There are a number of reasons why a pharmacological treatment for psychosis may be ill-suited or inadequate. In the face of persistent, sometimes debilitating symptoms, clinical researchers like Joe have turned to ACT.
The following is an interview with Joe Oliver, consultant clinical psychologist and joint director of the University College London Cognitive Behavioural Therapy in Psychosis Post Graduate Diploma. Joe is an experienced acceptance and commitment therapy (ACT) therapist and researcher, a peer-reviewed ACT trainer, and director of the ACT-based consultancy Contextual Consulting. He is co-editor of the textbook Acceptance and Commitment Therapy and Mindfulness for Psychosis, co-author of the self-help book, ACTivate Your Life, and co-author of the forthcoming ACT for Psychosis Recovery.
Joe is presenting a webinar, ACT with Psychosis on January 10, 2017.
ACT with Psychosis: Q & A with Joe Oliver
Praxis: Why is ACT so promising for people with psychosis?
JO: The experience of distressing psychosis has a number of qualities that make an ACT approach very useful. Symptoms are often personally salient, meaningful, scary, and can lead a person to be very drawn into the experience or engage in high levels of experiential avoidance. These responses can come at a significant life cost.
ACT helps to build in more compassionate and accepting responses that make new values-based action possible—despite ongoing symptoms. The bold invitation is to bring these experiences along for the ride and guide the person as they explore alternatives to fear and avoidance.
ACT also works effectively with the emotional correlates that often go along with psychosis (i.e. feeling anxious, low, hopeless, purposeless), by strengthening a flexible self that is not dominated by a conceptualized past or future self. In my experience, this is often the most important piece of work in ACT for psychosis.
The Challenge of Values
Praxis: Where do values fit into ACT with people who hear voices or experience delusions?
JO: Values work is crucial, as it is with any ACT intervention.
In my experience, however, values work can be very painful for people who have led lives dominated by psychosis and it can come with feelings of grief and loss. It may be the case that the client has never been asked what’s important to them or really had the space to think it through. So it’s useful to have other skills in place first.
Normally, I would leave values work until later in the therapy process. Having said that, I usually encourage the client to put a broad value on the table, such as well-being or the freedom to choose in life. What we work on together can then be evaluated on the basis of this value.
Inner Voices
Praxis: Tell us about the way inner voices are viewed from an ACT perspective.
JO: The experience of hearing voices is very diverse and differs immensely from person to person. Some people find deep and rich meaning in their voice experience. Others find their voices incredibly dominating or terrifying.
The ACT approach emphasizes a respectful curiosity to the experience, and the therapist helps the person build their own chosen meaning. Research evidence suggests that individuals who develop a healthy relationship with their voices (i.e. a relationship that is not only characterized by struggle or immersion) can increase their psychological well-being.
Many individuals who hear distressing voices have experienced traumatic events in their early development and there are indications that dissociative processes may be important. Recent applications of relational frame theory (RFT) highlight the importance of the ACT concept of self-as-context: incorporating both a flexible individual self and one in relation to others.
Praxis: Are mindfulness practices taught differently to clients with psychosis?
JO: Yeah, so there are significant differences that are necessary to ensure the experience is supportive.
Key differences involve more scaffolding for the experience: keeping practices short without long gaps, using more frequent instructions and being creative in teaching the skills as opposed to relying solely on meditative exercises. Evidence to date suggests that with these modifications, mindfulness is helpful to people experiencing psychosis. And as always, any mindfulness work should be in a clear plan developed with the client.
Delusions
Praxis: How does the ACT approach to delusions differ from other approaches?
JO: Work on delusions, or any strongly held belief, is where psychological theories have the most work to do. However, from an ACT perspective, gentle mindfulness, acceptance, defusion work, and compassion all function to reduce the negative processes that amplify the distress associated with delusions.
Undoubtedly, deictic (contextual) processes are important here. This is how the individual relates to their ‘self story’ and others when the contingencies of their interpersonal relating (such as past developmental experiences) operate outside of their awareness. The intervention, from an ACT perspective, focuses on exploring and developing the kind flexible self that can take steps toward their valued action.
The Importance of Compassion
Praxis: Though it is not officially a part of the ACT hexaflex, ACT work encourages self-compassion. Why is this important for people with psychosis?
JO: Good point. It’s not “officially” in there, but it’s so crucial.
First, on the part of the therapist, compassion is needed to really see the client’s pain and not to run from it. I’m often shocked by the level of pain and distress that people with psychosis carry quietly with them. I find that I need to be prepared to witness this from a place that embodies genuine compassion.
And then, of course, self-compassion is also needed on the part of the client, to bring kindness to even the most difficult parts of experience and to recognize their shared humanity. It’s not easy to do when voices are hurling your worst fears at you, or when everyone can see into you and know your dirtiest secrets, or when life feels devoid of meaning. Gradually sowing the seeds of self-compassion is such an important part of the work.
The Evidence Base
Praxis: Is ACT with psychosis supported by evidence?
JO: Our own research group published an open trial—The ACT for Life Trial—looking at group intervention with very encouraging results. We have also completed an RCT—The ACT for Recovery Trial—that developed an intervention for both people with psychosis and caregivers of people with psychosis.
We have six randomized controlled trials (RCTs) out now that are also expected to show that ACT is an effective treatment for psychosis.
We have a long way to go, both in the ACT research world and the CBT for psychosis world. In the future, we will see more specific targeted trials for particular issues and also a focus on the emotional issues underlying psychosis. RFT points to more precise interventions that work to develop deictic flexibility—a flexible sense of self.
Alternatives
Praxis: What are some of the ways that the ACT approach to psychosis differs from other talk therapy approaches?
JO: The other main evidenced-based approach for working with voices is cognitive behavioral therapy (CBT) for psychosis, and in a lot of respects, there are many similarities. In fact, both approaches come from the same traditions.
The main differences, however, are an explicit emphasis in ACT on reducing unhelpful struggle (i.e. accepting—not giving up or resigning to—the experience) and using mindfulness to facilitate a nonjudgmental stance toward experiences.
Finally, ACT’s central focus on values asks people what they want to stand for in the face of what is often a very distressing or overwhelming experience.
Praxis: In addition to your upcoming webinar, can you recommend other resources for ACT clinicians working with clients with psychosis?
JO: You can check out our book, Acceptance and Commitment Therapy and Mindfulness for Psychosis, and also our group intervention for psychosis manual, ACT for Life, which is free to download on the ACBS website.
Finally, the ACT for Psychosis Recovery is due out with New Harbinger in 2017 and will be packed full of super practical tips about running groups, working individually, and setting up ACT-friendly cultures in mental health teams.
For more about ACT with psychosis, and to ask Joe your questions, tune into his upcoming webinar on January 10, 2017.
For upcoming ACT webinars, see The Spring 2017 webinar line-up.
Season passes for the 2017 webinar series and are on sale for a limited time. 2017 webinars will soon be available for individual sale.