Adapting and implementing Acceptance and Commitment Therapy groups to support personal recovery of adults living with psychosis: a qualitative study of facilitators’ experiences [paper]

It is excellent to share our latest paper on ACT for psychosis groups, published online in the journal Psychosis. 

This paper shares what it is like to set up a group program that offers Acceptance and Commitment Therapy for psychosis in public mental health settings. 

We report on the experiences of facilitators who adapted the ACT for Recovery group protocol to local needs in north-west Melbourne, Australia (called “Recovery ACT”) and what they discovered in running groups for people recovering from psychosis. We used a thematic analysis to identify important themes about adaptation and implementation of groups in community mental health teams. 

The paper summarises the themes emerging from facilitators’ experiences, such as the value of supervision, learning the group protocol, organisational support, and the rewarding personal experiences of running the groups. 

 We hope this paper will be useful for people running these groups in their own settings. The paper outlines the steps we took, and how helpful it was to have the support of service management and clinician enthusiasm to do this. Facilitators also describe advantages in having input from clinical academics to enable a successful evaluation of this service development. 

Facilitators also share what it is like to learn to do ACT groups, including how running these sessions may differ from other groups, particularly with the pacing, use of repetition and metaphors. 

This study was a collaboration between clinicians working at NorthWestern Mental Health and researchers at La Trobe University in Melbourne, Australia. We are grateful to the mental health consumers who participated in the groups and the associated research studies. The Recovery ACT program is currently being evaluated across four health services in Melbourne (NorthWestern Mental Health; Alfred Health; St Vincent’s Mental Health; Peninsula Health) .  

The pre-print of the paper is freely available here. 

I think of this paper as a companion piece to the study we published earlier this year of group participant experiences, also in the Psychosis journal.

There is also a published treatment manual describing ACT for Psychosis Recovery and various ways to train and support group facilitators (published by New Harbinger).

If you are interested in the background of this ACT for psychosis group program and evaluations, you can check out a recorded presentation.

Adapting and implementing Acceptance and Commitment Therapy groups to support personal recovery of adults living with psychosis: A qualitative study of facilitators’ experiences

Authors: Jesse Gates, Eliot Goldstone, Jacinta Clemente, Marilyn Cugnetto, Eric Morris & John Farhall

Background: Psychosocial, evidence-based interventions (EBI) may support personal recovery from psychosis; however, little is known about their implementation.  

Methods: This paper describes the adaptation, implementation, and evaluation of a psycho-social EBI, group Acceptance and Commitment Therapy (ACT), designed to support personal recovery of people living with psychosis who are accessing Australian public mental health services. We outline the process of adapting and implementing a group program, and present results of a qualitative analysis of facilitator experiences of the first 6 groups conducted involving 69 participants.  Eight facilitators participated in an expert-led reflective interview developed to gather feedback in five domains.  

Results: A thematic analysis of transcribed audio-recorded interviews elicited nine themes that indicated: local adaptations facilitated participant learning; targeted efforts to engage all stakeholders were successful; clinical supervision and research support by local experts enabled program implementation and evaluation; implementation offered facilitators personal rewards; and a need for further engagement of organisational support.  

Discussion: This paper identifies enablers of successful adaptation and implementation of ACT groups for recovery from psychosis, an EBI in public mental health services. Study limitations include the risk of a self-serving reporting bias and the absence of lived experience expertise in group facilitation and evaluation.  

Keywordspsychosis; Acceptance and Commitment Therapy; group therapy; public mental health services; evidence-based interventions; adaptation and implementation



“My voices are just part of me, they don’t own me”: a qualitative investigation of Acceptance and Commitment Therapy groups for people experiencing psychosis [paper]

Our qualitative study of the experiences of people with psychosis who engaged in Acceptance and Commitment Therapy groups to support their recovery has just been published online in the journal Psychosis

The qualitative study was led by Dr Sally Bloy, who interviewed people participating in ACT for Life groups, meeting them after the group program to hear about their experiences. [the larger ACT for Life group evaluation was published in 2016; Dr Louise Johns was the chief investigator]

The ACT for Life groups were brief, running over 4 weekly sessions, and focused on supporting wellbeing through promoting mindfulness and values-based actions. The groups use a central metaphor of the Passengers on the Bus to illustrate the potential of trying out different ways of responding to experiences (such as feelings, thoughts, memories, urges, voices etc) to go in valued life directions. The groups were run in inner-city locations in the London Borough of Lambeth, in community mental health teams in the South London & Maudsley NHS Foundation Trust. We have previously described the key aspects of these groups in a paper published in the Journal of Contextual Behavioral Science (Butler et al., 2016). There is also a detailed description of the group program here.

We developed a grounded theory of the processes of change as experienced by the participants: themes were identified of Awareness, Relating Differently, Reconnecting with Life, and a general group theme, Leaning on Others. These appear in the diagram below (also in the paper):    

A model of processes of change as articulated by participants (Bloy, Morris et al)

We are grateful to the experts by experience who shared their perspectives on the ACT for Life groups reported in this paper, along with all the participants who took part in the larger evaluation study (Johns et al., 2016). Their engagement helped us to better understand how group ACT is experienced by people with psychosis in community settings and led to further developments, including a preliminary randomised controlled trial of a longer version of the group and the publication of a treatment manual by New Harbinger (ACT for Psychosis Recovery). This group program is being offered in routine care in community mental health services in Australia (see here for a recent evaluation), the United Kingdom, New Zealand, and other countries.  

It seems right to have final words be from a participant:

Talking about those passengers in the bus . . . I never thought in that way, but once I was reassured that they are just part of me, they are not owning me, that really helped me to . . . you know, okay let them be there. I know I can’t get rid of those thoughts but I know they’re there. As long as I know they’re there they can’t take control over me. That’s fine for me.

Participant 6

The pre-print of the paper is here (PDF).

‘My voices are just part of me, they don’t own me’: a qualitative investigation of Acceptance and Commitment Therapy groups for people experiencing psychosis  

Authors: Sally Bloy, Eric Morris, Louise Johns, Anne Cooke & Joseph Oliver

Objectives:  This study aimed to generate a grounded theory of change processes as experienced by people with psychosis who engaged in an Acceptance and Commitment Therapy (ACT) group program. A secondary aim was to identify how participants described changes in their relationship to distress following the groups. 

Design: The study used a qualitative research methodology, grounded theory. This was used to explore emergent themes in the participants’ subjective experiences of group ACT delivered in community mental health services. 

Methods: The experience of the ACT group process was investigated for nine participants. Semi-structured interviews were used to explore how the group experience and the exercises, metaphors and skills promoted by ACT were used by participants in their daily lives. 

Results: There were four main themes emerging from the interviews: awareness, relating differently, reconnection with life, leaning on others. 

Conclusions: The participants all described experiencing subjective benefits from being involved in the ACT groups, along with perspectives on processes of change. These reports of changes were consistent with the model and extend our understanding of the lived experience of engaging in ACT for psychosis groups.   

Keywords: Psychotic Disorders; Acceptance and Commitment Therapy; Cognitive Behavioural Therapy; Community Mental Health Services; Grounded Theory; Recovery  



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

Very pleased to have this paper published, summarising the evaluation of group Acceptance and Commitment Therapy for people with psychosis and caregivers. [pre-print here]

This study was conducted in Lambeth & Southwark community mental health teams in the South London & Maudsley NHS Foundation Trust, United Kingdom. The study is funded by a grant from the Maudsley Charity. Dr Suzanne Jolley led the study, and the trial coordinator was Dr Emma O’Donoghue. The group manual has been published by New Harbinger and we have supporting materials free to access here.

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

Authors: Suzanne Jolley, Louise C Johns, Emma O’Donoghue, Joseph Oliver, Mizanur Khondoker, Majella Byrne, Lucy Butler, Carmine De Rosa, Daniela Leal, Jessica McGovern, Brigita Rasiukeviciute, Faye Sim, Eric Morris


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.

Keywords: cognitive therapy; community mental health services; group psychotherapy; schizophrenia.


Recovery ACT: feasibility & acceptability of Group Acceptance and Commitment Therapy for people with psychosis (ABCT 2020)

Our team had the fortunate opportunity to present a paper at the ABCT 54th Annual Convention on group ACT for people with psychosis.

Thanks to Dr Lyn Ellett from Royal Holloway University of London for organising the symposium on “Mindfulness and Acceptance Based Approaches for Psychosis: Current Evidence and Future Directions” where I presented the paper. It is terrific to be able to share about developments in mindfulness based interventions for people with psychosis at the ABCT Convention.

Here is a recorded version of our presentation:

This research is being conducted in Melbourne in public mental health services (a collaboration between La Trobe University and NorthWestern Mental Health), and our focus has been on adapting ACT to be useful in supporting the recovery of people with psychosis. This builds upon treatment developments that originated in the UK National Health Service (here is a recent paper). (for a background on ACT for Psychosis, check out this webinar recording)

Here’s the paper abstract:

Recovery ACT: Feasibility and Acceptability of Group Acceptance and Commitment Therapy for People with Psychosis

Authors: Eric Morris, Marilyn Cugnetto, Eliot Goldstone, Jacinta Clemente, Jesse Gates, John Farhall

This paper presents results of a mixed-methods, uncontrolled, single-group prospective cohort design to test feasibility, acceptability and pilot effectiveness of Group ACT for Australian mental health services. The Recovery ACT 8-session group program was adapted from the protocol described by O’Donoghue et al (2018), using principles outlined by Butler et al (2015), and previously evaluated in the National Health Service in the United Kingdom. We hypothesized the intervention would be feasible and acceptable, and group engagement would increase participants’ psychological flexibility (measured by increased cognitive defusion, acceptance, mindfulness and connection with personal values). These changes were hypothesized to lead to improvements in participants’ wellbeing and personal recovery. Of those invited to participate (N = 96), 90 participants consented, with 58.9% attending three or more sessions and 41.1% withdrawing (i.e., attending two or fewer sessions). Participants who withdrew provided reasons including anxiety about group attendance, and deterioration of mental state (to our knowledge, unrelated to the intervention). No adverse events were reported. A majority of participants who engaged in group sessions completed post-measures (N = 48, 90.6%). Recovery ACT was found to be feasible and acceptable (based on participant ratings and qualitative interviews). Participants who engaged in groups experienced on average a significant increase in wellbeing and sense of personal recovery. Improvements were accompanied by increases in mindfulness and valued actions; there were no changes in cognitive defusion or acceptance. The linear combination of process measures was significantly related to change in wellbeing; however, no  partial correlations between process measures and wellbeing were significant. These findings inform a pragmatic randomised controlled trial currently being conducted across multiple health services in Melbourne, Australia.


Acceptance and Commitment Therapy Groups for Psychosis Recovery – Webinar

In May 2018 I had the opportunity to present a webinar hosted by ISPS-US about “Acceptance and Commitment Therapy for Psychosis Recovery”.

The webinar introduced Acceptance and Commitment Therapy and how this approach can be adapted to the needs of people with psychosis.

I shared the developments in group ACT my research team evaluated across a couple of studies in the UK. The groups are currently being evaluated in public mental health services in the UK and Australia.

The group manual is described in our new book, ACT for Psychosis Recovery (published by New Harbinger Publications).

The webinar was recorded:

Thanks very much to the webinar audience for lots of great questions and comments, and to Ron Unger of ISPS-US for organising the event!

ACT for Psychosis is also described in a chapter I wrote for a new book, CBT for Psychosis: Process-oriented Therapies and the Third wave, published by the Internal Society for Psychological and Social approaches to Psychosis (ISPS).

For more details about Acceptance and Commitment Therapy for Psychosis please check out our website and resources:



“Back to basics, and then beyond”: a post-CBT future… to process based therapy?

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.

The first is their paper, “the third wave of cognitive behavioral therapy and rise of process-based care“, published in World Psychiatry in September 2017.

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 book even provides the analytic tools to help readers grasp when arguments based on philosophy are useful or not (e.g., Sean Hughes’ terrific chapter on philosophy of science in clinical psychology).

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?

Feel free to comment!



Five ways to improve clinical supervision using contextual behavioural science: the SHAPE framework

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).

What is considered effective in supervision is based on consensus views about best practices; the evidence base for supervision is comparatively limited. There is scope for greater integration of theory and practice to develop more effective supervision (e.g., contemporary developments in CBT training and 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.

The full paper can be accessed here [PDF].

In future posts I will discuss the SHAPE framework components in more detail, and share experiences of using SHAPE as a supervision approach.

We’re interested in your views. What makes for effective supervision? Does a focus on experiential learning strengthen the process?

Please feel free to comment and share your perspectives.


So long to SUDs – Exposure is not about fear reduction… it’s about new learning and flexibility

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)

2) people don’t have to experience distress reduction between sessions for exposure to be effective   (e.g., Prenoveau, Craske et al., 2013)

[See Craske et al., 2014 for a discussion of this research]

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.


Top 10 links for 2016 

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! 

Here are the 10 most-clicked links from my Twitter account in 2016: 
1) How to run Acceptance and Commitment Therapy groups for people with psychosis (PDF) 

2) Is mindfulness making us ill? 

3) Is the functional analysis of behaviour important?

4) The “self” in pain: the role of psychological inflexibility in chronic pain adjustment

5) Creating courageous CBT therapists: how to work with therapist fears about using exposure therapy

6) Physiotherapy informed by acceptance and commitment therapy for persistent low back pain: the pact study

7) Pushed by Symptoms, Pulled by Values: Promotion Goals Increase Motivation in Therapeutic Tasks

8) Psychological flexibility under fire: Testing the incremental validity of experiential avoidance 

9) Can Relational Frame Theory help us to understand delusions? 

10) Acceptance and Commitment Therapy for Individuals with Disabilities: A Behavior Analytic Strategy for Addressing Private Events in Challenging Behavior 

Thanks to all who followed my Twitter and Facebook feeds in 2016!  Your comments, retweets, and back-channel messages encourage me to keep updating the feed. 

I’ll continue to share interesting articles and posts in the coming year. Best wishes for 2017. 


ACT y la atención plena para la psicosis – Traducción al español

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).

El Curso fue el lanzamiento de una traducción al español de “Terapia de Aceptación y Compromiso y Atención Integral para la Psicosis“, con cada delegado recibiendo el libro. Estará disponible para comprar en el sitio web de la conferencia próximamente:

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.

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).