ACT Early: Acceptance, mindfulness and values in early intervention for psychosis - PowerPoint PPT Presentation


PPT – ACT Early: Acceptance, mindfulness and values in early intervention for psychosis PowerPoint presentation | free to view - id: 453f8b-M2Q1M


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

ACT Early: Acceptance, mindfulness and values in early intervention for psychosis


Keep it simple to account for range of cognitive ... behavioural activation tool that ... Research with early psychosis Individual Therapy ACT is an ... – PowerPoint PPT presentation

Number of Views:259
Avg rating:3.0/5.0
Slides: 42
Provided by: EricM66


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: ACT Early: Acceptance, mindfulness and values in early intervention for psychosis

ACT Early Acceptance, mindfulness and values in
early intervention for psychosis
  • Eric Morris, Sally Bloy Joe Oliver
  • Lambeth Early Onset Services
  • South London Maudsley NHS Foundation Trust

The aim of this presentation
  • To present the case for how ACT may be useful in
    early intervention
  • To present the work of the Lambeth ACT crew Eric
    Morris, Joe Oliver, Sally Bloy, Louise Johns
  • ACT in early intervention is not about a whole
    new therapeutic approach to psychosis
  • We would argue that ACT is fairly consistent with
    the CBTp approach that has been developed in the

Workshop overview
  • Provide a psychological view of psychosis
  • ACT and early intervention for psychosis
  • ACT components and EIP
  • Values
  • Mindfulness
  • Defusion
  • Self stigma
  • A service user perspective of ACT
  • ACT for EIP in practice

A Psychological View of Psychosis
  • Dimensional rather than categorical Normalising
  • Work with symptoms rather than diagnoses
  • Diagnoses lack scientific validity
    schizophrenia is less useful than understanding
    behaviour in context
  • Biological vulnerabilities undoubtedly
    contribute, however symptoms/behaviour are
    heavily influenced by the environment
  • We dont work with brain diseases, we work with
    whole human beings whose behaviour is influenced
    by context

Recovery from first episode psychosis
  • up to 20 show persisting positive symptoms
  • 50-65 will relapse within 2 years despite
    medication adherence there is a growing risk of
    treatment-resistant symptoms with each subsequent
  • over 50 report significant depression and/ or
    anxiety secondary to psychosis
  • Up to 70 will continue to be unemployed/ out of
    education 12 months after starting treatment
  • most of the disability associated with
    schizophrenia occurs within the first five years
  • Suicide occurs in 10-15 of cases mainly in
    first 5 years
  • Sources Edwards et al., 2002 Birchwood, 2003
    Whitehorn, 2002 Robinson, 1999

The ACT stance
  • Focusing on symptom impact
  • Emphasising acceptance rather than disputation
  • Pragmatic truth criterion focused on moving
    things forward, rather than finding the cause of
    psychotic symptoms
  • Targets symptoms indirectly by altering the
    context within which they are experienced rather
    than frequency and believability per se

The Primary ACT Model of Treatment (Hayes et al.,
Unclear values Resignation/ Entrapment Serial
approach of fixing self before valued living
Engaging in thought suppression, avoidance, drug
use, DSH, etc
Engaging in Rumination Worry
Psychological Flexibility
Actions unhelpfully guided by self/other
appraisals, unusual experiences, stigma, trauma
Lack of persistence and flexibility in activating
Domination of Self as content broken, flawed, or
confusing/untrustworthy, mad
ACT Early Intervention Possibilities
  • Recovery may usefully be linked with values
    moving from unhelpful pliance and tracking
    methods (just take your meds youll stay
  • a pragmatic alternative to symptom elimination,
    through behavioural activation and promotion of
    psychological flexibility to anomalous
    experiences, emotions and thoughts in general
  • May help clients to develop early flexibility
    toward the dominant messages about psychosis
    (symptom elimination or limited life meaning,
    stigma of mental illness, minds can be controlled
  • Helping the psychological flexibility of
  • Morris Oliver, 2009

ACT Early Intervention Practicalities
  • Consistent with CBTp principles
  • Slow pace
  • Focus on recovery
  • Not about challenging thoughts/ experiences
  • Focus on increasing flexibility
  • Normalising
  • Workability always on table. No hard and fast
    rules - as long as it works.
  • Keep it simple to account for range of cognitive
    abilities. Be prepared to distil down to most
    basic parts
  • Sessions often aim to hit multiple points on

Offering psychology to EI folk
Using values as part of recovery
  • Values work often early
  • Values/ recovery focus rather than distress/
    symptom elimination
  • responses to unwanted or engulfing internal
    experiences are viewed in the context of personal
    values, which provide a measure of functional
    utility of coping methods.

Advantages of a values focus
  • provides constructive and consistent direction,
  • enhances response flexibility and motivation,
  • encourages persistence in the face of unwanted
    private experiences (especially in values-
    related situations that involve intimacy,
    vulnerability, or ambiguity)
  • Example Ahmed
  • 23.y.o. Male, socially anxious following FEP
  • Values of connection to others, learning
  • Provided self-generated rationale for exposure to
    college and friendship contexts

Sallys video
Introducing mindfulness
  • Generally keep it simple
  • Avoid long eyes-shut exercises short bursts
  • Creatively use mindfulness
  • Mindful eating an MM
  • Mindful walking
  • Mindful rolling a cigarette (yes, this may
    slightly undermine the healthy living focus, but
    we're being pragmatic in the moment)
  • Be clear that there is no right way
  • Reinforce all sorts of noticing

Using ACT processes in Relapse Prevention
  • Mindful awareness of symptoms
  • Acceptance and approach (flexible responding) as
    alternative to avoidance/ denial
  • RP plan in service of values rather than just
    staying well
  • Example Sarah
  • 25y.o. Female, hospitalised in FEP frightened of
    relapse, sense of helplessness about RP
  • Approached from a values perspective, identifying
    short- long-term actions, Swamp metaphor, and
    using present moment focus

Metaphor use
  • with cognitive impairment
  • Use simple, brief metaphors
  • Concrete examples
  • Use physical props/ pictures/ cartoons
  • Personally relevant stories relate metaphors to
    important clinical issues
  • Repetition
  • Be prepared for people not to get it, limit
    your explanations/ move on to something else
  • (Bach, 2004)
  • with paranoia
  • Tread carefully

Self Stigma
  • We have found that the self as observer skills in
    ACT are useful in managing stigma about psychosis
    and mental illness
  • Experientially contact the sense of self that is
    noticing all experience - And who is noticing
    this right now? Notice that you are noticing -
    along with defusion from stigma thoughts
  • This work involves developing a kind stance
    toward yourself and others stigmatising beliefs
    about psychosis are mainstream, reinforced by the
    verbal community

Erics video
The iACT
  • We try to use metaphors and analogies that are
    relevant to the young people we see.
  • The iACT is a values/behavioural activation tool
    that draws an analogy between our daily
    activities and a mp3 playlist.
  • It lends itself to such discussions as
  • Which tracks would you choose?
  • Are there tracks that are just there to look
    cool/ because your parents put them on/ block out
    bad thoughts etc.?

(No Transcript)
Defusion and voices
  • Assess degree that person buys voices
  • If lots of fusion with content, similar defusion
    strategies for thoughts may be helpful
  • Noticing repetitive patterns blah, blah, blah
  • Different tones/accents to how voice normally
  • Leaves on stream/ Clouds in sky
  • If not so fused with content, focus on unhelpful
    evaluations/ beliefs about voices
  • I cant cope Voices too powerful
  • Focus on stepping back to be able to make more
    informed choice based on values

Joes Video
Defusion and paranoia/delusions
  • Usefulness rather than truthfulness
  • Gentle enquiry rather than challenging
  • Too early and defusion can seem challenging its
    just a thought
  • Often essential to have done values work prior
  • Defusion strategies
  • Externalising whats the paranoia telling you to
  • Leaves on Stream noticing thoughts
  • Saying it differently to how its normally said

  • When conviction is very high may be more useful
    to target preoccupation, in the context of values
  • I must make sense of/ figure out/ solve/
    understand these experiences
  • Given your experiences, is there a way to not
    get so hooked in and still do whats important to
  • Example Eddies metaphor of street sellers and

(No Transcript)
Service Context Lambeth Early Onset Service (LEO)
  • A service for young people aged 16-35, residing
    in Lambeth (south London), experiencing symptoms
    of psychosis for the first time
  • service focuses on engagement, multi-modal
    treatment, and relapse prevention
  • works within a recovery model

ACT across the system
  • Individual therapy
  • Group therapy in a community team
  • Group therapy on an inpatient unit
  • Staff training in mindfulness, compassionate
  • Group therapy with clients at risk of developing
  • Research with early psychosis

Individual Therapy
  • ACT is an option for every client in our service,
    offered flexibly across the various phases of
    recovery from psychosis (acute, post-episode
    recovery, persisting symptoms)
  • Informed by British CBT for psychosis approach
    (normalising, functional)
  • Amount of sessions can vary
  • Supported and reinforced by group program

ACT in Groups
  • We run regular 1- and 3-session groups to
    introduce ACT to EI service users.
  • The purpose of these groups is to support the
    individual psychology and vocational work.
  • Groups are run in both community and inpatient
  • Focus is not on psychosis per se, but rather
    recovery and values-directed actions.
  • Groups are deliberately conducted in a light
    breezy, fun style hopefully not like school
    emphasising choice just ideas to try

Content of ACT for Life Groups
  • Noticing an Object (The Raisin)
  • Values as Direction and Action (Heading West)
  • Noticing barriers (Introduce monster telling you
    to take detour)
  • Noticing Exercise (Mindfulness/Centering)
  • Willingness as alternative (Tug of War Leaves
    on the Stream)
  • Increasing willingness through defusion
    (Don't-Get-Eaten Machine Junk Mail Two
    Computers Repeating NATS)
  • Notice control of actions versus thoughts (Purple
    Hat Two Tracks of Life)
  • Homework each group Take a valued action

Inpatient ACT group
  • Weekly ACT-focused group run on the LEO inpatient
  • Facilitated by psychologist and ward nurses
  • Open door policy
  • Emphasise fun - competitions and prizes
  • Average of 6 people a week
  • Aim to provide a taster to ACT ideas such as
    values, present moment focus, defusion
  • Try to be as accessible to everyone concepts
    very simple, people are guided through with
  • Often use case scenarios and then use this as a
    way in for people to talk about their own

ACT group
Lets practice having a thought vs buying a
Youre not good enough!
Youre too depressed
No-one likes you!
Youre not motivated enough!
ACT group
JunkMail Having a thought vs buying a thought
ACT group
Two Tracks of Life
  • Inner Life (Your Mind)
  • Feelings Thoughts Urges Memories
  • less control over these - can happen without you
    wanting them
  • it takes a lot of effort to change these, can
    lead to doing things that are harmful in the long
  • a private experience only you observe what
    happens in your mind, other people only know if
    you tell them
  • Outer Life (what You do)
  • Actions Behaviour Choices
  • more control over this, greater choice about what
    you do
  • able to do things even if your mind
    (thoughts/feelings) says that you cant
  • choices and actions are things that other people
    can observe, you can act in a way that is
    different from how you feel

ACT group
Who is the worst famous person you can think of?
  • To win a million pounds you have to pretend to be
    their biggest fan - what would you do?

ACT group
Gina hears voices. She doesnt fight with them
but she doesnt necessarily believe what they say
to her.
Is this like A Trying to pull out of the
trap? or B Moving into the trap?
ACT group
  • Which of these famous people has admitted to self
  • Amy Winehouse (singer)
  • Johnny Depp (actor)
  • Angelina Jolie (actress)
  • Princess Diana (princess)

Video Service User Perspective on ACT
  • Early days but sense that ACT model is relevant
    to EI and psychosis
  • Fits in with adopting a recovery stance
  • Focus not on symptoms
  • Pragmatic approach
  • Normalising experiences
  • Functioning aspect useful focus for EIP folk
    getting life back
  • Promotes willingness, less of a struggle
  • Hopefulness

What is it like to do ACT in this setting?
Contact Joseph.Oliver_at_sl