What is the future of CBT? For two leading researchers, the future could be that science and practice goes beyond the “alphabet soup” of branded therapies, to process based CBT.
Steven Hayes and Stefan Hofmann have shared a fascinating video, discussing their views on the third wave, process based CBT, and the future of evidence-based therapy:
They speculate there may even be a “post-CBT” future.
As processes of change across therapies from various traditions are understood, there may be greater opportunities to “create bridges rather than walls” in the empirical understanding of how people change, and thrive.
It is evident from their conversation that the bridge building has definitely been happening – a cognitive therapist and researcher (Hofmann) agreeing on many points with a contextualist (Hayes), while also acknowledging their philosophical differences.
[This is such a difference from the conversations that I saw in 2008, when Stefan Hofmann graciously participated in the ACBS World Conference held in Chicago. At that conference, it was almost maddening – for someone with a foot in both CBT camps – to see that, while there were areas of agreement, Hofmann could not acknowledge the importance of philosophical differences, and why radical behaviourists functional contextualists would choose differing independent and dependent variables to someone working within a cognitive perspective.
It is my dearest wish that conversations in CBT circles show the same understanding that Hayes and Hofmann model – no more cheap shots, straw men and silly characterisations of perspectives based on differing philosophies, and instead interactions of genuine curiousity and openness]
For me, the Hayes and Hofmann conversation also works as additional material to two of their recent, important publications.
This brief paper outlines the essence of their position – that the third wave (note that Steve Hayes is talking about it in the past tense in the video!) led to a:
greater recognition of philosophical assumptions in the science of CBT;
greater focus on moderators and mediators of change, and the development of interventions that promote functionally important pathways of change that cut across problems and syndromes (transdiagnostic processes).
These trends in the science of CBT have also led to changes in perspective, which may lead to greater integration across areas:
As a purely syndromal focus weakens and a process focus strengthens, human psychological prosperity and the thriving of whole persons, not merely psychopathology, is also becoming more central. Behavioral and mental health is ultimately about health, not solely the absence of disorders.
This set of changes is accelerating a transition in evidence-based care toward a process-based field that seeks to integrate the full range of psychosocial and contextual biological processes. Such a field is so broad that it stretches the very term CBT almost to a breaking point and we would not be surprised if that term soon wanes in importance.
The second important publication is newly released textbook, “Process Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy”, published in January 2018 by New Harbinger Publications.
I am currently reading “Process Based CBT”, and thinking through the book’s implications as a clinician, researcher and as a teacher of clinical psychology. Already I can see new ways of teaching and supervising others in CBT, based on the ways processes of change are discussed in the book.
In my view, this is the first major modern CBT textbook that presents a serious integration of the cognitive and contextual perspectives in clinical psychology. It reflects consensus views of contemporary competencies in CBT and likely directions the field is heading in.
While there have been previous CBT textbooks that have described cognitive therapy and acceptance and commitment therapy models and techniques, this is the first attempt at presenting the pluralism of contemporary CBT (including philosophy of science, assumptions of models, links to learning theory, neuroscience and evolution) in a way that doesn’t call for practitioners to sign up to one side or another.
It is truly integrative and certainly beyond “therapy brands”, with discussions of how various common CBT methods, such as reappraisal, decentring, exposure, and behavioural activation can be understood from differing perspectives.
For a mainstream text, the even-handed presentation of this pluralism is excellent.
The video provides more background on this book: as Hofmann and Hayes describe, “Process Based CBT” is an evolution rather than a revolution. They discuss how behaviour therapy may have lost it’s roots in processes and functional analysis, by historically embracing DSM syndromes and packages of interventions, which brought with it latent disease model notions of psychological functioning. I got the sense that while empirical development of CBT has been successful within this syndrom/ package approach, it has also led to a weakening of the link between basic science and applied research.
They share in their conversation that a process-based approach to CBT and to therapy writ large, moves beyond the validity problems of diagnosis, and returns to a central focus on understanding processes and mechanisms. This focus can join together processes from different therapies, as the analytic tools are now available to researchers to understand better how change occurs. It is exciting to hear Hayes and Hofmann discuss the implications of coherence across levels of analysis, joining biological and psychosocial factors, considering evolution science terms of variation, selection and retention in considering changes processes etc.
This conversation between colleagues, friends, and occasional intellectual combatants, is thoroughly recommended!
What’s your perspective? Do you think that a process based approach to therapy is the future of science and practice?
How can the process of clinical supervision be enhanced?
It is widely recognised regular supervision is useful for psychological practitioners to offer safe and effective services. Supervision provides relationship-based education and training that supports, manages, develops and evaluates the supervisee and their work.
The skilled supervisor fosters a relationship with a supervisee that allows for openness, reflection, creativity and support. Along with creating a safe space for doubts and concerns to be raised, the responsible supervisor also considers whether the supervisee is practising in clients’ best interests, and whether they are capable to conduct their duties (the normative, formative and restorative functions of supervision).
I’m pleased to have a recent paper published which explores how to improve supervision, informed by developments in contextual behavioural science (CBS):
Morris, E. M., & Bilich‐Eric, L. (2017). A Framework to Support Experiential Learning and Psychological Flexibility in Supervision: SHAPE. Australian Psychologist, 52(2), 104-113.
The paper was written with my colleague, Linda Bilich-Eric, who works at the Australian National University. Linda and I work in similar posts on clinical psychology training courses, as supervisors for internal placements (university psychology clinics), where the focus is on developing trainees in their fundamental professional competencies. As contextual researchers we are interested in how psychological flexibility may contribute to enhancing these training experiences.
The SHAPE Framework
In the paper we identify five supervision components, based on CBS, that may enhance supervision sessions. Our interest is how these components may promote experiential learning and psychological flexibility for supervision in general, rather than being focused on a particular area of practise or mode of therapy.
We have called this framework SHAPE (an acronym of the components):
Supervision values – connecting supervision with personal values about professional practice may increase willingness to be open about experiences such as doubt and anxiety in the supervisory space. We appreciate that expressing values does add a level of vulnerability in supervision; we think an advantage for doing this is that it enhances rapport for the supervisor and supervisee, and to provides a way to assess whether supervision behaviours are serving their stated purposes.
Hold stories lightly – we think that supervision conversations can be judged as “ways of speaking” that may or may not progress the goals of supervision (improved client outcomes, development of competencies, providing safe and effective services). The story-telling process can be noticed and remarked upon during supervision, and judged in terms of goal progression (that have been contracted for supervision). Building in this reflective stance toward languaging can help the supervisee and supervisor to remain aware that the “stories” told in supervision may be told in other ways, and that formulations/conceptualizations are usually better judged by whether they are helping the client, not matter how intellectually elegant they may seem.
Analysis of function – we argue that supervision should focus on identifying functional relationships in supervisee/client interactions, and understanding the client’s problems by discovering contextual influences (that potentially be modifiable). We think there are at least three areas to consider for functional analysis: 1) the client’s presenting problems and life circumstances, 2) the therapeutic relationship, and 3) the supervisory relationship.
Perspective-taking – strengthening flexible perspective-taking is a process and outcome of supervision. This is done by taking different points of view (time, place and person), in ways that foster experiential knowing of an observing stance across experiences, judgements and actions.This may support the supervisee to be open, aware and engaged with the challenging material they are exposed to in the course of their work.
Experiential methods – the supervisor provides opportunities for experiential learning by inviting the supervisee to engage in methods such role-play, use of imagery and metaphor, mindfulness, defusion and values clarification. Exercises can be useful to shift the process of supervision, particularly on occasions when the session conversation is having a lifeless, uncreative or repetitive feel. Experiential exercises can assist the supervisee to come into contact with a variety of thoughts, feelings and sensations, and strengthen the process of learning at a “bodily felt level”.
We have drawn upon the literature on functional analysis, psychological flexibility and rule-governed behaviour to present ideas on how supervision may be improved. The SHAPE components link to best practices in supervision and a contemporary interest in promoting experiential learning; we hope that this framework will encourage research into supervision using a contextual lens.
Exposure is one of the most powerful and effective methods therapists have to help clients whose lives are restricted by struggles with fear and anxiety. It is a classic method of behaviour therapy, with over 40 years of research to support its use.
Whatever approach to working with cognitions and inner experiences a cognitive-behavioural therapist takes in helping clients with anxiety, (a cognitive approach, such as Beckian CBT; or contextual one, like Acceptance and Commitment Therapy), there will usually be the use of exposure.
While it would seem that we should know how exposure works, recent research suggests that there is a still a lot more to discover about the best ways to engage clients in this approach.
Does habituation matter?
Many therapists have been trained in using exposure based upon a habituation rationale. Typically, sessions are conducted where the client is asked to rate their distress (using a SUDS – subjective units of distress scale) while doing exposure over the course of the session, with the aim of having distress reduce by the session end (typical treatment protocols suggest at least a 50% reduction in distress, e.g. Foa et al., 2012). What is also tracked are reductions in distress between sessions. The process of exposure is thought to be successfully occurring if these reductions in distress (habituation) are happening.
However, there is not much support for habituation being the process of change in exposure. For example, it has been found that:
1) people don’t have to experience distress reduction in session for exposure to be effective (e.g., Baker et al., 2010)
If reductions in distress in exposure sessions seems unimportant to outcome, then what should the therapist focus on instead?
Learning from new models of exposure
The contemporary empirical literature gives some indications, from an inhibitory learning perspective, and the psychological flexibility model (based on Relational Frame Theory, which underpins ACT).
The inhibitory learning model hypothesises that fear learning is not extinguished when people participate in exposure. Instead, what happens is that people learn new associations with what they fear, and this new learning inhibits old learning (such as fearful responding). From this model, the aim of exposure therapy is to maximise the ways that this new learning occurs. This could be done by:
1) violating the client’s expectancies of what will happen when doing exposure (I.e., learning is focused on whether the expected negative outcome occurred or not, or was as ‘bad’ as expected), and the degree of “surprise” a client has about the exposure practice. In this model new learning is impactful by the degree of a mismatch between what the client expects, and what they experience; sessions focus on this goal, rather than distress reduction;
2) increasing uncertainty associated with learning, by occasional reinforced extinction (the client experiencing occasional negative outcomes, such as social rejection if socially phobic, through “shame attack” exercises or deliberately doing things that will invite criticism from others), which may strengthen inhibitory learning if the client is later in contexts that would risk a relapse of fearful responding;
3) removing safety signals and safety behaviours, as these interfere with new learning. The therapist paying attention to the development of any new safety signals, such as the client learning that distress reduction reliably occurs during exposure;
4) the use of variable exposure, where exposure is conducted to items from the hierarchy in random order, without regard to distress levels or distress reduction (usually starting with the least anxiety producing item to avoid drop-out), and for variable lengths of time (again, with client agreement);
5) deepened exposure, where multiple cues are combined (that have previously been used in isolation in exposure sessions), such as the use of in-vivo (e.g., contamination with an “unclean” environment) and imaginal exposure (e.g., imagining someone becoming sick due to the contact with the client’s contaminated hands) together in an exposure session.
6) conducting exposures in multiple contexts – being creative about the range of occasions where exposure can be done, such as when alone, in unfamiliar places, or at varying times of day or varying days of the week. This reduces the risk of new learning being “context bound” (risking increased chance of relapse), such as if exposures were only done in the therapist’s clinic.
7) broadening contact by engaging in affect labelling, with the therapist asking the client to state their emotional responses, without attempting to change these responses, in the midst of exposure.
The psychological flexibility model emphasises helping the client learn how to pursue a values-based living regardless of anxiety, fear and urges (such as escaping or avoiding). For this model, the focus is on maximising client actions that are personally meaningful, whether in the presence of life-narrowing stimuli or not. The functions of anxiety and fear are transformed by experiencing them in the context of values, so that these experiences are responded to with qualities of openness, curiosity and compassion. The connection to values can mean that the client is reinforced for being in contact with fear and anxiety, in the context of acting in personally meaningful ways:
1) Engaging in exposure is explicitly linked to the client’s values, with meaningful (values-linked) activities chosen for the exposure sessions. Thus, there is a clear relationship with the stimuli and tasks chosen for exposure, and the kind of life that the client wants to be living;
2) Exposure sessions reflect the ACT approach: instead of monitoring ratings of distress levels during exposure (SUDS), the client is asked to provide ratings of their willingness to experience anxiety and other inner experiences (urges, unwanted thoughts, feelings) throughout exposure tasks. Over exposure sessions, work is done to increase willingness (through using exercises linked to acceptance, defusion, present moment contact, and flexible perspective-taking);
3) it does not matter whether the exposure task is easy or difficult (in a level of distress sense); rather, it is about how open and accepting the client is to what shows up while doing exposure;
4) exposure provides an excellent opportunity to practice experientially, the skills of psychological flexibility that ACT promotes;
5) following a session, the client should be encouraged to reflect on being willing and open during exposure, to strengthen experiential learning; if a client is starting to respond in a rule-bound way to doing exposure (“e.g., I just need to allow that feeling to be there and not fight it”), then the therapist should encourage curiosity, in light of workability (Therapist: “how has it worked in terms of your goals? How has this worked compared to other things you do?”)
Considering the recommendations from both these models of exposure, you can see that we are long way from the traditional, habituation-based approach. While the models have theoretical differences (see Arch & Abramowitz, 2015 for a discussion), there are commonalities.
For the ACT therapist, I think this can inform how to engage clients in exposure that maximises learning and flexibility, by:
having a focus on willingness and noticing the experience of fear and anxiety, without working to reduce distress within or across sessions.
linking exposure with “ultimate outcomes”, by engaging the client in approaching exposure within the hierarchical framing of values;
strengthening therapist and client willingness for exposure sessions to have variability in the intensity of distress, without controlling or avoiding this (and having sessions where distress may vary, including times when it remains high at the end of the session);
promoting present-moment awareness and expanded contact by affect labelling during exposures
working with the client to be in contact with feared outcomes (in-vivo, imaginal) as part of openness to experience and discovery.
encouraging client curiosity about what they are learning during exposure, without focusing on there being a “right” or “definitive” view to take;
moving away from using hierarchies as means of structuring of exposure, and introduce more variability into exposure sessions in terms of exposure difficulty (while ensuring that the client is choosing to engage in exposure)
expanding the contexts where exposure is practiced, so that new learning is not context-bound.
It is an interesting time to be practicing exposure therapy, with increased empirical interest in the processes that strengthen learning, and discovery of new ways to conduct sessions that may increase therapy effectiveness. These new ways to do exposure increase the options for the therapist and client to work in flexible and creative manner.
Another year of tweeting the latest, and the most progressive, research in contextual behavioural science (CBS), along with “fellow traveller” approaches (CBT, mindfulness, metacognition, behaviour analysis etc).
Some trends over the past year:
The rate of CBS publications has increased, particularly for randomised controlled trials of Acceptance & Commitment Therapy. It is hard to keep up to date across areas, due to the amount being published on ACT.
Many more ACT papers published in broader areas than psychology, such as physiotherapy, occupational therapy, speech therapy etc.
Papers informed by Relational Frame Theory that are clinically-relevant and interesting are increasing in number. Bring on more RFT experimental papers of a clinical nature!
As with previous years, critical stances and empirically-based criticisms of topics like mindfulness and psychological flexibility, get plenty of clicks!
En diciembre de 2016 tuve el honor de ser invitado a hablar en el Curso Anual de Esquizofrenia, en Madrid, España. El Curso es una de las mayores conferencias sobre enfoques psicológicos para ayudar a las personas con psicosis.
El Curso fue un evento excelente: amable y bien organizado, con más de 750 delegados y una gama de oradores interesantes. Mientras que muchas de las presentaciones eran de carácter psicodinámico, me complació estar presentando sobre Terapia de Aceptación y Compromiso y enfoques de la tercera ola, junto con mi amigo y colega, el Dr. Ross White (Universidad de Liverpool).
Agradezco al Prof. Manuel González de Chávez y al comité organizador por invitarme a hablar en la conferencia. Me sentí humillado honrado por la reacción positiva al trabajo que nuestro equipo había estado desarrollando en los grupos de ACT (colaboradores: Louise Johns, Joe Oliver, Emma O’Donghue y Suzanne Jolley).
In December 2016 I had the honor of being invited to speak at the Anual Curso de Esquizofrenia, in Madrid, Spain. The Curso is one of the largest annual conferences on psychological approaches for people with psychosis.
The Curso was excellent: friendly and well-organised, with over 750 delegates and a range of interesting speakers. While many of the presentations were psychodynamic in nature, I was pleased to be presenting on Acceptance and Commitment Therapy and third wave approaches, along with my friend and colleague, Dr Ross White (University of Liverpool).
The Curso was the launch of a Spanish translation of “Acceptance and Commitment Therapy and Mindfulness for Psychosis”, with each delegate receiving the book. It will be available to purchase from the conference website soon. www.cursoesquizofrenia.com/Castellano/nuestros_libros.html
I am grateful to Prof Manuel González de Chávez and the organising committee for inviting me to speak at the conference. I was humbled by the positive reaction to the work our team had been developing on ACT groups (collaborators: Louise Johns, Joe Oliver, Emma O’Donghue & Suzanne Jolley).
As discussed in previous posts, clinicians’ attitudes and practices about exposure are influenced both by their knowledge about the approach and their openness to witnessing client discomfort (and experiencing distress themselves). Cautious clinicians, if they do offer exposure, may do it in a way that limits its effectiveness.
So how do we support clinicians to use exposure more routinely, and effectively?
It seems that what is needed is training and supervision that: 1) addresses knowledge gaps, and 2) increases clinician “courage” to offer exposure and deliver it in a way that maximises effectiveness.
A recent paper published in Behaviour Research & Therapy investigates how to train clinicians in using exposure, by seeing what happens if you directly address their concerns by giving accurate information AND work with their feelings about engaging clients in the approach:
Targeting clinician concerns about exposure therapy: A pilot study comparing standard vs. enhanced training
Nicholas R. Farrell, Joshua J. Kemp, Shannon M. Blakey, Johanna M. Meyer, & Brett J. Deacon
Owing to concerns about the safety and tolerability of exposure therapy, many clinicians deliver the treatment in an overly cautious manner, which may limit its effectiveness. Although didactic training in exposure reduces clinician concerns about the treatment to a moderate extent, improved training strategies are needed to minimize these concerns and improve exposure delivery. The present study compared the effectiveness of a standard (i.e., didactic) exposure therapy training model to an “enhanced” training paradigm encompassing strategies derived from social-cognitive theory on attitude change. Clinicians (N = 49) were assigned to one of the two training approaches. Relative to standard training, clinicians who received enhanced training showed: (a) significantly greater reductions in concerns about exposure from pre- to post-training, and (b) superior self-reported delivery of the treatment. Reduction in concerns during training mediated the effects of training condition on clinicians’ self-reported exposure delivery. These findings underscore the importance of addressing clinician concerns about exposure therapy in training contexts.
The enhanced training procedure described in the paper involved providing accurate information about exposure, as well as addressing clinician concerns. The authors described that the enhanced training was informed by a social psychology perspective on how to influence people’s attitudes (the model described further here). In this study this was done by a balance of empirical information, correcting common mistaken beliefs about exposure, emotion-based appeals (client testimonials to the effectiveness and tolerability of exposure therapy), and an experiential/ self-practice exercise.
The study compared two training packages:
• an overview of exposure therapy, and a review of its efficacy,
• a description of cognitive-behavioural maintaining factors in anxiety disorders,
• applied practice in case formulation and treatment planning,
• descriptions of different variations of exposure (e.g., interoceptive, imaginal
• training in developing exposure hierarchies,
• instruction in “coaching” clients during exposure exercises,
• a discussion of the importance of context in fear learning and extinction.
Enhanced training involved the elements of the standard training, along with presenting:
• direct, empirically-based information that challenged common clinician myths about exposure therapy
• testimonials from clients who had experienced exposure therapy, attesting to it’s safety and tolerability
• an interoceptive exposure exercise – where the training participants were encouraged to engage in hyperventilation as self-practice during training. This was done so that they may discover experientially the safety and tolerability of evoked sensations associated with anxiety.
Compared to the standard training, the researchers found enhanced training resulted in a greater reduction in clinicians’ concerns about exposure therapy. Additionally, the enhanced training was associated with clinicians reporting the use of exposure in a higher quality way – endorsing various elements of practice closer to the ideal of how exposure should be offered. Finally, the mediation analyses (of the processes of change) suggest that the quality of clinician’s self-reported practices of exposure were influenced by reductions in their fears about it.
There are a limitations with this study (discussed by the authors): the sample was made up of experienced clinicians, the outcome of the training in exposure was a single-item measure, and there was no more objective assessment of whether clinicians actually ended up doing exposure in a consistent way. The mediation analyses were conducted with concurrent data, rather than taking potential process measures at an earlier time to measuring outcomes (which may have demonstrated causality).
This is a useful paper in exploring the ways that the training of practitioners can be strengthened, to increase the possibility that they will offer exposure to clients with anxiety. As a trainer of psychologists it made me consider how I can best teach them to use exposure: it seems that time spent providing the background and rationale for use of exposure, along with exploring clinicians beliefs about exposure, is important. Additionally, I like that an experiential and self-practice approach to learning about exposure seems useful (the interoceptive exposure component).
I remain interested in whether enhanced training for exposure may also benefit from having components that address clinicians’ psychological inflexibility or anxiety sensitivity. This could be informed by using principles from Relational Frame Theory, such as motivative augmenting (e.g., relating the therapist offering exposure, being open to client distress, as being in a hierarchical network with the therapist’s values). I also wonder about training that presents exposure with an alternate rationale, such as the “repertoire expanding” approach that is used in Acceptance & Commitment Therapy and other contextual CBTs (compared to a habituation, anxiety-reduction rationale for exposure).
This pilot study suggests that giving a “how to” on exposure is not enough to train clinicians. If you want them to offer exposure to clients in a high quality way, then it is about taking time to address common concerns, share the experiences of clients who have participated in exposure, and use experiential exercises to help clinicians perspective-taking and discovery.
A Contextual Behavioral Approach to the Study of (Persecutory) Delusions
Corinna Stewart, Ian Stewart and Sean Hughes
Throughout the past century the topic of delusions has mainly been studied by researchers operating at the mental level of analysis. According to this perspective, delusional beliefs, as well as their emergence and persistence, stem from an interplay between (dysfunctional) mental representations and processes. Our paper aims to provide a starting point for researchers and clinicians interested in examining the topic of delusions from a functional-analytic perspective. We begin with a brief review of the research literature with a particular focus on persecutory delusions. Thereafter we introduce Contextual Behavioral Science (CBS), Relational Frame Theory (RFT) and a behavioral phenomenon known as arbitrarily applicable relational responding (AARR). Drawing upon AARR, and recent empirical developments within CBS, we argue that (persecutory) delusions may be conceptualized, studied and influenced sing a functional-analytic approach. We consider future directions for research in this area as well as clinical interventions aimed at influencing delusions and their expression.
A pre-pub version of the paper is available here.(ResearchGate link)
From my perspective, the starting points that this paper identifies are very welcome.
The authors focus on identifying the likely contextual factors involved in delusional thinking. They do this by first clearly outlining the variables and processes that have been identified from the cognitive accounts of delusions (such as, cognitive biases, Theory of Mind deficits, defensive efforts): a range of mental mechanisms that do help us to understand the phenomena of delusions (all variables that have been researched over the last 30 years of progressive empirical study of delusions).
Deftly, the authors describe that while these variables are useful for understanding delusions, what is frequently missing from these accounts is the step further in understanding context.
The example is provided of the cognitive bias, jumping to conclusions. While there are reliable findings about this style of responding and delusional thinking, for the contextualist who is interested in both prediction-and-influence, what is missing is an understanding of the environmental variables or history of learning that brings this about. This further step in understanding is important, as mental mechanisms cannot be directly influenced. We need to understand what environmental variables are functionally linked with jumping to conclusions or persecutory delusions, in order to find ways to influence this behaviour.
Contextual behavioural science provides an analytic frame to do this, as it does not explain behaviour in terms of mental mechanisms. Rather, behaviour is explained in terms of environmental events (past and present): the task is to identify functional relations between environments and behaviours.
The paper outlines a way of understanding cognition and language as behaviours, using Relational Frame Theory. The authors describe how several features of language allow humans to generate rules, that can undermine sensitivity to changes in the environment, sometimes with undesirable consequences. This language-influenced insensitivity can limit learning from experience or people discovering that their rules/ beliefs are unhelpful to follow. This seems particularly relevant to persecutory delusions.
Persecutory beliefs as behaviours: implications
Consistent with this, the authors then define persecutory delusional beliefs as behaviours, and as forms of arbitrarily applicable relational responding (AARR). In Relational Frame Theory, AARR is a form of operant behaviour where stimuli are related based on contextual cues independent of their physical properties, and in ways that never experienced or instructed in the past (i.e., derived relating). Considering persecutory delusions as AARR may open several avenues of understanding how:
1) fear, threat, and avoidance may be established and transformed from one stimulus to another without prior experience, and despite physical dissimilarity among stimuli. This may explain how delusional relational networks develop, and how innocent remarks and gestures from others may be incorporated into these networks, so that they are experienced as aversive;
2) transformation of functions through complex relational networks may account for the internally coherent nature of delusional beliefs and how fear and avoidance may be readily emitted given certain (social) stimuli or ambiguous stimuli.
3) the effects of unhelpful rule-following (by undermining sensitivity to environmental changes) may help clarify why these beliefs persist despite contradictory evidence; and, it may be that people with persecutory delusions have relational networks that are elaborate, frequently derived, and internally coherent. This repertoire of relating could mean that contact with contradictory information is experienced as incoherent and thus aversive (as coherence is reinforcing). Rule- following and motivative augmenting may explain how people with persecutory delusions can develop narrow behavioural repertoires that end up perpetuating delusional beliefs and related responding.
4) Perspective taking (deictic relating) is likely to be important, in understanding whether self-generated rules are responded to in different ways to those that are socially-delivered, by people with persecutory delusions (they may strive more for coherence with self-generated rules).
Throughout the paper, the authors cite RFT and other research that suggests to these processes being present in both non-clinical and clinical populations (although only a few studies with participants experiencing psychosis, such as Cella et al., 2009; Monestes et al 2014).It is evident that there is plenty of scope for extending these investigations to participants who describe persecutory delusions.
Conclusion: clinical RFT – a progressive direction?
This paper is well-informed about mainstream research on delusions, and strives to make links to the broader literature. In my view, the authors make a good case for how using RFT could extend what is already known in useful empirical directions.
It is great to read a clinically-oriented paper that makes the case for Relational Frame Theory research, that may address some of the current issues in understanding delusions. My hope is this clinical RFT may lead to more effective psychological approaches to help people distressed by these experiences.
Can mindfulness and acceptance-based psychological approaches help people with psychosis in their personal recovery? Is it possible to “just notice” the frightening and preoccupying experiences associated with psychosis, such as paranoia, voices, stigmatising thoughts and unusual perceptions? How can psychological therapists help people with serious mental illness to improve their wellbeing and find meaning and life purpose?
Psychological therapies have been recommended as key interventions in supporting the recovery and well-being of people with psychosis (NICE, 2014), particularly cognitive-behavioural therapy for psychosis (CBTp) and family intervention. Both of these interventions as recommended by NICE are high intensity in form: 16 planned sessions for CBT, and 10 for family intervention. It is evident that many mental health services and providers struggle to provide these high intensity interventions to consumers, due to a lack of resources in available therapist expertise and time (Ince, Haddock & Tai, 2015; Onwumere, Grice & Kuipers, 2016).
One way to increase the availability and access that people with psychosis have to psychological therapies is to develop low intensity CBT interventions (e.g, Waller et al., 2015), including group CBTs. Over the past 10 years CBT for psychosis has expanded to include investigations of mindfulness-based interventions, such as Acceptance and Commitment Therapy. I will describe recent work done in the UK to develop Acceptance and Commitment Therapy groups as low-intensity interventions to support recovery for people with psychosis.
Acceptance and Commitment Therapy and the problems of psychosis
Acceptance and Commitment Therapy (ACT), a contextual behaviour therapy, aims to promote wellbeing and quality of life, by strengthening psychological flexibility. Psychological flexibility is a set of skills characterised by openness and non-judgement to inner experiences (such as thoughts, feelings, sensations, urges, voices), an observing sense of self, and commitment to actions guided by personal values. Psychological flexibility has been found to be a key determinant in wellbeing and personal effectiveness across populations (Kashdan & Rottenberg, 2010). People with psychosis who have greater psychological flexibility tend to be less preoccupied and distressed in the face of experiences like auditory hallucinations (Morris, Garety & Peters, 2014) and paranoia (Udachina et al., 2014).
Our team at King’s College London and the South London & Maudsley NHS Foundation Trust (Louise Johns, Emma O’Donoghue, Joe Oliver, Suzanne Jolley & myself) have been developing group ACT as a low-intensity intervention to support the recovery of people with psychosis.
We have researched the feasibility and effectiveness of these groups in community settings in Lambeth, a socially and culturally-diverse inner-city borough. Typically group participants are long-term consumers of mental health services, who are prescribed stable medication regimes and engaged in case management, but are at risk of crises and rehospitalisation/ home treatment. This group of consumers experience stigma and social isolation, and have high rates of depressive and anxiety symptoms (Birchwood et al., 2005; Pokos & Castle, 2006). Additionally, a high percentage of mental health consumers in Lambeth are from Black and Minority Ethnic backgrounds, who may have additional experiences of discrimination and social exclusion.
Our groups are brief (six 2-hour sessions) and have four components, present in every session:
A central metaphor – Passengers on the Bus
Mindfulness and noticing exercises
Values exploration and construction
Committed action in daily life (out of session activities)
Central metaphor: We use the Passengers on the Bus metaphor (Hayes, Strosahl & Wilson, 2011) as a way to scaffold the central ideas and skills of the group. The metaphor likens our relationship to inner experiences (thoughts, feelings, urges) to that of being a bus driver who has various passengers on their “bus of life” (an animation of this metaphor is below).
At times our unhelpful responses to these passengers can mean that our bus is hijacked (doing things because we are caught up by feelings or trying to avoid them), or we end up fighting with the passengers, with the bus going nowhere (when we seek to stop feelings, argue with thoughts etc). In the group, we explore another way of responding to the passengers: to be willing to have them just as experiences, while doing the things that matter to us (steering the bus in the direction we wish to go, even if that means vulnerability).
We use this metaphor in various ways: we tell the story about it; show an animation; use an example of another person’s suffering (with a video vignette) to illustrate “passengers”; we act out the metaphor (see below for a demonstration of this) , with the participants acting as the bus driver and passengers. Throughout the group we will constantly refer to the metaphor, by asking participants about their “passengers”, where they want their bus to go (valued directions), and whether they are getting hijacked or fighting unhelpfully with their passengers. Group facilitators will also self-disclose occasions when they fight or get hijacked by their passengers, to illustrate the common humanity in struggling with experiences, especially when we are seeking to engage in valued actions. We have found that using a central metaphor is useful in helping people remember the group focus (our relationship to inner experiences & chosen life purposes), provides a common language, and is flexible in containing the range of responses and experiences that participants describe.
Mindfulness and noticing exercises: we introduce various ways of practicing being open and aware toward inner experiences, and describe these as noticing exercises. This aims to build active openness and non-judgement toward unwanted experiences (such as critical thoughts, voices, worries and bodily sensations). Typically these are brief (5-10 minutes) experiential activities, where participants are encouraged to bring mindful awareness to what they are noticing (noticing a piece of fruit; how their body feels stretching; breathing while sitting in a chair; imagery of leaves on a stream). Compared to other mindfulness-based therapies, we don’t use lengthy meditation exercises or have long periods of silence in between instructions (due to the challenges of participants’ attention spans and intrusive mental experiences). A more talky, physically active form of mindfulness works in this setting: we have found that such practices, along with post-exercise enquiry, increase mindful awareness for participants.
Values exploration and construction: values in ACT are described as chosen life directions, and we encourage participants to consider what they would choose to do, if they didn’t have to struggle or fight with their “passengers”. We simplify the exploration of values to just a couple of life areas (work, love, play, health), and introduce the idea that what we value does not have be “set in stone”. Instead, we can work to discover what matters to us, by “trying out” and exploring various ways to act in our daily life. By combining this with the noticing skills we encourage participants to approach life with curiosity and openness. This approach is about constructing a life that matters to the participant, with what is available here and now. This can then be contrasted with the experience of struggling/ fighting with their experiences.
Committed action in daily life (out of session activities): the noticing skills and values construction are used to identify activities to carry out before the next session (usually a week), forming values-based goals. We discuss, plan and review these activities in smaller groups (2-3 participants), led by a facilitator. Facilitators will also identify values-based actions to take for the next session, and share these with the group: again, this is to foster universality and model openness about “passengers” and engaging in activity. When reviewing out of session activities the facilitators encourage all sorts of noticing about the process of engaging in values-based action, reinforcing the participants’ learning from their own experience.
Each session has these four components, both to foster learning and to present ACT as a whole – that experiential openness is in the service of taking actions that foster life purpose and meaning (personal values). This also means that if participants miss a group session, they can easily link back in to the process (each session presents variants of the four components).
Learning from peers: An innovation we introduced in our most recent study (Jolley et al., in review) was to have the groups co-facilitated by experts by experience: people with serious mental health disorders who were engaged in personal recovery. We felt that this would provide opportunities for learning, especially from a peer, about how psychological flexibility skills may promote wellbeing. We trained peer co-facilitators alongside mental health staff to run the groups, providing support and supervision, along with compensation for their time. This was an excellent experience: group participants highly valued the perspective of peers who shared their recovery journeys and led ACT exercises.
Outcomes so far
Our initial studies have promising outcomes: following the groups there are demonstrated improvements in quality of life (Johns et al., 2016) and wellbeing (Johns et al., 2016; Jolley et al., in review), and indications that group participants show greater psychological flexibility and mindfulness. Qualitative investigations suggest that along with the mutual support and sense of universality that results from a therapeutic group, that participants describe subsequently responding to their experiences in ways that were different (“seeing thoughts as thoughts”), aware (“shifting attention), and reconnected with life. Additionally participants have shared that they found having peer co-facilitators very helpful, by adding credibility to the skills suggested, and giving hope that change is possible.
Group Acceptance & Commitment Therapy shows promise as a low-intensity psychological approach to promoting wellbeing and quality of life of people recovering from psychosis. Group ACT has been found to be highly acceptable to a diverse range of consumers, and running groups in community mental health settings is feasible. Involving peers in co-leading groups is recommended, as this brings a valuable lived-experience perspective to the use of psychological flexibility skills to promote personal recovery. The group helps to connect people who can feel alienated and stigmatised because of their experiences, both to others in similar circumstances, and also to the common challenge of being human: how we find meaning and purpose in daily life.
Is it important to understand behaviour in context?
Psychology has a myriad of models about understanding humans and their behaviour. For the person interested in finding ways to help people change, many of these models have a big gap: they don’t point to what you can actually do to influence behaviour. Many (?most) psychological models are uninformative when it comes to how to help people, even if they are about behaviours that are distressing, harmful or socially limiting. Frequently, the predictors of behaviours described in these models are internal variables (such as self-efficacy, schemas, etc), unaccessible to direct influence by the individual or others. What is missing is understanding how (whether?) a person’s environment can be altered to change their behaviours.
So, it was with interest that I read a recent paper about a central idea in contextualism – that considering the function of behaviour is important when designing interventions:
Hurl, K., Wightman, J., Virues-Ortega, J., & Haynes, S. N. (2016). Does a pre-intervention functional assessment increase intervention effectiveness? A meta-analysis of within-subject interrupted time-series studies. Clinical Psychology Review.
This meta-analysis (analysing results across multiple studies) investigates whether doing a functional behavioural assessment makes a difference to the effectiveness of interventions. The authors analysed interventions for challenging behaviour (self-injury, property destruction, aggression, and stereotypy) done with or without a functional analysis, involving the same participants (typically people with intellectual or developmental disabilities).
A functional behavioural assessment involves a precise description of a behaviour, its context, and its consequences, to better understanding the behaviour and the factors influencing it. When we use this type of assessment in clinical practice, we are trying to understand the contingencies that maintain a person’s problem behaviour, along with identifying what influences when it occurs (e.g., antecedents). This can help us find ways to alter the environment to influence the person’s behaviour, hopefully to increase quality of life and social opportunities, along with reducing harm and distress. [There are several ways to do a functional analysis: using indirect methods, descriptive analysis, & experimental functional analysis.]
However, assessing the function(s) of behaviour takes time and resources, and as the Hurl et al review describes, it is an important question whether the assessment makes a material difference to the outcome. Does functional analysis matter? Or can behaviour by changed by using behaviour principles in a simple or general way?
Here is the study abstract:
This study examined the relative effectiveness of interventions based on a pre-intervention functional behavioral assessment (FBA), compared to interventions not based on a pre-intervention FBA. We examined 19 studies that included a direct comparison between the effects of FBA- and non-FBA-based interventions with the same participants. A random effects meta-analysis of effect sizes indicated that FBA-based interventions were associated with large reductions in problem behaviors when using non-FBA-based interventions as a reference intervention (Effect size = 0.85, 95% CI [0.42, 1.27], p < 0.001). In addition, non-FBA based interventions had no effect on problem behavior when compared to no intervention (0.06, 95% CI [− 0.21, 0.33], p = 0.664). Interestingly, both FBA-based and non-FBA-based interventions had significant effects on appropriate behavior relative to no intervention, albeit the overall effect size was much larger for FBA-based interventions (FBA-based: 1.27, 95% CI [0.89, 1.66], p < 0.001 vs. non-FBA-based: 0.35, 95% CI [0.14, 0.56], p = 0.001). In spite of the evidence in favor of FBA-based interventions, the limited number of comparative studies with high methodological standards underlines the need for further comparisons of FBA-based versus non-FBA-based interventions.
Based on this study, for people with challenging behaviours, it is much more effective to do a functional analysis before trying to intervene. It seems that using behavioural principles without considering the person’s challenging behaviour in context is comparable in effect to not intervening. In contrast, in promoting appropriate behaviours, interventions without functional analysis did have effects, although based on the effect sizes reported, it is still preferable to engage in functional analysis for these behaviours too.
The authors also report secondary analyses that found that interventions based on experimental functional analysis had larger effects than other forms of functional analysis. Time spent doing this resource-intensive functional analysis appears to be worthwhile.
Across the 19 studies reviewed, there were a range of non-FBA-based interventions reported, that included those based on behavioural principles (e.g., time-out) and as well as not (cognitive therapy; sensory integration therapy). There was also variance in problem behaviours reported and participant characteristics (such as whether disabilities were described). The authors discuss that these sources of heterogeneity were not significant in moderating the effects reported however.
This study is also interesting because of the validity of doing a meta-analysis of studies with time series, within-participant designs, where individual factors and environments are considered (compared to group-based studies that will report average effects across a group of participants). Additionally, due to the intensive nature of behavioural assessment and intervention in this area of practice (challenging behaviour for people with disabilities), randomised controlled trials are highly unlikely to be done.
It is great to see a meta-analytic study that demonstrates the value of functional analysis. It seems that it is not enough to use behavioural principles or other interventions when assisting people with challenging behaviours, without considering the context in which behaviour occurs. Reviews like this, where there has been a fair degree of experimental control in the studies, provide high-quality evidence.
My Danish colleague, Jens Einar Jansen, has published a paper with me, where we argue that Acceptance and Commitment Therapy (ACT) shows promise in helping people recovering from a first episode of psychosis who have trauma symptoms (using a case series):
Jansen, J.E., & Morris, E.M.J. 2016. Acceptance and Commitment Therapy for Posttraumatic Stress Disorder in Early Psychosis: A Case Series. Cognitive and Behavioral Practice. doi:10.1016/j.cbpra.2016.04.003
Persons with psychosis often report high levels of posttraumatic stress disorder (PTSD) symptoms, which render them more vulnerable to relapse, symptom exacerbation, and reduced well-being. However, less is known about how to adequately accommodate the needs of persons recovering from a first episode of psychosis, presenting with PTSD. Further, the existing evidence-based interventions for PTSD seem less equipped to deal with serious mental illness and comorbid conditions. This study aimed to assess the efficacy, acceptability, and safety of Acceptance and Commitment Therapy (ACT) for persons suffering from PTSD with comorbid trauma and psychosis. Three consecutively referred participants meeting ICD-10 criteria for PTSD and a first-episode nonaffective psychotic disorder were treated in an outpatient service within a case-series analysis. A manual-guided ACT intervention of 12 sessions showed clinically relevant improvement on self-report measures of PTSD symptoms and emotional distress. These initial findings are promising and appear to justify a more controlled evaluation of this brief intervention.
In the paper we outline the challenges in providing psychological therapies to people recovering from early psychosis when they have trauma symptoms. We share how the transdiagnostic ACT model may provide ways to work safely and effectively with these clients, including the use of exposure informed by a psychological flexibility approach. We describe how using metaphors, perspective taking and mindfulness may support committed action for clients that is recovery-focused. This is demonstrated through a case series of three clients who engaged in ACT in an early psychosis service. These uncontrolled observations are promising: further investigation with greater methodological rigour is warranted.