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
(No Transcript)
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
(No Transcript)
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 likeA Trying to pull out of the
trap?orB 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
ContactEric.Morris_at_kcl.ac.ukJoseph.Oliver_at_sl
am.nhs.ukSally.Bloy_at_slam.nhs.uk