1. latrobe.edu.au CRICOS Provider 00115M What is happening inside ACT for psychosis sessions? Consumer reports and session ratings from the Lifengage RCT Tory Bacon 1, John Farhall 1,2, Ellie Fossey 1, Neil Thomas 1,3, Fran Shawyer 1,4, 1 La Trobe University, 2 North Western Mental Health, 3 Swinburne University, 4 Monash University Association for Contextual Behavioural Science World Conference XI, Sydney, July 2013

2. The Lifengage Trial: A randomised controlled trial of ACT for medication-resistant psychotic symptoms

3. 3 The Lifengage trial  Objectives ̶Conduct the first ACT for psychosis trial meeting CONSORT criteria ̶Target medication-resistant positive symptoms (consistent with our model & area of high public health need)  Sample ̶96 outpatients with Schizophrenia or Schizoaffective Disorder ̶Persisting and distressing psychotic symptoms ̶> 6 months continuously on antipsychotic medication  ACT Therapy ̶ACT manual developed for study. ̶Conducted by 4 experienced psychologists (supervision by Steven Hayes)

4. 4 Lifengage Study Design Current status: Main analyses still underway… Baseline Ass’t T2 Ass’t Befriending therapy - 8 sessions ACT therapy - 8 sessions Randomise T3 Ass’t 3-4 months6 months In-session verbal behaviour study Sessions 3,5,7 Optional i/v Subjective experience of therapy study Treatment As Usual ‘TAU’

5. Interview study Bacon, Farhall & Fossey (2013) Behavioural and Cognitive Psychotherapy doi:10.1017/S1352465813000209

6. 6 Aim: Understand clients’ experiences of ACT processes ̶Was the therapy acceptable and understandable for consumers? ̶Did clients believe they had improved? ̶Did consumers connect ACT components with any outcomes? Participants: All consenting ACT participants from the final phase of the study (n=9) Method: Semi ‑ structured interviews Analysis: Thematic analysis of session transcripts Interview study

7. 7 Table of themes and subthemes ThemeSubtheme 1. Usefulness of therapy1.1 Useful (a)Generally therapy was useful (b)Recommend ACT 1.2 Processes (a)Values and goals (b)Mindfulness (c)Defusion (d)Acceptance 2. Changes attributed to ACTp 2.1 Symptoms (a)Continued to act despite symptoms (b)Changed perspective (c)Reduced intensity and impact of symptoms 2.2 Behavioural 3. Understanding therapy 3.1 Connection with therapy 3.2 Understanding of therapy and exercises 4. Non-specific therapy 4.1 Therapist factors

8. 8  All participants found therapy useful to some degree, and recommended it  Two participants recommended it for being listened to rather than for ACT components and had some negative views: “...it was a bit useless as in the type of therapy” [P1]  Most useful components: Mindfulness; Defusion; Acceptance and Values  Two participants noted some components were not useful “...experiences are too intense for ACT” [P3]; “...mindfulness was not useful or exacerbated symptoms” [P4].  Non-specific therapy factors were valued but not connected with outcome Theme 1.1 Usefulness of the therapy

9. 9 Theme 1.2 Usefulness of ACT processes - Values Values  Five participants identified values as giving direction and meaning “...[makes my] life a bit more fulfilled” [P5].  Three found goal setting helpful “... with the goal setting... that’s helped me... I’m getting a better relationship with my family [P3]”

10. 10  Eight participants commented on Mindfulness - as a helpful redirection of attention “If I’m hearing voices it will bring me back to focusing on what’s real... it’s really beneficial” [P6] ].  This was associated with a reduction in stress “It helps me focus on something other than the voices so they don’t become as distressing.” [P3].  Mindfulness not always helpful “If I’m deliberately listening to something it will exacerbate it” [P4] “for less intense [experiences] it works good” [P3]. Theme 1.2 Usefulness of ACT processes - Mindfulness

11. 11  Six participants reported defusion as useful with paranoia, negative thoughts and voices “...to try and look at my voices as a character... so they weren’t as scary... and also learning to not take what my voices say literally” [P8].  There were limitations to some defusion exercises “defusion worked a bit too but not so much with the funny voices...” [P4]  Two identified the “story” strategy as most useful for intense experiences: “... when it comes to suicide for instance...not so easy to make fun of [thoughts]... something like... ‘poor me story’ [helps]” [P5] Theme 1.2 Usefulness of ACT processes - Defusion

12. 12  Two participants reported acceptance as useful, with a focus on letting go of the struggle “that helped me in a way; it’s like accepting what they say and just go whether I choose or not to actually do anything about it” [P9]. Theme 1.2 Usefulness of ACT processes - Acceptance

13. 13  Continuing to act despite the presence of symptoms. ̶All participants described continuing to experience symptoms. ̶Six participants changed in their beliefs and attitude towards symptoms, e.g. ACTp “... made me realize that I did not have to buy into messages and that I can... accept what’s going on and move in the direction that I want to” [P4].  Change in (metacognitive) perspective ̶“ACT actually helps you to see that you can’t control your thoughts but you can control your behaviour and that’s definitely a very important thing to learn” [P5]. Theme 2: Changes attributed to ACT

14. 14  Reduced intensity and impact of symptoms (n=7) “... now I’ve been doing the mindfulness I haven’t been distressed” [P3], “... I guess it’s [paranoia] got a bit weaker... but I’ve got new ways of coping with it” [P4]  Positive behavioural change “I have been a lot cleaner with myself whereas before I wasn’t caring, I wouldn’t shave and stuff...” [P1], “... I’m going to have to totally change my way of life... I just want to start getting a lot more of a life happening... and I sort of believe that I can” [P4]. Theme 2: Changes attributed to ACT (cont.)

15. 15  Connecting with therapy exercises and concepts “I found it more comical than useful... I didn’t see the relevance” [P1] “... I didn’t know what she’s on about” [P2].  Understanding therapy and exercises. “... the whole objective of her methods and technique was just how to relax” [P2]. mindful walking was useful “... because I’m back in familiar surroundings I feel that my anxiety will go down as well” [P2]. “... if it had been over a longer period of time then it would have sunk in a bit more” [P4] “[I] actually found it [therapy] quite easy” [P8]. Theme 3: Variation in understanding of therapy

16. 16 Themes: ̶All 9 participants found therapy useful to some degree ̶Non-specific therapy factors: Were valued but not connected with outcome ̶Self as context and committed action not mentioned by these participants Observations (+ & -): ̶Values work may be particularly useful for this population. ̶Not all clients connected metaphors and concepts to the intended meaning ̶Mindfulness & defusion for intense experiences (e.g. Suicidal thoughts; intense hallucinations) exacerbated symptoms and distress (as reported in Veiga-Martinez et al, 2008) Summary

17. In-session process study Study 2 from Tory Bacon (2013) DPsych thesis, La Trobe University

18. 18 Research questions: a) To what extent are ACT processes identifiable in the verbal behaviour of participants during sessions? b) Can therapy processes be better understood by identifying the relative frequency and depth of consumer response to each ACT component, including any change across sessions? c) Is there any association between the extent of in-session response to ACT processes and therapy outcomes? Did consumers respond to ACT therapy during sessions? - Objective ratings of verbal behaviour

19. 19  Participants ̶17 women & 19 men for whom we had audio recordings and a post therapy assessment. (i.e. 36 of the 49 randomised to ACT).  Method ̶Listen to audio recordings & identify in-session verbal behaviour indicating one of the 6 ACT components ̶Rate each ‘utterance’ (an extension of the Hesser et al. 2009 approach)  Measures For each ACT component (Acceptance, Committed action, etc) three ratings of utterances were made: ̶Frequency – how many times in this session ̶Extensiveness – how in-depth each utterance was (0-5 scale) ̶Autonomy – how independent vs. therapist-prompted (0-5 scale) NB: ‘Peak’ ratings (highest score in session) used for Ext’ness & Autonomy In-session process study

20. 20  Inter-rater reliability ̶Expert vs. researcher, using random sample of 10 sessions ̶Identification of ACT related processes ranged between k =.66 (Present moment contact) and 1.0 (Acceptance). ̶Extensiveness & Autonomy: ICCs ranged from.87 (Acceptance extensiveness) to.99 (Defusion – autonomy)  Session selection ̶the 8-session course of therapy was divided into early phase, middle phase and late phase with sessions 3, 5 and 7 representing each phase respectively ̶108 sessions rated (3 per client) In-session process study

21. 21 Results: Frequency of verbal utterances across sessions reflecting ACT processes *

22. 22 Results: Mean peak ratings of extensiveness for ACT processes across sessions

23. 23 Results: Mean peak ratings of Autonomy for ACT processes across sessions

24. 24 Study 2 - Conclusions and next steps Main observations  On average 7-8 verbal utterances per session were coded as reflecting an ACT process  Most were brief, relatively unelaborated and prompted by therapist’s question  All components were observed, though Self-as-context and Committed Action less often Next Steps  Look at variation between individuals, esp. in peak ratings  Relate frequency, autonomy and extensiveness to outcomes

25. Thank you latrobe.edu.au CRICOS Provider 00115M Chief Investigators Dr John Farhall Dr Fran Shawyer Dr Neil Thomas Prof David Castle Prof David Copolov Prof Steven Hayes Therapists Dr Fran Shawyer Dr Neil Thomas Dr John Farhall Carole Pitt Specialist supervision Prof Steven Hayes Research assistants Kate Ferris Paula Rodger Emma White Postgraduate students Tory Bacon Suzanne Pollard Megan Trickey Lifengage Team Contact: j.farhall@latrobe.edu.au