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

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.

How Does Individual Psychotherapy Promote Recovery for Persons with Psychosis? A Systematic Review of Qualitative Studies to Understand the Patient's Experience

Psychotherapy for individuals with psychosis is an effective treatment that promotes recovery in various ways. While there is strong quantitative evidence across modalities, less is known from the patient's perspective. There are many varied forms of psychotherapy, and gaining the patient's perspective can improve understanding of salient elements of psychotherapy and increase engagement, ultimately improving recovery rates. The purpose of this review is to identify and integrate data from published studies of patient perspectives of psychotherapy for psychosis to understand essential elements across approaches, differences between approaches, and how psychotherapy impacts recovery. We aimed to understand further: what are the perceptions about individual psychotherapy from the perspective of individuals with psychosis? The current study was a systematic review using PRISMA guidelines of studies that included qualitative interviews with persons with experiences of psychosis who participated in psychotherapy. All three authors participated in the literature search using Pubmed, APA PsycInfo, and Psychiatry Online. We identified N = 33 studies. Studies included cognitive therapies, acceptance and mindfulness approaches, trauma therapies, metacognitive therapy, and music therapy. All studies reported participants' perceived benefit with the therapeutic relationship as especially salient. Participants described diverse aspects of objective (e.g., symptoms, functioning) and subjective (e.g., self-experience or quality of life) recovery improvements, with perceived mechanisms of change, and with music therapy having some unique benefits. Participants also reported challenges and suggestions for improvement. Study findings highlight the salient aspects of psychotherapy identified by patients that may help therapists to individualize and improve approaches to psychotherapy when working with individuals experiencing psychosis. Overall, findings support the potential for integrative psychotherapy approaches for maximal treatment personalization.

Effect of applying nursing-based cognitive defusion techniques on mindful awareness, cognitive fusion, and believability of delusions among clients with schizophrenia: a randomized control trial

Background

Applying cognitive defusion techniques to enduring psychotic symptoms, such as delusions, presents both a challenge and a promising opportunity for psychiatric nurses to manage delusions among schizophrenia clients.

Objective

This study aimed to examine the impact of cognitive defusion techniques on psychological flexibility, mindful awareness, cognitive fusion, and the believability of delusions in schizophrenia clients.

Methodology

This study used a single-blind, parallel-arm Randomized Controlled Trial design. Over five weeks, 70 clients with schizophrenia were randomized to either the cognitive defusion intervention group (n = 35) or the control group (n = 35).

Findings

The participants showed significant reductions in the believability of delusions, cognitive fusion, and psychological inflexibility immediately after the intervention and at follow-up. Notable enhancements were observed in cognitive defusion and mindfulness awareness abilities.

Conclusion

Cognitive defusion techniques positively affect schizophrenia clients who struggle with persistent delusional beliefs. This underscores the importance of further investigating this approach to decrease the intensity of delusions as part of a comprehensive therapeutic intervention. Psychiatric nurses must receive training in "cognitive defusion skills" to aid schizophrenia clients in becoming more aware of their emotions and modifying their coping strategies for delusional beliefs. On August 3, 2023, the research was retrospectively registered under the reference number NCT05759091 as a randomized clinical trial.

Clinical trial registration

https://classic.clinicaltrials.gov/ct2/show/NCT05759091, identifier NCT05759091.

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.

Acceptance and Commitment Therapy for individuals at risk for psychosis or with a first psychotic episode: A qualitative study on patients' perspectives

AIM

The aim of this qualitative study is to explore patients' perspectives on Acceptance and Commitment Therapy for early stages of psychosis. Therefore, we interviewed participants of the INTERACT study, that quantitatively investigated Acceptance and Commitment Therapy in Daily Life (ACT-DL) in combination with treatment as usual, for early stages of psychosis, comparing it to treatment as usual.

METHODS

Within 6 months after finishing ACT-DL, we conducted semi-structured, individual interviews with 19 participants. All interviews were audio-recorded and transcribed. Thematic analysis was used for coding and analysis.

RESULTS

Two overarching themes were formed: 'the meaning of ACT' and 'what to improve'. Considering the first, participants generally understood and connected with the meaning of ACT, noticing more awareness and acceptance of their thoughts and feelings, and living more in line with their personal values. The second theme included comments on the protocol not being personal or psychosis specific enough and some elements of ACT being too difficult to understand when having active psychotic symptoms.

CONCLUSIONS

This study suggests that ACT is an acceptable and promising new form of treatment for early stages of psychosis, and it provides relevant information to further develop ACT for this group.

Effect of a group-based acceptance and commitment therapy (ACT) intervention on self-esteem and psychological flexibility in patients with schizophrenia in remission

The present study explored whether acceptance and commitment therapy (ACT), a cognitive behavioral therapy approach, could improve the symptoms of schizophrenia spectrum disorders among patients with schizophrenia in remission. A pre- and post-treatment design with two evaluation time points was employed. Sixty outpatients with schizophrenia in remission were randomly divided into two groups: the ACT plus treatment as usual (ACT+TAU) and treatment as usual (TAU) groups. The ACT+TAU group participated in 10 group-based ACT interventions and TAU in the hospital, and the TAU group only received TAU interventions. General psycho-pathological symptoms, self-esteem, and psychological flexibility were assessed before intervention (baseline; pre-test) and after intervention (five weeks; post-test). Results indicated that, compared to the TAU group, the ACT+TAU group exhibited a more significant improvement in general psychopathological symptoms, self-esteem, cognitive fusion, and acceptance and action at post-test. ACT intervention could effectively decrease the general psycho-pathological symptoms and increase self-esteem level and psychological flexibility in people with schizophrenia in remission.

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.

"The thought is gonna come and the thought is gonna go": A qualitative study on how non-meditators learn and apply brief mindfulness-based instructions for food cravings

While brief mindfulness-based interventions have emerged as tools to modulate automatic responding in various domains of health and wellbeing, findings are primarily based on quantitative experimental research. However, these group-level findings do not capture the rich subjective experiences of individuals learning mindfulness. In the following qualitative study, we explored how non-meditators learn and apply brief mindfulness instructions in the domain of food cravings. Ten non-meditators listened to 'normal viewing' instructions, which asked them to view foods in the way that they normally would. They then viewed a video of attractive foods, and were interviewed about their experiences of learning and applying the instructions. Next, participants listened to a 5-min recording of mindfulness instructions, viewed another food video while applying the mindfulness instructions, and were interviewed again. The data were analysed using thematic analysis. When participants applied brief mindfulness, their relationship to the food stimuli changed such that they started perceiving their experiences as transient. Certain factors (e.g., use of visual metaphors) and processes (e.g., listening to the 'normal viewing' instructions first) facilitated this change. The ease of applying the instructions fluctuated with food preferences and perceived strength of cravings. Participants reported that they would apply the instructions in daily life if they felt a need for this, including in domains other than food. However, they anticipated challenges such as remembering and finding time to apply. Our findings highlight the specific aspects that influence how brief mindfulness instructions are learned and applied. These insights may change how brief mindfulness is studied empirically, and may inform the development of simple and empowering techniques that can promote wellbeing in daily life.

Group acceptance and commitment therapy for patients and caregivers in psychosis services: Feasibility of training and a preliminary randomized controlled evaluation

OBJECTIVE

Psychological interventions reduce the impact of psychosis, but widescale implementation is problematic. We tested the feasibility of group acceptance and commitment therapy for Psychosis (G-ACTp), delivered by frontline staff, and co-facilitated by service-user experts-by-experience (SU-EbyE), for service-users and informal caregivers (ISRCTN: 68540929). We estimated recruitment/retention rates and outcome variability for future evaluation.

METHODS

Staff and SU-EbyE facilitators completed 1-day workshops, then delivered closely supervised G-ACTp, comprising four sessions (weeks 1-4) and two boosters (10 and 12 weeks). Participants recruited from adult community psychosis services were randomized to receive G-ACTp immediately or after 12 weeks, completing outcome assessments at 0, 4, and 12 weeks. Service-use/month was calculated for 1-year pre-randomization, weeks 0-12, and 5-year uncontrolled follow-up.

RESULTS

Of 41 facilitators trained (29 staff, 12 SU-EbyE), 29 (71%; 17 staff, 12 SU-EbyE) delivered 18 G-ACTp courses. Participant refusal rates were low (9% of service-users [10/112]; 5% of caregivers [4/79]); 60% of those invited to participate attended ≥1 G-ACTp session (64% of service-users [39/61]; 56% of caregivers [35/63]). Randomization of facilitators and participants proved problematic and participant follow-up was incomplete (78% [66/85]; 82% of service-users [36/44]; 73% of caregivers [30/41]). Effect sizes ranged from very small to large mostly favouring treatment. Service-use reductions require cautious interpretation, as very few participants incurred costs.

CONCLUSIONS

Implementation appears feasible for service-users; for caregivers, retention needs improving. Outcome variability indicated n = 100-300/arm followed up (α = 0.05, 90% power). Methodological limitations' mean replication is needed: identified sources of potential bias may be reduced in a cluster randomized design with sessional outcome completion.

PRACTITIONER POINTS

Group acceptance and commitment therapy can be successfully adapted for people with psychosis and their caregivers. Implementation (training and delivery) is possible in routine community mental health care settings. Clinical and economic outcomes are promising, but replication is needed. Recommendations are made for future studies.

Traumatic loss and psychosis - reconceptualising the role of trauma in psychosis

Literature suggests that the occurrence of psychological trauma (PT) from various negative life experiences beyond events mentioned in the DSM-criterion A, receives little to no attention when comorbid with psychosis. In fact, despite research indicating the intricate interplay between PT and psychosis, and the need for trauma-focused interventions (TFI), there continue to be mixed views on whether treating PT would worsen psychosis, with many practitioners hesitating to initiate treatment for this reason. This study, therefore, aimed to understand patient perspectives on the role of PT in psychosis and related treatment options. A qualitative exploratory approach was adopted using in-depth interviews with individuals experiencing psychosis. The Global Assessment of Functioning (GAF) scale was administered on a predetermined maximum variation sample resulting in two groups of participants- those with moderate-mild disability (GAF 54-80; n = 10) and those experiencing moderate-severe disability (GAF 41-57; n = 10). With the former group, a semi-structured interview schedule was used, while with the latter, owing to multiple symptoms and difficulty in cognitive processing, a structured interview schedule was used. Results from interpretative phenomenological analysis (IPA) indicated that traumatic loss was central to experienced PT, but received no attention; this often contributed to the psychotic experience and/or depression, through maintenance factors such as cognitive distortions and attenuated affective responses. Further, the experience of loss seems to be more consequential to trauma-related symptoms than the event itself. Participants opined strongly the need for TFI and the role of it in promoting recovery from psychosis.

A qualitative evaluation of an ACT-based substance misuse treatment programme for service users within a secure mental health setting

Purpose

The purpose of this paper is to understand service users’ experience of a new acceptance and commitment therapy (ACT)-based substance misuse programme. The programme is designed for people in secure mental health services, presenting with complex mental health difficulties and co-occurring substance misuse problems.

Design/methodology/approach

A qualitative approach informed an exploratory pilot of this novel intervention. Service users completing a 16-week ACT programme were invited to participate in the current study. Out of the nine individuals enroled on the programme, six opted to take part in the exploratory pilot and completed semi-structured interviews following part 1 of the programme (eight weeks). Four of these participants proceeded into part 2 of the programme (eight weeks) and completed a further semi-structured interview.

Findings

The thematic analysis identified five main themes: “Increased awareness of personal values and the impact of substance use on values”, “Taking committed action towards values”, “Coping skills and the application of skills to manage difficult thoughts and feelings”, “Personal development” and “Use of metaphors/analogies”.

Research limitations/implications

A quantitative evaluation of clinical outcomes is recommended to gauge further programme effectiveness.

Practical implications

The findings provide preliminary support for the use of an ACT-based substance misuse programme in a secure mental health setting.

Originality/value

This study evaluates the use of a novel ACT-based substance misuse intervention with people in secure mental health care with co-occurring mental health and substance misuse difficulties. This paper provides an in-depth understanding of service users’ experience of participating in this new treatment programme.

The acceptance and commitment therapy model in occupational rehabilitation of musculoskeletal and common mental disorders: a qualitative focus group study

Aims: The aim of this study was to examine whether and how intended processes of behavioural change were reflected in participants' experiences after an inpatient occupational rehabilitation programme. The programme was transdiagnostic, lasted 3½ weeks and was based on the acceptance and commitment therapy model.Methods: Twenty-two participants (17 women and 5 men) took part in five qualitative focus group interviews after the programme. Analysis was data-driven, categorising participants' experiences using an initial explorative phenomenological approach. The emerging data-driven categories were re-contextualised within the theoretical framework of the therapy model.Results: The participants referred to experiences within all three intended domains of the model (openness, awareness, and engagement). Our results indicate that the transdiagnostic approach may have facilitated openness, while the attainment of flexible self-awareness was less evident. Participants expressed engagement and behavioural changes linked to personal values, but did not mention actions leading to imminent return to work.Conclusions: The results imply that for implementation in occupational rehabilitation, further development of this model is needed specifically regarding processes related to self-awareness and committed action towards work. These findings are relevant for the interpretation of results from randomised clinical trials on acceptance and commitment therapy in occupational rehabilitation.Implications for rehabilitationAcceptance and commitment therapy seems to be a feasible component in an occupational rehabilitation programme for persons with different diagnoses.A transdiagnostic approach mixing musculoskeletal pain disorders and common mental disorders in the same rehabilitation programme seems to facilitate the process of openness and acceptance.There is a need to further develop and operationalise some of the processes in Acceptance and commitment therapy to accommodate the approach to the occupational rehabilitation context.

The Acceptability, Feasibility and Potential Outcomes of an Individual Mindfulness-Based Intervention for Hearing Voices

BACKGROUND

A prominent area of advancement in the psychological treatment for people with persisting psychosis has been the application of mindfulness-based therapies. Recent literature has recommended the investigation of focused mindfulness interventions for voices (auditory hallucinations) as a specific experience. To date, only mindfulness programs in group format have been examined.

AIMS

This non-randomized pilot study aimed to assess the acceptability, feasibility and potential outcomes of an individual mindfulness program for persistent voices on the negative impact of voices on the subjective experience of mental health and wellbeing, depression and voice-related distress and disruption. Also, it aimed to identify potential psychological and neurocognitive mechanisms of change.

METHOD

A new 4-week individual Mindfulness Program for Voices (iMPV) was developed, and piloted with a group of 14 participants with a schizophrenia-spectrum disorder and persisting voices. Participants completed clinical and neurocognitive measures pre- and post-intervention and at 2-month follow-up.

RESULTS

Results revealed low attrition rates, high formal practice engagement levels and positive participant feedback. Pre-post outcomes suggested small to moderate effects for a reduction in the negative impact of voices on experience, depression and disruption. Large effects for changes in mindful responding and attentional switching were also identified.

CONCLUSIONS

Our findings suggest that this novel treatment protocol is appropriate, engaging and safe for persistent voice hearers. Findings for mindful responding and attentional switching suggest these to be potential mechanisms of change for further investigation. Further RCTs are warranted to ascertain the feasibility and efficacy for focused mindfulness interventions for voices of individual format.

Mindfulness- and acceptance-based interventions for psychosis: Our current understanding and a meta-analysis

In promoting optimal recovery in persons with psychosis, psychological interventions have become a key element of treatment, with cognitive behavioural therapy being widely recommended in clinical practice guidelines. One key area of development has been the trialling of "third wave" cognitive behavioural interventions, which promote mindfulness, acceptance and compassion as means of change. Trials to date have demonstrated encouraging findings, with beneficial effects observed on measures of psychotic symptoms. This meta-analysis evaluated the efficacy of third wave interventions for the treatment of psychosis in randomised controlled trials, with psychotic symptoms as the primary outcome. Overall, 10 studies were included. The primary outcome demonstrated a small but significant effect (g=0.29) for third wave interventions compared with control post-treatment. Trials of group format mindfulness-based interventions showed larger effects (g=0.46) than individual acceptance and commitment therapy based interventions (g=0.08), although methodological differences between trials were noted. Among secondary outcomes, a moderate, significant treatment effect (g=0.39) was found for depressive symptoms, but no significant effects were found on specific measures of positive and negative symptoms, hallucination distress, or functioning/disability. A moderate effect on mindfulness (g=0.56) was observed, but not on acceptance. Overall, findings indicate that third wave interventions show beneficial effects on symptoms in persons with psychotic disorders. However, further research is required to determine the efficacy of specific models of treatment.

User-experiences with a web-based self-help intervention for partners of cancer patients based on acceptance and commitment therapy and self-compassion: a qualitative study

BACKGROUND

Partners of cancer patients are the cornerstone of supportive cancer care. They assume different roles and responsibilities that optimally support the patient. Such support is highly demanding, and many partners report (mental) health problems. However, many of them do not use professional supportive care themselves. Offering a Web-based self-help intervention based on Acceptance and Commitment Therapy (ACT) and self-compassion could be an important resource to support this group. This qualitative study aimed to examine user-experiences with a Web-based self-help intervention based on ACT and self-compassion among partners of cancer patients.

METHODS

Individual in-depth interviews, about partners' appreciation of the intervention and lessons learned, were conducted with 14 partners of cancer patients who used the Web-based self-help intervention. Interviews were audio-recorded, transcribed verbatim and analyzed by three independent coders both deductively and inductively.

RESULTS

In general, partners appreciated the intervention, however, they also expressed ambivalent feelings towards peer support, the content of the feedback of their counselor, and the 'tunneled' structure of the intervention. The majority of the partners reported being more self-compassionate accepting that they experienced negative thoughts and feelings, they reported that they learned to increase the distance between their thoughts and themselves, they indicated being more aware of their personal values, and they thought that they were better able to commit to those values. They also reported other (non-specific) helpful processes such as insight and acknowledgement, positivity, the possibility to tell their story, time for themselves, and feeling closer and more connected with their partner (the patient).

CONCLUSIONS

Partners of cancer patients indicated to appreciate the Web-based self-help intervention based on ACT and self-compassion. They felt that the intervention helped them to cope with negative emotions, thoughts, and one's suffering; to practice self-kindness; and to clarify values based on difficult recent experiences. In addition, they felt that the intervention supported them to obtain insight and acknowledgement, positivity, to tell their story, make time for themselves, and feeling closer and more connected with the patient. We think that a Web-based psychological intervention based on ACT and self-compassion may be a valuable contribution in supporting partners of cancer patients.

Acceptance and commitment therapy for psychosis: randomised controlled trial

BACKGROUND

The efficacy of acceptance and commitment therapy (ACT) in psychosis has been reported but not for medication-resistant psychosis.

AIMS

To test the efficacy of ACT in a sample of community-residing patients with persisting psychotic symptoms. (Australian New Zealand Clinical Trials Registry: ACTRN12608000210370.) METHOD: The primary outcome was overall mental state at post-therapy (Positive and Negative Syndrome Scale - total); secondary outcomes were psychotic symptom dimensions and functioning. In total, 96 patients were randomised to ACT (n = 49) or befriending (n = 47). Symptom, functioning and process measures were administered at baseline, post-therapy and 6 months later.

RESULTS

There was no group difference on overall mental state. In secondary analyses the ACT group showed greater improvement in positive symptoms and hallucination distress at follow-up: Cohen's d = 0.52 (95% CI 0.07-0.98) and 0.65 (95% CI 0.24-1.06), respectively.

CONCLUSIONS

Improvements reflected the treatment focus on positive symptoms; however, absence of process-measure changes suggests that the ACT intervention used did not manipulate targeted processes beyond befriending. Symptom-specific therapy refinements, improved investigation of process and attention to cognitive functioning and dose are warranted in future research.

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.

Can we respond mindfully to distressing voices? A systematic review of evidence for engagement, acceptability, effectiveness and mechanisms of change for mindfulness-based interventions for people distressed by hearing voices

Adapted mindfulness-based interventions (MBIs) could be of benefit for people distressed by hearing voices. This paper presents a systematic review of studies exploring this possibility and we ask five questions: (1) Is trait mindfulness associated with reduced distress and disturbance in relation to hearing voices? (2) Are MBIs feasible for people distressed by hearing voices? (3) Are MBIs acceptable and safe for people distressed by hearing voices? (4) Are MBIs effective at reducing distress and disturbance in people distressed by hearing voices? (5) If effective, what are the mechanisms of change through which MBIs for distressing voices work? Fifteen studies were identified through a systematic search (n = 479). In relation to the five review questions: (1) data from cross-sectional studies showed an association between trait mindfulness and distress and disturbance in relation to hearing voices; (2) evidence from qualitative studies suggested that people distressed by hearing voices could engage meaningfully in mindfulness practice; (3) MBIs were seen as acceptable and safe; (4) there were no adequately powered RCTs allowing conclusions about effectiveness to be drawn; and (5) it was not possible to draw on robust empirical data to comment on potential mechanisms of change although findings from the qualitative studies identified three potential change processes; (i) reorientation of attention; (ii) decentring; and (iii) acceptance of voices. This review provided evidence that MBIs are engaging, acceptable, and safe. Evidence for effectiveness in reducing distress and disturbance is lacking however. We call for funding for adequately powered RCTs that will allow questions of effectiveness, maintenance of effects, mechanisms of change and moderators of outcome to be definitively addressed.