Group Acceptance and Commitment Therapy for Recovery From Psychosis: Protocol for a Single-Group Waitlist Trial.

BACKGROUND: Psychological interventions, along with antipsychotic medications, are recommended for adults diagnosed with a psychotic disorder. While initially designed to mitigate positive symptoms, psychological interventions targeting personal recovery were developed and aligned with the recovery framework that many mental health services have adopted. Acceptance and Commitment Therapy (ACT) for psychosis is one such intervention that shows promise when delivered in an individual format. There is preliminary evidence that ACT for psychosis in a group format improves recovery. OBJECTIVE: This trial aims to evaluate the effectiveness of the "Recovery ACT" group program on personal recovery among adults living with a psychotic disorder. METHODS: Our unfunded study is a multiagency, prospective, nonrandomized, waitlist control, single-group trial of the Recovery ACT group program. The program involves 7 weekly group sessions of 90 minutes duration and a 90-minute booster session held 1 month later. We intend to recruit 160 adults living with a psychotic disorder who enroll in a group that is offered as a routine clinical service at participating public mental health services in Melbourne, Victoria, Australia. The 4 assessment time points are 4-6 weeks before the start of the group program, at the start of the group program, at the end of the group program, and at the booster session. There is an optional midgroup assessment and follow-up study. The primary outcome is personal recovery. Secondary outcomes include participants' well-being and psychological flexibility processes. Qualitative data are also collected from participants and facilitators. RESULTS: Recruitment began in September 2019 and is ongoing until 2024, subsequent to a 24-month disruption due to the COVID-19 pandemic. As of the submission of this paper, 93 participants consented to the evaluation, 65 completed T1 measures, and 40 had a complete data set for the proposed analyses. CONCLUSIONS: This is the first trial evaluating the effectiveness of the Recovery ACT group program on personal recovery for adults living with a psychotic disorder. Findings will contribute to knowledge about psychosocial interventions for adults living with psychosis. This trial may also serve as an example of a partnership between clinicians and academics that can facilitate the translation of research into practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12620000223932; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000223932. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49849.

Acceptability and feasibility of recovery-oriented group acceptance and commitment therapy for psychosis in routine practice: an uncontrolled pilot study.

BACKGROUND: Personal recovery is a persisting concern for people with psychotic disorders. Accordingly, mental health services have adopted frameworks of personal recovery, prioritizing adaptation to psychosis alongside symptom remission. Group acceptance and commitment therapy (ACT) for psychosis aims to promote personal recovery alongside improved mood and quality of life. AIMS: The objectives of this uncontrolled, prospective pilot study were to determine whether 'Recovery ACT' groups for adults are a feasible, acceptable and safe program within public mental health services, and assess effectiveness through measuring changes in personal recovery, wellbeing, and psychological flexibility. METHOD: Program feasibility, acceptability and safety indicators were collected from referred consumers (n=105). Adults (n=80) diagnosed with psychotic disorders participated in an evaluation of 'Recovery ACT' groups in Australian community public mental health services. Participants completed pre- and post-group measures assessing personal recovery, wellbeing, and psychological flexibility. RESULTS: Of 101 group enrollees, 78.2% attended at least one group session (n=79); 73.8% attended three or more, suggesting feasibility. Eighty of 91 first-time attendees participated in the evaluation. Based on completer analyses (n=39), participants' personal recovery and wellbeing increased post-group. Outcome changes correlated with the linear combination of psychological flexibility measures. CONCLUSIONS: 'Recovery ACT' groups are feasible, acceptable and safe in Australian public mental health services. 'Recovery ACT' may improve personal recovery, wellbeing, and psychological flexibility. Uncontrolled study design, completer analyses, and program discontinuation rates limit conclusions.

The role of metacognitive beliefs in the proneness to hallucinations and delusions: an analysis across clinical and non-clinical populations.

OBJECTIVES: This study explored specific and differential effects of metacognitive beliefs on proneness to both hallucinations and delusions in a general population sample, including a control for the alternate symptom. The study then examined whether similar findings were reproduced in a sample of people with psychotic disorders. DESIGN: Linear and hierarchical regressions were used to determine the role of metacognitive beliefs in the proneness to symptoms, whilst ANCOVAs analysed group differences. METHODS: Participants were recruited to a non-clinical sample (N = 133) and a psychosis sample (N = 100). Both groups completed the Launay-Slade Hallucinations Scale-Revised (Laroi et al., ; Eur. Psychiatry, 19, 15), the Peters Delusions Inventory (Peters et al., ; Schizophr. Bull., 25, 553), and the Metacognitions Questionnaire-30 (Wells & Cartwright-Hatton, ; Behav. Res. Ther., 42, 385). RESULTS: Metacognitions were predictive of both hallucination- and delusion-proneness in the non-clinical sample. Controlled analyses in the non-clinical sample revealed specific effects: low cognitive confidence (CC) predicted hallucination-proneness, whilst negative beliefs about the uncontrollability and danger of thoughts (NBUD) predicted delusion-proneness. Mean ratings on NBUD, low CC, and need to control thoughts were elevated in the psychosis sample; however, after controlling for comorbid symptoms, no metacognitive belief predicted symptom-specific vulnerability in the clinical sample. CONCLUSIONS: The pattern of findings provided little support for Morrison's theoretical model of symptom-proneness. Metacognitive beliefs may be related to sub-acute vulnerability to psychosis symptoms; however, the specificity of the relationship between individual metacognitive beliefs and positive psychosis symptoms appeared no longer significant in psychosis patients. The possibility that these metacognitive beliefs are evoked by psychotic experiences, rather than primarily functioning as a driver of them, warrants greater attention. CLINICAL IMPLICATIONS: Metacognitive beliefs appear at least equally associated with delusion-proneness as hallucination-proneness. Negative metacognitive beliefs appear more central to delusion-proneness than hallucination-proneness in the general population. When controlling for alternate symptom, no individual metacognitive belief appears reliably able to predict symptom-proneness in psychosis patients. LIMITATIONS: Consistent with existing literature on metacognitions in psychosis, this study adopted a cross-sectional design, meaning we were unable to determine the causal direction of the observed associations between metacognitive beliefs and symptom-proneness. Although a strength of this study design was its control for alternate psychotic symptoms, we did not control for non-psychotic symptoms, particularly, anxiety and depression. The symptom measures used were developed primarily for assessment of psychosis-proneness within the general population; thus, their use by people with established psychosis may have been less sensitive to clinical manifestations of these phenomena.

Modelling the emergence of hallucinations: early acquired vulnerabilities, proximal life stressors and maladaptive psychological processes.

BACKGROUND: The study aimed to expand upon existing findings on the vulnerability to psychosis by examining synergistic models of hallucination emergence. Hypothesised vulnerability factors were separated into three stages of vulnerability; early acquired and enduring vulnerabilities (heredity, childhood trauma, early cannabis use), proximal life stressors (life hassles) and psychological appraisals/coping (metacognitions/experiential avoidance). METHODS: Participants were recruited to a non-clinical sample (N = 133) and a clinical sample of psychosis patients (N = 100). RESULTS: Path analyses in the non-clinical sample indicated that experiences of childhood emotional trauma, in combination with subsequent experiences of life hassles, best predicted vulnerability to both hallucinations in general and auditory hallucinations specifically. This pathway was partially mediated by negative metacognitions. The models were then replicated in the clinical sample, with two notable differences: (1) childhood sexual trauma replaced childhood emotional trauma as the best enduring predictor in the clinical model. (2) Experiential avoidance replaced metacognitions as the best cognitive predictor of hallucinations. CONCLUSIONS: The study's findings highlighted how vulnerability to hallucinations can occur developmentally across time, with early acquired vulnerability factors, combining additively with more proximal day-to-day factors and cognitive style, to propel a person further towards the formation of hallucinations.

Synergistic pathways to delusions: enduring vulnerabilities, proximal life stressors and maladaptive psychological coping.

AIM: We sought to extend findings on the vulnerability to psychosis by investigating multifactorial pathways to delusions. Risk factors assessed spanned across early acquired vulnerabilities (heredity, childhood trauma, early cannabis use), proximal life stressors (life hassles, methamphetamine use) and psychological coping (experiential avoidance). METHODS: Participants were recruited to a non-clinical sample (n = 133) or a clinical sample of psychosis patients (n = 100). RESULTS: Path analyses indicated three distinct pathways predicting vulnerability to delusions in the non-clinical sample: (i) childhood emotional trauma combined with subsequent experiences of life hassles; (ii) heredity in combination with experiential avoidance; and (iii) early cannabis use combined with proximal methamphetamine use. The first pathway was partially mediated by experiential avoidance. The model was largely replicated in the clinical sample, with childhood sexual trauma replacing emotional trauma in the model. CONCLUSION: The study demonstrated that vulnerability to delusions can be usefully predicted by a synergistic model incorporating early-acquired vulnerability factors, proximal day-to-day factors and cognitive styles.

Life hassles, experiential avoidance and distressing delusional experiences.

Life hassles have been implicated in both the formation and maintenance of psychosis symptoms. However, little is understood about the mechanism through which these stressors impact on psychosis. The current study proposed experiential avoidance (EA), a psychological coping style that is a central focus for change in Acceptance and Commitment Therapy (ACT), as a potential mediator of the link between life hassles and both the emergence and maintenance of delusional ideation. Participants were recruited to a non-clinical sample (N=133) and a clinical sample of psychosis patients (N=100). All participants completed a self-report questionnaire including a measure of delusions and delusional distress (Peters Delusions Inventory), life hassles (Survey of Recent Life Experiences) and EA (Acceptance and Action Questionnaire-II). Mediation testing (bootstrapping) indicated a significant mediation effect of EA in the relationship between life hassles and both delusions and delusional distress, in both clinical and non-clinical samples. The findings suggest that individuals (irrespective of their diagnostic status) with a tendency to suppress or avoid unwanted thoughts are significantly more likely to experience distressing delusions in response to stressful life occurrences. The use of ACT and Cognitive Behavioural Therapy to reduce EA in those at risk of emerging delusions and in patients with an already established psychosis is discussed.

Personality and the predisposition(s) to bipolar disorder: heuristic benefits of a two-dimensional model.

OBJECTIVES: The aim of this study was to model normal personality correlates of the predisposition(s) to bipolar disorder (BD), and in so doing explore the proposition that the tendency to bipolar depression [trait depression (T-Depression)] and the tendency to mania [trait mania (T-Mania)] can usefully be viewed as separable but correlated dimensions of BD predisposition. METHODS: A well student sample (n = 176, modal age 18-25 years, 71% female) completed the NEO Personality Inventory-Revised and the General Behavior Inventory. RESULTS: A good-fitting model (normed chi2 = 0.60, significance of chi2 = 0.73) was identified in which T-Depression was determined solely by neuroticism, while T-Mania was determined by extraversion and (negative) agreeableness. The pathway from T-Depression to T-Mania was also significant (standardized regression weight = 0.80), with a weaker significant reciprocal path (coefficient = 0.27). A model in which bipolar vulnerability was represented as a single dimension (T-Bipolarity) also provided a good fit to the data, but provided less heuristic power. CONCLUSIONS: Predisposition to BD can be usefully understood in terms of two reciprocally related dimensions of vulnerability (T-Depression and T-Mania), which can be separated on the basis of their personality correlates.