACT-DL) in a multi-centre randomised controlled trial of individuals with UHR or FEP.

Methods/design

In a multi-centre randomised controlled trial, individuals aged 16–65 years with UHR or FEP will be randomly allocated to ACT-DL in addition to treatment as usual (TAU) as the experimental condition or a control condition of TAU only, which will include – for the entire study period – access to routine mental health care and, where applicable, CBT for psychosis (CBTp). Outcomes will be assessed at baseline (i.e. before randomisation), post-intervention (i.e. after the 8-week intervention period), and 6-month and 12-month follow-ups (i.e. 6 and 12 months after completing the intervention period) by blinded assessors. The primary outcome will be distress associated with psychotic experiences, while secondary outcomes will include (momentary) psychotic experiences, social functioning and psychopathology. Process measures to assess putative mechanisms of change will include psychological flexibility, stress sensitivity and reward experiences. In addition, acceptability, treatment adherence and treatment fidelity of ACT-DL will be assessed.

Discussion

The current study is the first to test the efficacy of ACT-DL in individuals with UHR and FEP. If this trial demonstrates the efficacy of ACT-DL, it has the potential to significantly advance the treatment of people with UHR and FEP and, more generally, provides initial support for implementing mHealth interventions in mental health services.

Trial registration

Netherlands Trial Register, ID: NTR4252. Registered on 26 September 2013.

Acceptance and Commitment Therapy for Inpatients with Psychosis (the REACH Study): Protocol for Treatment Development and Pilot Testing

Patients with schizophrenia-spectrum disorders frequently require treatment at inpatient hospitals during periods of acute illness for crisis management and stabilization. Acceptance and Commitment Therapy (ACT), a "third wave" cognitive-behavioral intervention that employs innovative mindfulness-based strategies, has shown initial efficacy in randomized controlled trials for improving acute and post-discharge outcomes in patients with psychosis when studied in acute-care psychiatric hospitals in the U.S. However, the intervention has not been widely adopted in its current form because of its use of an individual-only format and delivery by doctoral-level research therapists with extensive prior experience using ACT. The aim of the Researching the Effectiveness of Acceptance-based Coping during Hospitalization (REACH) Study is to adapt a promising acute-care psychosocial treatment for inpatients with psychosis, and to pilot test its effectiveness in a routine inpatient setting. More specifically, we describe our plans to: (a) further develop and refine the treatment and training protocols, (b) conduct an open trial and make further modifications based on the experience gained, and

Contextual Cognitive-Behavioral Therapies Across the Psychosis Continuum

Abstract. Considering several etiologic, therapeutic, and comorbidity-related factors, a psychosis continuum model has been proposed for the understanding and treatment of psychotic disorders. Within the new emerging treatment approaches, Contextual Cognitive-Behavioral Therapies (CCBT) seem to hold promise for the psychosis continuum. However, considering their novelty for this specific population, the quality of efficacy evidence remains unclear. Objective: To examine, critically analyze, and summarize the results from studies based on therapeutic models within the CCBT approach (Mindfulness and Acceptance-based interventions, Compassion-Focused Therapy, Dialectical Behavior Therapy, and Metacognitive Therapy) for patients with a diagnosis within the psychosis continuum (schizophrenia, schizoaffective disorder, bipolar disorder). Methods: Three leading electronic databases (MEDLINE/PUBMED; PsycINFO; Cochrane Library), a grey literature database (OpenGrey), and registered clinical trials (ClinicalTrials.Gov) were searched using combinations of key terms regarding the CCBT models and the diagnosis considered. Reference lists of the relevant studies and reviews were searched. Only Randomized Controlled Trials (RCTs) were included. The “Cochrane Risk of Bias Assessment Tool” was used for quality assessment. Results: A total of 17 articles were included. This review was based on a majority of unclear or low risk of bias studies. Benefits regarding clinical variables such as psychotic symptoms, anxiety and depression, functioning or quality of life were found. Conclusion: Overall the studies supported some benefits of CCBT approaches for the psychosis continuum. The conceptual perspective on treatment has changed, nevertheless the outcomes assessed are still symptom-focused and there is still need for improvement. Methodological considerations and future directions are presented.

Current Definitions of "Transdiagnostic" in Treatment Development: A Search for Consensus

Research in psychopathology has identified psychological processes that are relevant across a range of Diagnostic and Statistical Manual (DSM) mental disorders, and these efforts have begun to produce treatment principles and protocols that can be applied transdiagnostically. However, review of recent work suggests that there has been great variability in conceptions of the term "transdiagnostic" in the treatment development literature. We believe that there is value in arriving at a common understanding of the term "transdiagnostic." The purpose of the current paper is to outline three principal ways in which the term "transdiagnostic" is currently used, to delineate treatment approaches that fall into these three categories, and to consider potential advantages and disadvantages of each approach.

Investigating the Role of Acceptance, Mindfulness, and Values in Patients with Psychosis in the Context of Depression

BACKGROUND

Emerging research suggests that interventions incorporating acceptance, mindfulness, and values clarification elements are efficacious when treating patients experiencing major depression with psychotic features. However, there is little research on how these psychological constructs relate to symptoms and functioning in this population to guide future intervention efforts.

METHODS

Patients with psychotic symptoms (hallucinations and/or delusions) occurring in the context of a major depressive episode (N = 29) were recruited primarily during a psychiatric hospitalization and assessed using a battery of self-report and interviewer-rated measures.

RESULTS

Psychological acceptance was correlated with hallucination severity, behavioral activation, and family functioning; mindfulness was correlated with depression severity and behavioral activation; and values-action consistency was correlated with family functioning. Significant associations between acceptance, mindfulness, and values remained in most cases in multivariate analyses after controlling for the presence of the other variables and accounted for large amounts of variance.

CONCLUSIONS

Although requiring future replication due to the sample size, findings support the conclusion that acceptance, mindfulness, and values appear to have meaningful and somewhat unique associations with important aspects of symptoms and functioning in individuals with psychotic depression. Potential treatment targets and mechanisms of psychosocial interventions are discussed.

The feasibility and acceptability of a brief Acceptance and Commitment Therapy (ACT) group intervention for people with psychosis: The 'ACT for life' study

BACKGROUND AND OBJECTIVES

Acceptance and Commitment Therapy (ACT) is a contextual cognitive-behavioural approach with a developing evidence base for clinical and cost-effectiveness as an individually-delivered intervention to promote recovery from psychosis. ACT also lends itself to brief group delivery, potentially increasing access to therapy without inflating costs. This study examined, for the first time, the feasibility and acceptability of ACT groups for people with psychosis (G-ACTp).

METHODS

Participants were recruited from community psychosis teams. Ratings of user satisfaction, and pre-post change in self-rated functioning (primary outcome), mood (secondary outcome) and ACT processes were all completed with an independent assessor. Of 89 people recruited, 83 completed pre measures, 69 started the four-week G-ACTp intervention, and 65 completed post measures.

RESULTS

Independently assessed acceptability and satisfaction were high. Functioning (Coeff. = -2.4, z = -2.9, p = 0.004; 95% CI: -4.0 to -0.8; within subject effect size (ES) d = 0.4) and mood (Coeff. = -2.3, z = -3.5, p = 0.001; 95% CI: -3.5 to -1.0; d = 0.4) improved from baseline to follow-up. Commensurate changes in targeted ACT processes were consistent with the underlying model.

LIMITATIONS

The uncontrolled, pre-post design precluded blinded assessments, and may have inflated effect sizes. Participants may have improved as a result of other factors, and findings require replication in a randomized controlled trial (RCT).

CONCLUSIONS

This preliminary study showed that brief group ACT interventions for people with psychosis are feasible and acceptable. Uncontrolled, pre-post assessments suggest small clinical improvements, and changes in psychological processes consistent with an ACT model. Replication in an RCT is required, before implementation can be recommended.

Mindfulness improves psychological quality of life in community-based patients with severe mental health problems: A pilot randomized clinical trial

OBJECTIVE

To examine the effectiveness of group mindfulness-based intervention (MBI) in patients diagnosed with severe mental illness. The primary outcome was health-related psychological quality of life. Secondary measures were environmental, social and physical health related quality of life, frequency and intensity of psychotic symptoms and daily-life mindfulness.

METHOD

Forty-four patients from a public community rehabilitation center for people with severe mental illness were recruited, and randomly allocated to Integrated Rehabilitation Treatment (IRT) or IRT plus MBI. Measures included PANSS interview, WHOQOL-BREF, and Mindfulness Attention Awareness Scale. MBI comprised 26 one-hour weekly sessions. Intention-to-treat analysis was used.

RESULTS

One patient did not complete IRT+MBI and two did not complete IRT. At baseline there were no statistical group differences in demographic characteristics or primary and secondary outcomes. At post-treatment interaction between treatment and time in health-related psychological quality of life was statistically significant, and simple effect analysis showed significant differences for between and within subject factor in favor of MBI. Interaction was also significant in PANSS negative symptoms, simple effects showed a statistical trend in within subject factor. Time factor was significant in environmental and physical quality of life.

CONCLUSIONS

Data suggest mindfulness added to IRT may enhance psychological quality of life in people with severe mental illness from a public community center. Results also suggest that mindfulness may impact frequency and intensity of negative symptoms.

Acceptance-based Behavior Therapy for Depression With Psychosis: Results From a Pilot Feasibility Randomized Controlled Trial

Acceptance-based depression and psychosis therapy (ADAPT), a mindfulness/acceptance-based behavioral activation treatment, showed clinically significant effects in the treatment of depression with psychosis in a previous open trial. The goal of the current study was to further test the feasibility of ADAPT to determine the utility of testing it in a future clinical trial, following a stage model of treatment development. Feasibility was determined by randomizing a small number of patients (N=13) with comorbid depression and psychosis to medication treatment as usual plus enhanced assessment and monitoring versus ADAPT for 4 months of outpatient treatment. Both conditions were deemed acceptable by patients. Differences in between-subjects effect sizes favored ADAPT posttreatment and were in the medium to large range for depression, psychosocial functioning, and experiential avoidance (ie, the target mechanism). Thus ADAPT shows promise for improving outcomes compared with medications alone and requires testing in a fully powered randomized trial.

Bringing the "self" into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of "self" (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

[The psychological flexibility model: a new approach to mental health]

OBJECTIVE

This paper presents a vision of mental health using the model of psychological flexibility of Acceptance and Commitment Therapy (ACT). ACT is a representative approach of the third wave of cognitive-behavioural therapy (CBT). This article first describes the theoretical and practical aspects of ACT and, in a second part, reviews some of the empirical data supporting its clinical use. Due to the high rate of comorbidity in mental health settings, transdiagnostic approaches in CBT, such as ACT, have recently become popular and particularly appealing to various clinical settings.

METHOD

The theoretical aspects underlying ACT, as well as its clinical components in the treatment of psychopathology were described based on major books in this area, such as Hayes, Strosahl and Wilson (2012). A descriptive literature review was undertaken to explore the data on the efficacy of ACT for the treatment of mental health problems. Psycinfo and Medline, as well as the Association for Contextual Science website were analyzed for relevant articles. The key search terms were: "Acceptance and Commitment therapy" or "ACT" or "acceptance" or "mindfulness" or "defusion." The reference lists of the articles retrieved were also analyzed. The articles that were not in English or French were excluded.

RESULTS

Data suggest that ACT is particularly effective for stress, anxiety disorders, depression, substance abuse and various chronic medical conditions. The six processes of the model of psychological flexibility have been validated based on the results of correlational and meditational studies. More than seventy randomized clinical trials and a meta-analysis including 18 randomized control trials conclude that ACT is more effective than waiting list, placebo and treatment as usual control conditions.

CONCLUSION

ACT is a promising and evidence-based approach in mental health for the treatment of anxiety and depression as well as for complex and chronic conditions. More research is needed to further validate its theoretical model and further refine our understanding of how ACT could be effective for the management of mental health illness and how it could enhance quality of life for people who suffer from these conditions.

Relationships among self, others, and persecutors in individuals with persecutory delusions: a repertory grid analysis

The purpose of the current study was to examine the way individuals with persecutory delusions construe the self, others, and their main persecutor with reference to the constructs of malevolence and omnipotence, and examine the extent to which these interpersonal beliefs link to distress, self-esteem, and delusion conviction. Repertory grid methodology was used to explore interpersonal beliefs about malevolence and omnipotence in a sample (N=30) of individuals with current persecutory delusions (mean age 36.4 years; 62% male and 53% White). Participants also completed measures of emotional distress (depression and anxiety) and self-esteem. The findings suggested that persecutors were construed as more omnipotent and malevolent than both the self and others; others in turn were construed as more omnipotent and malevolent than the self. Beliefs about self as powerful were associated with lower anxiety, depression, and higher self-esteem, and beliefs about persecutors' omnipotence predicted delusion conviction. As with voices, the concepts of power/omnipotence and malevolence/benevolence appear to be important constructs when seeking to understand the relationship between individuals and their perceived persecutors. These findings support working therapeutically with negative schematic beliefs about self, others, and persecutors, which is consistent with a person-based cognitive therapy model of distressing psychosis.

Putting a Hold on the Downward Spiral of Paranoia in the Social World: A Randomized Controlled Trial of Mindfulness-Based Cognitive Therapy in Individuals with a History of Depression

Context

Paranoia embodies altered representation of the social environment, fuelling altered feelings of social acceptance leading to further mistrust. Mindfulness-based cognitive therapy (MBCT) may relieve paranoia and reduce its impact on social acceptance.

Objective

To determine whether MBCT alters momentary feeling of paranoia and social acceptance in daily life.

Design

Randomized controlled trial of daily-life repeated measures (up to 120 per participant) before and after allocation to MBCT or waiting list control.

Participants

Volunteer sample of 130 eligible men and women with residual affective dysregulation after at least one episode of major depressive disorder.

Interventions

Eight weeks of MBCT in groups of 10–15 participants in addition to participants' usual treatment.

Outcome Measures

Daily-life ratings of paranoia and social acceptance. This manuscript concerns additional analyses of the original trial; hypotheses were developed after data collection (focus initially on depressive symptoms) but before data analysis.

Results

Sixty-six participants were assigned to the waiting list control group and 64 to the MBCT intervention group, of whom 66 and 61 respectively were included in the per-protocol analyses. Intention-to-treat analyses revealed a significant group by time interaction in the model of momentary paranoia (b = −.18, p<0.001, d = −0.35) and social acceptance (b = .26, p<0.001, d = 0.41). Paranoia levels in the intervention group were significantly reduced (b = −.11, p<0.001) and feelings of social acceptance significantly increased (b = .18, p<0.001), whereas in the Control condition a significant increase in paranoia (b = .07, p = 0.008) and a decrease in social acceptance was apparent (b = −.09, p = 0.013). The detrimental effect of paranoia on social acceptance was significantly reduced in the MBCT, but not the control group (group by time interaction: b = .12, p = 0.022).

Conclusions

MBCT confers a substantial benefit on subclinical paranoia and may interrupt the social processes that maintain and foster paranoia in individuals with residual affective dysregulation.

Trial Registration

Netherlands Trial Register NTR1084

Comparing experiential acceptance and cognitive reappraisal as predictors of functional outcome in individuals with serious mental illness

BACKGROUND

Two psychological regulation strategies to cope with psychotic symptoms proposed by the cognitive behavioral tradition were examined in this study: cognitive reappraisal and experiential acceptance. Although cognitive behavior therapy for psychosis has increasing empirical support, little is known about the role of these two strategies using methods of known ecological validity.

METHODS

Intensive longitudinal data was gathered from 25 individuals diagnosed with a psychiatric disorder with psychotic features. During the course of six days we measured contextual factors, psychotic and stressful events, psychological regulation strategies and functional outcome.

RESULTS

Positive psychotic symptoms and stressful events had negative associations with quality of life and affect, whereas experiential acceptance had positive associations with them. Cognitive reappraisal had inconsistent associations with quality of life and no association with affect. Social interactions and engagement in activities had a positive association with quality of life. Results were supported by additional and exploratory analyses.

CONCLUSIONS

Across measures of functional outcome, experiential acceptance appears to be an effective coping strategy for individuals facing psychotic and stressful experiences, whereas cognitive reappraisal does not. In order to inform treatment development efforts, results suggest the need to further investigate the role of these psychological regulation strategies using ecologically valid methods.

An open trial of a new acceptance-based behavioral treatment for major depression with psychotic features

Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of behavioral activation and acceptance and commitment therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to 6 months of Acceptance-Based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through posttreatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.

The Active Therapeutic Processes of Acceptance and Commitment Therapy for Persistent Symptoms of Psychosis: Clients’ Perspectives

Background: There is limited research on the applicability and effectiveness of Acceptance and Commitment Therapy (ACT) for people experiencing psychotic disorders. Clinical trials suggest ACT may be efficacious in reducing distress and rehospitalization rates in psychosis. Mindfulness and reduced literal believability of thought content have been associated with reduced distress for this population. Aims: To better understand ACT for psychosis, this study investigated clients’ perspectives of the hypothesized active therapeutic processes of ACT. Method: Semi‑structured interviews, conducted with nine adults diagnosed with schizophrenia or schizoaffective disorder and persistent positive symptoms, were analysed thematically. Results: Four themes emerged: Usefulness of therapy; Changes attributed to ACT; Understanding of therapy; and Non-specific therapy factors. All participants found therapy useful and recommended ACT. Mindfulness, defusion, acceptance and values work were described as the most useful therapy components and contributing to positive changes. Self-rated frequency of symptoms did not change; however a reduction in the intensity and distress associated with symptoms was reported. Non-specific therapy factors were deemed useful by participants but not directly related to outcome. Conclusions: These findings are consistent with the theoretically defined underlying active processes of ACT and are relevant for this population. The findings also indicate important clinical implications for ACT for this client group: greater attention to the client connecting metaphors and concepts to the intended meaning may be valuable; caution should be used with some mindfulness and defusion techniques for intense experiences; and values work may be particularly useful for this population.

Using session-by-session measurement to compare mechanisms of action for acceptance and commitment therapy and cognitive therapy

Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive "defusion" (the ability to see one's thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.