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People within the early stages of psychosis often have positive symptoms (e.g., hearing, seeing, smelling, feeling, and believing things that others do not), negative symptoms (e.g., lack of motivation, interest in social interactions, emotional expression), cognitive difficulties and co-morbid mental health problems, which impact on their functioning and quality of life (Fusar-Poli et al., 2017, 2020).
NICE guidelines recommend the use of cognitive behavioural therapy (CBT) and family therapy for everyone in the early stages of psychosis (NICE, 2014) and antipsychotic medication for people specifically diagnosed with first-episode psychosis (NICE, 2014). However, NICE guidelines for adults with psychosis have not been updated for almost a decade and there is increasing evidence for a variety of different therapeutic approaches.
There is growing but inconsistent evidence to support the use of ACT with people who experience psychosis (Jansen et al., 2020; Yildiz, 2020). Acceptance and Commitment Therapy (ACT) is a third-wave cognitive-behavioural intervention which focusses on improving psychological flexibility and decreasing experiential avoidance. ACT sessions have recently been combined with Ecological Momentary Intervention (Myin-Germeys et al., 2016) to further enhance the therapeutic effects of ACT in Daily Life (ACT-DL) for people with psychosis (Vaessen et al., 2019).
A clinical trial provided evidence for ACT-DL plus treatment as usual (TAU) significantly improving distress related to experiences of psychosis, functioning, and negative symptoms, compared to TAU alone (Myin-Germeys et al., 2022; Vereeken, 2022). This is a particularly valuable finding given that clinicians often experience difficulties in identifying, assessing and working with negative symptoms in people with psychosis (Correll & Schooler, 2020; Veerman et al., 2017; Vereeken, 2022).
Given that only two qualitative studies have previously explored people’s experiences of ACT for psychosis, Bouws et al. (2023) aimed to build on this work by exploring participants experiences of ACT-DL for psychosis, their engagement with ACT principles, and what they found to be helpful or unhelpful.
This study aimed to explore participants experiences of acceptance and commitment therapy in daily life, how they engaged with the principles of this psychotherapy and what they found helpful or unhelpful.
Methods
Seventeen participants were included in this qualitative study, from The Netherlands (71%) and Belgium (29%), all of whom either met criteria for being at high risk of developing psychosis (41%) or having a first episode of psychosis (59%). They were aged between 21 and 40, with just over two-thirds identifying as female.
The ACT intervention involved taking part in eight sessions. One session was focussed on psychoeducation and seven sessions based on the six ACT principles: acceptance, cognitive defusion, self-as-context, contact with the present moment, values, and committed action. See the original paper (Bouws et al., 2023) and Russ Harris (2009) for further information on ACT.
Participants who were randomly allocated to receive ACT-DL were invited to take part in a semi-structured interview using open ended questions related to their pathway to the trial, ‘what ACT meant for them, what they remembered about it, if and how it had influenced their lives, and what they had (not) appreciated about it’. Interviews lasted between 34 and 83 minutes. The data were analysed using reflexive thematic analysis (Braun & Clarke, 2019, 2020, 2022).
Results
Two over-arching themes and nine sub-themes were generated by the authors.
Theme 1: The purpose of ACT
Participants demonstrated their understanding of ACT and referred to each of the ACT core processes and the ways their acquired knowledge and psychoeducation was implemented in their daily life. The participants discussed acceptance towards their lived experience and hearing voices, cognitive defusion and the observing oneself, contact with the present moment and grounding, values clarification and committed action towards living closer to those values, and psychological flexibility.
(Since ACT) I try, because I hear voices, to not let them disappear, I experience them and ask them to stop talking. I do not want them to leave anymore (…) which used to make them stronger.
It was educational to see that some things, well, you just cannot change, but you can focus on the things that are changeable.
Theme 2: What to improve?
Participants offered their constructive suggestions on how ACT-DL can be improved for people with psychosis. They discussed how ACT needs to be further tailored to the experiences and symptoms of people with psychosis or psychotic symptoms, and the interventions suitability for individuals who were at risk of psychosis or may had a diagnosis of first-episode psychosis.
I feel like ACT is developed for different people and applied now to people with psychosis, whereas the world of someone with psychosis is so far from the real world (…) You are detached from the daily life, I missed a part on this experience in ACT.
The metaphors were not for me, I mean, tug-of-war here, a dragon there, it makes me think: come on people, please, for someone with already such a full head, just tell me what you mean!
Some participants reflected on the suitability of the modality and the lack of flexibility, as treatment fidelity did not leave much room to adapt the approach. Lastly, participants discussed the importance of a person-centred approach and the development of a trusting therapeutic relationship through time.
The therapist told me, that the treatment has been designed like this for a reason and we were going to follow it exactly. But I was like, if this does not work for me, or I feel uncomfortable with it…then why cannot we search for a different way of doing it?
I do not know this person in front of me yet, so I am not going to tell him: hey, this is what bothers me, (…) because you do not have that relationship of trust yet.
Participants demonstrated a good understanding of ACT principles and suggested improvements for individual experiences of psychosis.
Conclusions
The qualitative paper suggests that ACT-DL helped participants to be more aware of their unwanted and challenging thoughts and emotions and notice fewer urges to change them. This is also reflected within other qualitative studies exploring people’s experiences of taking part in ACT for psychosis (Bacon et al., 2014; Bloy et al., 2021). The study suggests that flexibility in the therapist’s approach and incorporating psychosis-specific interventions may enhance ACT-DL for people with psychosis.
ACT-DL and living closer to one’s life values was feasible and acceptable for people with psychosis.
Strengths and limitations
This is a valuable study as it addresses a key question regarding the experiences of ACT-DL by people with psychosis. By focusing on the lived experience, this study amplifies the voices of people with psychosis. The authors also transparently reflect on their position in relation to the research question, population, intervention, and analysis, which is commendable. Such reflexivity could have been strengthened further by outlining the epistemological position (Denzin & Lincoln, 2013) guiding the study design and conduct.
During analysis, data from participants who were at high risk of psychosis and experiencing a first-episode of psychosis were combined. The authors reflect that in hindsight a richer analysis could have been achieved if the two groups were separated and the data analysed respectively. Additionally, there is a possible limitation in the way that the results section was written as it was not quite clear how the themes were derived as limited analytic points were presented alongside quotes in tables. This may be more of a reflection of limited journal word counts, which is a common systemic issue that qualitative researchers face when publishing their research.
By focusing on participants’ lived experience of acceptance and commitment therapy in daily life, this study amplifies the voices of people with psychosis.
Implications for practice
Acceptance and commitment therapy is a holistic approach which can be tailored to the needs of the individual. The therapy aims to alter an individual’s relationship to unwanted and challenging inner experiences, reduce the impact of such experiences and support them to act in line with their values (Pérez-Álvarez et al., 2008).
ACT’s focus on values and committed action resonated with many study participants and has the potential to help people with psychosis connect or re-connect with themselves and identify or re-identify what matters to them in life. This is particularly important for people with psychosis especially if they have become disconnected from themselves and others, for example, during dissociative experiences (Černis et al., 2020) and/or suicidal experiences (Gooding et al., 2023).
Therefore, this study contributes to the growing evidence-base which suggests that ACT could be another treatment option for people with psychosis. Further studies of ACT for people with psychosis are required to continue building upon the evidence-base.
Within healthcare services, we facilitate ACT-based groups for people with mental health difficulties. We have an opportunity here to set up ACT-based groups specifically for people with psychosis and conduct service evaluation studies to evaluate their feasibility in services.
Further studies of acceptance and commitment therapy for people with psychosis are required to continue building upon the evidence-base.
Statement of interests
Charlotte Huggett is a Clinical Psychologist working in an Early Intervention Psychosis service and her interests include third wave modalities, such as ACT, tailored for people with psychosis. No conflicts of interest to declare.
Links
Primary paper
Bouws, J., Henrard, A., de Koning, M., Schirmbeck, F., van Ghesel Grothe, S., van Aubel, E., Reininghaus, U., de Haan, L., & Myin‐Germeys, I. (2023). Acceptance and Commitment Therapy for individuals at risk for psychosis or with a first psychotic episode: A qualitative study on patients’ perspectives. Early Intervention in Psychiatry.
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