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

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


1
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

2
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
    UK...

3
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

4
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

5
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
    relapse
  • 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

6
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

7
The Primary ACT Model of Treatment (Hayes et al.,
2004)
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
etc
Lack of persistence and flexibility in activating
self
Domination of Self as content broken, flawed, or
confusing/untrustworthy, mad
8
ACT Early Intervention Possibilities
  • Recovery may usefully be linked with values
    moving from unhelpful pliance and tracking
    methods (just take your meds youll stay
    well)
  • 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
    etc).
  • Helping the psychological flexibility of
    clinicians
  • Morris Oliver, 2009

9
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
    model

10
Offering psychology to EI folk
11
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.

12
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

13
Sallys video
14
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

15
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

16
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

17
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

18
Erics video
19
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.?

20
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21
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
    sounds
  • 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

22
Joes Video
23
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
    do?
  • Leaves on Stream noticing thoughts
  • Saying it differently to how its normally said

24
  • 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
    you?
  • Example Eddies metaphor of street sellers and
    trains

25
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26
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

27
ACT across the system
  • Individual therapy
  • Group therapy in a community team
  • Group therapy on an inpatient unit
  • Staff training in mindfulness, compassionate
    approaches
  • Group therapy with clients at risk of developing
    psychosis
  • Research with early psychosis

28
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

29
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
    settings.
  • 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

30
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
    Notice!

31
Inpatient ACT group
  • Weekly ACT-focused group run on the LEO inpatient
    ward
  • 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
    examples.
  • Often use case scenarios and then use this as a
    way in for people to talk about their own
    experiences

32
ACT group
Lets practice having a thought vs buying a
thought
Youre not good enough!
Youre too depressed
No-one likes you!
Youre not motivated enough!
33
ACT group
JunkMail Having a thought vs buying a thought
34
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
    run
  • 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

35
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?

36
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?
37
ACT group
  • Which of these famous people has admitted to self
    harming?
  • Amy Winehouse (singer)
  • Johnny Depp (actor)
  • Angelina Jolie (actress)
  • Princess Diana (princess)

38
Video Service User Perspective on ACT
39
Summary
  • 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

40
What is it like to do ACT in this setting?
41
Contact Eric.Morris_at_kcl.ac.uk Joseph.Oliver_at_sl
am.nhs.uk Sally.Bloy_at_slam.nhs.uk
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