latrobe.edu.au

CRICOS Provider 00115M

CRICOS Provider 00115M

What is happening inside ACT for psychosis sessions? Consumer reports and session ratings from the Lifengage RCT

Tory Bacon1, John Farhall1,2, Ellie Fossey1, Neil Thomas1,3, Fran Shawyer1,4,

1La Trobe University, 2North Western Mental Health, 3Swinburne University, 4Monash University

Association for Contextual Behavioural Science World Conference XI, Sydney, July 2013

The Lifengage Trial:A randomised controlled trial of ACT for medication-resistantpsychotic symptoms

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

Lifengage Study Design

Current status: Main analyses still underway…

BaselineAss’t

T2

Ass’t

Befriending therapy - 8 sessions

ACT therapy - 8 sessions

RandomiseT3

Ass’t

3-4 months 6 months

In-session verbal behaviour studySessions 3,5,7

Optional i/v

Subjective experience of therapy study

Treatment As Usual ‘TAU’

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

Table of themes and subthemesTheme Subtheme1. Usefulness of therapy 1.1 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 therapy3.2 Understanding of therapy and exercises

4. Non-specific therapy 4.1 Therapist factors

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

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

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

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

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

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

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

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

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

In-session process study

Study 2 from

Tory Bacon (2013) DPsych thesis, La Trobe University

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

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)

MeasuresFor 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

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

Results: Frequency of verbal utterances across sessions reflecting ACT processes

*

22

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

23

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

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

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