Psychological flexibility and nonjudgemental acceptance in voice hearers – paper published

Great to have this paper (the first from my PhD) out in the Australian and New Zealand Journal of Psychiatry:

Psychological flexibility and nonjudgemental acceptance in voice hearers: relationships with omnipotence and distress

  1. Eric MJ Morris1,2
  2. Philippa Garety1,2
  3. Emmanuelle Peters1,2

  1. 1Institute of Psychiatry, King’s College London, Department of Psychology, London, UK

  2. 2NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust, London, UK

Abstract

Objective: The psychological flexibility model has been hypothesized as a transdiagnostic, process-oriented approach to understanding various clinical disorders and problems, including chronic pain, anxiety, and substance misuse. In this study we investigated the model’s applicability to the experience of hearing distressing voices.

Methods: Fifty people experiencing persisting auditory hallucinations were administered the Kentucky Inventory of Mindfulness Skills, Acceptance and Action Questionnaire, Beliefs about Voices Questionnaire-Revised, Thought Control Questionnaire, and the Beck Anxiety and Depression Inventories. We predicted that psychological flexibility, mindful action, and nonjudgemental acceptance would be negatively associated with distress, disability, and behavioural responses to voice hearing and would have additional explanatory power when included with appraisals of voices and thought-control strategies (as predicted by cognitive models of auditory hallucinations).

Results: The results showed differential contributions between measures of psychological flexibility and nonjudgemental acceptance. Psychological flexibility accounted for a significant proportion of the variance in regression-based models of depression and anxiety, while nonjudgemental acceptance contributed to the prediction of emotional and behavioural resistance to voices, in addition to appraisals of voices and use of thought-control strategies. However, this was not found for distress associated with voice hearing, life disruption, and engagement with voices, which were explained solely by cognitive variables.

Conclusions: The study results suggest that psychological flexibility and nonjudgemental acceptance are related to general emotional well being and resistance response styles to voices, but not to specific dimensions of voice hearing.

The link to the abstract/ access to the paper is here ($).

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The building blocks of empathy, mindfulness and compassion: paving the way with Relational Frame Theory

The infinite chessboard… a hierarchical Self as Observer?

Last Friday I was fortunate to hear Louise McHugh speak at UCL about the bottom-up approach of Relational Frame Theory (RFT) to understanding mindfulness and the self. Louise’s excellent talk, hosted by the BABCP ACT Special Interest Group, demonstrated how the contextual behavioural science approach is making progress in identifying the building blocks for skills such as empathy, sense of self, mindfulness, and compassion.

Here is the description of Louise’s talk:

The self is a concept that is widespread in modern psychology and has played either a central or supporting explanatory role in several major theoretical approaches to human behaviour including psychodynamics, humanism and positive psychology. Despite the popularity of ‘self’ as an explanatory concept within these approaches, however, it has arguably remained ill-defined in operational terms. Recently, however, a strand of behavioural psychology, namely Contextual Behavioural Science (CBS), has emerged that has begun to provide an account of human language and cognition characterised by precision, scope and depth. From this perspective only humans have a sense of self. This is because only humans have language. In order to have a sense of self, a creature must be a language-user and only humans are language users. So what is language and what does it mean to be a language user? The current talk will address these questions and demonstrate to the audience why the CBS approach to the self has important implications for training socially important skills such as perspective taking, self compassion and mindfulness.

Perspective-taking is one of the most progressive empirical areas in Relational Frame Theory, particularly in terms of the potential for applied work. Louise described three fundamental frames that build a perspective-taking repertoire: I-YOU (changing perspective with another person), HERE-THERE (changing perspective according to location), and NOW-THEN (changing perspective based on time).

Promising associations have been found, and outcomes shown from training in perspective taking informed by RFT (for examples, check out McHugh et al, 2004; Weil et al, 2011; Villatte et al., 2010). Clinically-relevant questions have also been investigated – such as whether distress is reduced more by training the observation of thoughts from a perspective of self-distinction from the experience (“You are not your thoughts”), or in a hierarchical relation with the experience (“You are the container of your thoughts”) – Foody et al (2013) found that hierarchical relating was  superior at reducing distress (so keep using those Chessboard and Sky and Weather metaphors) .

This talk reinforced my view that CBS will head in the direction of “Clinical RFT”, where therapists and trainers fluent in how relational responding is elaborated and functions are transformed will be able to develop interventions with greater precision and impact, rather than relying on the mid-level terms of the psychological flexibility model (ACT Hexaflex). I had similar thoughts when Matt Villatte visited London in 2013 to lead a very accessible RFT-based therapist skills training workshop (co-developed with Jennifer Villatte; look out for the forthcoming book from Guilford Press, The Language of Psychotherapy: Strengthening Clinical Practice with Relational Frame Theory).

In the near future clinical practice will be informed by a number of lab-based procedures to develop perspective-taking. This will be interesting because many of the classic ACT exercises have been taken from other sources, while RFT-based procedures will be distinctive methods, existing because of these empirical developments. Of course, due to the focus on function in CBS, there will continue to be methods taken from elsewhere (such as mindfulness), used for the purpose of promoting flexible responding.

The audio recording of the talk is available from here. And the slides are here(PDF). The two-hour presentation includes Louise leading several perspective-taking exercises and encouraging the audience to provide feedback. Well worth a listen!   [NB there is feedback from yours truly; the event was the last London ACT Networking Event I hosted for the BABCP]

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Starting your own ACT peer supervision group

A challenge for UK therapists learning to do Acceptance and Commitment Therapy is access to supervision. Outside of working at the specialist clinical and research centres that focus on ACT or accessing supervision online from international trainers, there are currently very limited options to get supervision from an experienced ACT therapist.

One option is to start your own peer supervision group: finding like-minded colleagues and working together to develop your practice as ACT therapists. In this post I’ll describe how we set up our peer supervision group within the South London & Maudsley NHS Foundation Trust.

We have been running a peer supervision group for the past 6 years in Lambeth, with up to 20 psychologists and therapists meeting monthly. Just about all of the people who participate in our peer supervision group have a background in CBT, many of them interested in third wave approaches through mindfulness (usually through exposure to MBCT).

The peer supervision group is on the large size: our strategy has been to promote ACT by providing a space where people of varying levels of experience can interact. This means less regular supervision for any particular therapist’s work (presenting a case once or twice a year), with the trade-off of learning from the experiences of others (Group members also receive individual supervision for their cases). The group largely consists of NHS clinical and counselling psychologists, along with trainees and assistants, so discussions are informed by similar settings and working practices.

The group started following an “Introduction to ACT” workshop that we ran for psychologists working in NHS adult mental health services in Lambeth. There was a lot of enthusiasm after the workshop so we suggested some follow-up activities, including an “ACT Video Club”. The DVDs of “ACT in Action” had just been released, and this seemed like a good opportunity to increase familiarity with the model and encourage discussion.

Following six months of the “ACT Video Club”, our focus shifted to peer supervision, as a core group of therapists wanted to develop their skills and become familiar with case formulation.  Due to the interests of this core group the case discussions tended to be around working with people with serious mental illness (psychosis) and making links with other cognitive behavioural therapies.

The usual format of the group is to:
1)  review a chapter of an ACT book,
2) for someone to practice/ demonstrate an experiential exercise, and
3) for case material to be discussed.

Readings
The books we have reviewed have been:
•    ACT Made Simple – Russ Harris
•    Learning ACT – Jason Luoma, Steve Hayes and Robyn Walser
•    The 2nd edition of the ACT manual – Steve Hayes, Kirk Strosahl and Kelly Wilson

Assigning a chapter a month has been workable. In our experience, clinical material (e.g., Russ Harris’ books) have been easier to get to grips with for the majority of the group, compared to sources written from a more academic perspective, such as the ACT manual. Material about methods and techniques, rather than theory, has also led to more free-wheeling discussion.

Our group has members who are pretty familiar with functional contextualism and Relational Frame Theory, so there can be theoretical discussions: however (from my perspective) these tend to involve greater reticence from most group members to engage with(!). I think also that when a group that has a core set of members and a larger number that occasionally participate, reviewing clinical rather than theoretical reading is more engaging, and requires less from the occasional members to get up to speed.

Exercises
Experiential exercises usually work best if there is a way of doing them in a larger group (on any given meeting we may have 8 – 12 people attending), or at least in pairs. My observation is that therapists new to ACT like to practice mindfulness exercises first, possibly due to the scripts and structured way that they can be done (also taking exercises from MBCT/ MBSR), and then start to branch out to defusion and values-based exercises. More adventurous therapists bring in exercises they have created, to try out before sessions with clients.

Usually someone leads an exercise, we discuss what the exercise evoked, give feedback on delivery, and then finally link to the psychological flexibility model.

Case Material
There are several ways that case material is worked with in the meeting. The most typical situation is when a therapist feels stuck, or unsure of how to approach a client problem.

Similar to CBT supervision, the therapist may outline the client’s presenting problems, background and goals, then describe their understanding of maintaining factors, triggers, personal strengths etc. This may lead to a group discussion of the case formulation in ACT terms, with some variant of describing in terms of the six core processes of psychological flexibility (or three – Open /Aware /Active, or two – mindfulness /values-based action).

My observations are that clarifying the goals of the client can be useful, particularly there may be unclear links to values. Examples would be identifying elimination/suppression goals toward private events, client experience suggesting an unworkable change agenda, or process goals being used as outcome goals. Another common task is using our understanding of Relational Frame Theory to create therapeutic metaphors based on the client’s description of problems, which we hope may engage the client and promote flexible responding.

Other times (or indeed following on from discussion), the therapist may want to take a more experiential approach, such as:
•    roleplaying the therapeutic interaction,
•    engaging in perspective taking about the client, or
•    contacting an experience evoked by the client work that may be acting as a barrier.

Roleplays may be done in pairs, with either another group member playing the client, or with the therapist playing the client, and the rest of the group being observers. We have also run role-plays as a round, with group members taking turns acting as therapist, or having a pause for someone to suggest an ACT-consistent move to try in the interaction (this is similar to the “ACT Tennis” game that Gordon Mitchell and colleagues from NHS Fife use to develop ACT skills – responding back and forth like a volley in tennis). Perspective taking and practicing willingness have been done using imagery, such as imagining being behind the client’s eyes and how they experience the therapist, or the Physicalising Exercise to practice just observing and being curious toward feelings and thoughts that invite therapist struggle.

And finally…

I send a summary email after each meeting to the larger group of therapists, outlining the chapter discussion, description of experiential exercises, and the themes from the case discussion (no client details). The email describes the reading for the next group along with the volunteers for leading exercises and case discussion. This keeps people linked in and serves as the record of our activities.

 

I hope that you have found this a useful outline.  It’d be great to hear about your experiences of ACT peer supervision, any useful tips etc. Feel free to comment below!

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Behind the Scenes: the UK & Ireland ACT/ CBS conference 2013

One of the best things to happen last year was seeing the UK and Ireland ACT/CBS conference take shape, and then finally run in November 2013. With over 200 delegates attending each day over the four days of the conference, it was gratifying to see the months of hard work by the conference committee pay off.

Joe Oliver, conference chair, opening the ACT/CBS conference 2013

Joe Oliver, conference chair, opening the ACT/CBS conference 2013

The conference had been a long-held goal of the BABCP ACT Special Interest Group.  The SIG was formed by Mark Webster with 20 BABCP members following the 2006 ACT World Conference in London, and we “dared to dream” that one day we could host a conference.  We hoped that this would strengthen the UK ACT community by encouraging home-grown research and clinical developments, and promote contextual behavioural science more broadly. Over the next 7 years we hosted events to build the community and ensured we had a presence at the BABCP national conference.

In 2009 we got close to having a business plan approved by the BABCP for a proposed conference in Edinburgh, but were unsuccessful. We redoubled our efforts following this disappointment to put on successful events, that raised the profile of ACT and contextual behavioural science, and allowed the build up a surplus in the SIG bank account. Two events in London in particular contributed to this: the 2010 workshop with Steve Hayes (close to 200 delegates), and the 2011 “ACT Made Simple” workshop with Russ Harris (over 140 delegates).

October 2012 – conference business plan

In October 2012 the SIG prepared another business plan for a conference, with Joe Oliver submitting this to the BABCP. To broaden the appeal and reach of the conference we approached Frank Bond, President of the ACBS UK and Ireland Chapter, with the idea of a jointly hosted event, which he fully supported. The time looked right: the ACT SIG had a healthy 1000+ members, a decent surplus, and a track record of well-organised events. A further factor that we thought strengthened our business plan was that the Association for Contextual Behavioral Science had planned for the next two World Conferences to be held outside Europe: in Australia (2013), and the US (2014). This would mean that there were no major  conferences to compete with, giving the SIG conference a good chance of attracting UK, Irish and European delegates for a London event.

As part of our preparations we sent out a “call for interest” email to the SIG membership and the ACBS, to produce a mailing list of people interested in the conference. This generated a response of around 250 people, mostly based in the UK.

In the business plan we pitched the scale of the conference and basic structure: we hoped to attract 200 delegates across 4 days (2 days pre-con workshops, 2 days a multi stream scientific and applied conference; plus the Follies, a social event and tradition in CBS conferences). Thinking about the scale and structure, informed the expenses of invited speakers, venue, catering and marketing, to determine the anticipated cost per delegate. This cost per delegate then helped us to price student, early bird and standard delegate rates.

The time of year for the conference was a challenging issue –  the major events for the BABCP are the Spring workshops and the National Conference, we had to avoid scheduling against those. Similarly, not scheduling in the same month as the EABCT conference. This left us with an autumn/winter conference. This was also a challenge in terms of finding affordable venues in London for that time of year: university campuses were out, due to the teaching requirements of a busy term. It was looking pretty clear that we would need to host in a conference centre, which did increase the overall venue cost of the conference.

November 2012

We received the green light from the BABCP, who agreed to financially underwrite the entire conference!

Now the work would really begin…

January 2013 – the committee gets to work

We formed a conference committee, with BABCP ACT SIG representatives (Joe Oliver, myself, Sue Hart, Henry Whitfield, Elizabeth Burnside, Martin Wilks) , the ACBT Chapter (Frank Bond), and Amy Donohue and Marie-Anne James from Eyas Limited (the event organising company). Joe as ACT SIG Chair, took on the role of the Conference Chair, while I agreed to be Programme Chair. Working with Eyas was essential: their experience in running the BABCP national conference meant that they could use their expertise to set up the conference website, scope for venues, establish costs for various conference expenses etc. We met monthly to plan the conference, using a combination of face to face and online meetings, and email discussions. We received great support and advice from the BABCP, in particular Ian Preston (the Finance Manager) and Dr Stephen Gregson (the Communications Manager).

February 2013 – getting the word out

Our first advertising in February 2013 for the conference may have seemed a little premature, but we had two aims 1) to alert people to the conference and encourage them to save the date/ plan ahead, and 2) to make the most of the end of the UK tax year, which sometimes results in training spends by employers. We advertised via email to BABCP members, Facebook groups for ACT, the UKACT listserv, and the international ACT listserv. From this first marketing we did receive a small number of registrations and plenty of interest from the community.

April 2013 – call for submissions

Our call for submissions provided the next opportunity to advertise the conference. By this time we had confirmed our pre-conference workshop and keynote speakers, so as well as calling for submissions we could increase interest in the conference programme.

The call for submissions had followed planning for the structure for the conference. We anticipated that most of the conference delegates would be practitioners (75%), with the remainder being researchers (25%). Similar to other ACT conferences this meant that we needed to program content that would appeal to the range of delegates (typically research symposia are less popular than skills classes). We came up five types of submissions: symposia, skills classes, open papers, panel discussions, and posters.

We also confirmed the presenters for three half-day in-conference workshops (David Gillanders & Helen Bolderston; Niklas Törneke; Martin Brock & Chris Irons), which we hoped would be highly attractive to practitioners.

The call for submissions was open for 6 weeks (closing end of May 2013): it was hard to judge the level of interest, and behind the scenes the committee encouraged people to submit the work they had been developing. We all knew of great speakers and interesting developments happening around the UK and Ireland, but would the community respond?

May/June 2013 – submissions close and advertising deadlines

Marketing a conference is a major task. From our experience of running events for the ACT SIG we knew we could use several no-cost channels: the international ACT listerv, Facebook groups, the UK ACT yahoo group, CBT Cafe, Twitter, and the London ACT networking events mailing list. I found that the tension with these channels is to make sure you get the message out about the conference, be responsive to queries, but not overuse the channel so that you are spamming(!).

During this period we also decided where we were paying for advertising space – this included the BABCP magazine, inserts for the BABCP national conference and ACBS World Conference, and the British Psychological Society’s magazine.

We set the close of the early bird rate for conference registration at the end of August 2013, which we hoped would give us a sense of numbers with two months to go before the conference.

July 2013  – handling submissions and finalising the conference programme

As Programme Chair my responsibility was to coordinate the conference content. Thankfully I was well-supported by the Programme Committee (Jo Lloyd, David Gillanders, and Louise McHugh), who evaluated the submissions with agreed criteria. This resulted in an overall ranking of the 71 submissions.

Jo Lloyd and I also agreed upon content classifications of the submissions (e.g., health, psychosis, RFT, workplace etc). [It was brilliant to have so many RFT submissions, reflecting the research strength of our region, and meaning that this was a solid stream throughout the conference].

The standard of submissions was high, which led to some tough decisions when it came to the final programme. We probably had enough content to easily run a 3-day conference of high quality.

As we did not have a sense of the registrations yet (early bird registration was yet to close), there was a decision to be made about whether we would have four or five concurrent streams of presentations. Five streams (adding space for 8 more sessions over two days) would mean an increased spend in terms of room space. Joe Oliver and I had several conversations about this, mindful of the financial risk involved. In the end we white-knuckled it; thankfully it paid off.

Joe and I also planned out the structure and timings of the conference. As the committee’s goal with this conference was to maximise engagement of the community, highlighting the widest range of developments and greatest number of presenters, we decided to have each day begin and end with a 1 hour keynote, and contain four, 75 minute sessions. One hour and quarter is not long to present applied material or run a symposium: so the challenge for our speakers was to maximise their impact within this limitation.

Responding back to people about their conference submissions was a busy couple of weeks for me. Perhaps not the most efficient way of doing it, I emailed every contributor about the outcome personally. This was fun to do with the people who had things accepted, much less fun when contacting people whose work did not get accepted. Where I could I suggested poster presentations as an alternative (which did bolster the poster session). Some people took the bad news with grace, some did not! (you know who you are). It certainly helped my perspective-taking with submitting things to conferences: someone, somewhere is sweating over what is accepted and what isn’t!

Another reason to finalise the conference programme as early as we could was to be able to advertise the conference content to attract delegates. Again we received key support from the BABCP, with Stephen Gregson  doing an excellent job in turning the raw material of the submission information into the conference programme. In the end the committee thought we had an excellent programme across the four days: would this engage the community and attract (enough) delegates?  It was a good time to be practicing acceptance and mindfulness skills!

September 2013 – promising times

The early bird deadline came and went: the response was promising, about 50% of our target. The committee decided to then extend the early bird registration period to the end of September, in an effort to boost registrations. This would mean that the full delegate rate would apply from October on.

One of the unexpected tasks during this time was to remind speakers that they did have to register for the conference (45 or so people). This reminder did produce some “interesting” responses from a couple of people (again, you know who you are). Things were tight enough financially, without the committee giving away freebies! I had heard about this problem before, with the reminders at the BABCP national conference about the needing to register if you are speaker, but got a new appreciation of the issue from this perspective! Thankfully the reminders sorted things out.

We didn’t let up on using the no-cost advertising during this period, and with weekly updates on the delegate numbers it really wasn’t until about 2 weeks before the conference that we had a reassuring number of registrations.

November 2013 

Well, the conference happened. People showed up, and being an ACT conference, they showed up experientially too!  The venue was lovely, the attentiveness of the staff was top notch, the food got great comments, and things ran smoothly. Many excellent presenters, cool research and developments, and keynotes that inspired.

Eric Morris, Joris Corthouts, Ross White - ACT/ CBS Conference 2013, London

Eric Morris, Joris Corthouts, Ross White – ACT/ CBS Conference 2013, London

The committee kept hearing excellent feedback about the conference over the four days, it was a bit overwhelming!  Credit where credit is due: our partners at Eyas really did a top-class job with the conference organisation.

And, most importantly, the Follies rocked – showcasing British and Irish humour, ACT/CBS geekery, with some European craziness thrown in (you know who you are….).

No doubt it is a lot of work to plan and run a conference, it was also a lot of fun too.  I hope that this is the start of many CBS conferences in the UK and Ireland.

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Mindfulness and Psychosis – BABCP 2008

At the 2008 BABCP National Conference held in Edinburgh, Amy McArthur, Gordon Mitchell and I led a half-day workshop on “Acceptance and Commitment Therapy for Psychosis”.

The workshop represented a distillation of our understanding of the field currently, and some of the clinical methods that we use for running groups and doing individual therapy in our services.

A description of the workshop is below:

Acceptance and Commitment Therapy (ACT) is a contextual CBT that uses mindfulness and values-based behavioural activation strategies to help people develop a workable relationship with internal experiences as part of a direction of increasing life meaning and vitality. ACT involves an experiential approach to therapy, based upon empirical principles of behaviour change. Clients are guided through exercises and metaphors to develop a present moment focus, clarify personal values and explore the functional utility of coping strategies. There has been promising evidence to suggest ACT can help people who are distressed and/or disabled by psychosis to learn a mindful and accepting stance toward unusual experiences, reducing the impact of symptoms, and improving social functioning (Bach & Hayes 2002; Gaudiano & Herbert, 2006). This workshop will present an ACT approach to psychosis, including how the problems of psychosis are conceptualised in this model and modifications to mindfulness and acceptance techniques for this population.

We had excellent attendance for the workshop and it was obvious that a fair number of CBT therapists have an interest in mindfulness and ACT approaches for helping people distressed and disabled by psychosis.

There is a description of the workshop available here (on the contextualpsychology.org website). On the same page is the workshop handout, as well as the audiorecordings of the presentations.

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Psychosis from a psychological perspective

I recently sat in on a presentation about psychological interventions for serious mental illness at an international conference, where the audience was mostly made up of US health professionals working in psychiatric settings.

What was interesting (or to be more accurate, disconcerting) for me were the number of comments from the audience expressing surprise that the problems of a “brain disorder” like schizophrenia could be amenable to psychological therapy. It seemed surprising for some of the audience that engaging a person in discussing the meaning and impact of their psychotic experiences (such as hearing voices or persecutory beliefs) could be of benefit.

Now this wouldn’t have been surprising 15 years ago, but things have certainly moved on, at least in Australia and the United Kingdom (my two frames of reference). It made me think about how your view of the world is structured by assumptions, and how much influence the unhelpful assumptions of an illness model of schizophrenia may have on the care that people receive from mental health services. The worst aspects of the “schizophrenia as brain disorder” explanation lead to invalidating people because they have unusual experiences, encouraging a passive approach to living, and not considering the influence of social and psychological influences upon peoples lives.

Sadly, it appears that the work of British psychologists in developing psychosocial models of psychosis and more effective talking therapies has not yet permeated the healthcare culture in some parts of the US. What gives hope is that despite the diligent work of drug companies it appears that the general public at least remain less convinced by causal biological models of schizophrenia, preferring psychosocial accounts.

There certainly was interest from the audience in understanding psychosis from a psychological perspective, and the presenter spent most of the time discussing normalisation and the dimensional view of symptoms. This was of value, but also a shame, as these things are really the basic assumptions of a cognitive behavioural approach to psychosis and there was not much time to then discuss more detailed therapeutic methods. This information is also more broader than one particular therapeutic model and should be considered part of a working clinician’s understanding of psychosis.

Where can someone start if they want to understand a contemporary psychological view of psychosis? Below are several sources that are worth checking out:

Richard Bentall’s book, “Madness Explained”, is an excellent and comprehensive discussion of the limitations of the diagnostic approach and reductionism in understanding psychosis, and value of psychological models and research to address some of the problems with a strict biological account. There is a summary presentation of the arguments in the book available on the MIND website.

Several years ago the British Psychological Society’s Division of Clinical Psychology produced a useful summary of psychological research, “Recent advances in understanding mental illness and psychotic experiences”, hosted here.

The Schizophrenia Guidelines website, designed to help UK health services implement the NICE Guidance for Schizophrenia, is a good resource for seeing how these psychological perspectives can influence care.

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Acceptance and Commitment Therapy in Early Psychosis

Recently, with my colleague Joe Oliver, we presented our work (at the ACT Summer Institute IV) on developing acceptance and commitment therapy to help young people recovering from a first episode of psychosis. We titled our presentation “ACT Early”, and described the work we have been doing in developing groups and individual therapy for this population.

Conference Abstract:

The stance of acceptance and committed action may allow for flexibility in response to persisting psychotic experiences, as has been suggested in ACT studies with the seriously mentally ill (Bach & Hayes, 2002; Gaudiano & Herbert, 2006). There is also the exciting potential for researching the impact of ACT in the early phase of psychosis – helping first episode clients to recover from psychosis through the development of a more mindful approach toward unusual experiences and critical appraisals, and committing to values-based actions.

More specifically, the use of ACT may:

[1] foster the development of a psychologically flexible stance toward anomalous experiences,

[2] enable a “values-based” recovery,

[3] reduce the impact of “fear of recurrence” of psychosis through development of mindfulness and self as context,

[4] enable individuals to notice the process of self-stigmatisation, contexts where this operates as a barrier, and commit to valued directions in the face of these appraisals, and

[5] improve relapse prevention plans through the use of mindfulness and committed action.

We describe a group program we have developed, as well as individual work with young people who have experienced a first episode of psychosis. In addition there is discussion about a pilot ACT/mindfulness group for people experiencing at risk mental states, who may be in a prodromal phase of psychosis.

The .pdf of this workshop is here: act-early-morris-oliver-2008 and the audio recording of our presentation is here (.mp3 format, 30MB download)

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Contextual Cognitive-Behavioural Therapies

I have a terrible confession to make about my background as a clinical psychologist: I trained as a behaviourist.

Why is this “terrible”? Well, because I now work in the UK, where it seems that behaviourally-oriented clinical psychologists are scarce (at least in my field), and I am a member of the British Association for Behavioural and Cognitive Psychotherapies, where the dominant paradigm is cognitive.

The dominance of the cognitive paradigm to CBT is so complete in the UK that it appears trainee clinical psychologists and CBT therapists are taught very little about basic behavioural principles, functional analysis, or therapeutic approaches that have developed from the behavioural wing of CBT. Behavioural criticisms of a cognitive approach are seen as out-dated, equated with stimulus-response psychology, or just plain weird. BF Skinner is treated with as much disdain as Freud. Behavioural methods are regarded as part of a CBT package, but it is widely believed that the “really effective” components are cognitive (thought challenging etc.). Proponents of modern behavioural approaches presenting their work in the UK are liable to experience harsh (and most times, ill-informed) criticism from the custodians of the CBT approach.

Professor David Richards writes in the March 2007 BABCP magazine about the apparent arrogant and inflexible attitude displayed by CBT therapists toward other therapies (in response to Henck Van Bilsen’s article in the previous edition encouraging CBT therapists to celebrate the field’s successes, particularly the evidence base). This attitude unfortunately also extends to the behavioural approach:

“Nor is this attitude confined to an arrogant dismissal of other supposedly ‘non evidence-based psychotherapies’. Despite Henck claiming that CBT is a ‘large house with many rooms’ the voice of the cognitive lobby within CBT has drowned out most other approaches. At a meeting recently [of the BABCP] I was astonished to hear a very senior person in our fraternity unable to comprehend that a member of the CBT family of treatments could be conceptualised outside of a cognitive paradigm, could even regard cognitions as inconsequential private events. All this despite the treatment in question – a contextual, socialbehavioural one – being the subject of nearly 20 randomised controlled trials demonstrating at least equivalent effectiveness to cognitive therapy. Henck makes the same mistake by asserting that ‘A core element of all cognitive behavioural interventions is that they work towards change by influencing thinking.’ Not so Henck.”

Well, for the sake of balance my little blog is going to list some of the modern behavioural approaches to CBT, in the vain hope that UK CBT therapists will chance upon it and follow some of the links. It seems a shame to me that UK CBT therapists are not at least made aware of the work that is being done by behaviour analysts that speaks directly to the reasonable theorectical and technique-based concerns about cognitive therapy (see here for a blog discussion of a recent meta-analysis regarding the empirical status of thought challenging; Longmore & Worrell, 2007).

The modern behavioural approach to CBT is contextual, and this philosophical stance informs how cognitions (private events) are viewed. Cognition is not assumed to be causal for overt behaviour, instead cognition is regarded as a form of behaviour itself, and the interest for contextualists is in the historical and current environmental variables that may influence the occurrence, incidence, prevalence, or probability of behaviour, both overt and private. Contextualists take a pragmatic approach, being interested in what predicts and influences behaviour. Models of psychological problems that have predictive power but do not identify how to influence or change problems are of limited use pragmatically. A contextualist will focus on identifying potentially manipulable environmental variables in the functional analysis of a client’s problems; the behaviour of the therapist is considered a “manipulable environmental variable” and the social context of therapy as an influential environment to produce change, hence the focus in these therapies on creating powerful therapeutic relationships.

Enough philosophy and theory. Below is a list of these contextual CBT approaches, with links to discover more about them:

Acceptance and Commitment Therapy – incorporating mindfulness, acceptance and behaviour change methods to enable clients to live valued lives, ACT is based upon a behavioural account of cognition (Relational Frame Theory) and has a developing evidence base of both randomised controlled trials, mediational studies, that links to basic science about language. (check out the link here)

Dialectical Behavior Therapy– originally developed for the treatment of women with emotional vulnerability who coped with self-injury or suicidal behaviour, DBT incorporates acceptance and change methods, including mindfulness and CBT emotional regulation skills. DBT also involves an explicit program for the psychological care of therapists who work with challenging clients. (check out the link here)

Functional Analytic Psychotherapy – based upon a behaviour analytic approach to the therapeutic relationship, FAP focuses on how therapists can create powerful, influential therapeutic contexts through functional analysis of in-session behaviour. (link here)

Behavioral Activation Therapy– demonstrating equal or superior effectiveness to cognitive therapy in the treatment of depression, the contextual approach of BA does call into question the assumption that cognitive methods are the essential component in CBT for depression. (see a description here)

Happy Reading!

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The “do as I do, not as I say” approach to therapy supervision

The other week I participated in a training workshop for supervision in cognitive behavioural therapy, which was well-attended by the psychologists in my Trust. It was a useful workshop – with some theory in the morning, going through the (albeit limited) evidence for CBT supervision, and then the afternoon spent doing roleplays of supervision issues (such as scenarios where the supervisee departs from the cognitive model unnecessarily, or feels hopeless about progress in therapy, or dislikes their client).

The workshop got me thinking about a paper I had read soon after qualifying in the mid 90′s, that described a behaviour analysis account to therapy supervision. The main argument of the paper written by William Follette & Greg Callaghan (see reference below and available here) was that it is difficult to train therapists to do therapy well if you only rely on direct instruction (verbal descriptions of how to behave, in written form or face to face supervision). This type of supervision has the potential to produce rigid therapist behaviour, where the trainee carefully follows the supervisor’s instructions regardless of the client’s presentation or description of new problems. Follette and Callaghan describe that this in-session therapist behaviour, that is not necessarily sensitive to changes in the therapeutic relationship, is not necessarily the fault of the trainee but perhaps an unintended consequence of the training method.The supervision setting can inadvertantly strengthen this process if the focus is based solely upon retrospective descriptions of the content of the therapy sessions.

Follette and Callaghan describe this as the unfortunate effect of rule-governed behaviour, where the trainee is reinforced for following the verbal instructions of the supervisor, rather than reinforced for effectively “tracking” contingencies in the therapy relationship. Rule governed behaviour is useful when you want behaviour to be fairly immune to situational contingencies; however, in the case of therapy you want to develop trainees who effectively attend to changes in the client’s in-session behaviour. Follette and Callaghan describe the mathematical and practical limitations of providing “rules” to trainees, as effective therapy cannot be reduced to simple formulae to be slavishly followed.

The authors describe an alternative/associated training technology: using direct feedback to the trainee within the therapy session by the supervisor, giving moment-by-moment feedback through the use of a computer monitor in the room. The monitor shows graphically the supervisor’s rating of the quality of the therapy provided by the trainee.The aim of this method is to direct the trainee to be sensitive to the emerging contigencies in the therapeutic context, as inflexible application of techniques and focus will result in low ratings by the supervisor. This is contingency-shaped behaviour, where the trainee is reinforced for effective tracking in the therapy session. The article is interesting in discussing the advantages of this method, although I did think about the anxiety of the trainee in the process of moment-by-moment therapy ratings!

This approach makes sense if you think about the complex social behaviour that is required when doing psychological therapy. Beginning (and experienced!) therapists can become focused on “doing CBT right”, which can result in paying less attention to the client’s behaviour within the session. There may be many opportunities to strengthen the influence of the therapeutic relationship that are missed when therapists become overly focused on technique. Creating the context for change would seem as important as the methods used to make the change.

This may seem to be at odds with the view of CBT as technique-focused enterprise, with the traditional criticism that in CBT there is less interest in the dynamics of the therapeutic relationship. In contrast, I think it is reasonable to say that a CBT approach considers the therapeutic relationship to be a necessary but not sufficient condition for change to occur. Effective CBT involves therapists who are attentive to the “moment” AND use evidence-based methods to assist the client to change.

Reference

Follette, W. C., & Callaghan, G. M. (1995). Do as I do, not as I say: A behavior- analytic approach to supervision. Professional Psychology Research and Practice, 26, 413–421.

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The psychology of paranoia

Recent reports on the study of paranoid thinking have supported the view that suspiciousness and anxiety of harm from others are common experiences, with possibly up to a third of the population being regularly bothered by suspicious or paranoid thoughts.

Daniel Freeman, Jason Freeman, and Philippa Garety have written a self-help guide to “Overcoming Paranoid and Suspicious Thoughts”, published by Robinson (2006) . Considering how common these concerns are in the general population a self-help guide that addresses paranoia and suspiciousness per se, rather than talk about it just in the context of psychosis, seems a good idea.

It is a good read, describing a cognitive behavioural approach to understanding paranoid thinking and various ways of testing out suspicions to reduce their impact upon decision making and distress. Well-written for the general reader, the book also is useful for clinicians who want to discuss these concerns with clients, as it provides an example of describing paranoia and suspicion that is non-stigmatising and empathic in tone. Moreover the book’s contents represent the latest thinking in a cognitive behavioural approach to these concerns, with a number of exercises that can be used within therapy.

In the book the authors have detailed ways of coping with paranoid thoughts, which can be described in CBT terms as:

  • developing insight into the causes of suspicious thoughts (e.g., stress and major life changes, emotions, external and internal triggers, explanations for triggers, and reasoning);
  • becoming a detached observer of your fears;
  • practicing deliberately considering alternative explanations for suspicions and testing them out using behavioural experiments;
  • learning how to let go of suspicious thoughts when they come, and focus on what you are doing, not what you are thinking;
  • learning how to spend less time worrying about paranoid thoughts
  • deliberately thinking about positive aspects of your self

There is also a website, based upon the book, that is worth checking out.

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