Tania Lecomte, Ph.D., Universit

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Using ACT and Mindfulness in group therapy for
individuals with early psychosis - adaptations
and successes

• Tania Lecomte, Ph.D., Université de Montréal
• Bassam Khoury, Ph.D.-candidate, Université de
  Montréal
• Alexandre Benoit, RN, M.Sc., Hôpital Louis-H.
  Lafontaine
• Claude Leclerc, R.N., Ph.D., Université du Québec
  à Trois-Rivières

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Relevance of ACT and Mindfulness for early
psychosis

• Individuals with early psychosis are increasingly
  being offered psychological therapies
  medication in order to help improve coping
  strategies stress management, and to prevent
  relapse.
• Studies have suggested that ACT (Bach Hayes,
  2004 Gaudiano Herbert, 2006) could be useful
  for individuals with psychotic disorders, though
  few have specifically investigated it with
  individuals with early psychosis.
• Individuals with early psychosis experience
  distress, anxiety and depression linked with
  their diagnosis and the overall experience of
  psychosis, difficulties which have been
  documented as responding well to ACT and
  Mindfulness.

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Our interest for ACT and Mindfulness for early
psychosis

• We recently conducted a large RCT using group CBT
  for psychosis (Lecomte et al., 2008, J Nerv and
  Ment Dis)and have obtained significant results in
  terms of decrease in symptoms and increase in
  self-esteem
• in the intervention, there was a brief
  mindfulness/relaxation intervention that was
  rated as one of the preferred activities for many
  participants.
• Recovery, as defined by the consumer-survivor
  movement, is about hope, redefining oneself
  according to ones values, and includes spiritual
  as well as functional aspects many of these
  same principles are present in ACT

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Objectives

• Determine the feasibility and overall
  acceptability of ACT/Mindfulness for early
  psychosis

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Study 1

• Conducted by Alexandre Benoît, under the
  supervision of Claude Leclerc.
• Procedure
• A manualized 4 session group ACT for individuals
  with early psychosis was initially developed
  closely following the ACT principles, for
  recently discharged patients in a specialized
  first episode clinic.
• Each session included activities that covered one
  or more of the following six ACT clinical steps
• Creative despair
• Control as a problem
• Cognitive defusion or distance from thoughts
• Self as an observer
• Clarifying values
• Engagement towards values and actions

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Study 1 (contd)

• The sessions included various activities, e.g.

• The bus driver (one participant is the driver and
  the others say things that make to make the
  person anxious, sad, guilty, shameful, or feel
  good)
• Bringing your thoughts for a walk (in pairs)
• The polygraph (if anxious get shocked what
  will happen?)
• Do not think of a pink elephant

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Study 1 (contd)

• Procedure

• Participants could only be referred by a
  psychiatrist (ethics board demand), if between
  18-35 and at the First Episode Clinic (less than
  2 years with psychotic symptoms)
• Over the course of 1 year, only 6 participants
  were referred, of which 4 accepted and completed
  the intervention (X30, 1 woman).
• Reasons
• psychiatrists in the clinic were not open to new
  psychological interventions, even after
  presentations.
• The intervention was offered by nurses (perhaps
  more referrals if psychiatry residents were
  involved)

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Study 1 (contd)

• -

• Overall the intervention was appreciated.
• Participants enjoyed
• the group setting, learning relaxation
  strategies and socializing-sharing.
• The small sample size did not allow to obtain
  statistical differences pre-post on any of the
  symptom measures, but on psychosocial constructs,
  there was a trend towards better social
  functioning and better self-esteem.

• Concret thinking made metaphors difficult to
  understand.
• Too many concepts/activities per session.
• Sessions lasted 2 hours (too long?)
• Talk of suffering too difficult in too few
  sessions for participants to be at ease (and
  attend each session).
• Referral system inadequate.

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Study 2

• Conducted by Bassam El-Khoury, under the
  supervision of Tania Lecomte.
• Goal
• To fix the problems found in the previous group
  approach by offering more sessions (8 sessions),
  adapting the content for individuals with
  cognitive deficits (limit metaphors, no more than
  one or two activities per session), positive
  concepts introduced first, and limit concepts to
• Compassion
• Acceptance
• Mindfulness
• Also, the participants will be assessed at 3
  months follow-up.

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Study 2

• Each participant gets their own workbook, in
  which they can write their answers prior to
  sharing them.
• The workbook is divided in two section
• Values
• How to deal with difficulties in order to live
  our values
• Each session ends with a mindfulness
• or meditation exercise (e.g.
• mindfully eating an apple, breathing,
• visualizing a safe place, meditation with
• focus on compassion)

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Study 2 (contd)

• Procedure

• Participants are referred by members of the
  clinical staff to senior clinician
  (psychologist), if between 18-35 and at the First
  Episode Clinic (less than 2 years with psychotic
  symptoms)
• The pilot study will involve 10 individuals in
  the intervention and 10 matched-controls
  receiving TAU. Qualitative and quantitative
  information is gathered on
• Emotional regulation
• Social functioning
• Insight
• Psychological distress
• Medication adherence
• Mindfulness
• Symptoms (BPRS)
• Their experience of the treatment

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Study 2 (contd)

• Preliminary results

• So far only one group has been conducted.
• 6 participants referred 4 completed the
  intervention (one stopped after one session, the
  other too ill was rehospitalized)
• Quantitatively
• Too soon to tell (small N) but Wilcoxon rank test
  suggest that 3/4 had fewer overall symptoms at
  post-therapy, higher scores on mindfulness
  (Freiburg), on overall emotional regulation.
• N.B. the fourth person had a comorbid cluster B
  axis II disorder and disliked the female
  therapist (who was more structuring).

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Study 2 (contd)

• Preliminary results

• Qualitatively
• 3 out of 4 really enjoyed the intervention
• What they liked the most distancing themselves,
  meditation, hearing others optinions and tips
• What they didnt like nothing (2), having to
  break down situations (1), one of the therapists
  (1)
• What they learned the importance to live in the
  moment self-esteem and compassion how to relax
  how to eat more slowly.
• What changed for them think twice before acting
  and more patient more self-confidence, know my
  values not sure eat better, take time to eat.
• N.B. 2/4 mentioned meditating everyday since the
  group ended

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Conclusion

• Individuals with early psychosis need specific
  adaptations in order to truly benefit from ACT
  and mindfulness therapies in a group format.
• Study 1 demonstrated the difficulties that could
  be encountered (few references, comprehension
  difficulties, more sessions needed, etc) whereas
  Study 2 (still underway) gives us more hope in
  the potential feasibility and impact of the
  approach (though one person apparently did not
  benefit as much).
• Studies looking into third wave cognitive
  therapies for individuals with early psychosis
  should measure and take into account cognitive
  deficits as well as Axis II disorders, since
  these might influence the results.
• To be continued

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Thank you!

• Tania Lecomte, Ph.D.
• Professeure Agrégée, chercheure au CRFS
• Département de Psychologie
• Université de Montréal,
• Bur C-358, 90 rue Vincent dIndy,
• C.P. 6128, Succ. Centre-Ville,
• Montréal, QC, H3C 3J7
• Tel [phone]
• Fax [phone]
• Email tania.lecomte_at_umontreal.ca