psychosis

Objective

Acceptance and Commitment Therapy for Inpatients (ACT-IN) with psychosis has been found to be efficacious in previous trials, but its effectiveness has not been studied when implemented by frontline clinicians in routine settings.

Method

In this pilot randomized controlled effectiveness trial, inpatients with schizophrenia-spectrum disorders were randomized to ACT-IN plus treatment as usual (TAU) (n = 23) or a time/attention matched (TAM) supportive condition plus TAU (n = 23) delivered by routine hospital staff. Both conditions received individual and group therapy during inpatient care and completed follow-up phone sessions during the first month post-discharge. Patients were assessed through 4 months post-discharge (blinded to condition) to determine feasibility, acceptability, and preliminary effectiveness of ACT-IN.

Results

ACT-IN was feasible to deliver with fidelity by frontline staff when integrated into an acute care setting. At post-treatment, patients reported significantly greater treatment satisfaction in ACT-IN relative to TAM. Overall, results showed significant but similar improvements for both conditions through 4-month follow-up in psychiatric symptoms, functioning, and mindfulness. Only ACT-IN improved over time in distress. Furthermore, patients receiving TAM had a 3.76 times greater risk of rehospitalization over 4 months compared with ACT-IN.

Conclusions

ACT-IN is feasible and acceptable for patients with psychosis, can be implemented by hospital staff when integrated into acute treatment, and may result in decreased rehospitalization compared to alternative therapies. A future full-scale randomized-controlled implementation trial is warranted.

Introduction
The psychological inflexibility model proposes several transdiagnostic processes maintaining psychological distress and is one of the models forming the basis of Acceptance and Commitment Therapy (ACT). ACT has been used as an intervention for psychosis but prior to the present review and meta-analysis (PROSPERO ID: CRD42022369048) the relationship between psychological inflexibility and other ACT processes in the context of psychosis or psychosis-like symptoms has not been investigated.

Method
A Literature search of PsychINFO, Medline, PsychArticles, Web of Science and Embase was conducted, and methodological quality assessed. 655 titles were screened and were included if they explored the relationship between psychological inflexibility (experiential avoidance, cognitive fusion, values clarity, committed action) and psychosis or psychosis-like symptoms in the general population.

Results
A total of 35 studies were included in this review. Most studies were cross sectional and rated moderate in their methodological quality. Meta-analyses revealed a large effect of psychological inflexibility on paranoia, medium effect on delusions, small effect on auditory hallucinations. A medium effect of cognitive fusion on paranoia was found and medium effect size when comparing group differences (psychosis vs controls) in psychological flexibility. Additional findings (mostly mediation and moderation effects) not included in the meta-analyses are reported.

Discussion
The overall evidence suggests that there is a significant relationship between psychological flexibility and psychotic symptoms, particularly paranoia. This provides evidence supporting the use of interventions which target these processes in the context of psychosis. Limitations and future directions are discussed.

To find the full text version of this article and other JCBS articles (as well as download a full text pdf.), ACBS members need to login and then access the JCBS ScienceDirect homepage here. Click here if you'd like to learn more about joining ACBS.

Mindfulness skills are a component of many modern cognitive-behavioral therapies that are used to treat a wide range of disorders, including psychotic disorders. While habitual (i.e., trait) mindfulness is associated with clinical outcomes, the effects of momentary (i.e., state) mindfulness are unclear. This is due in part to previous studies using cross-sectional designs relying on trait self-report questionnaires. Although such approaches are invaluable, they lack temporal specificity to evaluate momentary changes and effects of mindfulness. To address these limitations, the current study used ecological momentary assessment (EMA) to evaluate state levels of two mindfulness skills, acceptance and monitoring, and their association with state fluctuations in symptoms. Participants included individuals with affective and non-affective psychotic disorders (PD; n = 49) and healthy controls (CN; n = 53) who completed six days of EMA. Results indicated that the PD group endorsed lower state acceptance than CN; however, the groups did not significantly differ in monitoring. Further, greater state mindfulness skills in both acceptance and monitoring were associated with greater positive affect, reduced negative affect, and reduced negative symptoms. However, participants with a predominantly affective psychosis presentation showed differential effects compared to those with non-affective presentations. These findings suggest that mindfulness training for people with psychotic disorders may benefit from focusing on improving acceptance in order to improve emotional experience and build on existing monitoring skills. Further, mindfulness based psychosocial interventions may offer a novel means of treating negative symptoms in people with PD, which are currently stalled and largely unresponsive to other treatments.

To find the full text version of this article and other JCBS articles (as well as download a full text pdf.), ACBS members need to login and then access the JCBS ScienceDirect homepage here. Click here if you'd like to learn more about joining ACBS.
 

Background
There is a lack of research on psychological treatments for psychosis in the inpatient setting. Acceptance and Commitment Therapy for psychosis (ACTp) is a diagnose specific adaptation of the transdiagnostic ACT treatment model which has shown promising results in patients with psychosis.

Aim
The aim was to explore treatment effects of ACTp on inpatients with psychosis on symptoms, level of functioning, level of activity, psychological flexibility, –health-related quality of life, valued living, and to explore the acceptability and feasibility of ACTp.

Method
Twelve inpatients with psychosis were treated with 3–10 daily sessions of ACTp in a non-concurrent single case AB design with additional pre-post and mid-measures. The mean age at clinic A was 48.88 (SD = 11.59) and 48.75 (SD = 16.07) at clinic B. We calculated non - overlap of all pairs (NAP) in daily measures, and reliable change index (RCI), and clinical significance in pre-post measures.

Results
Half of the participants improved significantly on health-related quality of life and depression in daily measures and on depression and anxiety in pre-post measures. ACTp was quite acceptable and recruitment and the deliverance of therapy in the inpatient setting was feasible.

Conclusion
In the present study, participants found the ACTp treatment to be comprehensive and helpful. Recruitment and treatment of inpatients were feasible, however, since most participants were discharged before ACTp protocol was completed, fewer sessions or having sessions more frequently needs further investigation. Daily measurement showed a significant improvement in health-related quality of life and depression for a majority of the participants.

To find the full text version of this article and others (as well as download a full text pdf.), ACBS members can visit the ScienceDirect homepage here. 

Acceptance and Commitment Therapy (ACT) has demonstrated promising outcomes to date with clinical populations affected by psychosis, however there is a dearth of such investigations involving non-clinical samples despite evidence that symptoms of psychosis exist on a continuum in the general population. The present study aimed to investigate how key ACT processes relate to psychosis-like symptoms in the general population. A convenience sample of 77 adults completed self-report measures of cognitive fusion, mindfulness, experiential avoidance, and psychosis-like symptoms, and relative distress, intrusiveness and frequency. A series of correlational and hierarchical regression analyses investigated the relationship between target variables. Higher mindfulness was related to lower levels of psychosis-like symptoms as well as lower distress, intrusiveness, and frequency in relation to these experiences, as were lower levels of cognitive fusion and experiential avoidance. Higher levels of cognitive fusion and experiential avoidance, as well as lower levels mindfulness, emerged as significant predictors of higher levels of psychosis-like symptoms, and higher relative distress, intrusiveness, and frequency. Findings are discussed in relation to implications for future clinical research.

To find the full text version of this article and others (as well as download a full text pdf.), ACBS members can visit the ScienceDirect homepage here. 

A new model of medication adherence, rooted in an understanding of psychological flexibility, is presented here to illustrate how Acceptance and Commitment Therapy processes might guide the development of more effective adherence interventions for patients with psychotic-spectrum disorders. Medication adherence is a product of a negotiated, collaborative agreement between patient and provider, and it is predicted by a number of internal and external contextual factors. Irrespective of the ongoing debates about the long-term necessity and utility of antipsychotic pharmacotherapies, data clearly demonstrate that suboptimal medication adherence in the acute phase of treatment for psychosis undermines their potential benefits and puts undue burden on the healthcare system. However, every patient's reasons for nonadherence are unique, those reasons can change over time, and a patient's attitudes and beliefs about medications can fluctuate and can be inconsistent across medications. Psychological flexibility provides a dynamic framework in which adherence behaviors can be interpreted through a contextual lens, allowing providers to work collaboratively with patients to improve their self-care.

To find the full text version of this article and others (as well as download a full text .pdf.), ACBS members can visit the ScienceDirect homepage here.

This review explores the evidence base for Acceptance and Commitment Therapy (ACT) for people experiencing psychosis, the quality of the evidence, and potential benefits of this intervention. A systematic search of the literature was conducted on the electronic academic databases MEDLINE, Google Scholar, PsycArticles and PsycINFO up to October 2016. A systematic search identified 427 articles and thirteen studies were selected as eligible for review. The current research base indicates that ACT has the potential to be considered an effective treatment in psychosis even in briefer forms, such as 4 sessions for inpatients, and in individuals experiencing severe symptoms or complex co-morbidities. There is emerging evidence that ACT is a useful intervention for individuals that may present with psychosis whether at inpatient settings or in community teams. ACT can be utilised in group settings as this indicates time and cost-effectiveness (reaching a larger range of individuals). The studies suggest ACT can help reduce rehospitalisation rates, have an impact on the psychological inflexibility of people experiencing psychosis and is beneficial for people with either first episode or enduring psychosis. Nevertheless, there is a need to take the current findings with caution due to methodological criticism and potential for bias within some studies, which is discussed in the review. Despite this, advances to our understanding of ACT for those experiencing psychosis is improving. To continue this, larger randomised controlled trials are required to give this research area a more robust evidence base. Studies should also aim to include follow up data to assess the impact of the brief interventions on a much longer scale. Other recommendations for future research studies are noted.

Find the full text version of this article here.

Described as a contextual behavioural approach, Compassion-focused Therapy (CFT) aims at helping people develop compassionate relationships both with others and with the self. CFT has been used to promote recovery in psychosis with promising results. The development process of the Compassionate Approach to Schizophrenia and Schizoaffective Disorder (COMPASS) builds upon the available research on contextual behavioural approaches for psychosis. Its main framework is the affect regulation system's model and the compassion-focused therapy rationale as it was adapted for psychosis. Other theoretical and empirical influences are presented and innovations regarding CFT protocols for psychosis are highlighted. COMPASS is already being studied and details on the pilot study are provided. With further study and continuing improvement COMPASS has the potential to help foster recovery in psychosis.

Alleviating the suffering of patients treated in psychiatric inpatient wards is a great challenge. Preliminary or multiple diagnoses, inherent complexities of the inpatient milieu and the lack of potentially effective psychological treatment form part of this challenge. The present study explored the usefulness of a transdiagnostic psychological treatment model (Acceptance & Commitment Therapy, ACT) as a means of improving inpatient care from the perspective of psychiatric nurses. Nurses (n =10) participated in three ACT workshops, a total of 21 h, and were interviewed about the experienced usefulness and difficulties of the ACT model, as a tool for improving everyday ward work. Results, revealed by qualitative content analysis, suggest usefulness in the areas of alleviating patients symptoms, enriching typical ward duties, and handling one's own thoughts and feelings. Difficulties stemmed from lack of time, the model itself and patients’ severe illness. Possible adjustments of the ward context are suggested.

To find the full text version of this article and others (as well as download a full text .pdf.), ACBS members can visit the ScienceDirect homepage here.