About the Editors xiv List of Contributors xvi Acknowledgements xix Foreword: Acceptance, Mindfulness and Psychotic Disorders: Creating a New Place to Begin xx 1 Introduction to Mindfulness and Acceptance-based Therapies for Psychosis 1 Joseph E. Oliver, Candice Joseph, Majella Byrne, Louise C. Johns and Eric M. J. Morris 1.1 Introduction to Psychosis 1 1.2 Interventions 2 1.2.1 Cognitive Behavioural Therapy 2 1.2.2 Developments in CBT: Contextual Approaches 3 1.2.3 Acceptance and Commitment Therapy 4 1.2.3.1 Open 5 1.2.3.2 Aware 6 1.2.3.3 Active 6 1.2.4 Mindfulness and Person-based Cognitive Therapy for Psychosis 7 1.3 Conclusion 8 2 Theory on Voices 12 Fran Shawyer, Neil Thomas, Eric M. J. Morris and John Farhall 2.1 Phenomenology 12 2.2 Mechanisms and Origins of Hearing Voices 13 2.3 Meaning Given to Voice Experience 14 2.4 Responses to Voices 15 2.4.1 Resistance 16 2.4.2 Engagement 17 2.5 Implications for the Role of Acceptance and Mindfulness in Voices 18 3 Emotional Processing and Metacognitive Awareness for Persecutory Delusions 33 Claire Hepworth, Helen Startup and Daniel Freeman 3.1 Introduction 33 3.2 Persecutory Delusions 33 3.3 Improving Treatments for Persecutory Delusions 34 3.4 Development of the Intervention 35 3.5 The EPMA Intervention 38 3.6 The EPMA Pilot Study 40 3.7 Case Study 41 3.8 Conclusion 42 4 Clinical Assessment and Assessment Measures 47 John Farhall, Fran Shawyer, Neil Thomas and Eric M. J. Morris 4.1 Introduction 47 4.2 Clinical Assessment 47 4.2.1 Overview 47 4.2.1.1 Aims and Scope 47 4.2.1.2 General Principles 48 4.2.2 Structure and Methods of Assessment 49 4.2.2.1 Assessment Interwoven with Interventions 49 4.2.2.2 Use of Assessment Instruments 49 4.2.2.3 Role of Self-monitoring in Assessment 49 4.2.2.4 Goal Setting 50 4.2.3 A Guide to Clinical Assessment 51 4.2.3.1 The Problems Experienced by the Client 51 4.2.3.2 Understanding the Client 52 4.2.4 Assessing and Addressing Potential Barriers to and Risks Arising from Therapy 52 4.3 Assessment Measures 54 4.3.1 Issues in the Use of Self-report Measures 55 4.3.2 Mindfulness Measures 55 4.3.3 Measures of ACT Processes and Constructs 57 4.3.3.1 Acceptance and Action Questionnaire 57 4.3.3.2 The Voices Acceptance & Action Scale 58 4.3.3.3 Believability of Symptoms 58 4.3.3.4 Additional Measures 59 4.4 Conclusion 60 5 Acceptance and Commitment Therapy Case Formulation 64 Patty Bach 5.1 Introduction 64 5.2 Case Study 64 5.2.1 Avoidance 66 5.2.2 Cognitive Fusion 67 5.2.3 Attachment to Content 67 5.2.4 Weak Self-knowledge, Dominating Concept of the Past or Feared Future 68 5.2.5 Lack of Values Clarity 68 5.2.6 Persistent Inaction, Impulsivity or Avoidance 69 5.3 Case Formulation using the Inflexahex Model 70 5.4 Conclusion 73 6 Engaging People with Psychosis in Acceptance and Commitment Therapy and Mindfulness 76 Brandon A. Gaudiano and Andrew M. Busch 6.1 Introduction 76 6.1.1 Treatment Adherence and Engagement in Psychosis 76 6.2 Acceptance and Commitment Therapy 77 6.3 Functional Analytic Psychotherapy 78 6.4 Acceptance-based Methods and Techniques for Improving Engagement 79 6.4.1 Workability 81 6.4.2 Values Clarification 81 6.4.3 Acceptance and Mindfulness 82 6.4.4 Committed Action 83 6.4.5 The Therapeutic Relationship 84 6.5 Special Contexts and Issues 85 6.5.1 ACT Made Even Simpler 85 6.5.2 Involuntary Admission and Lack of Insight 86 6.5.3 Other Cognitive Behavioural Approaches for Psychosis 86 6.5.3.1 Traditional CBT 86 6.5.3.2 Motivational Interviewing 87 6.6 Case Study 88 6.6.1 Early Sessions (1–5) 88 6.6.2 Mid-treatment Sessions (6–15) 89 6.6.3 Late-treatment Sessions (16–20) 89 6.7 Conclusion 90 7 Acceptance and Commitment Therapy for Voices 95 Neil Thomas, Eric M. J. Morris, Fran Shawyer and John Farhall 7.1 Introduction 95 7.2 Formulating how Voices are a Problem 95 7.3 Overall Considerations in Conducting ACT with Voices 96 7.3.1 Sequence of Therapy 98 7.3.2 Acceptance: Letting Go of Struggle with Voices 98 7.3.2.1 Discussing Responses to Voices 98 7.3.2.2 Letting Go of Struggle 99 7.3.3 Defusion 100 7.3.4 Mindfulness: Present Moment and Self as Observer 101 7.3.5 Willingness: Values and Committed Action 103 7.4 Case Study 104 7.4.1 Current Mental-health Problems 104 7.4.2 Mental-health History 105 7.4.3 Relevant Background 105 7.4.4 Assessment and Formulation 105 7.4.5 ACT Case Formulation 106 7.4.6 The ACT Approach 106 7.4.6.1 Initial Phase (Sessions 1–3) 107 7.4.6.2 Mid-therapy (Sessions 4 − 7) 107 7.4.6.3 End Sessions (Sessions 8 − 10) 108 7.4.7 Outcomes 108 7.4.7.1 Psychotic Symptoms 108 7.4.7.2 Depression and Anxiety 109 7.4.7.3 Valued Action, Quality of Life and Social Functioning 109 7.4.7.4 Changes in Mindfulness towards Voices and Thoughts 109 7.4.8 Discussion 110 8 Acceptance and Commitment Therapy for Delusions 112 José Manuel García Montes, Marino Pérez Álvarez and Salvador Perona Garcelán 8.1 Introduction 112 8.2 Delusions as Ways of Making Contact with Experience 112 8.2.1 Delusions as Active Forms of Experiential Avoidance 113 8.3 Intervention with ACT 115 8.3.1 Create a State of Creative Hopelessness 115 8.3.2 Clarify and Strengthen the Patient’s Values 117 8.3.3 Suggest the Possibility that the Problem is Control 120 8.3.4 Create a Distance from Language 122 8.3.5 Help Create a Transcendental Sense of Self 123 8.3.6 Developing Willingness 124 8.4 Conclusion 125 9 Acceptance and Commitment Therapy for Emotional Dysfunction following Psychosis 129 Ross White 9.1 Introduction 129 9.2 Understanding Emotional Dysfunction following Psychosis 129 9.3 Emotional Dysfunction and Experiential Avoidance 130 9.4 An ACT Conceptualisation of Emotional Dysfunction following Psychosis 131 9.5 Treating Emotional Dysfunction following Psychosis 132 9.5.1 Socialising the Individual to the ACT Model 133 9.5.2 Assessment and Formulation 133 9.5.2.1 Suffering List 135 9.5.2.2 Attempts to Solve Suffering 136 9.5.2.3 Valued Life Direction 136 9.5.2.4 Valued Action 138 9.5.3 Beyond Formulation: Progressing with the ACT Intervention 138 9.5.3.1 Showing Up to Distress 139 9.5.3.2 Defusion 139 9.5.3.3 Mindful Acceptance 140 9.5.3.4 Worries about Psychosis Recurring 141 9.5.4 Moving Beyond the ACT Intervention 141 9.6 Conclusion 142 10 Person-based Cognitive Therapy for Distressing Psychosis 146 Lyn Ellett 10.1 Introduction 146 10.2 Zone of Proximal Development 146 10.2.1 Overview of the Zones of Proximal Development 147 10.2.1.1 Symptomatic Meaning 147 10.2.1.2 Relationship with Internal Experience 148 10.2.1.3 Schemata 148 10.2.1.4 Symbolic Self 149 10.2.1.5 Radical Collaboration (RC) 149 10.2.1.6 Acceptance 149 10.2.1.7 Metacognitive Insights 150 10.3 Case Formulation in PBCT 150 10.3.1 Symptomatic Meaning: ABC Formulation 150 10.3.2 Relationship with Internal Experience: Mindfulness-based Formulation of Distress 151 10.3.3 Negative and Positive Self-schema 152 10.4 Experiential Methods of Change 153 10.4.1 Symptomatic Meaning 153 10.4.1.1 Goodness of Fit (‘Evidence’) and Generating Alternative Symptomatic Meaning 153 10.4.1.2 Behavioural Experiments 156 10.4.1.3 Accepting Fixity 156 10.4.2 Relationship with Internal Experience 156 10.4.2.1 Rationale and Preparation for Mindfulness Practice 156 10.4.2.2 Overview of Mindfulness Meditation 156 10.4.2.3 Specific Adaptations of Mindfulness Practice 157 10.4.3 Working with Schemata 157 10.4.3.1 Two-chair Method 157 10.4.4 Symbolic Self 158 10.5 Conclusion 159 11 Spirituality: A New Way into Understanding Psychosis 160 Isabel Clarke 11.1 Introduction 160 11.2 Repositioning Psychosis and Spirituality: Recognition of the Two Ways of Knowing 161 11.3 Research Basis 162 11.4 Spirituality and Mental Health 162 11.5 Clinical Approach: The Therapeutic Alliance 164 11.5.1 The What is Real and What is Not Approach 164 11.5.2 Schizotypy and ‘Unshared Reality’ 165 11.5.3 From Conceptualisation to Coping Strategies 166 11.5.4 Role of Mindfulness 167 11.6 Psychosis as a Spiritual Crisis 168 12 The Service User Experience of Acceptance and Commitment Therapy and Person-based Cognitive Therapy 172 Joseph E. Oliver, Mark Hayward, Helena B. McGuinessand Clara Strauss 12.1 Introduction 172 12.2 An Overview of Service User Involvement 172 12.3 The Importance of a Service User Perspective in Informing ACT and PBCT for Psychosis 174 12.4 A Service User Perspective on the Experience of ACT for Psychosis 175 12.4.1 Background 176 12.4.2 The Therapy 178 12.4.3 How the Therapy Helped 178 12.4.4 Conclusion 179 12.4.4.1 How I Felt before ACT Therapy 179 12.4.4.2 How I Feel after ACT Therapy 180 12.5 Summary of Qualitative Findings from PBCT Groups on Participant Experiences of Mindfulness Practice and What was Learned from these Studies 180 12.5.1 Acceptance of Voices 181 12.5.2 Development of Sense of Self beyond Voices 182 12.5.2.1 Relating to Voices 184 12.5.2.2 Relating to Self 185 12.5.2.3 Relating to Others 186 12.5.3 The Value and Challenges of Seeking Service User Views 188 12.6 Conclusion 188 13 Acceptance and Commitment Therapy for First-episode Psychosis 190 Joseph E. Oliver and Eric M. J. Morris 13.1 Introduction 190 13.2 Recovery from a First Episode of Psychosis 191 13.2.1 At-risk Mental States 192 13.3 Using ACT to Enhance Recovery from a First Episode of Psychosis 192 13.3.1 Assessment and Formulation 192 13.3.2 Being Aware and Present 194 13.3.3 Opening Up 195 13.3.4 Being Active 197 13.4 ACT in Different Modalities 198 13.4.1 Group Work 198 13.4.2 Working with Families and Carers 199 13.5 Case Study 200 13.6 Conclusion 203 14 Acceptance and Commitment Therapy for Psychosis in Acute Psychiatric Admission Settings 206 Gordon Mitchell and Amy McArthur 14.1 Introduction 206 14.2 Acute Psychosis and ACT Interventions 206 14.3 ACT in the Acute Psychiatric Admission Ward 209 14.4 Case Study 209 14.5 Convergence of Mindfulness/Metacognitive-based Cognitive Therapy Approaches 214 14.6 Reflections on Developing Systemic Applications of ACT 215 14.7 Conclusion 216 15 Developing Acceptance and Commitment Therapy for Psychosis as a Group-based Intervention 219 Amy McArthur, Gordon Mitchell and Louise C. Johns 15.1 Introduction 219 15.2 A Six-session ACT-for-Psychosis Group Protocol 221 15.2.1 Session 1: Introducing the ACT Approach and Exploring the Workability of Current Strategies for Managing Distress 222 15.2.1.1 The Matrix 222 15.2.1.2 Between-session Task 223 15.2.2 Session 2: Exploring the Impact of the Struggle for Control and Introducing Willingness as an Alternative 223 15.2.2.1 Between-session Task 225 15.2.3 Session 3: Identifying Personal Valued Directions 225 15.2.3.1 The Ripple Exercise 225 15.2.3.2 Between-session Task 227 15.2.4 Session 4: Moving in Valued Directions 227 15.2.4.1 The Passengers-on-the-Bus Exercise 228 15.2.4.2 Between-session Task 229 15.2.5 Session 5: Continuing to Develop Self-as-Context and Willingness to Move towards Values 229 15.2.5.1 Between-session Task 230 15.2.6 Session 6: Summarising the Themes of the Course and Reviewing Experiences of the Work 230 15.2.7 Optional Follow-up Session 230 15.3 Case Study 231 15.4 Reflections on the Experience of Developing and Delivering the Groups 233 15.5 Other Protocols 234 15.5.1 ACT for Life Group 235 15.6 Conclusion 237 16 Group Person-based Cognitive Therapy for Distressing Psychosis 240 Clara Strauss and Mark Hayward 16.1 Introduction 240 16.2 Person-based Cognitive Therapy 240 16.2.1 Group PBCT 242 16.3 The Importance of the Group Process in PBCT 242 16.4 Facilitating a PBCT Group 243 16.4.1 Inclusion Criteria 243 16.4.2 The 12-week Programme 243 16.4.3 Mindfulness Practice in PBCT 244 16.4.4 Cognitive Therapy in PBCT 247 16.4.4.1 Session 2 247 16.4.4.2 Session 3 247 16.4.4.3 Session 4 248 16.4.4.4 Session 5 249 16.4.4.5 Session 6 249 16.4.4.6 Session 7 249 16.4.4.7 Session 8 250 16.4.4.8 Session 9 251 16.4.4.9 Session 10 251 16.4.4.10 Session 11 251 16.4.4.11 Session 12 252 16.5 PBCT: An Integrated Model 252 16.6 Group PBCT: The Evidence 253 16.7 Conclusion 254 Appendix A Chessboard Metaphor 256 Appendix B Leaves-on-the-Stream Metaphor 257 Appendix C Passengers-on-the-Bus Metaphor 259 Appendix D Person-in-the-Hole Metaphor 261 Appendix E Polygraph Metaphor 262 Appendix F See the Wood for the Trees (And Other Helpful Advice for Living Life) 263 Appendix G Skiing Metaphor 270 Appendix H Tug-of-War-with-the-Monster Metaphor 271 Index 272

• Psychiatry

• Clinical psychology

• Mindfulness

• Professional & Vocational

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