1. ACT Early: Acceptance, mindfulness and values in early intervention for psychosis Eric Morris, Sally Bloy & Joe Oliver Lambeth Early Onset Services South London & Maudsley NHS Foundation Trust

2. The aim of this presentation To present the case for how ACT may be useful in early intervention To present the case for how ACT may be useful in early intervention To present the work of the Lambeth ACT crew: Eric Morris, Joe Oliver, Sally Bloy, Louise Johns To present the work of the Lambeth ACT crew: Eric Morris, Joe Oliver, Sally Bloy, Louise Johns ACT in early intervention is not about a whole new therapeutic approach to psychosis ACT in early intervention is not about a whole new therapeutic approach to psychosis We would argue that ACT is fairly consistent with the CBTp approach that has been developed in the UK... We would argue that ACT is fairly consistent with the CBTp approach that has been developed in the UK...

3. Workshop overview Provide a psychological view of psychosis Provide a psychological view of psychosis ACT and early intervention for psychosis ACT and early intervention for psychosis ACT components and EIP ACT components and EIP  Values  Mindfulness  Defusion  Self stigma A service user perspective of ACT A service user perspective of ACT ACT for EIP in practice ACT for EIP in practice

4. A Psychological View of Psychosis Dimensional rather than categorical: Normalising Dimensional rather than categorical: Normalising Work with symptoms rather than diagnoses Work with symptoms rather than diagnoses Diagnoses lack scientific validity – “schizophrenia” is less useful than understanding behaviour in context Diagnoses lack scientific validity – “schizophrenia” is less useful than understanding behaviour in context Biological vulnerabilities undoubtedly contribute, however symptoms/behaviour are heavily influenced by the environment Biological vulnerabilities undoubtedly contribute, however symptoms/behaviour are heavily influenced by the environment We don’t work with “brain diseases”, we work with whole human beings whose behaviour is influenced by context We don’t work with “brain diseases”, we work with whole human beings whose behaviour is influenced by context

5. Recovery from first episode psychosis up to 20% show persisting positive symptoms 50-65% will relapse within 2 years despite medication adherence; there is a growing risk of treatment-resistant symptoms with each subsequent relapse over 50% report significant depression and/ or anxiety secondary to psychosis Up to 70% will continue to be unemployed/ out of education 12 months after starting treatment most of the disability associated with schizophrenia occurs within the first five years Suicide occurs in 10-15% of cases; mainly in first 5 years Sources: Edwards et al., 2002; Birchwood, 2003; Whitehorn, 2002; Robinson, 1999

6. The ACT stance Focusing on symptom impact Focusing on symptom impact Emphasising acceptance rather than disputation Emphasising acceptance rather than disputation Pragmatic truth criterion: focused on moving things forward, rather than finding the cause of psychotic symptoms Pragmatic truth criterion: focused on moving things forward, rather than finding the cause of psychotic symptoms Targets symptoms indirectly by altering the context within which they are experienced rather than frequency and believability per se Targets symptoms indirectly by altering the context within which they are experienced rather than frequency and believability per se

7. Psychological Flexibility The Primary ACT Model of Treatment (Hayes et al., 2004) Actions unhelpfully guided by self/other appraisals, unusual experiences, stigma, trauma etc Engaging in thought suppression, avoidance, drug use, DSH, etc Domination of Self as content: broken, flawed, or confusing/untrustworthy, mad Unclear values Resignation/ Entrapment Serial approach of fixing self before valued living Lack of persistence and flexibility in activating self Engaging in Rumination & Worry

8. ACT & Early Intervention: Possibilities Recovery may usefully be linked with values – moving from unhelpful pliance and tracking methods (“just take your meds & you’ll stay well”) Recovery may usefully be linked with values – moving from unhelpful pliance and tracking methods (“just take your meds & you’ll stay well”) a pragmatic alternative to symptom elimination, through behavioural activation and promotion of psychological flexibility to anomalous experiences, emotions and thoughts in general a pragmatic alternative to symptom elimination, through behavioural activation and promotion of psychological flexibility to anomalous experiences, emotions and thoughts in general May help clients to develop early flexibility toward the dominant “messages” about psychosis (symptom elimination or limited life meaning, stigma of mental illness, minds can be controlled etc). May help clients to develop early flexibility toward the dominant “messages” about psychosis (symptom elimination or limited life meaning, stigma of mental illness, minds can be controlled etc). Helping the psychological flexibility of clinicians Helping the psychological flexibility of clinicians Morris & Oliver, 2009 Morris & Oliver, 2009

9. ACT & Early Intervention: Practicalities Consistent with CBTp principles Consistent with CBTp principles Slow pace Slow pace Focus on recovery Focus on recovery Not about challenging thoughts/ experiences Not about challenging thoughts/ experiences Focus on increasing flexibility Focus on increasing flexibility Normalising Normalising Workability always on table. No hard and fast rules - as long as it works. Workability always on table. No hard and fast rules - as long as it works. Keep it simple to account for range of cognitive abilities. Be prepared to distil down to most basic parts Keep it simple to account for range of cognitive abilities. Be prepared to distil down to most basic parts Sessions often aim to hit multiple points on model Sessions often aim to hit multiple points on model

10. Offering psychology to EI folk…

11. Using values as part of recovery Values work often early Values work often early Values/ recovery focus rather than distress/ symptom elimination Values/ recovery focus rather than distress/ symptom elimination responses to unwanted or engulfing internal experiences are viewed in the context of personal values, which provide a measure of functional utility of coping methods. responses to unwanted or engulfing internal experiences are viewed in the context of personal values, which provide a measure of functional utility of coping methods.

12. Advantages of a values focus provides constructive and consistent direction, provides constructive and consistent direction, enhances response flexibility and motivation, enhances response flexibility and motivation, encourages persistence in the face of unwanted private experiences (especially in values- related situations that involve intimacy, vulnerability, or ambiguity) encourages persistence in the face of unwanted private experiences (especially in values- related situations that involve intimacy, vulnerability, or ambiguity) Example: “Ahmed”  23.y.o. Male, socially anxious following FEP  Values of connection to others, learning  Provided self-generated rationale for exposure to college and friendship contexts

13. Sally’s video

14. Introducing mindfulness Generally keep it simple Generally keep it simple Avoid long eyes-shut exercises –short bursts Avoid long eyes-shut exercises –short bursts Creatively use mindfulness Creatively use mindfulness Mindful eating an M&M Mindful eating an M&M Mindful walking Mindful walking Mindful rolling a cigarette (yes, this may slightly undermine the healthy living focus, but we're being pragmatic in the moment) Mindful rolling a cigarette (yes, this may slightly undermine the healthy living focus, but we're being pragmatic in the moment) Be clear that there is no “right way” Be clear that there is no “right way” Reinforce all sorts of “noticing” Reinforce all sorts of “noticing”

15. Using ACT processes in Relapse Prevention Mindful awareness of symptoms Mindful awareness of symptoms Acceptance and approach (flexible responding) as alternative to avoidance/ denial Acceptance and approach (flexible responding) as alternative to avoidance/ denial RP plan in service of values rather than just staying well RP plan in service of values rather than just staying well Example: “Sarah”  25y.o. Female, hospitalised in FEP: frightened of relapse, sense of helplessness about RP  Approached from a values perspective, identifying short- & long-term actions, Swamp metaphor, and using present moment focus

16. Metaphor use with cognitive impairment: Use simple, brief metaphors Use simple, brief metaphors Concrete examples Concrete examples Use physical props/ pictures/ cartoons Use physical props/ pictures/ cartoons Personally relevant stories & relate metaphors to important clinical issues Personally relevant stories & relate metaphors to important clinical issues Repetition Repetition Be prepared for people not to “get it”, limit your explanations/ move on to something else Be prepared for people not to “get it”, limit your explanations/ move on to something else (Bach, 2004) with paranoia: Tread carefully Tread carefully

17. Self Stigma We have found that the self as observer skills in ACT are useful in managing stigma about psychosis and mental illness We have found that the self as observer skills in ACT are useful in managing stigma about psychosis and mental illness Experientially contact the sense of self that is noticing all experience - “And who is noticing this right now? Notice that you are noticing” - along with defusion from stigma thoughts Experientially contact the sense of self that is noticing all experience - “And who is noticing this right now? Notice that you are noticing” - along with defusion from stigma thoughts This work involves developing a kind stance toward yourself and others – stigmatising beliefs about psychosis are mainstream, reinforced by the verbal community This work involves developing a kind stance toward yourself and others – stigmatising beliefs about psychosis are mainstream, reinforced by the verbal community

18. Eric’s video

19. The iACT We try to use metaphors and analogies that are relevant to the young people we see. We try to use metaphors and analogies that are relevant to the young people we see. The iACT is a values/behavioural activation tool that draws an analogy between our daily activities and a mp3 playlist. The iACT is a values/behavioural activation tool that draws an analogy between our daily activities and a mp3 playlist. It lends itself to such discussions as: It lends itself to such discussions as: “Which tracks would you choose?” “Which tracks would you choose?” “Are there tracks that are just there to look cool/ because your parents put them on/ block out bad thoughts etc.?” “Are there tracks that are just there to look cool/ because your parents put them on/ block out bad thoughts etc.?”

21. Defusion and voices Assess degree that person “buys” voices Assess degree that person “buys” voices – If lots of fusion with content, similar defusion strategies for thoughts may be helpful  Noticing repetitive patterns– blah, blah, blah  Different tones/accents to how voice normally sounds  Leaves on stream/ Clouds in sky – If not so fused with content, focus on unhelpful evaluations/ beliefs about voices  “I can’t cope” “Voices too powerful” Focus on stepping back to be able to make more informed choice based on values Focus on stepping back to be able to make more informed choice based on values

22. Joe’s Video

23. Defusion and paranoia/delusions Usefulness rather than truthfulness Usefulness rather than truthfulness Gentle enquiry rather than challenging Gentle enquiry rather than challenging Too early and defusion can seem challenging – its just a thought Too early and defusion can seem challenging – its just a thought Often essential to have done values work prior Often essential to have done values work prior Defusion strategies: Defusion strategies: Externalising “what’s the paranoia telling you to do?” Externalising “what’s the paranoia telling you to do?” Leaves on Stream – noticing thoughts Leaves on Stream – noticing thoughts Saying it differently to how its normally said Saying it differently to how its normally said

24. When conviction is very high may be more useful to target preoccupation, in the context of values When conviction is very high may be more useful to target preoccupation, in the context of values “I must make sense of/ figure out/ solve/ understand these experiences” “I must make sense of/ figure out/ solve/ understand these experiences” “Given your experiences, is there a way to not get so hooked in and still do what’s important to you?” “Given your experiences, is there a way to not get so hooked in and still do what’s important to you?” Example: “Eddie’s” metaphor of street sellers and trains Example: “Eddie’s” metaphor of street sellers and trains

26. Service Context Lambeth Early Onset Service (LEO) A service for young people aged 16-35, residing in Lambeth (south London), experiencing symptoms of psychosis for the first time A service for young people aged 16-35, residing in Lambeth (south London), experiencing symptoms of psychosis for the first time service focuses on engagement, multi- modal treatment, and relapse prevention service focuses on engagement, multi- modal treatment, and relapse prevention works within a recovery model works within a recovery model

27. ACT across the system Individual therapy Individual therapy Group therapy in a community team Group therapy in a community team Group therapy on an inpatient unit Group therapy on an inpatient unit Staff training in mindfulness, compassionate approaches Staff training in mindfulness, compassionate approaches Group therapy with clients at risk of developing psychosis Group therapy with clients at risk of developing psychosis Research with early psychosis Research with early psychosis

28. Individual Therapy ACT is an option for every client in our service, offered flexibly across the various “phases” of recovery from psychosis (acute, post-episode recovery, persisting symptoms) ACT is an option for every client in our service, offered flexibly across the various “phases” of recovery from psychosis (acute, post-episode recovery, persisting symptoms) Informed by British CBT for psychosis approach (normalising, functional) Informed by British CBT for psychosis approach (normalising, functional) Amount of sessions can vary Amount of sessions can vary Supported and reinforced by group program Supported and reinforced by group program

29. ACT in Groups We run regular 1- and 3-session groups to introduce ACT to EI service users. We run regular 1- and 3-session groups to introduce ACT to EI service users. The purpose of these groups is to support the individual psychology and vocational work. The purpose of these groups is to support the individual psychology and vocational work. Groups are run in both community and inpatient settings. Groups are run in both community and inpatient settings. Focus is not on psychosis per se, but rather recovery and values-directed actions. Focus is not on psychosis per se, but rather recovery and values-directed actions. Groups are deliberately conducted in a “light & breezy, fun” style: hopefully not like school; emphasising choice; just ideas to “try” Groups are deliberately conducted in a “light & breezy, fun” style: hopefully not like school; emphasising choice; just ideas to “try”

30. Content of “ACT for Life” Groups Noticing an Object (The Raisin) Noticing an Object (The Raisin) Values as Direction and Action (Heading West) Values as Direction and Action (Heading West) Noticing barriers (Introduce monster telling you to take detour) Noticing barriers (Introduce monster telling you to take detour) Noticing Exercise (Mindfulness/Centering) Noticing Exercise (Mindfulness/Centering) Willingness as alternative (Tug of War + Leaves on the Stream) Willingness as alternative (Tug of War + Leaves on the Stream) Increasing willingness through defusion (Don't-Get- Eaten Machine; Junk Mail; Two Computers; Repeating NATS) Increasing willingness through defusion (Don't-Get- Eaten Machine; Junk Mail; Two Computers; Repeating NATS) Notice control of actions versus thoughts (Purple Hat; Two Tracks of Life) Notice control of actions versus thoughts (Purple Hat; Two Tracks of Life) “Homework” each group: Take a valued action & Notice! “Homework” each group: Take a valued action & Notice!

31. Inpatient ACT group Weekly ACT-focused group run on the LEO inpatient ward Weekly ACT-focused group run on the LEO inpatient ward Facilitated by psychologist and ward nurses Facilitated by psychologist and ward nurses Open door policy Open door policy Emphasise fun - competitions and prizes Emphasise fun - competitions and prizes Average of 6 people a week Average of 6 people a week Aim to provide a “taster” to ACT ideas such as values, present moment focus, defusion Aim to provide a “taster” to ACT ideas such as values, present moment focus, defusion Try to be as accessible to everyone – concepts very simple, people are guided through with examples. Try to be as accessible to everyone – concepts very simple, people are guided through with examples. Often use case scenarios and then use this as a way in for people to talk about their own experiences Often use case scenarios and then use this as a way in for people to talk about their own experiences

32. Let’s practice having a thought vs buying a thought You’re not good enough! You’re too depressed You’re not motivated enough! No-one likes you! ACT group

33. JunkMail: Having a thought vs buying a thought ACT group

34. Two Tracks of Life Inner Life (Your Mind) Feelings Thoughts Urges Memories less control over these - can happen without you wanting them it takes a lot of effort to change these, can lead to doing things that are harmful in the long run a private experience – only you observe what happens in your mind, other people only know if you tell them Outer Life (what You do) Actions BehaviourChoices more control over this, greater choice about what you do able to do things even if your mind (thoughts/feelings) says that you can’t choices and actions are things that other people can observe, you can act in a way that is different from how you feel ACT group

35. Who is the worst famous person you can think of? To win a million pounds you have to pretend to be their biggest fan - what would you do? ACT group

36. Gina hears voices. She doesn’t fight with them but she doesn’t necessarily believe what they say to her. Is this like: A: Trying to pull out of the trap? or B: Moving into the trap? ACT group

37. Which of these famous people has admitted to self harming?  Amy Winehouse (singer)  Johnny Depp (actor)  Angelina Jolie (actress)  Princess Diana (princess) ACT group

38. Video: Service User Perspective on ACT

39. Summary Early days but sense that ACT model is relevant to EI and psychosis Early days but sense that ACT model is relevant to EI and psychosis Fits in with adopting a recovery stance Fits in with adopting a recovery stance Focus not on symptoms Focus not on symptoms Pragmatic approach Pragmatic approach Normalising experiences Normalising experiences Functioning aspect useful focus for EIP folk – getting life back Functioning aspect useful focus for EIP folk – getting life back Promotes willingness, less of a struggle Promotes willingness, less of a struggle Hopefulness Hopefulness

40. What is it like to do ACT in this setting?

41. Contact: Eric.Morris@kcl.ac.uk Joseph.Oliver@slam.nhs.uk Sally.Bloy@slam.nhs.uk