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).
ACT has a developing evidence base across a range of problems and disorders, showing comparable effects to other CBTs (A-tjak et al., 2014). There are indications that ACT and other mindfulness-based interventions may promote wellbeing for people with psychosis (White et al., 2011; Khoury et al., 2013; Strauss, Thomas & Hayward, 2015), by strengthening a more observing, and less reactive, way of responding to unusual experiences and self-critical thoughts (Morris, Johns & Oliver, 2013).
Group ACT for Recovery
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.
To make ACT relevant to the needs of consumers in Lambeth, we carefully adapted experiential exercises and concepts to be a better fit. This is possible because ACT is a model, rather than a set of techniques: psychological flexibility can be promoted in a variety of ways, sensitive to the context of the client (Hayes, Strosahl & Wilson, 2011). We were influenced by the work of Chadwick and colleagues (Chadwick et al., 2005) in adapting mindfulness exercises for people with psychosis, early research on ACT for psychosis (Bach & Hayes, 2002; Gaudiano & Herbert, 2006), and our own experience in providing flexible forms of CBT and ACT for psychosis (Johns et al., 2002; Valmaggia et al., 2008; Bloy, Oliver & Morris, 2011). Our group adaptations are described in detail elsewhere (Butler et al., 2015), however the description below will give an outline.
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.
We have made our treatment manual freely available, with positive feedback from colleagues in Europe, Australia and New Zealand about their experiences in running the groups, including evaluation in an early psychosis setting (Brand & Palmer, 2015). Further adaptions and evaluations of group ACT for Recovery are occurring at the NorthWestern Mental Health in Melbourne, with early indications that consumers engage well in a longer form of the intervention (up to 10 sessions). [We presented a “how to” on leading these groups at the Australian Psychological Society Congress in September 2016. A detailed clinical guide on the ACT for Recovery group program will be published by New Harbinger Publications in March 2018].
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.