ACT for Psychosis Recovery A Practical Manual for Group

Based Interventions Using Acceptance and Commitment

Therapy

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“As a direct result of my participation in ACT, and practicing the essential
taught tools, ACT for psychosis recovery disrupted my revolving door, long
sessions in locked psychiatric hospitals, and led to my learning how to
productively identify constructive approaches and manage challenges to
ensure my enjoyment daily, of a quality of life with my mental health
diagnoses, that had been denied to me before this therapy. Prior to ACT, my
psychosis was indeed so pronounced, aggressive, and bleak, that I also
spent time in prison. ACT for psychosis recovery was my final attempt at
therapy.”
—Yvonne Patricia Stewart-Williams, artist, and author of Still On The
Cusp Of Madness

“Compiled by experts in the field, this is a comprehensive and invaluable

resource for supporting recovery in the context of psychosis. Written in an
engaging and accessible way, the importance of close collaboration with
experienced experts is highlighted throughout. The authors are to be
commended for developing an approach that richly recognizes the common
humanity shared by those who have experienced psychosis, and those who
are committed to helping.”
—Ross G. White, PhD, DClinPsy, associate professor of clinical
psychology at the University of Liverpool

“As evidence of the benefits of ACT for psychosis are piling up, there is a
need for a clear and practical manual on how to implement ACT for
psychosis in the clinical workplace. This book is offering exactly that, an
extensive and detailed manual of a four-session ACT group intervention for
people suffering from psychosis at different stages of illness, as well as
their caregivers. With additional information on training, supervision, and
inclusion of peer-support ­co-facilitators, this book is a must-read for all
clinicians interested in third-wave psychotherapies for people with
psychosis.”
—Inez Myin-Germeys, professor of psychiatry, and head of the Center
for Contextual Psychiatry at KU Leuven in Belgium
“ACT has enriched the family of cognitive behavioral therapies
immeasurably. This book distills over ten years of the authors’ work
developing ACT for and with people struggling with psychosis. ACT for
Psychosis Recovery provides detailed guidance on how to run groups for
people with psychosis, and their caregivers. In the spirit of generosity
associated with ACT, the book includes all the worksheets, metaphors, and
measures needed to run these groups in clinical practice.”
—Katherine Newman-Taylor, consultant clinical psychologist at
Southern Health NHS Foundation Trust, and associate professor at the
University of Southampton

“ACT for Psychosis Recovery is a unique resource for practitioners from

any background. Developed by expert clinicians who are also leading
researchers, the manual shows how to engage participants in simple and
powerful group exercises that foster hope and enable action today toward
living a more satisfying life. The use of a central metaphor and
straightforward language accommodates all abilities, and innovations in
peer facilitation and caregiver groups open new directions. When
implementing it in our services, the degree of change in participants
surprised even our group leaders. The authors are onto something special
here!”
—John Farhall, PhD, associate professor of clinical psychology at La
Trobe University, and consultant clinical psychologist at NorthWestern
Mental Health in Melbourne, Australia
Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the
subject matter covered. It is sold with the understanding that the publisher is not engaged in
rendering psychological, financial, legal, or other professional services. If expert assistance or
counseling is needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright © 2018 by Emma K. O’Donoghue, Eric M.J. Morris, Joseph E. Oliver,
and Louise C. Johns
Context Press
An imprint of New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
 www.newharbinger.com
Cover design by Amy Shoup
Acquired by Catharine Meyers
Edited by James Lainsbury
Indexed by James Minkin

All Rights Reserved

Library of Congress Cataloging-in-Publication Data on file

Emma O’Donoghue
To my darling Johnny and my amazing family and friends. I love you
dearly.
Joe Oliver
To my wife, Shalyn, with much love.
Eric Morris
To my parents, Nev and Bev. I am, as ever, grateful for your love and
support.
Louise Johns
Per Andrea. Grazie per il tuo impegno.
 Contents
Contents
List of Figures
List of Tables
Foreword
ACT for Psychosis: It Is Time
An Introduction to Acceptance and Commitment Therapy (ACT) for
Psychosis Recovery

Part 1
Pretreatment Overview
Chapter 1
Introduction to Acceptance and Commitment Therapy for Psychosis
Figure 1. The ACT model of psychological flexibility, or hexaflex
Table 1. Central ACT processes
Chapter 2
Adapting ACT Workshops for Caregivers of People with Psychosis
Written with Suzanne Jolley
Chapter 3
Adapting ACT Workshops for Acute Inpatient Settings
Written with Rumina Taylor and Georgina Bremner
Table 2. The content of workshop sessions in ACT for recovery in
acute inpatient settings
Chapter 4
Peer-­Support Cofacilitators
Working Alongside Clients with Lived Experience of Mental Health
Issues
Chapter 5
Running Successful and Effective Workshops
Training
Chapter 6
Running Successful and Effective Workshops
Supervision and Evaluation
Figure 2. The ACTs of ACT Fidelity Measure

Part 2
Treatment Manual
Introduction to ACT for Psychosis Recovery Workshop Protocol
Written with Natasha Avery
Taster Session
The Reservoir Metaphor
Passengers on the Bus Metaphor
Automatic Pilot
Mindfulness of Breath and Body Exercise
Session 1
Introducing Noticing, Values, and Committed Action
The Reservoir Metaphor
Automatic Pilot
Mindfulness of Breath and Body Exercise
Passengers on the Bus Metaphor
Mindful Stretch Exercise
Session 2
Workability as an Alternative
Mindful Eating Exercise
Pushing Against the Folder Exercise
Three-­Minute Breathing Space Exercise
Session 3
Acting on Values with Openness, Awareness, and Willingness
Leaves on the Stream Exercise
Sticky Labels Exercise
Three-­Minute Breathing Space Exercise
Session 4
Bringing It All Together—Open, Aware, and Active
Mindful Walking Exercise
Clouds in the Sky Exercise
Booster Session 1
Mindfulness of Breath and Body Exercise
Booster Session 2
Clouds in the Sky Exercise
Acknowledgments
Appendix A
Exercise Prompt Sheets
A1. Reservoir Metaphor
A2. Mindfulness of Breath and Body Exercise
A3. Passengers on the Bus Metaphor
A4. Mindful Stretch Exercise
A5. Mindful Eating Exercise
A6. Paul’s Story Transcript
A7. George’s Story Transcript
A8. Pushing Against the Folder Exercise
A9. Acting Out the Passengers on the Bus Exercise
A10. Three-­Minute Breathing Space Exercise
A11. Leaves on the Stream Exercise
A12. Mindful Walking Exercise
A13. Key Messages Cards
Open
Passengers on the Bus Exercise
Committed Actions
Pushing Against the Folder Exercise
Having vs. Buying into Thoughts Exercise
Sticky Labels Exercise
Aware
Mindfulness of Breath and Body Exercise
Mindful Stretch Exercise
Mindful Eating Exercise
Three-­Minute Breathing Space Exercise
Leaves on the Stream Exercise
Mindful Walking Exercise
Clouds in the Sky Exercise
Videos of Paul and George
Weekly Telephone Call from Facilitator
Having vs. Buying into Thoughts Exercise
Noticing Others’ Values Exercise
Active
Coming to the Workshops
Choosing Valued Directions
SMART Goals
Committed Action
Having vs. Buying into Thoughts Exercise
Passengers on the Bus Exercise
A14. Clouds in the Sky Exercise
A15. Client Satisfaction Questionnaire
A16. The ACTs of ACT Fidelity Measure
Appendix B
Session Worksheets
B1. Values Worksheet
B2. Passengers on the Bus Worksheet
B3. Committed Action Worksheet
B4. Developing Aware Skills Worksheet
B5. Driving License Worksheet side 1
Reference List
Index
 FOREWORD

ACT for Psychosis: It Is Time

W
hen people trot out statistics on the cost of mental health
problems, they often fail to note that psychosis produces a large
share of those costs. I’m not talking just about dollars and cents.
People struggling with psychosis die at a far younger age; they are
commonly in poverty; they are frequently victims of violent crime; and they
have dramatically poorer overall physical health.
Meanwhile, the mental health establishment has been all too willing to
accept that anti-psychotic medications are full and ready solutions to these
problems, with psychosocial interventions playing only a minor and
supportive role. As providers, family members, and recipients of care all
increasingly realize: this approach is not working. All anti-psychotic
medications have serious side effects that grow with time and dose. Some
of these include metabolic problems and cardiovascular disease, which
contribute to the health problems and lowered life expectancy I just noted.
Because the use of anti-psychotic medications prematurely settled into a
status of accepted community practice before the data were fully in, many
of the needed studies on long-term effects were never done, leading to a
serious hole in our knowledge base that we have yet to fill adequately.
Existing medications do have a role in the care of psychotic patients, but it
is more limited than current practice suggests. Medication as a form of
intervention needs to be combined with evidence-based psychosocial
methods.
In the last 15 years, there has been steady progress in the investigation of
acceptance and commitment therapy (ACT) as a psychosocial method with
broad applicability to the range of problems that emerge in intervention
with psychosis. ACT is not a psychotherapy designed to eliminate the signs
and symptoms of psychosis. The target of ACT is the empowerment of
people to deal with life, including the presence of various experiences that
may be challenging, such as hearing voices or having ideas of reference.
ACT is focused on goals such as increasing quality of life or employment,
staying out of the hospital, and reducing distress and entanglement with
symptoms. Empowering people to face life’s challenges, however, does not
just apply to recipients of care. It applies also to family members,
caregivers, and professionals.
In all of these areas, the evidence in support of ACT is growing. Take
rehospitalization: there are now three completely independent studies
examining the impact of very brief ACT interventions for people
hospitalized with psychosis, examining its impact on rehospitalization.* All
of them found significant reductions of rehospitalization over four months
using survival analysis. Having a larger body of evidence available across
studies now allows us to ask very simple but very important questions, like
“Does ACT help keep psychotic patients out of the hospital at all?” The
answer, in short, is yes. Counting all missing data as bad outcomes (the
most conservative possible assumption), across these studies 46% of the
treatment as usual condition were rehospitalized over 4 months, as
compared to 28% in the ACT condition. That is a significant difference
(Fisher’s exact, p = .037) that represents a nearly 40% drop in the rate of
rehospitalization—a number sure to get the attention of both researchers
and the treatment community worldwide.
That is now happening. In 2017, scientists for the National Registry of
Evidence-based Programs and Practices (NREPP) of the Substance Abuse
and Mental Health Services Administration of the United States examined
the ACT for psychosis studies. NREPP decided to categorize acceptance
and commitment therapy as “Effective” for its impact on rehospitalization.
The impact of ACT was listed as “Promising” also for psychosocial
disability and overall psychiatric problems.
Supportive data is not just available for outcomes, and we now know that
psychological flexibility mediates the outcome of ACT for psychosis.
Longitudinal and cross-sectional studies show that the theory applies to the
life impact of hallucinations and delusions as well. This all suggests that
something important is going on in ACT for psychosis, and after 15 years of
development work, it is time to move these methods more fully into
systems of care.
This book is the first to present a comprehensive and practical approach
to the full range of issues involved in the treatment of psychosis using ACT.
Written by some of the leading developers in the area, it contains sections
on the theory underlying ACT, how its methods fit into existing systems of
care, how ACT can be done in inpatient settings using peers and
cofacilitators, how ACT applies to caregivers and providers, and how ACT
can be trained and supervised. There is no other resource available that
addresses such a breadth of practical topics that systems of care need to
know in order to take advantage of ACT methods.
The core of the book is the group ACT for psychosis protocol itself. Well
crafted, flexible, and wise, it is a protocol that can be fitted to a wide range
of practice settings, and for low cost. The protocol is designed to be
deployed in a handful of sessions—a restriction that anyone working in the
area knows is necessary. The sessions are described in detail, but the
principles and purposes are described so that modification is not difficult.
Breakdowns by time help group facilitators know if they are managing their
time effectively, and the protocol offers an attention to contextual details
and implementation issues that can only be learned one way: by being used.
What you have here is a method that has been refined over years of
implementation, presented by experts. This is not a beta-test. This is a group
protocol you can use with confidence in which most of the issues you will
encounter in its use have been anticipated.
We now know that evidence-based psychosocial methods are key to
reducing the human costs of psychosis. The field is looking for a new way
forward. This book can help you provide just that to your agency and to the
lives of those you serve.
—Steven C. Hayes
University of Nevada, Reno
An Introduction to Acceptance and
Commitment Therapy (ACT) for
Psychosis Recovery

T
he experience of psychosis is almost always an incredibly disruptive
event in a person’s life. For the approximately 3 percent of us
affected by psychosis, its impact extends to every area of life,
including relationships, work, health, and overall well-­being. Families and
caregivers also experience this impact as they do their best to support their
loved one on the path toward recovery. Heartbreakingly, recovery is not
guaranteed, and even when there is success, interventions such as
medications come with unpleasant side effects, and diagnostic labels are
extraordinarily stigmatizing.
Psychological therapies offer hope and are often a crucial and important
treatment option for individuals with psychosis. For clients in close contact
with their families, treatment guidelines also recommend family
interventions and caregiver support, to improve caregiver well-­being and
their interactions with clients. Individual psychological therapies can be
complex and lengthy. In addition to training more mental health staff to
deliver these therapies, briefer or group-­based variants of therapy have been
developed to improve both dissemination and access.
Targeting common processes that contribute to psychological well-­being
can increase therapy impact and access. A key component of mental well-­‐
being is psychological flexibility, which involves developing helpful
responses to situations and experiences using mindful awareness and
values-­based choices and actions. The transdiagnostic approach of
acceptance and commitment therapy (ACT) aims to increase psychological
flexibility, and it has been used successfully with a wide range of mental
and physical health problems in clinical and nonclinical groups.
 ACT promotes social and functional recovery by shifting client focus
from symptom control to connecting with personal values and participating
in life more fully. In addition to enhancing values-­based living, ACT may
be particularly useful for symptoms of psychosis. The qualities of
distressing voices and delusional beliefs can increase the likelihood that
people respond either with avoidance or engagement, both of which can
have high personal cost in the long term. Similarly, for caregivers the worry
and demands of caring responsibilities can be overwhelming, leading to
unhelpful responses to distress. The aim of ACT is to change the
relationship people have with their symptoms, worries, or distress, and how
they respond to them, in order to reduce the impact of these difficulties and
help people focus more on valued actions.
The group context provides a powerful setting within which ACT
concepts and skills can be taught and modeled. In addition, aspects of the
intervention lend themselves to a group setting, such as acting out ACT
metaphors, observing other people being present and willing, and making
commitments in a social context. For people with psychosis, and their
caregivers, group interventions also offer opportunities for normalizing and
accepting psychotic experiences, gaining peer support, reducing isolation,
and developing self-­compassion. Along with these benefits, there is the
opportunity to validate the courage and commitment participants show in
expanding their lives despite the personal and wider difficulties associated
with psychosis.
During the last ten years, we progressively developed an ACT for
recovery group intervention for people with psychosis (G-­ACTp) and for
their caregivers. This process has been gradual and iterative, as we’ve
sought to create a successful, engaging, and effective group program for
both individuals affected by distressing psychosis and caregivers and family
members walking alongside them in the journey to recovery. We are
incredibly grateful for all the feedback, suggestions, and ideas we’ve
received over the course of this enormous project. Given the difficulties
some people have accessing individual and family therapies, and the fact
that there are benefits of group approaches, we believe that G-­ACTp offers
promise in expanding the choice and availability of high-­quality
psychological therapies, which can positively impact people on the pathway
to recovery.

Structure of the Book

This book details the various aspects of our ACT for recovery group
intervention, describing adaptations we have made and providing the
manualized session content. Chapter 1 introduces ACT and its application
to psychosis and outlines the development of the group intervention.
Chapters 2 and 3 describe adaptations to the protocol for use with
caregivers and acute inpatients, respectively. Chapter 4 details the approach
of training and supervising peer-­support cofacilitators, including the
practical considerations and the perspectives of peer-­support facilitators
who have been involved. Chapter 5 discusses skills and tips for running
successful workshops, both in relation to your own practice and in training
others to facilitate these workshops. Chapter 6 highlights the importance of
ongoing supervision and using ratings to ensure adherence to the model,
and in it we consider how to measure outcomes and processes of change in
the workshops. Part 2 describes the protocol for running ACT for recovery
group intervention workshops; we outline each session, including scripts for
exercises and tips about how to present material and foster discussion. We
also provide downloadable resources at the website for this book,
http://www.actforpsychosis.com, as well as advice about how to produce
your own resources that better fit your service setting.
We hope you find that the book and additional resources enrich your ­‐
clinical practice as you walk together with your clients on the journey to
recovery!
 PART 1

Pretreatment Overview
 CHAPTER 1

Introduction to Acceptance and

Commitment Therapy for
Psychosis

I
n this chapter we give a brief overview of psychosis and psychological
treatment approaches. We introduce acceptance and commitment
therapy (ACT) and its application to psychosis, and then outline the
development of our ACT for recovery group intervention.
Given that antipsychotic medication is not well tolerated, is only partially
effective, and can have harmful side effects (Furukawa et al., 2015;
Lieberman et al., 2005), psychological therapies offer a vital treatment
option for clients. International clinical guidelines recommend that people
with psychosis are offered individual cognitive behavioral therapy (CBT;
Gaebel, Riesbeck, & Wobrock, 2011), but access remains limited in front-­‐
line services, mainly due to a lack of trained therapists. To help meet
demand, group-­based CBT interventions have been evaluated, as these can
be offered to more clients at a time and can also be manualized and taught
within services to increase the scope of their delivery.
ACT is a contextual cognitive behavioral intervention that lends itself to
brief group therapy and to the diverse presentations of psychosis. Rather
than targeting particular appraisals, as in traditional CBT, the ACT approach
is not symptom specific. It emphasizes the person’s relationship with
symptoms and encourages values-­based living (Hayes, 2004). ACT
concepts and skills can be taught and modeled within a group format, plus
this approach can appeal to clients who are unable or reluctant to engage
with lengthy individual treatments. In addition to these aspects of ACT, the
development of our workshops was also informed by our local context and
the clients accessing the service, many of whom had histories of
marginalization, low educational achievement, and a distrust of authority
figures. We wanted to offer a brief group intervention that would be
engaging, nonthreatening, and usable by clients in their daily lives.

Psychosis
Psychosis is a broad concept that is something of an umbrella term for lots
of different experiences. Clinicians use the term to refer to the positive
symptoms of psychotic disorders: unusual beliefs (delusions), anomalous
experiences (hallucinations and other perceptual changes), and disturbances
of thought and language. Individuals experiencing psychosis may say that
people are trying to harm them in some way, or that they are being
controlled by an external agent, and they may hear voices insulting them or
commanding them to do things against their will. Their thoughts may be
jumbled or experienced as inserted into, or stolen from, their mind, and
thought disturbances can manifest as tangential or circumstantial speech.
Although psychotic experiences are hallmark symptoms of schizophrenia,
they also occur with other problems, such as mood and personality
disorders, and they are reported by people who don’t have a psychiatric
diagnosis (Kelleher & DeVylder, 2017; McGrath et al., 2015). People
diagnosed with a psychotic disorder, particularly schizophrenia, are also
likely to experience negative symptoms, such as lack of motivation and
reduced emotional expression, plus cognitive problems of poor memory and
concentration. It’s worth keeping in mind that all these symptoms can be
accompanied—­and often preceded—­by more common emotional
difficulties, such as anxiety and depression (Birchwood, 2003). It is also
worth noting that psychotic experiences are not always experienced as
unwanted or distressing, and they do not necessarily result in a need for
care (Brett, Peters, & McGuire, 2015; Linscott & van Os, 2013).

Outcomes Following Psychosis

Diagnosable psychotic disorders affect 3 percent of the population. So, in
a group of 100,000, that works out to be 3,000 people. Psychosis is