Acceptance

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Acceptance Commitment Therapy for people with
persisting psychosis Rationale, evidence, and
work in progress from Melbourne, Australia

• John Farhall, Neil Thomas, Fran Shawyer
• School of Psychological Science, La Trobe
  University, Melbourne, Australia
• Steven Hayes
• University of Nevada, USA

ACBS World Conference June 2010 Reno, Nevada
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Overview

• ACT for psychosis efficacy research so far
• Our current trial
• Design
• Adaptations of ACT for psychosis
• Preliminary results

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Arguments for applying ACT to psychosis

• Several features and components of ACT suggest
  its value in working with persisting
  hallucinations or delusions
• Acceptance Persisting symptoms are difficult to
  change learning ways to get on with life even
  though they persist is a realistic focus for a
  therapy
• Mindfulness defusion are promising alternatives
  to unsuccessful coping with symptoms by
  resistance, suppression, avoidance or engulfment
• The values focus - getting in touch with what is
  important in your life and translating this into
  everyday living - is consistent with recovery
  models

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ACT and psychosis treatment studies

• Two case studies in English
• (Pankey Hayes, 2003 Veiga-Martinez et al.,
  2008)
• Bach and Hayes, 2002
• 80 inpatients with positive symptoms randomized
  to either ACT or usual treatment
• Brief intervention 3 hours of ACT (4 sessions)
  all but one session in-patient
• Significant reduction in believability of
  delusions and in hospital re-admission rates in
  the following 4 months
• Gaudiano Herbert (2006)
• Similar study showing improvements in overall
  symptoms (BPRS) and reduction in distress
  associated with hallucinations

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Importance of these clinical trials

• Demonstration that ACT can be conducted for
  people presenting with acute psychosis
• Evidence that a brief ACT intervention may impact
  on the illness presentation (re-hospitalisation
  some aspects of symptom severity)
• Evidence that believability of psychotic symptoms
  mediates change supportive of the theoretical
  base

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Limitations of these two trials

• No standardised control treatment in either study
• Assessments not blind (tho hospitalisation
  outcomes notable)
• Participants had a range of diagnoses
• Restricted to in-patients in USA
• Variations in dose received (1-5 sessions)
• Gaudiano Herbert study was underpowered may
  explain failure to replicate Bach Hayes main
  results on hospitalisation and believability
• Gaudiano Herberts objective measure of
  positive symptoms (BPRS) did not improve, but
  subjective distress did

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Is the evidence base sufficient for ACT to be a
recommended psychosis treatment?

• No! (not yet)
• ACT (in general) does not yet meet the criteria
  for an empirically supported treatment (Ost,
  2008), due to insufficient quality in research
  studies
• ACT for psychosis has not yet been subjected to a
  randomised controlled trial that meets Consort
  criteria for rigor
• And
• ( there is an alternative with more substantive
  evidence - CBT for psychosis)

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So, what have we been doing?
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Unpublished trial of a CBT ACT intervention
(Shawyer et al, in preparation).

• Our previous work in CBT for psychosis gradually
  moved away from a therapeutic focus on the
  content of voices to coping with the experience
  (i.e. the phenomenon)
• The Treatment Of Resistant Command Hallucinations
  (TORCH) trial
• 3 groups A combined Belief Modification (CBT)
  ACT intervention Befriending and waitlist
  (n42)
• Little difference between groups, but
  underpowered
• However, observation of good response to ACT
  elements

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Development of an ACT relevant process measure
for hallucinations

• Voices Acceptance Action Scale (VAAS Shawyer
  et al, 2007) items address general and command
  hallucinations
• Acceptance items I struggle with my
  voicesR
• Action items My voices stop me doing the
  things I want to doR
• Short version (VAAS-9) suitable for any
  hallucinated voices now piloted (Kirk Ratcliffs
  thesis)
• Two factors (Acceptance Autonomy). Only weakly
  related to voice severity
• Strongly related to convergent measures of
  validity (AAQ II SMVQ)
• Negatively related to measures of depression
  (BDI), voice distress (PSYRATS) and disability
  (Sheehan Disability Scale)

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• A Randomised Controlled Trial of Acceptance and
  Commitment Therapy for Medication-Resistant
  Psychosis

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Design features

• A single blind RCT of ACT for persisting positive
  symptoms
• A credible comparison treatment (Befriending)
• Targets community-residing consumers with
  medication-resistant symptoms (a more relevant
  target group for Australia)
• Investigating therapy process factors
• Non-specific specific factors in each therapy
• Uses validated measures
• Independent blind rating of audiotapes for
  treatment fidelity developed the ACT for
  Psychosis Adherence and Competence Scale - APACS
  (Susan Pollards thesis)

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The therapies

• 8 x 50 min sessions course of therapy
• 4 therapists all deliver both therapies
• Local peer supervision plus specialist
  supervision from Steven Hayes
• Manualised ACT for psychosis
• Six modules relating to the six components of ACT
• Elements from modules conducted flexibly in
  parallel across the therapy
• Manualised Befriending intervention (Bendall et
  al)

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Comparison Therapy - Befriending

• Used as a control condition for non-specific
  factors in therapy e.g. contact time with a
  therapist and emotional and social support
• Conversation-based or low-key activity-based
  (play a game have a coffee go for a walk)
• Focus is on good things that are happening and
  topics of interest to participants symptoms and
  problems are explicitly not talked about
• Originally developed as a treatment for
  depression
• Not a no-treatment condition some efficacy in
  depression some evidence it can reduce symptoms
  of psychosis in the short-term (Sensky et al.,
  2000)
• Assumed to have different mechanisms of action

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Reasons for modifying ACT materials and
strategies when working with psychosis

• Engagement variability
• Reduced information processing capacity
• Higher order cognitive deficits
• Perception of internal events as external
• Compelling salience and strong emotional
  investment in symptoms
• Delusions or voices may be positive/valued

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Engagement in therapy

• Challenges
• Often referred by others vs self-motivation
  driving therapy
• Absence of distress around ego-syntonic delusions
  voices may reduce motivation for change
• Strategies
• Start with values work

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Stimulus overload

• Challenges
• Stimulus overload or too much emotional arousal
  can lead to symptom exacerbation
• Strategies
• Caution required with exposure/exercises applied
  directly to symptoms e.g., Taking your mind for
  walk
• Keep to a matter of fact, collaborative,
  psychoeducational tone high levels of emotion
  unlikely to be helpful

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Cognitive deficits

• Challenges
• Problems in verbal learning concentration
  abstract thinking may interfere with
  understanding metaphors, retaining information
• Strategies
• Use more concrete and briefer written material
• Slow the pace (in the session and over time) but
  be as active as possible
• Use simple, short metaphors
• Adapt standard metaphors exercises to
  personalise as much as possible
• Physical props if possible (e.g., fingertraps,
  chessboard, towel)
• Record sessions and burn CDs to take home
• Use Therapy folder to store copies of metaphors,
  CDs of sessions
• Repetition (using same or variants of
  exercises/metaphors)
• Christmas tree hang new ideas off one that has
  made a significant impact

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Perception of internal events as external

• Challenges
• Mindful acceptance and defusion are intended to
  be directed at internal experiences BUT psychotic
  symptoms are subjectively experienced as external
  more likely to be viewed as fact than thought -
  undermines the rationale
• Strategies
• General approach Take on clients terminology
  for psychosis/symptoms (not well, concerns)
• Step around issues of reality (entangling). Refer
  back to having space to move, workability, to
  live - letting values be the real thing that is
  important
• Work with internal responses to psychotic
  experiences
• The client may tolerate defusion and mindfulness
  anyway (in the absence of the usual rationale of
  them being internal events)

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Compelling salience and strong emotional
investment in symptoms

• Challenges
• A high investment in delusions over the long term
  means that direct work may not be feasible
• Strategies
• a focus on values commitment small steps may
  open up areas of living that have been neglected
• continue generic work learning ACT skills,
  e.g., defusion using non-delusional material,
  openness to discomfort

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Delusions or voices may be positive/valued

• Challenges
• Absence of struggle with internal experiences -
  Positive/valued delusions or voices may be a form
  in which experience is being avoided - rather
  than aversive
• Strategies
• If no struggle present start with values and
  goals.
• If delusions are expressed in identified goals,
  drill down to underlying value
• If delusions expressed in values (e.g. living a
  spiritual life), focus on non-delusional values
  since already doing a lot in the (delusional)
  value area!

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Participants

• Target 100 participants
• Outpatients from public mental health services
  and non-government psychiatric rehabilitation
  providers across Melbourne
• Inclusion criteria
• Age 18-65
• Diagnosis of schizophrenia or schizoaffective
  disorder (SCID)
• Ongoing distressing delusions or hallucinations
  (PsyRATS)
• Taking antipsychotic medication for gt 1 year
• Absence of intellectual disability or
  neurological disorder

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Primary Measures

• Outcome measures administered pre-therapy,
  post-therapy and 6-month follow-up (independent
  blind raters)
• Symptom-related outcomes
• Psychotic Symptom Rating Scales (PSYRATS)
• Positive and Negative Syndrome Scale (PANSS)
• Behaviour-related outcomes
• Time Budget Measure (Jolley et al)
• Social Functioning Scale (SFS)
• Process measures
• Acceptance and Action Questionnaire (AAQ II)
• Voices Acceptance and Action Scale (Shawyer et
  al)

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Assessed for eligibility n 69
Excluded n 2117 ineligible1 declined
participation2 withdrew during assessment
Randomised n 48
Allocated to ACT n 24 Completed therapy n
19Currently in therapy n 5
Allocated to Befriending n 24 Completed
therapy n 17Currently in therapy n
5Withdrew during therapy n 2
Post-therapy n 17 Completed assessment n
16Withdrew during assessment n 1
Post therapy n 19 Completed assessment n 19
Follow-up n 19 Completed assessment n
8Pending 6-mo assessment n 11
Follow-up n 16 Completed assessment n
7Pending 6-mo assessment n 9
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Results Psyrats post-therapy change
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Results participant ratings of change
Since receiving therapy, my problems with
psychosis are...
no different better or much better
ACT 2 (12) 15 (88)
Befriending 8 (62) 5 (38)
p .007
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Lifengage Team

• Chief Investigators
• Dr John Farhall
• Dr Fran Shawyer
• Dr Neil Thomas
• Prof David Castle
• Prof David Copolov
• Prof Steven Hayes

• Research assistants
• Kate Ferris
• Paula Rodger
• Emma White
• Postgraduate students
• Tory Bacon
• Suzanne Pollard
• Megan Trickey

Therapists Dr Fran Shawyer Dr Neil Thomas Dr John
Farhall Carole Pitt Specialist supervision Prof
Steven Hayes
www.lifengage.org.au j.farhall_at_latrobe.edu.au