64 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

Cognitive Fusion

Cognitive fusion is related to experiential avoidance as well. The person who

is defused with thoughts feels no need to avoid them—they are seen as mere
verbal events that do not need to be eliminated. In contrast, the person fused
with thoughts takes their content literally. Having a thought that “no one likes
me” or “today is going to be a bad day” means that dire events are certain and
action must be taken to avoid negative outcomes or at least to stop the unwanted
thoughts. In the context of fusion, delusions are fused thoughts and not much
different from other sorts of thoughts. The use of defusion strategies is where
ACT most differs from therapies that aim to challenge delusional beliefs. Maher
(1988) pointed out that delusional beliefs and related overt behaviors are no more
difficult to modify than are beliefs and practices regarded as non-delusional, for
instance, political or spiritual beliefs. In ACT, there is no attempt to change
thought content directly. Instead, the client is encouraged to relate to his or her
thoughts differently. This can lead to increased disengagement from thoughts,
which is associated with greater detachment from them (Shawyer et al., 2007).

Deficits in Perspective Taking

Poor perspective taking may also play a role in the maintenance of both posi-
tive and negative symptoms of psychosis. Perspective taking is related to the
construct of theory of mind, which is known to be impaired in persons with
schizophrenia (Corcoran, 2001). The ability to relate oneself in time and space to
other persons, times, and places allows one to understand past events, consider
the future, including the consequences of past and present behavior, appreciate
the differences between one’s own perspective and the perspectives of others,
and respond to others in a socially appropriate manner. Poor perspective-taking
skills can have negative consequences and may be related to both positive and
negative symptoms (Bach, 2007).
A person who has limited ability to think about the future may show a lack of
motivation and have little concern with such things as keeping appointments or
thinking about future health or finances. A person who does not appreciate that
others have a perspective may be insensitive to the effect of his or her behavior
on others and fail to be concerned with matters such as personal hygiene and
grooming, and may misattribute the actions of others and believe that he or she
is being persecuted. A person who cannot properly relate events in the present
to the past or future may be more likely to misattribute events and be more sub-
ject to delusional beliefs. Recent research on perspective-taking ability suggests
that persons with schizophrenia make more errors in this ability than healthy
controls (Villatte, Monestes, McHugh, Esteve, & Loas, 2010). Facilitating contact
with the present moment can increase one’s ability to relate the present to the
future and the past, and values clarification exercises can improve attention to
future outcomes and consequences of behavior in the present.
Acceptance and Commitment Therapy for Psychosis65

Lack of Values Clarity

For persons with chronic and persistent mental illness, a lack of values clar-
ity may result from a combination of poor perspective-taking ability as well as
lack of opportunity to engage in thinking about values and goals. Persons with
frequent and lengthy hospitalizations may have difficulty making plans for the
future, and treatment planning is often limited to more immediate needs such
as housing and treatment arrangements. Values are important because they give
us a sense of purpose and meaning and help guide behavior. In ACT, values may
also function to increase willingness (Juarascio, Forman, & Herbert, 2010). That
is, one may be more willing to engage in behaviors likely to be accompanied by
unwanted thoughts or feelings when behavior is in the service of values. For
example, a person applying for a job may be more willing to accept rather than
avoid feelings of anxiety and fears of rejection if the behavior is in the service
of values such as self-sufficiency or taking care of others. Values clarification is
similar in some ways to motivational interviewing (Wagner & Sanchez, 2002),
which has been associated with improved insight and medication adherence in
persons with schizophrenia (Rusch & Corrigan, 2002).

Low Commitment

While some may have difficulty identifying values, others may have avoidant val-
ues. This occurs when behavior is in the service of avoiding unwanted thoughts and
feelings. A person who uses illicit substances to avoid anxiety or voices, or someone
who is nonadherent to treatment because they associate participation in treatment
with acceptance of mental illness, may be behaving on the basis of avoidance values.
Values clarification can help the individual identify behaviors that are values con-
sistent and can increase motivation for change, that is, increased committed action.
While the ACT model can be applied to the conceptualization and treatment
of psychosis, some modifications to standard ACT treatment protocols may be
needed for some persons with schizophrenia and other chronic and persistent
mental disorders.

A DA P T I N G ACT TO T H E T R E AT M EN T O F PER SO N S
W I T H PSYC H O S I S

Early studies of ACT for psychosis were followed by recommendations for adapt-
ing ACT to better meet the specific needs of this population (Bach et al., 2006).
Some of the more important modifications to standard ACT protocols include
increasing the amount of repetition while decreasing session duration; simplify-
ing metaphors and using physical metaphors; introducing values early in treat-
ment for involuntary patients; linking treatment adherence to values; and, where
applicable, educating staff and family members about the aims of ACT.
66 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

Cognitive deficits are common in schizophrenia and other chronic and per-
sistent mental illness (Penn, Combs, & Mohamed, 2001). Bach and colleagues
(2006) have recommended that a third of each session be spent reviewing previ-
ous material. Farhall and colleagues (Farhall, Thomas, Shawyer, & Hayes, 2010)
additionally recommend making audio recordings of all therapy sessions. They
provides their therapy clients with an audio CD at the end of each session. They
have found that listening to the recorded session between sessions is positively
associated with therapy outcome. Cognitive deficits may also be accommo-
dated by simplifying the presentation of some of the content in ACT. Popular
clinician guides to ACT include exemplars of many common ACT exercises.
Care can be taken to select and develop one’s own exercises that are shorter in
duration and that are less abstract. While metaphors are necessarily abstract,
they can be made easier to understand by using physical props and/or acting
them out, such as by putting thought content on paper and holding it close to
the client to illustrate fusion with verbal content, or pushing away index cards
with hallucinatory content written on them, to illustrate avoidance. However,
if a client is not motivated for treatment, even these modifications will not be
helpful.
Medication adherence is a sensitive concern for many diagnosed with psy-
chotic disorders. On the one hand, medication adherence tends to be lower than
is desirable. Data on the effectiveness of even so-called second-generation anti-
psychotics are mixed, with some studies showing that they are no more effec-
tive than older medications and have a limited impact on quality of life (Dixon
et al., 2010). Other studies suggest that addressing both the therapeutic alliance
and treatment adherence in treatment tends to improve medication adherence,
and that having a more positive attitude toward medication is associated with
improved adherence and better community functioning (Mohamed et al., 2009).
Further, Rose, Novitsky, and Dubin (2009) suggest the utility of addressing med-
ication adherence with strategies such as CBT and motivational interviewing,
in addition to providing psychoeducation, and spending time identifying and
addressing barriers to treatment adherence. During the committed action pro-
cess, the ACT therapist can help the client identify where medication nonadher-
ence, and indeed nonadherence to any form of treatment, might be a barrier to
attaining valued outcomes. Such strategies may improve willingness to engage in
treatment and promote better outcomes.
Many clients with psychotic disorders are treated on an involuntary basis, and
others, having voluntary status in a legal sense, may be disengaged from treat-
ment. In such cases it can be helpful to begin treatment with values clarification
(Bach et al., 2006). A more motivated client may be willing to practice accep-
tance and defusion; however, a less engaged client may be unwilling. Quickly
engaging the client around the larger context of values clarification can help to
focus and engage clients on the issue of relapse rather than the issue of getting
out of the hospital. Emphasizing what the client wants in his or her life can be
more helpful than focusing on problems first, as might occur if treatment were
to begin by exploring experiential avoidance and acceptance.
Acceptance and Commitment Therapy for Psychosis67

Once a client is engaged in treatment it may be helpful in some cases, depend-

ing on the particular situation of the client, to provide psychoeducation about
ACT to interdisciplinary treatment providers and/or to family members. While
mindfulness and acceptance-based treatments are becoming more common, to
many they remain outside of the mainstream or are associated with “alternative”
practices. Bach and Hayes (2002) found that inpatient participants exposed to
ACT were more likely to report symptoms of psychosis following exposure to
ACT. They interpreted this observation to mean that clients were more accept-
ing of and defused from symptoms, and thus were also more willing to report
them. Even while taking medications as prescribed, the majority of persons with
a diagnosis of schizophrenia continue to report positive symptoms, although
often in attenuated form. For instance, in a study of 6,642 patients, only a third
reported no or minimal positive symptoms or psychosis 3 years after begin-
ning treatment (Novick, Haro, Suarez, Vieta, & Naber, 2009). However, some
treatment providers and family members might find reports of such symptoms
concerning. In some cases reporting a symptom such as the presence of halluci-
nations may be grounds to keep a patient hospitalized, so it would be essential
for the ACT therapist to provide some education about ACT and to let important
others know that ACT is aimed at increasing acceptance of and defusion from
symptoms, and that this approach might be followed by an increase in reported
symptoms of psychosis. A case example is provided next to illustrate how ACT
in the treatment of psychosis might proceed.

ACT I N ACT I O N: CAS E V I G N E T T E O F

ACT FO R PSYC H O S I S

History

The case of Justin will be considered in order to illustrate the use of ACT in
the treatment of psychosis. Justin is a 38-year-old single white male diagnosed
with paranoid schizophrenia. His first hospitalization was at age 20 when he was
hospitalized for almost 3 months. He had persistent persecutory delusions that
people were plotting against him and wished to harm both him and his father.
Specifically, he believed that they were poisoning the water. He was admitted
for the first time after he made suicidal and homicidal threats. During periods
of remission Justin functioned rather well. He lived in an apartment with some
financial assistance from his father, he had completed some college and worked
part-time doing data entry. He had a close relationship with his father and one
of his sisters visited him regularly. When his symptoms were in remission he
took medication as prescribed and attended monthly visits with a case manager.
During acute episodes of his illness he typically became increasingly paranoid
over a period of several weeks, during which he usually ceased communica-
tion with all family members except for his father, who lived a quarter of a mile
away. His work attendance became sporadic, and his hygiene and grooming
68 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

deteriorated because he avoided showering and laundering his clothing, fear-

ing that the water was poisoned. He would also stop taking his medications and
experience increasingly persistent auditory hallucinations when unmedicated.
On each occasion, 11 times overall, Justin was hospitalized for 1 to 2 months. He
usually had significant symptoms of depression following each hospitalization
and took some time to return to premorbid levels of functioning.
Justin was first introduced to ACT while an inpatient, having been recently
hospitalized with paranoid delusions and auditory hallucinations. He was
approached about therapy a few days following his admission, after he had started
medication and his symptoms had remitted somewhat. Therapy was a standard
part of treatment on the unit, with about half of inpatients receiving individual
therapy in addition to participation in psychosocial groups. The specific therapy
approach varied by clinician. Justin had not heard of ACT specifically. He was
willing to participate in therapy and acknowledged that he had found therapy
helpful in the past. Justin and the therapist agreed that they would meet two or
three times a week for the duration of Justin’s hospitalization.
Justin had reasonable insight into the nature of his illness—a favorable predic-
tor of treatment outcome in schizophrenia (Mohamed et al., 2009), though also
associated with increased depression (Narvaez, Twamley, McKibbin, Heaton, &
Patterson, 2008). While he lacked insight into the delusional nature of his beliefs
when fully in the acute phase of the illness, most times he was able to acknowl-
edge that “sometimes I get paranoid.” His insight was important, for it made it
somewhat easier to describe and implement techniques for coping with delu-
sional beliefs and auditory hallucinations.
Like many individuals with schizophrenia, Justin had few close relationships
with others. He was especially close with his father, and he wanted his father’s
admiration and trust. He had a reasonably close relationship with one of his sis-
ters. He named his outpatient case manager, who had been working with him for
8 years, as someone he liked and trusted.

Treatment

The first two sessions were spent introducing the ACT model to Justin. The
clinician explored his attempts to cope with unwanted symptoms. He avoided
delusional thought content by staying indoors and avoiding even telephone and
Internet contact with others, with the exception of his father. He stopped going
to work and stopped participating in treatment. On occasions when his case
manager made a welfare check-in visit, he told her he was “fine” and asked her to
leave. He said that he did these things because he was afraid.
The therapist asked him if his actions helped stop his fearful thoughts and
feelings. Justin acknowledged that his fear usually increased with time, and that
all he could think about was the possibility of being poisoned. The therapist also
asked him about the consequences of his actions, reviewing the previous two
hospitalizations. Justin noted that on both occasions he was fired from his job,
Acceptance and Commitment Therapy for Psychosis69

he failed to meet financial obligations such as paying bills, and he stopped taking
medications, which increased his auditory hallucinations and general distress.
He said, “Now [while medicated] it seems dumb. I wish I didn’t have this [schizo-
phrenia], and I don’t know what else to do when it seems like people want to hurt
me.” He was able to see that his strategy for coping with his distress had negative
consequences, and he said that he was willing to try something new.
The idea of accepting symptoms and defusing from verbal content such as
delusional beliefs and hallucinatory content was new to Justin. He was skeptical
and said that he preferred to be rid of the symptoms. The therapist gave some
examples of how one can notice thoughts without “buying” them. For instance,
one could have a thought about eating and choose not to eat, or have a thought
about staying home from work and still go to work. Justin wondered if it was
okay to acknowledge thoughts instead of denying them, and the therapist had
him begin noticing and labeling his thoughts in session. He found it difficult not
to get caught up in his thoughts and that he was not confident he would be able to
“just notice” paranoid thoughts. The therapist assured him that this was difficult
for everyone to do, and that it would be important for him to practice between
sessions. At this point in his treatment, Justin was permitted access to the hos-
pital grounds; one homework exercise was for him to walk around the grounds
and practice labeling the things he saw (and later in treatment, he also practiced
labeling what he heard, as an alternate exercise). This allowed him to get in the
habit of focusing his attention and observing the present moment. He also was
able to notice how easy it is to become distracted, and that at any moment one
could redirect attention and resume noticing the present. After 1 week, Justin
began practicing noticing his thoughts, for 5 minutes twice a day. He completed
this assignment about half the time, saying that he sometimes “forgot.” He found
noticing and labeling his thoughts to be more difficult than labeling what he saw
and heard. He said that he often was distracted and that he did not want to notice
negative feelings and thoughts. The therapist used the standard intervention of
asking the client about his experience of avoidance—had he used avoidance
strategies before? When? How had they worked? Justin rather quickly acknowl-
edged that avoidance had not been helpful in the past. However, he continued to
maintain that delusional beliefs were “crazy” and should be gotten rid of.
Justin also noted that his father, sister, and case manager often inquired about
his symptoms, and stated that he often denied the presence of symptoms to oth-
ers. He expressed concern that his father or case manager might “send me here
again” if he reported to them that he was experiencing symptoms of psycho-
sis and “just accepting them.” Justin’s reaction to disclosing symptoms is not
uncommon—avoidance of unwanted thought content is common, and treat-
ment providers and family members routinely inquire about the presence of
symptoms. This information was important, since others might not be aware of
acceptance as a coping strategy and regard the presence of hallucinatory or delu-
sional content as “bad.” The therapist decided to include Justin’s father during a
later session to explain what they were trying to do—relate differently to symp-
toms rather than trying to eliminate them. The therapist also met with Justin’s
70 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

case manager, who knew a little about ACT, so that she would also be on board
with Justin’s new cognitive approach to working with symptoms. These conver-
sations were important for assuring Justin that it would be okay to acknowl-
edge the presence of symptoms to his father and to his case manager, and that
his treatment goal of accepting and defusing from verbal content would not be
undermined by his verbal community.
Even while Justin’s symptoms of psychosis were remitting and he appeared
to be coping with them, as occurs quite often in acute phases of schizophrenia,
his feelings of depression began to increase, leaving Justin to feel hopeless and
guilty. Although, as noted earlier, poor perspective-taking skills may be associ-
ated with symptoms of psychosis, this deficit appeared to increase Justin’s sense
of “badness,” as he judged himself harshly and presumed that others did too,
and he was convinced that “nothing will ever change.” Increased work on defus-
ing from judgments and other depressogenic thoughts was somewhat helpful to
Justin, and working on developing self-as-perspective skills was also introduced
at about this time. Justin participated in a modified version of the observing-self
exercise. In most versions of this exercise (e.g., see Bach & Moran, 2008; Hayes,
Strosahl, & Wilson, 2011; Zettle, 2007) individuals are invited to recall a moment
from the recent past and “see” themselves in their mind’s eye, as if they were an
observer, and to notice that even while it is the present moment, one can look
back at past moments. The exercise continues with the client being invited to
notice body sensations, roles, feelings, and thoughts . . . and to notice that he or
she is distinct from all of these things and experiences . . . that even while one has
a body, and has memories, and had thoughts, feelings, and sensations . . . there
is an important sense in that although one has feelings, thoughts, sensations . . .
one is not one’s thoughts, feelings, and sensations.
Work on perspective taking is necessarily abstract. The exercise was modi-
fied to begin with Justin imagining seeing words on a computer screen, specifi-
cally words that functioned as descriptions about him—for instance, reading the
words, “you are a bad person.” Could he read those words on a computer and
observe them and notice that even while they might seem to be about him, they
were not him and he was free to disregard them? By beginning the exercise with
a more concrete example of observing content, Justin was better able to under-
stand and participate in the later, more abstract parts of the exercise. Many cli-
ents find the exercise peaceful and experience the self as being at peace when not
being buffeted about by feelings and judgments about the self.
Justin was making good progress, and while his depressive symptoms remained,
his symptoms of psychosis were remitted somewhat as he was taking medication.
The next phase of treatment was values work. Values clarification was most impor-
tant for linking Justin’s unworkable behaviors—avoidance and medication non-
adherence—to his values and goals. He initially had difficulty identifying values,
so the therapist had him instead describe some of his goals. He was able to iden-
tify several goals, including finding employment (e.g., he was let go from his most
recent job just before his hospitalization), “not worrying his father,” and thinking
he might want to quit smoking. He thought he “maybe wanted a girlfriend,” and
Acceptance and Commitment Therapy for Psychosis71

he was unsure since he had not dated since being diagnosed with schizophrenia.
When he elaborated on these goals, they were more easily linked to some impor-
tant values for Justin. He valued being self-sufficient and self-supporting, valued
close family relationships, and did not want to be a financial or emotional burden
to his family. He wanted to explore romantic relationships but was unsure what
the outcome might be and lacked dating skills. He wanted to quit smoking in the
service of improving his health and in the interest of better managing his money.
These values were then linked to specific committed actions that Justin could take.
Justin did not mention medication adherence as a goal, and the therapist
wanted to link medication adherence to Justin’s values. Most of his hospitaliza-
tions had quickly followed periods of medication nonadherence. The therapist
revisited unworkable change agendas with Justin, and he was able to acknowledge
that discontinuing his medication was often associated with negative outcomes.
Most importantly, he recalled past hospitalizations and linked specific negative
consequences of medication nonadherence to his own experience, rather than
through persuasion on the part of the clinician. He committed to improving his
medication adherence, and both he and the clinician noted that this was espe-
cially difficult for him when his symptoms worsened. Justin agreed to sign an
advance directive authorizing his father and case manager to hospitalize him in
the event of medication nonadherence and the presence of significant symptoms
of psychosis. While this strategy might not prevent hospitalization completely, it
could very well lead to less severe consequences to Justin’s freedom, employment,
and finances. Justin also signed up to participate a dating skills group offered at
the community mental health center where he received outpatient treatment,
and he said he would work with his case manager on smoking cessation. He also
made a commitment to continue to do mindfulness exercises, such as noticing
and labeling his thoughts and feelings or things in the environment.
At this point in time Justin was engaged in discharge planning. His last few
therapy sessions were spent on exploring “barriers to values.” Specifically, he
and the clinician worked on troubleshooting what Justin perceived to be barri-
ers to completing his committed actions. He worried that he might not be able
to adhere to his plan if he became paranoid or if his symptoms of depression
worsened, and he acknowledged that he had attempted to quit smoking in the
past will little success. His plans for overcoming these barriers were to report
symptoms to his case manager, and to practice defusion when he encountered
paranoid or depressive thoughts. He noted that fear of failing was no reason
not to attempt quitting smoking, or dating, and that these were worth doing no
matter what the outcome might be. Justin was discharged after 7 weeks in the
hospital and 16 sessions of ACT.

Post-Discharge

Approximately 15 months later he experienced an exacerbation of his symptoms.

With the advance directive in place, his case manager had him hospitalized.
72 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

While Justin was initially furious, on later reflection he agreed that “it was a
good thing,” as he was quickly stabilized on medication and his hospitalization
was only 3 days in duration. He was discharged with his job and dignity intact.
During those 15 months he had quit smoking four times, had remained absti-
nent from smoking for up to 6 weeks, and vowed to persist in attempting to
attain complete smoking cessation. He completed the dating skills course and
decided that while he felt he had learned useful skills, he did not really want to
date, and that dating would in fact be in the service of pleasing others rather than
doing something that truly interested him at the time. Overall, he evaluated his
course of therapy as helping him to “figure out what I want and hopefully stay
out of the hospital so I can do what I want.”

R ES E A R C H S U PP O RT FO R AC C EP TA N C E A N D
C O M M I T M EN T T H ER A PY FO R PSYC H O S I S

Justin’s course of treatment is fairly typical with respect to the course of ACT
for psychosis. The first study of ACT for symptoms of psychosis was published
in 2002 (Bach & Hayes). The participants were inpatients at a state psychiatric
hospital in Nevada. The inclusion criteria were the presence of hallucinations or
delusional beliefs at intake, and that the client was able to consent to participate.
Exclusion criteria were having a legal guardian, a diagnosis of substance-induced
psychosis, or comorbid mental retardation. Most who agreed to participate had
a long history of treatment at the facility including multiple hospitalizations;
individuals who had not been hospitalized before tended to decline to partici-
pate. The majority of the 80 participants recruited for the study had a diagnosis
of schizophrenia (N = 43), and others had diagnoses of schizoaffective disor-
der, mood disorder with psychotic features, psychotic disorder not otherwise
specified (NOS), or delusional disorder. The primary outcome measure was time
(days) to rehospitalization. The treatment group participated in four sessions of
ACT plus treatment as usual (TAU), while a control group received TAU only.
The results were that 20% of the ACT participants and 40% of the TAU par-
ticipants were rehospitalized during a 120-day follow-up. Considered as a group,
ACT participants remained out of the hospital an average of 22 days longer than
TAU participants. These differences were statistically significant, and the differ-
ence remained significant at 1 year follow-up and after controlling for previous
hospitalization and duration of hospital stay (Bach, Hayes, & Gallop, 2012). ACT
participants also showed greater reductions in believability of symptom content
as measured by a Likert-type rating scale created for the study. Interestingly,
the ACT participants were twice as likely as TAU participants to report symp-
toms of psychosis at follow-up. The authors suggested that this finding may have
been due to ACT participants becoming more accepting of symptoms and thus
more likely to acknowledge their presence post-treatment. While not a direct
measure of acceptance, those who reported symptoms reported significantly
reduced symptom-related distress at follow-up. In contrast, an individual who
Acceptance and Commitment Therapy for Psychosis73

is avoiding symptoms might deny their presence even while they are occurring
(Bach & Hayes, 2002). Indeed, Waters (2010) subsequently found that symptom
underreporting is common in persons with psychotic disorders because of the
negative consequences of reporting symptoms. Limitations of Bach and Hayes’
(2002) study were that diagnoses were not assigned in a standardized manner
and treatment integrity was not assessed. Also, a TAU comparison group is
less than ideal, compared to an active treatment comparison group. The sample
was also less likely to have a diagnosis of secondary substance abuse and more
likely to be fully or partially medication adherent than the average person with
a chronic and persistent mental illness, so the results may not generalize to all
persons with psychotic disorders. That said, given the high social and economic
costs associated with hospitalization, the results may be regarded as meaning-
ful: rehospitalization was reduced, and results were consistent with the ACT
model of psychopathology.
Gaudiano and Herbert (2006) completed a replication and extension of the
Bach and Hayes (2002) study. Their study was completed at an inpatient facility
in Philadelphia. Participants received an average of three sessions of ACT, the
exact number of sessions being determined by length of participant hospital-
ization. This study improved on some of the limitations of the Bach and Hayes
(2002) study. For instance, Gaudiano and Herbert (2006) used an enhanced
treatment as usual (ETAU) comparison condition in which the number of
contact hours of treatment was controlled and equal for participants in each
condition, and they administered standardized measures of symptom sever-
ity and global functioning, such as the Brief Psychiatric Rating Scale (Overall
& Gorham, 1962), at baseline and post-treatment. Although the results did
not reach statistical significance in uncontrolled analyses, they were similar
to results of the first study, with rehospitalization rates of 45% for the TAU
group compared to 28% for the ACT group. Additionally, the ACT partici-
pants had lower symptom believability and greater reductions in psychiatric
symptoms, social impairment, and hallucination-related distress as compared
to the ETAU group (Gaudiano & Herbert, 2006). A later follow-up analysis
showed that the ACT group had a significantly longer time to rehospitaliza-
tion than that for the ETAU group after controlling for baseline symptoms
severity (Bach, Gaudiano, Hayes, & Herbert, 2013). Gaudiano, Herbert, and
Hayes (2010) followed up this study with a mediation analysis and found that
symptom believability at post-treatment mediated the relationship between
treatment condition and symptom-related distress. In a further mediation
analysis, the data from the two ACT for psychosis studies were combined so
as to achieve greater statistical power; it was found that post-treatment symp-
tom believability mediated the effect of treatment condition on hospitalization
(Bach et al., 2012). Further, neither symptom frequency nor symptom-related
distress mediated the outcome. These mediation studies provide support for
the proposed mechanism of ACT—that relating differently to symptoms can
reduce negative consequences attributed to their presence, even when symp-
tom frequency remains high.
74 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

Since the first randomized controlled trials of ACT were completed there
have been additional trials of ACT for psychosis. ACT was also recently applied
in order to assess its feasibility for treating depression in persons with psychotic
disorders. Depression is common in persons with schizophrenia and is asso-
ciated with poorer outcome. Analysis of a large-scale study on the effective-
ness of both pharmacological and psychosocial treatments for schizophrenia
included the recommendation that there be more study on the effectiveness of
CBT for depression in persons with schizophrenia (Dixon et al., 2010). White
and colleagues (2011) completed a feasibility study of ACT for emotional dys-
function following psychosis. They found that in a sample of 27 participants
who met criteria for a psychotic disorder and scored high on a measure of
depression, ACT participants were more likely than TAU participants to have
their status change from depressed to non-depressed, showed greater reduc-
tions in negative symptoms, and demonstrated increases in mindfulness skills.
These findings are particularly encouraging, given that depression is common
in schizophrenia and is associated with poorer quality of life (Narvaez et al.,
2008). In addition to the research studies described here, there are a few pub-
lished case studies documenting the utility of ACT for schizophrenia (e.g.,
Garcia-Montes, Luciano, Hernandez, & Zaldivar, 2004; Veiga, Perez, & Garcia,
2008), and a recent open trial of ACT delivered in a group treatment format
(Morris & Oliver, 2008) resulted in improved recovery following a first episode
of psychosis.
Patients’ evaluations of ACT have also been assessed. Bacon, Farhall, and
Fossey (2014) specifically studied clients’ perceptions of ACT through adminis-
tering a semi-structured interview to nine participants diagnosed with schizo-
phrenia. They found that all of the participants found ACT helpful and would
recommend it to others; participants also reported that, as predicted by the ACT
model, symptom frequency did not change, while symptom intensity and associ-
ated distress were reduced. Acceptance, defusion, mindfulness, and values work
were described as the most useful components of treatment.
There have also been some attempts to combine components of ACT with
other treatments, and the results have been mixed. One study combined ele-
ments of ACT and more traditional CBT for command hallucinations. Patients
were taught both how to modify beliefs and work on accepting hallucinations as
part of a 15-session intervention called treatment of resistant command halluci-
nations (TORCH). This treatment was compared to befriending, a manualized
control treatment that provides similar therapist engagement to CBT, and to a
waitlist condition. On the one hand, participants in the TORCH group showed
more improvement than the waitlist group. On the other hand, the TORCH and
befriending groups had similar outcomes across several variables. Although
both groups reported at post-treatment that they felt they would be better able
to resist command hallucinations, these gains were not maintained at follow-up.
However, there were some group differences in several variables. For instance,
the TORCH group showed greater symptom reduction at follow-up and the
befriending group showed greater decreases in symptom-associated distress.
Acceptance and Commitment Therapy for Psychosis75

The TORCH participants were also more likely to show gains and maintain
improvements at follow-up, whereas befriending participants reported most
gains post-treatment and not all were maintained at follow-up. The authors
pointed out that the study was small (N = 44) and to the possibility that com-
bining techniques of both CBT and ACT may have created some confusion
(Shawyer et al., 2012).
Another study combining treatment approaches attained more success-
ful outcomes. Cognitive-behavioral therapies including ACT have been
applied and studied in persons with depression and, more recently, albeit
to a lesser extent in persons with psychotic disorders. Gaudiano and col-
leagues (Gaudiano, Nowlan, Brown, Epstein-Lubow, & Miller, 2013) have
combined these approaches and published the results of the first open trial
of acceptance-based depression and psychosis treatment (ADAPT) for per-
sons with psychotic depression. Their treatment combined behavior activa-
tion with ACT. They provided up to 6 months of ADAPT combined with
medication to 14 individuals diagnosed with depression with psychotic fea-
tures. The 11 participants that completed treatment had improved depressive
and psychotic symptoms. Further, their scores on measures related to ACT
processes also improved. Specifically, there were large effect size improve-
ments on measures of psychological flexibility, values-consistent behaviors,
and mindfulness.

C O M M O N VS. D I ST I N CT I V E EL EM EN TS O F ACT

ACT is often described as a “stance” toward treatment, rather than a treat-

ment per se. This is in part because specific interventions of many varieties
can be applied as part of the committed action process, while acceptance, con-
tact with the present moment, and values clarification might be used to bol-
ster willingness to actively participate in behavior change activities through
committed actions.
ACT is most incompatible with conventional cognitive therapy strategies
in the specific areas of acceptance and defusion vs. cognitive restructuring.
Acceptance and defusion exercises teach clients to notice their thoughts as they
are, and to accept and be willing to have whatever thoughts, feelings, and sensa-
tions show up. In contrast, many cognitive restructuring techniques are aimed at
changing thought content, which is at odds with the notion of accepting thought
content. In spite of this area of conflict, other interventions appear to be more
compatible, and the practice of combining treatment strategies is on the rise. For
instance, mindfulness techniques and values clarification are being combined
with other approaches such as the addition of values clarification to behavior
activation (Kanter et al., 2010) and the addition of mindfulness techniques to
treatments as diverse as eye movement desensitization and reprocessing (EMDR)
and relapse prevention for alcohol and substance abuse (Witkiewitz, Marlatt, &
Walker, 2005).
76 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

F U T U R E R ES E A R C H D I R ECT I O N S

Research on ACT for psychosis has been promising thus far. However, more
research is needed. Three aspects of research on ACT for psychosis that must
be enhanced are samples and sample sizes, the specificity of ACT for psychosis
treatment protocols, and outcome measures. The largest controlled trial included
80 participants; all other trials of ACT for psychosis have had fewer than 40
participants. Trials with larger numbers of participants are needed. Further,
both of the two largest trials included samples that were mixed with regard to
diagnosis, and those that were limited to participants with the same diagnosis
include case studies and/or small samples with protocols that combined ACT
with other interventions. Larger studies with samples that are more homogenous
with regard to diagnosis can refine knowledge about the effectiveness of ACT
for psychosis.
A second area for future research is to provide more clearly specified treat-
ment protocols with treatment integrity evaluated. The two largest trials to date
(Bach & Hayes, 2002; Gaudiano & Herbert, 2006) both had poorly specified
treatment protocols, making replication difficult. It is encouraging that media-
tional analyses of ACT for psychosis have supported the proposed mechanism
of change (Bach et al., 2012; Gaudiano et al., 2010), and further studies of large
samples of persons with symptoms of psychosis are needed in order to determine
if the results hold for persons with different disorders and different demographic
characteristics.
Future studies of ACT for psychosis will also benefit from improved outcome
measures. In the last decade since the first trials of ACT for psychosis were com-
pleted, measures of important ACT processes and outcomes have been devel-
oped and/or improved (e.g., see Bond et al., 2011), and a measure specific to
acceptance of symptoms of psychosis has been developed (Shawyer et al., 2007).
These advances will allow for improved assessment of effectiveness and media-
tion. Fortunately, the future is now; at the time of this writing, larger clinical
trials of ACT for psychosis are being developed or are underway.

C O N C LU S I O N

While medications have traditionally been the treatment of choice for persons
with symptoms of psychosis, there is growing awareness that although medica-
tions can be helpful for reducing symptoms, they are frequently not sufficient for
significant functional improvement and recovery. There is growing evidence that
psychotherapy can be a useful part of treatment for persons with symptoms of
psychosis (Dixon et al., 2010). ACT is one psychosocial approach to the treatment
of psychotic symptoms. ACT may be particularly useful because specific interven-
tions can be adapted to low functioning and involuntary clients, and ACT can
be used alone or it can be integrated with the interdisciplinary treatments com-
monly used in inpatient and other intensive settings. ACT is not aimed at reducing
Acceptance and Commitment Therapy for Psychosis77

symptoms of psychosis; in fact, most participants in ACT for psychosis continue to

acknowledge experiencing hallucinations and/or delusions. However, the believ-
ability of their symptoms is greatly reduced, which appears to mediate treatment
outcomes and may contribute to lower rates of relapse and rehospitalization and
to decreases in subjective distress associated with symptoms (Bach et al., 2006;
Gaudiano et al., 2010). The emphasis in ACT on engaging in committed actions
that are consistent with chosen values while accepting or allowing the occurrence
of psychotic symptoms is a departure from other common treatment approaches
that aim to reduce or eliminate positive symptoms. In contrast, the ACT thera-
pist aims to enhance client motivation to change behaviors, including adherence
to treatment, while working toward values-consistent goals, rather than acting in
accordance with their symptoms or engaging in detrimental behaviors in the ser-
vice of avoiding or escaping symptoms. On the whole, the body of evidence for
the effectiveness of ACT for psychosis remains small but encouraging. Research
results suggest that ACT may be useful for decreasing hospitalization and reducing
symptom-associated distress. Further, mediation studies suggest that ACT for psy-
chosis works through the mechanism posited by contextual scientific theory, and
specifically through decreasing symptom believability and related attachment to
reducing symptom frequency. More studies are certainly needed, and the evidence
that ACT can be an effective treatment for persons with psychosis is growing.

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 5

Treating Depression in Psychosis

Self-Compassion as a Valued Life Direction

ROSS G. WHITE ■

OV ERV I E W

Depression occurring in the context of psychosis is recognized as a clinically

important issue. Rates of depression following psychosis can be as high as
50% in first-episode populations and 33% in individuals with established psy-
chosis (Whitehead, Moss, Cardno, Lewis, 2002). The experience of depres-
sion has been highlighted as one of the major factors contributing to poorer
quality of life among individuals with psychotic disorders generally (Saarni
et al., 2010) and schizophrenia specifically (Meijer, Koeter, Sprangers, Schene,
2009; Narvaez, Twamley, McKibbin, Heaton, & Patterson, 2008). The asso-
ciation between depression and psychosis also appears to predate the emer-
gence of the psychosis. Research has indicated that 83% of individuals with
first-episode psychosis have previously experienced an episode of depres-
sion (Häfner et al., 2005). In an attempt to understand the phenomenology
of depression that occurs following the experience of psychosis, Birchwood
and colleagues (Birchwood, Mason, MacMillan, & Healy, 1993; Birchwood,
Iqbal, Chadwick, & Trower, 2000; Iqbal, Birchwood, Chadwick, & Trower,
2000) found that depression emerges independently of positive and negative
symptom severity and is associated with appraisals of loss (e.g., the ending of
friendships, aspirations for the future), entrapment (worrying that the psy-
chosis will recur), and humiliation (feeling embarrassed and stigmatized by
the experience of psychosis).
This chapter builds on the work of White (2013) to highlight how acceptance
and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) can be used to
treat depression occurring in the context of psychosis. The chapter will outline
82 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s

the role that threat-focused appraisals (relating to themes such as loss, entrap-
ment, and humiliation) play in activating what has been termed the social rank
mentality—an evolutionary derived set of psychological, behavioral, and biologi-
cal responses that serve to alert the individual to threat from others and internal-
ized self-generated threat (i.e., internalized stigma and/or self-criticism) (Gilbert,
2009). Although the social rank mentality can serve the adaptive function of
protecting the individual from harm, we propose that it also promotes excessive
cognitive fusion with the content of threat-focused appraisals, which leads to
rigid and avoidant patterns of responding that deprive the individual of oppor-
tunities to experience positive affect. The case will be made for supplementing
an ACT protocol with strategies that specifically aim to reduce the influence of
the social rank mentality. A vignette of an individual presenting with depres-
sion occurring in the context of psychosis will also be described. The chapter
will then describe a therapy protocol that can be used to address this important
clinical issue.

T R E AT I N G D EPR ES S I O N I N T H E C O N T E X T
O F PSYC H O S I S

Drawing on research highlighting the important role that rumination can play
in the emergence and maintenance of depression (Cribb, Moulds, & Carter,
2006; Nolen-Hoeksema, 2000; Nolen-Hoeksema, Morrow, & Fredrickson, 1993;
Watkins & Moulds, 2005), I have previously proposed that depression occur-
ring in the context of psychosis is the result of psychological and behavioral
rigidity that serves to minimize exposure to further sources of threat and/or
the possibility of being overwhelmed by levels of affect (White, 2013). In this
sense, we believe that it is inappropriate to think about “depression” as a tan-
gible entity in its own right. Instead, we propose that depression be regarded as
a process—a means to an end, rather than an end in itself. Rather than focusing
on the noun depression it might therefore be more helpful for us to consider the
verb to depress. From an ACT perspective, the principal therapeutic focus will
be the avoidant patterns of thinking, feeling, and behaving that are depressing
the individual’s capacity to engage with personally held values. This maladap-
tive attempt to minimize threat serves to also minimize opportunities to expe-
rience positive affect.
Our feasibility study of ACT for emotional dysfunction following psy-
chosis found that a significantly greater proportion of individuals receiv-
ing ACT, compared to those receiving treatment as usual, changed from
being depressed at the time of entry into the study to not being depressed at
3-month post-baseline follow-up (White et al., 2011). These results are con-
sistent with those of Gaudiano and Herbert (2006), who found a marginally
significant impact of ACT, relative to enhanced treatment as usual (TAU), on
mood as assessed by the Brief Psychiatric Rating Scale (BPRS) affect subscore.
More recently, Gaudiano, Nowlan, Brown, Epstein-Lubow, & Miller (2013)
Treating Depression in Psychosis83

conducted a trial in which 14 participants with major depressive disorder with

psychotic features were provided up to 6 months of acceptance and commit-
ment therapy. Clinically significant and persisting improvements in psycho-
social functioning and both depressive and psychotic symptoms were noted
through post-treatment follow-up. Furthermore, changes in ACT-related
processes (acceptance, mindfulness, and values) were significantly correlated
with changes in symptoms (Gaudiano et al., 2013). Building on this existing
research, we have commenced a pilot randomized controlled trial of ACT for
post-psychotic depression. This chapter will reflect on the development of a
therapy protocol for this ACT for Depression After Psychosis (ADAPT) trial
and the specific adaptations that can be made to ACT protocols that could
optimize the effectiveness of treatments for depression occurring in the con-
text of psychosis.
The development of ACT has coincided with the emergence of another inno-
vation in psychological therapy, called compassion-focused therapy (CFT;
Gilbert, 2010). ACT and CFT share some important features. For example,
both approaches place emphasis on the importance of evolutionary factors
as contributing to the maintenance of human suffering, and both approaches
stress the importance of mindful acceptance. In light of these commonalities,
it is unsurprising that there is continued dialogue between the originators
of both approaches, and that ACT and CFT have been referred to as “fellow
travelers” by the originators of the approaches. To date, however, little attempt
has been made to explore the possibility of integrating ACT and CFT proto-
cols. I believe that a strong case can be made for specifically emphasizing the
prominent role that compassion-focused work can play in addressing depres-
sion that can occur in the context of psychosis. In particular, I will present
the case for tackling depression occurring in the context of psychosis by using
an ACT framework, to help individuals develop self-compassion as a valued
life direction.

SO C I A L M EN TA L I T I ES A N D
C O M PAS S I O N - FO C U S ED T H ER A PY

Social mentality theory (Gilbert, 2001; 2005) proposes that evolutionary-derived

systems lead to the interplay between emotional, motivational, cognitive, and
behavioral processes that shape relationships between the self and others.
Social mentalities are context dependent. For example, the toning down of
positive emotion, confidence, and explorative behavior (features of the clini-
cal presentation of depression) may be adaptive when suffering a major defeat
or loss of attachment, but not under other circumstances. It is suggested that
social mentalities play an important role in appraising threat, enhancing safe-
ness, and regulating the affect associated with these evolutionary challenges
(MacBeth, Schwannauer, & Gumley, 2008). Building on the work of Panksepp
(1998), Depue and Morrone-Strupinsky (2005), and others, Gilbert (2009) has