Tania Lecomte, Ph.D., Université de MontréalBassam Khoury, Ph.D.-candidate, Université de MontréalAlexandre Benoit, RN, M.Sc., Hôpital Louis-H. LafontaineClaude Leclerc, R.N., Ph.D., Université du Québec à Trois-Rivières

Using ACT and Mindfulness in group therapy for individuals with early psychosis - adaptations and

successes

Relevance of ACT and Mindfulness for early psychosisIndividuals with early psychosis are increasingly

being offered psychological therapies + medication in order to help improve coping strategies & stress management, and to prevent relapse.

Studies have suggested that ACT (Bach & Hayes, 2004; Gaudiano & Herbert, 2006) could be useful for individuals with psychotic disorders, though few have specifically investigated it with individuals with early psychosis.

Individuals with early psychosis experience distress, anxiety and depression linked with their diagnosis and the overall experience of psychosis, difficulties which have been documented as responding well to ACT and Mindfulness.

Our interest for ACT and Mindfulness for early psychosis We recently conducted a large RCT using group

CBT for psychosis (Lecomte et al., 2008, J Nerv and Ment Dis)and have obtained significant results in terms of decrease in symptoms and increase in self-esteem in the intervention, there was a brief

mindfulness/relaxation intervention that was rated as one of the preferred activities for many participants.

Recovery, as defined by the consumer-survivor movement, is about hope, redefining oneself according to one’s values, and includes spiritual as well as functional aspects – many of these same principles are present in ACT…

ObjectivesDetermine the feasibility and overall

acceptability of ACT/Mindfulness for early psychosis

Study 1Conducted by Alexandre Benoît, under

the supervision of Claude Leclerc.Procedure:

A manualized 4 session group ACT for individuals with early psychosis was initially developed closely following the ACT principles, for recently discharged patients in a specialized first episode clinic.

Each session included activities that covered one or more of the following six ACT clinical steps:1. Creative despair2. Control as a problem 3. Cognitive defusion or distance from thoughts4. Self as an observer5. Clarifying values6. Engagement towards values and actions

Study 1 (cont’d)

The bus driver (one participant is the driver and the others say things that make to make the person: anxious, sad, guilty, shameful, or feel good)

Bringing your thoughts for a walk (in pairs)The polygraph (if anxious = get shocked…

what will happen?)Do not think of a pink elephant…

The sessions included various activities, e.g.

Study 1 (cont’d)

Participants could only be referred by a psychiatrist (ethic’s board demand), if between 18-35 and at the First Episode Clinic (less than 2 years with psychotic symptoms)

Over the course of 1 year, only 6 participants were referred, of which 4 accepted and completed the intervention (X=30, 1 woman).

Reasons: psychiatrists in the clinic were not open to new

psychological interventions, even after presentations.

The intervention was offered by nurses… (perhaps more referrals if psychiatry residents were involved)

Procedure

Study 1 (cont’d)

+ -Overall the intervention

was appreciated.Participants enjoyed:

the group setting, learning relaxation strategies and socializing-sharing.

The small sample size did not allow to obtain statistical differences pre-post on any of the symptom measures, but on psychosocial constructs, there was a trend towards better social functioning and better self-esteem.

Concret thinking made metaphors difficult to understand.

Too many concepts/activities per session.

Sessions lasted 2 hours (too long?)

Talk of suffering… too difficult in too few sessions for participants to be at ease (and attend each session).

Referral system inadequate.

Study 2Conducted by Bassam El-Khoury, under the

supervision of Tania Lecomte.Goal:

To ‘fix’ the problems found in the previous group approach by offering more sessions (8 sessions), adapting the content for individuals with cognitive deficits (limit metaphors, no more than one or two activities per session), positive concepts introduced first, and limit concepts to:CompassionAcceptanceMindfulness

Also, the participants will be assessed at 3 months follow-up.

Study 2Each participant gets their own workbook, in

which they can write their answers prior to sharing them.

The workbook is divided in two section:ValuesHow to deal with difficulties in order to live our

valuesEach session ends with a mindfulness or meditation exercise (e.g.:

mindfully eating an apple, breathing, visualizing a safe place, meditation with focus on compassion…)

Study 2 (cont’d)

Participants are referred by members of the clinical staff to senior clinician (psychologist), if between 18-35 and at the First Episode Clinic (less than 2 years with psychotic symptoms)

The pilot study will involve 10 individuals in the intervention and 10 matched-controls receiving TAU. Qualitative and quantitative information is gathered on:Emotional regulationSocial functioningInsightPsychological distressMedication adherenceMindfulnessSymptoms (BPRS)Their experience of the treatment

Procedure

Study 2 (cont’d)

So far only one group has been conducted.6 participants referred – 4 completed the

intervention (one stopped after one session, the other too ill was rehospitalized)

Quantitatively:Too soon to tell (small N) but Wilcoxon rank test

suggest that 3/4 had fewer overall symptoms at post-therapy, higher scores on mindfulness (Freiburg), on overall emotional regulation.

N.B. : the fourth person had a comorbid cluster B axis II disorder and disliked the female therapist (who was more structuring).

Preliminary results

Study 2 (cont’d)

Qualitatively:3 out of 4 really enjoyed the interventionWhat they liked the most: distancing themselves,

meditation, hearing others’ optinions and tipsWhat they didn’t like: nothing (2), having to break

down situations (1), one of the therapists (1)What they learned: the importance to live in the

moment; self-esteem and compassion; how to relax; how to eat more slowly.

What changed for them: think twice before acting and more patient; more self-confidence, know my values; not sure; eat better, take time to eat.

N.B. 2/4 mentioned meditating everyday since the group ended

Preliminary results

ConclusionIndividuals with early psychosis need specific

adaptations in order to truly benefit from ACT and mindfulness therapies in a group format.

Study 1 demonstrated the difficulties that could be encountered (few references, comprehension difficulties, more sessions needed, etc) whereas Study 2 (still underway) gives us more hope in the potential feasibility and impact of the approach (though one person apparently did not benefit as much).

Studies looking into third wave cognitive therapies for individuals with early psychosis should measure and take into account cognitive deficits as well as Axis II disorders, since these might influence the results.

To be continued…

Thank you!Tania Lecomte, Ph.D.Professeure Agrégée, chercheure au CRFSDépartement de PsychologieUniversité de Montréal, Bur C-358, 90 rue Vincent d’Indy,C.P. 6128, Succ. Centre-Ville,Montréal, QC, H3C 3J7Tel: 514-343-6274Fax: 514-343-2285Email: tania.lecomte@umontreal.ca