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

Despite a wealth of evidence that it is one of the most effective ways to help people with anxiety disorders, exposure therapy remains underused by clinicians

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 paper can be accessed here [PDF]. 

Training clinicians

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: 

Standard training

 • 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. 



Can Relational Frame Theory help us to understand delusions?

How can we understand delusional beliefs in behavioural terms?

A recent paper published in the Journal of Contextual Behavioral Science by Corinna Stewart, Ian Stewart and Sean Hughes presents a “call to action” for taking a natural science approach to discerning persecutory delusions, by outlining the directions that contemporary contextual research on language and cognition provide:

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.


Acceptance and Commitment Therapy for Recovery: a promising low-intensity intervention for people with psychosis


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., 2013Strauss, 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.


Is the functional analysis of behaviour important?

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.

My interest in finding effective ways to help people has led me to adopt a contextual stance to understanding behaviour. Considering how my actions (what I say, what I do) can be an environment for the client to learn new behaviours is enormously helpful.  It means that I stay grounded, in considering the function of behaviour and how it can be influenced, rather than rely on psychological explanations that are practically uninformative.

In my opinion, there is no “gap” if the psychological science you adopt has prediction and influence of behaviour as a goal (functional contextualism). This is not to say that contextualists claim to know everything about behaviour change: it just means that taking a pragmatic stance allows you to consider if a model is useful for the purpose you are pursuing. There is still a lot more to know about influencing behaviour from a natural science perspective.

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.

It will be interesting if future studies can demonstrate whether functional analysis in a psychotherapy context similarly provides incremental effectiveness to interventions.


ACT for PTSD in Early Psychosis: A Case Series – paper published

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.

A pre-pub version of the paper is available here.

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.


Building a life that is rich, fulfilling and fun – Joe Oliver on “ACTivate Your Life”

rulebookJoe Oliver, co-author of ACTivate Your Life, was recently interviewed on the Open Forwards podcast. The interview was hosted by Jim Lucas (founder and managing director of Open Forwards, a consultancy based in Birmingham, UK).

In the interview Joe talks about what attracted him to Acceptance and Commitment Therapy (ACT) as a model: the empirical development, an international community of like-minded people, and the usefulness of the ACT skills in his own life:

…the thing that stood out to me is , it was in the word acceptance which is a really unusual word, it is catchy, it is provocative  and it is hard to grapple with. The thing that unfolds for me is was this peace. It was kind of like, offering this suggestion maybe that the struggle wasn’t always necessary. And that was just a revolutionary idea for me personally. And perhaps noticing the times of my life where I was struggling against stuff, I was fighting things. Just a suggestion maybe that there is another way to approach this  stuff, It was really fascinating.

In the interview Joe outlines how the skills of being open, aware and active may help when we get stuck in life’s problems.

In ACTivate Your Life we describe how these skills are already present… but may be underused, as we get caught up in our mind’s messages and struggles.

Joe also describes the process of how we tackled writing the book, with the goal of creating an accessible ACT self-help guide.

Working as a trio to develop our ideas and find a consistent style was an important part of the process:

Joe:  It is not only important to have the right ideas but have a way to tell these ideas in a consistent voice. It is important to kind of get across as well. For example Eric and myself, we come from kind of an academic background, writing academic papers. We might come out as a little dry and dusty. For example Jon [Hill: our co-author], he has done tons of writing. He is definitely a wordsmith, he is I think the world’s…as far as I know only video game poet, which gives you an indication of his writing abilities. Bring that all together, different styles, getting a consistent voice was important,

Jim Lucas:  It is a good measure of a book where you can’t tell the writers apart through the chapters, because the writing style is so similar.

Of course, we also made sure that the book had great illustrations, and references to zombies, disaster movies, and Frank Zappa (!).

I encourage you to listen to the podcast, it is a fun conversation, and available here.

Thanks to Jim Lucas and Open Forwards for this great interview!

If you’d like to check out the first chapter of ACTivate Your Life, it is available here.


clinical RFT is here, and now – A review of “Mastering the Clinical Conversation”

mastering clinical conversationMastering the Clinical Conversation: Language as Interventionwas published in late 2015 by Guilford Press. The book’s authors, Matt Villatte, Jennifer Villatte, and Steven Hayes, have produced, in my opinion, the first clinical Relational Frame Theory (RFT) manual that is both immediately useful to clinicians, and repays with deeper study and repeated readings. The manual will be of interest to researchers and clinicians concerned with the empirical development of psychotherapies, and therapists seeking to understand how therapeutic interactions can be enhanced by using contemporary behavioural principles.  [For the remainder of this review I will use the abbreviation “MtCC” to refer to the book.]

MtCC presents a wholly functionally-analytic approach to psychotherapy, based on a basic science account of language and cognition. The book’s integrative presentation means that the principles described are relevant to the practice of various psychotherapies, including cognitive-behavioural, systemic, humanistic and psychodynamic approaches (more on this later).


MtCC was a hotly-anticipated title within the contextual behavioural science community, partly as there was the promise of a clinically-oriented RFT handbook, that was not an “ACT book”, and also because of the word-of-mouth buzz generated by the training workshops that Matt and Jenn Villatte had been giving over the previous 3 years.

These workshops, presenting what could be done with clinical RFT, demonstrated that interventions may be developed directly from using relational framing principles. All without requiring a model like Acceptance and Commitment Therapy, or using middle-level terms.

I was fortunate enough to participate in a workshop Matt led in London in 2013, hosted by the British Association for Behavioural and Cognitive Psychotherapies. This workshop was well-attended by a diverse audience of clinicians and academics (along with ACT aficionados, there were participants across theoretical orientations, from cognitive therapists, solution-focused and systemic therapists, behaviour therapists, to humanistic and psychodynamic therapists: it felt quite unusual to have such an eclectic crowd for an event hosted by a CBT organisation).

The workshop was excellent. Over two days Matt demonstrated how RFT could provide from the ground up a way of conceptualising problems functionally and working with clients with greater precision in therapeutic language, using various types of relational framing. This was beyond the usual work presented to clinicians about RFT’s relevance, such as in the development of apt metaphors… this was seeing the therapeutic context wholly through a RFT lens.

What was equally impressive was the integrative nature of the training: while behavioural in focus, there were links made across a range of psychotherapies regarding the use of language to achieve therapeutic aims. It could be observed, in fact, that there was very little over the 2 days that was “ACT” at all: it was much more about understanding (in RFT terms) practices in mainstream, established approaches or speaking about the generic tasks and goals of therapy.

So, my hopes were high that MtCC may reflect my workshop experience of clinical RFT.

“Accessible RFT”

Since the 2001 publication of original RFT book (dubbed “Purple Hayes” due to the cover design, and possibly also for the experience that the text has on the reader(!): an infamously dense and complex manuscript), there has been a pressing need for readable texts to introduce RFT to non-academics. Two preceding texts, “Learning RFT” and “The ABCs of Human Behavior”, have been excellent efforts at tackling this, particularly by describing the effects of rule-governed behaviour and then presenting the properties and implications of relational framing.

MtCC presents a further refinement. It is an accessible introduction to RFT, oriented to clinical situations. MtCC stands on the shoulders of the RFT books that preceded it, capably presenting relational learning in a digestible way for the general reader. It helps that the principles described in the first few chapters, are then expanded upon throughout the remaining ones, meaning that the reader has plenty of clinical examples to become fluent in the functional way that MtCC describes psychotherapy.

The initial chapters describe the basic principles of how language evolved as a unique form of learning, and the ways that it can lead to problems and challenges (along with advantages).

The authors present their definition of language – “the learned behavior of building and responding to symbolic relations” – and unpack this to help the reader understand the book’s stance.

First, language is about relating.  It is a skill that applies beyond words, to any way that symbols can be related. And, at least for humans, this skill includes relating in ways based on social whim (rather than just to the inherent properties of the object being related). The authors argue this makes it possible for ”everything to mean anything”.

Second, language is learned: the authors discuss how it is the only learning process that is itself learned, and that once learned it alters all other forms of learning. Due to the ubiquity of symbolic relating, therapists are working with language, even when they use methods such as inducing silence, mindfulness, hypnosis or imagery. The authors make the case that knowing the behavioural principles suggested by RFT may help clinicians to work with a broad range of clinical problems in a coherent and efficient way, regardless of their clinical tradition.

“The conversations that happen in psychotherapy and other clinical interactions are, in part, a process of learning how to manage relational frames and the contextual cues that regulate them in the service of living well”

The third chapter is key, presenting a framework for using language in therapy and considering the tools (relational frames) that can be used clinically. The chapter orientates the reader to how change may occur: therapists work to alter the client’s symbolic context in various ways. Rather than attempting to remove experiences, the therapist is encouraging the client to be more sensitive to the useful aspects of their experiences, in order to broadening and build behavioural repertoires.

The authors describe overarching goals (promoting flexible sensitivity to context, and functional coherence) and a strategy (altering contexts, so that transformation of symbolic functions occurs). Helping clients to be more in contact with their experience in a broader way may enable more effective behaviours to be chosen (flexible sensitivity to context). Doing so from a stance of wholeness and effectiveness (functional coherence), may allow the client’s experiences to be integrated flexibly and their actions to be in the service of meaningful living. This chapter is a fundamental statement of the focus of therapy and sets the scene for the remainder of the book.

“Without sensitivity to variations in the context, a single observation turns into a rule, a thought into a belief, a memory into a story, an emotion into a mood, and a behavior into a habit”

The fourth chapter outlines how to use RFT principles in the assessment of psychological problems. A central idea is to conduct the assessment from the client’s perspective, to support their ability to observe their own behaviours and how they are influenced (so repertoires are already being broadened in the assessment phase!). This is a necessarily collaborative process, that may involve the use of metaphors and perspective taking to connect what is happening outside of therapy, with what is happening in the therapeutic relationship. The way assessment is described in this chapter is as an augmentation of what would be done within the therapist’s theoretical orientation. The reader is encouraged to consider how they would assess context sensitivity and coherence alongside the processes important to their model.

The remainder of the book then has chapters that describe clinical methods for:

  • activating and shaping behaviour change,
  • building a flexible sense of self,
  • fostering meaning and motivation,
  • creating powerful experiential metaphors, and
  • strengthening the therapeutic relationship.

Each clinical methods chapter has a similar structure: introducing the general approach, which is then divided into various component skills.  For each component skill there is an outline of the therapeutic goal, why it is important from a RFT perspective, how it links with various clinical traditions, and how to do it (with example therapeutic exchanges). Several component skills are discussed in this way, before the chapter concludes with a clinical example, with an extended vignette and description of the intended functions that the therapist is trying to develop. Each chapter ends with a summary of the principles to remember for the particular skill (this content is also listed at the very end of the book, in the “Quick guide to using RFT in psychotherapy”).

The clinical examples presented illustrate the principles well. More so, they have a quality of verisimilitude: they do sound like the types of conversations heard in the therapy room. In my experience, this is unusual in therapy manuals, many times example therapeutic conversations can read as a little too contrived. The authors notes on what the therapist intends with a particular response are instructive and reinforce the chapter points.


As strong as MtCC is, it is not to say that the text cannot be criticised. For one, I have heard a view that publishing this book is premature: there is still a lot more experimental RFT research required before reliable statements can be made about certain types of relational framing. I see this as a tension between the (necessary) goal of doing basic science, and presenting the implications of this research for applied settings.

What may surprise the casual reader is the amount of RFT research that has been done over the last 15 years. The authors do a great job in describing how this research has implications for psychotherapy in general, rather than just for contextual approaches like ACT. Like any empirically-based approach, there are likely to components presented in MtCC that will be revised and refined with further research. Producing a treatment manual at this point, to outline RFT’s usefulness to the clinician, seems an important goal in its own right.

A second criticism I have heard is that the book is not “functional enough”, and that what is being presented is a form of “topographical RFT”. It is accurate that the approach described in the text does not involve doing a “true” functional analysis – controlled experimentation of the manipulable aspects of the client’s environment – however, there are a variety of conceptual and practical reasons which functional analysis is not done in this way in clinical practice (Haynes & O’Brien, 1990; Hayes & Follette, 1992, 1993). In many psychotherapy settings it is not possible to spend extended periods engaged in this form of experimental analysis: amongst other reasons, few clients will have the patience for such an enterprise.

I think in MtCC the authors have struck the right balance, presenting assessment of sensitivity to context and coherence as additional facets of what the therapist would be doing when developing a formulation. There are certainly a number of methods and ideas discussed in Chapter 4 about how to do assessment, even if it cannot be said (yet) that functional analysis using RFT is definitively described. I have no doubt that in the coming years there will be other clinical RFT books published, from different authors, with other approaches to assessment and conceptualisation. It is the early days of clinical RFT.

Resources and Strengths

This book is supported by a wealth of online materials. The reader can expand their learning by exploring the website devoted to the book (, where there are many video resources that illustrate the principles, along with demonstrations of the therapeutic methods. There is also an active Facebook group to support learning.

A strength this book has is the authors’ efforts at integration, across various therapeutic models. This integration is not “anything goes” eclecticism, but rather one of considering functionally the processes of various psychotherapeutic methods. More than any other contextual text, there is a deliberate move of building bridges.

An example here is the intelligent discussion of behavioural experiments, cognitive reappraisal, and exposure, within a RFT frame (yep, pun intended). It is an interesting empirical question: when is it useful clinically to expand relational networks (such as with reappraisal or behavioural experiments) as a primary focus (compared to, say, undermining them experientially)?  One hopes that the book’s impact  is that it encourages RFT-informed clinical research that moves the field beyond therapy “brands” (e.g. ACT, CBT, and the rest of the alphabet soup), and generates useful principles that benefit all.


In my view, MtCC is a milestone work in contextual behavioural science and clinical behaviour analysis. I think it stands alongside the original guide to Functional Analytic Psychotherapy (FAP; a foundational text), in providing a behaviour analytic understanding of psychotherapy. Similar to the FAP text, the principles described could be used to augment existing therapeutic approaches. In contrast to the FAP text, MtCC presents a post-Skinnerian approach to psychotherapy, illustrating how understanding the principles of reinforcement are important within the context of the transforming qualities of relational responding.

Time will tell about the impact of this book. My hope is that MtCC becomes one of the foundational texts that new and training clinicians read, as it provides such a pragmatic framework for understanding clinical interactions. I would put this book in the same company as texts like “Motivational Interviewing”, in providing therapists with a solid footing in their sessions. Similarly I would recommend this book to experienced therapists: there’s a wealth of ideas to explore and wrestle with here. This book may just transform your approach to clinical conversations.



How to run Acceptance and Commitment Therapy groups for people with psychosis – paper published

Excellent to have an “in practice” paper published in the Journal of Contextual Behavioral Science:

Butler, L., Johns, L.C., Byrne, M., Joseph, C., O’Donoghue, E., Jolley, S., Morris, E.M. and Oliver, J.E., 2015. Running acceptance and commitment therapy groups for psychosis in community settings. Journal of Contextual Behavioral Science.


In this paper, we discuss the practice implications of our group Acceptance and Commitment Therapy for psychosis (ACTp) evaluations, in terms of the adaptations required to ACT interventions for group implementation in routine services for people with psychosis. ACTp shows promise as a brief individual intervention for people with psychosis to improve recovery, reduce future relapse, and reduce healthcare costs. Outcomes for group ACT interventions for non- psychotic severe mental illnesses support the potential for further cost-savings, through group delivery, and two recent trials suggest that adapting group ACT interventions to suit people with psychosis is both feasible and clinically effective. Trials were run from 2010-2014, and included people with psychosis and caregivers. Qualitative feedback was collected from group participants and service user co-facilitators. Based on this experience, we recommend psychosis- specific content for group interventions, and highlight process considerations to accommodate the particular needs of people with psychosis and their caregivers. With these adaptations, group ACTp can be feasible, acceptable, and effective as a routine frontline intervention in services for people with psychosis, however; this work is in the preliminary stages and further research is needed to consolidate the evidence base.

The pre-pub manuscript of the paper can be accessed here.

Our research team are currently writing a book-length guide to running ACT for Recovery groups, to be published by New Harbinger in 2016. Check out this link for a demonstration on how we run the “Passengers on the Bus” exercise, a central experience in the groups.


LinkFest! Top 10 Links – December 2015

The top ten most-clicked links from my Twitter account in December 2015:

1] Evaluations of self-referential thoughts and their association with components of Acceptance and Commitment Therapy

ACT-consistent variables were associated with thought evaluations (believability, discomfort & willingness) rather than thought content; believability associated with greater psychological inflexibility and distress; believability of negative thoughts a partial mediator in the prediction of distress.

2] Feasibility & acceptability of a brief Acceptance and Commitment Therapy group intervention for people with psychosis

Paper from my research team, describing our first ACT groups study with people recovering from psychosis. Our core group exercises use the ACT classic metaphor“Passengers on the Bus” (click here for a how-to).

3] Using Brief Cognitive Restructuring & Cognitive Defusion Techniques to Cope With Negative Thoughts

What happens when you ask people to use cognitive restructuring or defusion with a personally-important negative thought, over 5 days? This important study explores the effect of these ways of managing negative thoughts, in terms of believability, discomfort, negativity, and willingness to experience the thoughts.

4] Terrorism as an act-in-context: A contextual behavioral science account [book chapter]

Understanding terrorism through the lens of contextual behavioural science; considering the implications of Relational Frame Theory, what strategies could policy makers take?

5] The Application of #Mindfulness in Coping With Intrusive Thoughts

Presented from a CBT and transdiagnostic perspective, the authors demonstrate how brief mindfulness skills can be incorporated in sessions to help clients with intrusive thoughts.

[You don’t even need to call it A-C-T. Just CBT will do: Contextual Behaviour Therapy]

6] Acceptance & Commitment Therapy: helping parents of children diagnosed with autistic spectrum disorders (video)

Dr Louise McHugh (University College Dublin, Ireland) describes the key concepts of Acceptance and Commitment Therapy, and outlines the studies demonstrating how this approach can help parents of children diagnosed with ASD.

7] Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder

What client behaviours predict poor outcomes in trauma-focused CBT?

8] Preliminary Evaluation of the Values Tracker: 2-Item Measure of Engagement in Valued Activities

A promising new brief measure of valuing (2 items!), validated with participants experiencing chronic pain.

9] Impact of CBT and Acceptance & Commitment Therapy Models Using Psychology Trainee Therapists

Beginning therapists were trained in ACT and traditional CBT, and engaged a client in each approach (randomly determined). Client symptom improvements were greater using ACT; processes of change associated with each model predicted outcomes; compared to doing CBT, therapists were more fearful and felt less knowledgeable while doing ACT. [sounds legit: the ACT therapist is an uncomfortable therapist!]

10] Pushed by Symptoms, Pulled by Values: Promotion Goals Increase Motivation in Therapeutic Tasks

Experimental study investigating analogues of two therapeutic goals (reducing symptoms or pursuing values-based behaviours), using a regulatory focus theory framework. Participants who construed treatment in terms of valued behavior promotion spent more time on a therapeutic task than the other experimental conditions. [consistent with other experimental studies on valuing contexts, e.g., Paez-Blarrina, et al., 2008].


Wearing It Differently: Talking about ACT for psychosis, clinical psychology, and career choices

I recently had the privilege of being interviewed for “We All Wear It Differently”, a podcast for early career psychologists.

Amy Felman, the enthusiastic host, created the podcast so that psychologists starting their careers could learn from experienced colleagues about the choices and opportunities that shaped their working lives.

The podcast features a collection of Australian psychologists, describing their careers in areas like neuropsychology, school psychology, sport psychology, and clinical psychology.

Amy skilfully interviews psychologists about the early experiences that led to their career directions, the big ideas in psychology that enthuse them, and advice they have for those starting their careers. It is really interesting to hear what motivates psychologists, the range of roles that they perform, and what sustains them during challenging times.

The podcast is the type of resource I wish had been around when I was starting out in clinical psychology [we can safely say I trained in a “pre-pod” age…]. Amy also hosts an active community of listeners through a Facebook group.

For my contribution, I talk about the personal experiences that motivated me to work in services for people with psychosis, the psychologists who inspire me, what it was like to train in Western Australia and then work in the UK for 15 years, and how Acceptance and Commitment Therapy continues to inspire me as a progressive empirical approach in clinical psychology.

You can listen to the podcast episode here.  Better still, subscribe to the podcast – there’s a bunch of great episodes!