Ultra-brief acceptance & commitment therapy for inpatients with psychosis - a single-case experimental design investigating processes of change

People with primary psychosis are among the most seen in inpatient psychiatry. Treatment guidelines recommend both pharmacological and psychological treatments. However, psychological treatments are not routinely offered in many settings. There is also a lack of research on psychological treatments for this vulnerable population in the inpatient setting. The first aim of the current study was to examine treatment effects of a brief form of Acceptance and Commitment Therapy on outcomes valued by the treatment recipients. The second aim was to explore hypothetical processes of change in relation to outcomes over time. Three people with primary psychosis were treated for two to four sessions. A replicated single-case experimental design with multiple baselines across subjects (Clinical Trials registration number ID NCT04704973) was employed to examine treatment effects. The Personal Questionnaire (PQ) was used as primary outcome, symptom believability and preoccupation as proposed processes of change. Data were analyzed using visual inspection, calculation of Tau-U values, and cross-lagged correlation. All participants improved significantly on PQ and the symptom preoccupation measure. Two improved significantly on the symptom believability measure. Cross-lagged correlation analyses showed no clear mediation. Change in proposed processes of change and primary outcome predominantly happened concomitantly, although patterns of results reflected individual differences.

Acceptance and commitment therapy for psychosis: Current status, lingering questions and future directions

PURPOSE

Acceptance and Commitment Therapy for psychosis (ACTp) is a contextual behavioural intervention that promotes psychological flexibility by fostering active acceptance, cognitive defusion, values construction and committed action to enhance well-being and recovery. Multiple studies have shown that ACTp is acceptable and efficacious, but questions remain as to its distinction from similar approaches and the conditions under which it would be implemented most effectively.

METHODS

We present the current evidence for processes and outcomes of ACTp and summarise the qualitative findings of experiences of service users in ACT programmes. We compare ACTp with other cognitive behavioural therapies and mindfulness-informed interventions for psychosis.

RESULTS

Acceptance and commitment therapy for psychosis is promising as a pragmatic, process-driven intervention model. Further efforts are needed to investigate psychological flexibility in the context of psychosis with observational, experimental and intervention studies that will inform model scope and treatment refinement. Additionally, implementation research is the necessary next step, including how support persons can be trained in ACTp. Lower intensity and technology-assisted approaches have the potential to reduce barriers to accessing ACTp and extend impact.

CONCLUSIONS

Over the last 20 years, ACTp has demonstrated meaningful effects in individual and group formats in a range of settings, targeting outcomes such as rehospitalisation, depression, psychotic symptom distress and impact. Future work should focus on how best to integrate ACTp with other current evidence-based interventions for psychosis.

Trait Mindfulness in Psychotic Disorders: Dimensions Predicting Symptoms, Cognition, and Functional Outcome

Mindfulness-based treatments are efficacious for psychotic disorders (PD). However, which components of mindfulness (i.e., attentive monitoring and nonjudgmental acceptance) are most relevant treatment targets is unclear. Further, there is a dearth of literature examining clinical correlates of mindfulness in people with PD. The present study aimed to examine group differences and clinical correlates of mindfulness in people with PD. We hypothesized that PD would report lower monitoring and acceptance than CN and that mindfulness components would be associated with symptoms including dysfunctional beliefs, alexithymia, neurocognitive ability, positive symptoms, and mood symptoms. Groups included individuals with PD (n = 54) and nonpsychiatric controls (n = 55). Participants completed self-report measures of mindfulness and related constructs and clinical interviews of symptoms. Results of ANOVA models indicated that global mindfulness was lower in PD relative to CN, with greatest differences evident for acceptance in the affective psychosis group. Regression models found that greater monitoring was associated with improved neurocognitive performance, while acceptance was associated with lower defeatist beliefs, alexithymia, and depression/anxiety symptoms. Results highlight the importance of targeting acceptance in the psychosocial treatment of PDs, especially for those with mood symptoms.

Effectiveness of acceptance and commitment therapy for inpatients with psychosis: Implementation feasibility and acceptability from a pilot randomized controlled trial

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.

CLINICALTRIALS

gov Identifer: NCT02336581.

Ecological Momentary Assessment Of State Fluctuations In Mindfulness And Symptoms In Psychotic Disorders

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.

Development of a Telephone-Delivered Acceptance and Commitment Therapy Intervention for People Living with HIV who are Hazardous Drinkers

Alcohol use among people living with HIV (PWH) has been increasingly recognized as an important component of HIV care. Transdiagnostic treatments, such as Acceptance and Commitment Therapy (ACT), that target core processes common to multiple mental health and substance-related problems, may be ideal in HIV treatment settings where psychological and behavioral health comorbidities are high. In advance of a randomized clinical trial (RCT), the overall objective of this study was to systematically adapt an ACT-based intervention originally developed for smoking cessation, into an ACT intervention for PWH who drink at hazardous levels. Consistent with the ADAPT-ITT model, the adaptation progressed systematically in several phases, which included structured team meetings, three focus group discussions with PWH (N = 13), and in-depth interviews with HIV providers (N = 10), and development of standardized operating procedures for interventionist training, supervision, and eventual RCT implementation. The procedures described here offer a template for transparent reporting on early phase behavioral RCTs.

Effectiveness of Acceptance and Commitment Therapy for Patients with Psychosis Being Monitored at a Community Mental Health Center: A Six-Month Follow-up Study

OBJECTIVE

This study aimed to examine the long-term efficacy of a short-term acceptance and commitment therapy-based (ACT) group psychotherapy on patients with psychosis in a community mental health center (CMHC).

METHODS

A total of 6 group-based ACT sessions were applied to 16 people diagnosed with psychotic disorders who met the inclusion criteria. They were evaluated at the start of, end of, and 6 months after the therapy using the acceptance and action questionnaire, the psychotic symptom rating scales, and the quality-of-life scale.

RESULTS

At the end of the 6 session group therapy and 6-month follow-up, a statistically significant decrease was found in patients' psychotic symptoms and experiential avoidance as well as a statistically significant increase in their quality of life (P < .001).

CONCLUSION

According to the results, ACT can be said to be an effective method for managing psychotic symptoms, reducing experiential avoidance, and improving the quality of life in patients diagnosed with psychotic disorders in CMHCs.

Psychological interventions for acute psychiatric inpatients with schizophrenia-spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Acute inpatient psychiatric wards are important yet challenging environments in which to implement psychological interventions for people with schizophrenia-spectrum disorders. No meta-analysis to date has evaluated whether psychological interventions are effective in this context.

METHODS

We systematically searched Embase, Medline and PsycInfo databases for randomised controlled trials (RCTs) of psychological interventions implemented in acute inpatient psychiatric settings with individuals with schizophrenia-spectrum disorders. We conducted random effects meta-analyses of between-groups outcomes at post-intervention and relapse/re-hospitalisation rates by follow-up.

RESULTS

Twenty-nine trials were suitable for meta-analysis. Psychological interventions improved post-intervention positive symptoms, social functioning and treatment compliance and reduced the risk of relapse/ re-hospitalisation, relative to control conditions. Analyses of specific intervention effects found positive effects of psychoeducation on several key outcomes (power > 80%) and preliminary evidence for positive effects of acceptance and commitment therapy (ACT), cognitive behaviour therapy (CBT) and metacognitive training (MCT) on some outcomes (power < 80%).

CONCLUSION

Psychological interventions can be helpful for acute inpatients with schizophrenia-spectrum disorders. However, risk of bias was often high or unclear, and some analyses were underpowered. Further research should use more rigorous RCT designs and publish meta-analysable data on positive symptoms, general psychopathology, relapse/ re-hospitalisation, social functioning and treatment compliance.

An Overview of the Evidence for Psychological Interventions for Psychosis: Results From Meta-Analyses

There are numerous psychological approaches to psychosis that differ in focus, specificity and formats. These include psychodynamic, humanistic, cognitive-behavioural and third-wave-approaches, psychoeducation, various types of training-based approaches and family interventions.

We briefly describe the main aims and focus of each of these approaches, followed by a review of their evidence-base in regard to improvement in symptoms, relapse and functioning. We conducted a systematic search for meta-analyses dating to 2017 for each of the approaches reviewed. Where numerous meta-analyses for an approach were available, we selected the most recent, comprehensive and methodologically sound ones.

We found convincing short- and long-term evidence for cognitive behavioural approaches if the main aim is to reduce symptom distress. Evidence is also strong for psychoeducative family interventions that include skills training if the main aim is to reduce relapse and rehospitalisation. Acceptance and commitment therapy, mindfulness-based approaches, meta-cognitive and social skills training, as well as systemic family interventions, were also found to be efficacious, depending on the outcome of interest, but meta-analyses for these approaches were based on a comparatively lower number of outcome studies and a narrower selection of outcome measures. We found no convincing evidence for psychodynamic approaches, humanistic approaches or patient-directed psychoeducation (without including the family).

An array of evidence-based psychological therapies is available for psychotic disorders from which clinicians and patients can choose, guided by the strength of the evidence and depending on the outcome area focused on. Increased effort is needed in terms of dissemination and implementation of these therapies into clinical practice.

Meta-analyses show convincing evidence for CBT if the main target is psychotic symptoms.

Meta-analyses show convincing evidence for family interventions if the main target is relapse.

Effects are promising for ACT, mindfulness-based and systemic approaches, but more research is needed.

The array of effective approaches allows clinicians and patients to select the most appropriate one.