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Eric M. J. Morris is a chartered consultant clinical psychologist and the psychology lead for early intervention for psychosis at the South London and Maudsley NHS Foundation Trust, UK. Eric has been practising Acceptance and Commitment Therapy (ACT) for more than ten years, and researches mindfulness and acceptance interventions for psychosis at the Institute of Psychiatry, King’s College London. Eric is a highly experienced trainer and supervisor in contextual cognitive behavioural therapies.
Louise C. Johns is a chartered consultant clinical psychologist and coordinator of a specialist clinical service at the Maudsley Hospital, London, UK, offering psychological interventions for outpatients with psychosis. She is also an honorary lecturer at the Institute of Psychiatry, King’s College London. Since qualifying as a clinical psychologist in 1998, she has worked in a clinical and research capacity in the field of psychosis. She has published over 50 articles on psychosis, covering development and psychopathology of symptoms, and cognitive behavioural treatments. She has led on the first UK funded studies to evaluate ACT for psychosis in group settings.
Joseph E. Oliver is a clinical psychologist currently working in an early intervention programme for psychosis in South London, UK. He is also co-director of Contextual Consulting, an ACT based consultancy, offering contextual-CBT training, supervision and therapy. In addition to teaching and research supervision at King’s College London’s Institute of Psychiatry, he has active research interests in the use of ACT for psychosis, in group contexts and in its potential to enhance workplace well-being.
List of Contributors xvi
Acknowledgements xix
Foreword: Acceptance, Mindfulness and Psychotic Disorders: Creating a New Place to Begin xx
1 Introduction to Mindfulness and Acceptance-based Therapies for Psychosis 1
Joseph E. Oliver, Candice Joseph, Majella Byrne, Louise C. Johns and Eric M. J. Morris
1.1 Introduction to Psychosis 1
1.2 Interventions 2
1.2.1 Cognitive Behavioural Therapy 2
1.2.2 Developments in CBT: Contextual Approaches 3
1.2.3 Acceptance and Commitment Therapy 4
1.2.3.1 Open 5
1.2.3.2 Aware 6
1.2.3.3 Active 6
1.2.4 Mindfulness and Person-based Cognitive Therapy for Psychosis 7
1.3 Conclusion 8
2 Theory on Voices 12
Fran Shawyer, Neil Thomas, Eric M. J. Morris and John Farhall
2.1 Phenomenology 12
2.2 Mechanisms and Origins of Hearing Voices 13
2.3 Meaning Given to Voice Experience 14
2.4 Responses to Voices 15
2.4.1 Resistance 16
2.4.2 Engagement 17
2.5 Implications for the Role of Acceptance and Mindfulness in Voices 18
3 Emotional Processing and Metacognitive Awareness for Persecutory Delusions 33
Claire Hepworth, Helen Startup and Daniel Freeman
3.1 Introduction 33
3.2 Persecutory Delusions 33
3.3 Improving Treatments for Persecutory Delusions 34
3.4 Development of the Intervention 35
3.5 The EPMA Intervention 38
3.6 The EPMA Pilot Study 40
3.7 Case Study 41
3.8 Conclusion 42
4 Clinical Assessment and Assessment Measures 47
John Farhall, Fran Shawyer, Neil Thomas and Eric M. J. Morris
4.1 Introduction 47
4.2 Clinical Assessment 47
4.2.1 Overview 47
4.2.1.1 Aims and Scope 47
4.2.1.2 General Principles 48
4.2.2 Structure and Methods of Assessment 49
4.2.2.1 Assessment Interwoven with Interventions 49
4.2.2.2 Use of Assessment Instruments 49
4.2.2.3 Role of Self-monitoring in Assessment 49
4.2.2.4 Goal Setting 50
4.2.3 A Guide to Clinical Assessment 51
4.2.3.1 The Problems Experienced by the Client 51
4.2.3.2 Understanding the Client 52
4.2.4 Assessing and Addressing Potential Barriers to and Risks Arising from Therapy 52
4.3 Assessment Measures 54
4.3.1 Issues in the Use of Self-report Measures 55
4.3.2 Mindfulness Measures 55
4.3.3 Measures of ACT Processes and Constructs 57
4.3.3.1 Acceptance and Action Questionnaire 57
4.3.3.2 The Voices Acceptance & Action Scale 58
4.3.3.3 Believability of Symptoms 58
4.3.3.4 Additional Measures 59
4.4 Conclusion 60
5 Acceptance and Commitment Therapy Case Formulation 64
Patty Bach
5.1 Introduction 64
5.2 Case Study 64
5.2.1 Avoidance 66
5.2.2 Cognitive Fusion 67
5.2.3 Attachment to Content 67
5.2.4 Weak Self-knowledge, Dominating Concept of the Past or Feared Future 68
5.2.5 Lack of Values Clarity 68
5.2.6 Persistent Inaction, Impulsivity or Avoidance 69
5.3 Case Formulation using the Inflexahex Model 70
5.4 Conclusion 73
6 Engaging People with Psychosis in Acceptance and Commitment Therapy and Mindfulness 76
Brandon A. Gaudiano and Andrew M. Busch
6.1 Introduction 76
6.1.1 Treatment Adherence and Engagement in Psychosis 76
6.2 Acceptance and Commitment Therapy 77
6.3 Functional Analytic Psychotherapy 78
6.4 Acceptance-based Methods and Techniques for Improving Engagement 79
6.4.1 Workability 81
6.4.2 Values Clarification 81
6.4.3 Acceptance and Mindfulness 82
6.4.4 Committed Action 83
6.4.5 The Therapeutic Relationship 84
6.5 Special Contexts and Issues 85
6.5.1 ACT Made Even Simpler 85
6.5.2 Involuntary Admission and Lack of Insight 86
6.5.3 Other Cognitive Behavioural Approaches for Psychosis 86
6.5.3.1 Traditional CBT 86
6.5.3.2 Motivational Interviewing 87
6.6 Case Study 88
6.6.1 Early Sessions (1–5) 88
6.6.2 Mid-treatment Sessions (6–15) 89
6.6.3 Late-treatment Sessions (16–20) 89
6.7 Conclusion 90
7 Acceptance and Commitment Therapy for Voices 95
Neil Thomas, Eric M. J. Morris, Fran Shawyer and John Farhall
7.1 Introduction 95
7.2 Formulating how Voices are a Problem 95
7.3 Overall Considerations in Conducting ACT with Voices 96
7.3.1 Sequence of Therapy 98
7.3.2 Acceptance: Letting Go of Struggle with Voices 98
7.3.2.1 Discussing Responses to Voices 98
7.3.2.2 Letting Go of Struggle 99
7.3.3 Defusion 100
7.3.4 Mindfulness: Present Moment and Self as Observer 101
7.3.5 Willingness: Values and Committed Action 103
7.4 Case Study 104
7.4.1 Current Mental-health Problems 104
7.4.2 Mental-health History 105
7.4.3 Relevant Background 105
7.4.4 Assessment and Formulation 105
7.4.5 ACT Case Formulation 106
7.4.6 The ACT Approach 106
7.4.6.1 Initial Phase (Sessions 1–3) 107
7.4.6.2 Mid-therapy (Sessions 4 − 7) 107
7.4.6.3 End Sessions (Sessions 8 − 10) 108
7.4.7 Outcomes 108
7.4.7.1 Psychotic Symptoms 108
7.4.7.2 Depression and Anxiety 109
7.4.7.3 Valued Action, Quality of Life and Social Functioning 109
7.4.7.4 Changes in Mindfulness towards Voices and Thoughts 109
7.4.8 Discussion 110
8 Acceptance and Commitment Therapy for Delusions 112
José Manuel García Montes, Marino Pérez Álvarez and Salvador Perona Garcelán
8.1 Introduction 112
8.2 Delusions as Ways of Making Contact with Experience 112
8.2.1 Delusions as Active Forms of Experiential Avoidance 113
8.3 Intervention with ACT 115
8.3.1 Create a State of Creative Hopelessness 115
8.3.2 Clarify and Strengthen the Patient’s Values 117
8.3.3 Suggest the Possibility that the Problem is Control 120
8.3.4 Create a Distance from Language 122
8.3.5 Help Create a Transcendental Sense of Self 123
8.3.6 Developing Willingness 124
8.4 Conclusion 125
9 Acceptance and Commitment Therapy for Emotional Dysfunction following Psychosis 129
Ross White
9.1 Introduction 129
9.2 Understanding Emotional Dysfunction following Psychosis 129
9.3 Emotional Dysfunction and Experiential Avoidance 130
9.4 An ACT Conceptualisation of Emotional Dysfunction following Psychosis 131
9.5 Treating Emotional Dysfunction following Psychosis 132
9.5.1 Socialising the Individual to the ACT Model 133
9.5.2 Assessment and Formulation 133
9.5.2.1 Suffering List 135
9.5.2.2 Attempts to Solve Suffering 136
9.5.2.3 Valued Life Direction 136
9.5.2.4 Valued Action 138
9.5.3 Beyond Formulation: Progressing with the ACT Intervention 138
9.5.3.1 Showing Up to Distress 139
9.5.3.2 Defusion 139
9.5.3.3 Mindful Acceptance 140
9.5.3.4 Worries about Psychosis Recurring 141
9.5.4 Moving Beyond the ACT Intervention 141
9.6 Conclusion 142
10 Person-based Cognitive Therapy for Distressing Psychosis 146
Lyn Ellett
10.1 Introduction 146
10.2 Zone of Proximal Development 146
10.2.1 Overview of the Zones of Proximal Development 147
10.2.1.1 Symptomatic Meaning 147
10.2.1.2 Relationship with Internal Experience 148
10.2.1.3 Schemata 148
10.2.1.4 Symbolic Self 149
10.2.1.5 Radical Collaboration (RC) 149
10.2.1.6 Acceptance 149
10.2.1.7 Metacognitive Insights 150
10.3 Case Formulation in PBCT 150
10.3.1 Symptomatic Meaning: ABC Formulation 150
10.3.2 Relationship with Internal Experience: Mindfulness-based Formulation of Distress 151
10.3.3 Negative and Positive Self-schema 152
10.4 Experiential Methods of Change 153
10.4.1 Symptomatic Meaning 153
10.4.1.1 Goodness of Fit (‘Evidence’) and Generating Alternative Symptomatic Meaning 153
10.4.1.2 Behavioural Experiments 156
10.4.1.3 Accepting Fixity 156
10.4.2 Relationship with Internal Experience 156
10.4.2.1 Rationale and Preparation for Mindfulness Practice 156
10.4.2.2 Overview of Mindfulness Meditation 156
10.4.2.3 Specific Adaptations of Mindfulness Practice 157
10.4.3 Working with Schemata 157
10.4.3.1 Two-chair Method 157
10.4.4 Symbolic Self 158
10.5 Conclusion 159
11 Spirituality: A New Way into Understanding Psychosis 160
Isabel Clarke
11.1 Introduction 160
11.2 Repositioning Psychosis and Spirituality: Recognition of the Two Ways of Knowing 161
11.3 Research Basis 162
11.4 Spirituality and Mental Health 162
11.5 Clinical Approach: The Therapeutic Alliance 164
11.5.1 The What is Real and What is Not Approach 164
11.5.2 Schizotypy and ‘Unshared Reality’ 165
11.5.3 From Conceptualisation to Coping Strategies 166
11.5.4 Role of Mindfulness 167
11.6 Psychosis as a Spiritual Crisis 168
12 The Service User Experience of Acceptance and Commitment Therapy and Person-based Cognitive Therapy 172
Joseph E. Oliver, Mark Hayward, Helena B. McGuiness and Clara Strauss
12.1 Introduction 172
12.2 An Overview of Service User Involvement 172
12.3 The Importance of a Service User Perspective in Informing ACT and PBCT for Psychosis 174
12.4 A Service User Perspective on the Experience of ACT for Psychosis 175
12.4.1 Background 176
12.4.2 The Therapy 178
12.4.3 How the Therapy Helped 178
12.4.4 Conclusion 179
12.4.4.1 How I Felt before ACT Therapy 179
12.4.4.2 How I Feel after ACT Therapy 180
12.5 Summary of Qualitative Findings from PBCT Groups on Participant Experiences of Mindfulness Practice and What was Learned from these Studies 180
12.5.1 Acceptance of Voices 181
12.5.2 Development of Sense of Self beyond Voices 182
12.5.2.1 Relating to Voices 184
12.5.2.2 Relating to Self 185
12.5.2.3 Relating to Others 186
12.5.3 The Value and Challenges of Seeking Service User Views 188
12.6 Conclusion 188
13 Acceptance and Commitment Therapy for First-episode Psychosis 190
Joseph E. Oliver and Eric M. J. Morris
13.1 Introduction 190
13.2 Recovery from a First Episode of Psychosis 191
13.2.1 At-risk Mental States 192
13.3 Using ACT to Enhance Recovery from a First Episode of Psychosis 192
13.3.1 Assessment and Formulation 192
13.3.2 Being Aware and Present 194
13.3.3 Opening Up 195
13.3.4 Being Active 197
13.4 ACT in Different Modalities 198
13.4.1 Group Work 198
13.4.2 Working with Families and Carers 199
13.5 Case Study 200
13.6 Conclusion 203
14 Acceptance and Commitment Therapy for Psychosis in Acute Psychiatric Admission Settings 206
Gordon Mitchell and Amy McArthur
14.1 Introduction 206
14.2 Acute Psychosis and ACT Interventions 206
14.3 ACT in the Acute Psychiatric Admission Ward 209
14.4 Case Study 209
14.5 Convergence of Mindfulness/Metacognitive-based Cognitive Therapy Approaches 214
14.6 Reflections on Developing Systemic Applications of ACT 215
14.7 Conclusion 216
15 Developing Acceptance and Commitment Therapy for Psychosis as a Group-based Intervention 219
Amy McArthur, Gordon Mitchell and Louise C. Johns
15.1 Introduction 219
15.2 A Six-session ACT-for-Psychosis Group Protocol 221
15.2.1 Session 1: Introducing the ACT Approach and Exploring the Workability of Current Strategies for Managing Distress 222
15.2.1.1 The Matrix 222
15.2.1.2 Between-session Task 223
15.2.2 Session 2: Exploring the Impact of the Struggle for Control and Introducing Willingness as an Alternative 223
15.2.2.1 Between-session Task 225
15.2.3 Session 3: Identifying Personal Valued Directions 225
15.2.3.1 The Ripple Exercise 225
15.2.3.2 Between-session Task 227
15.2.4 Session 4: Moving in Valued Directions 227
15.2.4.1 The Passengers-on-the-Bus Exercise 228
15.2.4.2 Between-session Task 229
15.2.5 Session 5: Continuing to Develop Self-as-Context and Willingness to Move towards Values 229
15.2.5.1 Between-session Task 230
15.2.6 Session 6: Summarising the Themes of the Course and Reviewing Experiences of the Work 230
15.2.7 Optional Follow-up Session 230
15.3 Case Study 231
15.4 Reflections on the Experience of Developing and Delivering the Groups 233
15.5 Other Protocols 234
15.5.1 ACT for Life Group 235
15.6 Conclusion 237
16 Group Person-based Cognitive Therapy for Distressing Psychosis 240
Clara Strauss and Mark Hayward
16.1 Introduction 240
16.2 Person-based Cognitive Therapy 240
16.2.1 Group PBCT 242
16.3 The Importance of the Group Process in PBCT 242
16.4 Facilitating a PBCT Group 243
16.4.1 Inclusion Criteria 243
16.4.2 The 12-week Programme 243
16.4.3 Mindfulness Practice in PBCT 244
16.4.4 Cognitive Therapy in PBCT 247
16.4.4.1 Session 2 247
16.4.4.2 Session 3 247
16.4.4.3 Session 4 248
16.4.4.4 Session 5 249
16.4.4.5 Session 6 249
16.4.4.6 Session 7 249
16.4.4.7 Session 8 250
16.4.4.8 Session 9 251
16.4.4.9 Session 10 251
16.4.4.10 Session 11 251
16.4.4.11 Session 12 252
16.5 PBCT: An Integrated Model 252
16.6 Group PBCT: The Evidence 253
16.7 Conclusion 254
Appendix A Chessboard Metaphor 256
Appendix B Leaves-on-the-Stream Metaphor 257
Appendix C Passengers-on-the-Bus Metaphor 259
Appendix D Person-in-the-Hole Metaphor 261
Appendix E Polygraph Metaphor 262
Appendix F See the Wood for the Trees (And Other Helpful Advice for Living Life) 263
Appendix G Skiing Metaphor 270
Appendix H Tug-of-War-with-the-Monster Metaphor 271
Index 272
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