Brandon A. Gaudiano - Incorporating Acceptance and Mindfulness Into The Treatment of Psychosis - Current Trends and Future Directions (2015, Oxford University Press)

Incorporating Acceptance and Mindfulness
into the Treatment of Psychosis

Incorporating Acceptance and
Mindfulness into the Treatment
of Psychosis
Current Trends and Future Directions
E D ITE D BY B R A N D O N A . G AU D I A N O
1
1
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Library of Congress Cataloging-in-Publication Data

Incorporating acceptance and mindfulness into the treatment of psychosis : current trends and
future directions / edited by Brandon A. Gaudiano.
pages cm
Includes index.
ISBN 978–0–19–999721–3 (hardcover : alk. paper)
1. Psychoses—Treatment. 2. Acceptance and commitment therapy. I. Gaudiano, Brandon A.
RC512.I43 2015
616.89′1425—dc23
2014024190
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
To my wife, Kristy, and my parents for their constant support and
encouragement, and to my mentors James Herbert, Ph.D., and Ivan Miller,
Ph.D., for all their guidance throughout the years.
—BG
CONTENTS
Foreword by Kim T. Mueser ix

About the Editor xiii
Contributors xv
SECTION I: Introduction and Background

1. An Introduction to Mindfulness and Acceptance Therapies
for Psychosis 3
Brandon A. Gaudiano
2. The Evolution of Cognitive-Behavioral Therapy for Psychosis: The Path

to Integrating Acceptance, Compassion, and Mindfulness 12
Douglas Turkington, Nicola Wright, and James Courtley
3. Ecological Momentary Assessments in Psychosis: A Contextual

Behavioral Approach to Studying Mindfulness and Acceptance 25
Roger Vilardaga, Michael McDonell, Emily Leickly, and Richard Ries
SECTION II: Specific Treatment Models

4. Acceptance and Commitment Therapy for Psychosis: Applying
Acceptance and Mindfulness in the Context of an Inpatient
Hospitalization 57
Patricia Bach
5. Treating Depression in Psychosis: Self-Compassion as a Valued Life

Direction 81
Ross G. White
6. Acceptance-Based CBT for Command Hallucinations: Rationale,

Implementation, and Outcomes of the TORCH Project 108
Frances Shawyer and John Farhall
7. Person-Based Cognitive Therapy for Distressing Psychosis: Integrating a

Mindfulness-Based Approach with Cognitive Therapy 150
Mark Hayward, Lyn Ellett, and Clara Strauss
viii C ontents
8. Mindfulness Meditation in Cognitive-Behavioral Therapy

for Psychosis 170
Katherine Newman Taylor and Nicola Abba
SECTION III: Synthesis and Analysis

9. A Model for the Development of Acceptance- and Mindfulness-Based
Therapies: Preoccupation with Psychotic Experiences as a Treatment
Target 203
Neil Thomas
10. Disseminating and Implementing Acceptance- and Mindfulness-Based

Approaches to Psychosis: Challenges and Opportunities 227
Hamish J. McLeod
11. Charting the Course Ahead: Future Clinical and Research Directions in

Mindfulness and Acceptance Therapies for Psychosis 253
Brandon A. Gaudiano
Index 277
FOREWORD
The mind is a wondrous but terrible thing—capable of giving birth to astound-

ing artistic and scientific achievements, selfless caring, love and joy, but also of
wreaking havoc, unspeakable cruelty and hate, and the depths of despair. But
does this perspective give too much credit to the mind? Steven Hayes, whose
groundbreaking work on relational frame theory led to the development of
acceptance and commitment therapy (ACT), said, “I used to think that the most
important part of my body was my brain, and then I asked ‘who is telling me
this?’” Must not there be something that operates outside or beyond the mind or
the brain as we know it, like a self, that is either capable of outright controlling
the mind or at least influencing it and the feelings and behaviors that flow from
it? In their own unique ways, cognitive-behavioral therapy (CBT) and ACT have
responded to this question with a resounding “Yes!” and have sought to give
people greater control over their mental and physical lives through rather differ-
ent, but not incompatible, approaches to dealing with the troubling mind.
The fundamental premise of CBT, often summarized with the thought–feel-
ing–behavior triad, is that how one responds to a situation (e.g., calling out
“hello” to a friend walking down the other side of the street who does not reply
back) is largely determined by the individual’s interpretation (i.e., thoughts and
beliefs) of that situation (e.g., “My friend doesn’t want to acknowledge me in
public”), which leads to the associated feelings (e.g., hurt) and behaviors (e.g.,
avoidance of friend). For a variety of reasons, people’s interpretations of events
are often inaccurate (e.g., the friend may not have heard the person), but they can
learn how to correct them, and that such correcting will alleviate suffering and
improve adaptable behavior. CBT assumes that the content of one’s thoughts is
primarily responsible for the feelings and behaviors that ensue. Its focus is on
changing the processes by which interpretations of events are made in order to
change the conclusions reached and the resulting content of thought. This may
include teaching people how to recognize “automatic” thoughts and to identify
belief structures or schemas that can be logically examined, and refuted and
changed when inaccurate, resulting in changes in associated feelings and behav-
iors. The importance of the content of thoughts and beliefs in CBT is reflected
not only in its theoretical role in determining feelings and behaviors but also
x F oreword
in the emphasis in many CBT approaches on developing a shared formulation

between the therapist and client that is aimed at establishing the personal mean-
ing of those thoughts and beliefs on the basis of past experiences and contexts in
which they arise (Morrison & Barratt, 2010).
ACT agrees with CBT that the unruly mind is the source of much emotional
turmoil and ineffective behavior, but ACT takes a different approach to rectify-
ing the situation. Instead of attempting to master the rambunctious mind, and
making sense and correcting its often obnoxious contents, the aim of ACT is
to emotionally distance the self from the upsetting contents of the mind, and
to foster the person’s ability to dispassionately observe their thinking while
paradoxically exercising the right to choose to “not buy into that thought.” The
importance of meaning is not lost in ACT, but rather invested somewhere else
than in CBT—in the exploration of personal values, so that the acceptance of
lack of control over the contents of one’s thoughts is done in the service to a com-
mitment to living one’s life in accordance with one’s values and goals. Instead of
disputing the irrational and upsetting thoughts, ACT emphasizes the articula-
tion of personal values and the teaching of strategies aimed at defusion, or the
minimization of negative emotional responses to upsetting thoughts by relating
to thoughts differently (e.g., mindfulness approaches that facilitate awareness of
thinking without engagement) and reducing behavioral avoidance of situations
anticipated to evoke such thoughts (i.e., experiential avoidance).
Despite the differences between CBT and ACT, both have a long and growing
list of problems and conditions for which they are effective, supporting the casual
observation that people can change the process and content of their thinking,
but not always, and that acceptance rather than control over thinking is a viable
alternative. Early applications of and research on CBT and ACT focused mainly
on depression and anxiety, with success in these areas emboldening attempts to
use the models for other disorders, such as addiction and, eventually, psycho-
sis. Persistent psychotic symptoms are relatively common in disorders such as
schizophrenia and are associated with high levels of distress. The use of CBT
or ACT to address psychotic symptoms is a natural extension of each model, as
both models posit a role for the self in the regulation of emotions and behavior
that is semi-independent of thoughts. Although the first published clinical appli-
cation of the CBT model over 60 years ago was with someone with paranoid
psychosis (Beck, 1952), following this, work on CBT shifted to depression and
anxiety; it was more than 30 years later that systematic attempts to apply CBT to
schizophrenia and other psychotic disorders began again in earnest (Chadwick,
Birchwood, & Trower, 1996; Fowler, Garety, & Kuipers, 1995; Tarrier et al., 1993).
Over the intervening years, empirical support for CBT for psychosis has grown,
and for more than a decade it has been a recommended practice in guidelines
for the treatment of schizophrenia in the United States (Dixon et al., 2010) and
in Great Britain (Kuipers, Yesufa-Udechuko, Taylor, & Kendall, 2014). But the
evidence supporting CBT continues to be hotly debated (McKenna & Kingdon,
2014), and there is clearly much room for improvement in helping people learn
how to manage their psychotic symptoms more effectively. CBT for psychosis
Forewordxi
continues to be refined and modified; it is informed by emerging research on

ACT and related approaches for this population.
The first controlled study of ACT for psychotic symptoms was published just
over a decade ago, with the exciting but predicted results that ACT led to higher
reporting of psychotic symptoms (perhaps because these patients became accept-
ing of and thus more willing to report these experiences) but lower believability of
symptoms and lower rates of rehospitalization (Bach & Hayes, 2002). Subsequent
research on ACT for psychosis has continued to report promising findings
(Gaudiano & Herbert, 2006; Gaudiano, Nowlan, Brown, Epstein-Lubow, &
Miller, 2013). Furthermore, as described in this timely book, encouraging results
have been reported from adaptations of other interventions for psychosis based
on or influenced by the concept of mindfulness, such as compassion-focused
therapy (Gumley, Braehler, Laithwaite, MacBeth, & Gilbert, 2010), person-based
cognitive therapy (Chadwick, 2006), and mindfulness-based approaches incor-
porating meditation (Johnson et al., 2009).
Psychotic symptoms are among the most distressing and alienating of all
psychiatric symptoms, by virtue of both their often derogatory and persecutory
nature and their impact on separating the person from others and society in
general. Psychosis is associated with the most severe and debilitating mental ill-
nesses, yet psychotic symptoms occur with moderate frequency in the general
population (Romme & Escher, 1989), which suggests that their presence need not
preclude normal functioning. ACT and other mindfulness-based approaches,
as alternatives to CBT or in combination with it, have enormous potential for
reducing the suffering related to psychotic symptoms in persons with severe
mental illness and for improving their everyday functioning in areas such as
social relationships, work and school, self-care, and quality of life.
The chapters in this book will arm clinicians with critical tools for helping
people with serious mental illness recover and reclaim their lives—not only
through the elimination of psychotic symptoms but also through learning how
to live with them and despite them. The focus in this book on theory and under-
standing mechanisms of change has great potential for advancing research in
this area and for bridging the gap between traditional CBT and newer mindful-
ness and acceptance interventions.
Kim T. Mueser, PhD

Executive Director, Center for Psychiatric Rehabilitation
Professor of Occupational Therapy, Psychology, and Psychiatry
Boston University
R EFER EN C ES
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to
prevent the rehospitalization of psychotic patients: A randomized controlled trial.
Journal of Consulting and Clinical Psychology, 70, 1129–1139.
xii F oreword
Beck, A. T. (1952). Successful outpatient psychotherapy with a schizophrenic with a

delusion based on borrowed guilt. Psychiatry, 15, 305–312.
Chadwick, P. (2006). Person-based cognitive therapy for distressing psychosis. Chichester,
UK: John Wiley & Sons.
Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions,
voices and paranoia. Chichester, UK: John Wiley & Sons.
Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M. E., Dickinson, D., Goldberg,
R. W., . . . Kreyenbuhl, J. (2010). The 2009 PORT psychosocial treatment recommen-
dations and summary statements. Schizophrenia Bulletin, 36, 48–70.
Fowler, D., Garety, P., & Kuipers, E. (1995). Cognitive behaviour therapy for psycho-
sis: Theory and practice. Chichester, UK: John Wiley & Sons.
Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic
symptoms using acceptance and commitment therapy: Pilot results. Behaviour
Research and Therapy, 44, 415–437.
Gaudiano, B. A., Nowlan, K., Brown, L. A., Epstein-Lubow, G., & Miller, I. W. (2013).
An open trial of a new acceptance-based behavioral treatment for major depression
with psychotic features. Behavior Modification, 37, 324–355.
Gumley, A., Braehler, C., Laithwaite, H., MacBeth, A., & Gilbert, P. (2010). A compas-
sion focussed model of recovery after psychosis. International Journal of Cognitive
Therapy, 3, 186–201.
Johnson, D. P., Penn, D. L., Fredrickson, B. L., Meyer, P. S., Kring, A. M., & Brantley, M.
(2009). Loving-kindness meditation to enhance recovery from negative symptoms
of schizophrenia. Journal of Clinical Psychology, 65, 499–509.
Kuipers, E., Yesufu-Udechuku, A., Taylor, C. B., & Kendall, T. (2014). Management of
psychosis and schizophrenia in adults: Summary of updated NICE guidance. British
Medical Journal, 348, g1173.
McKenna, P., & Kingdon, D. (2014). Has cognitive behavioural therapy been oversold?
British Medical Journal, 348, g2295.
Morrison, A. P., & Barratt, S. (2010). What are the components of CBT for psychosis?
A Delphi study. Schizophrenia Bulletin, 36, 136–142.
Romme, M. A., & Escher, A. D. (1989). Hearing voices. Schizophrenia Bulletin, 15,
209–216.
Tarrier, N., Beckett, R., Harwood, S., Baker, A., Yusupoff, L., & Ugarteburu, I. (1993).
A trial of two cognitive behavioural methods of treating drug-resistant residual psy-
chotic symptoms in schizophrenic patients: I. Outcome. British Journal of Psychiatry,
162, 524–532.
ABOUT THE EDITOR
Brandon A. Gaudiano, PhD, is a clinical psychologist in the Psychosocial

Research Program at Butler Hospital and associate professor (research) in the
Department of Psychiatry & Human Behavior at the Warren Alpert Medical
School of Brown University. Dr. Gaudiano has published over 65 peer-reviewed,
scientific articles on various topics including psychotherapy development and
testing, evidence-based practices, psychotic and mood disorders, and mindful-
ness and acceptance. His research on acceptance and commitment therapy and
other novel psychosocial interventions for psychosis has been funded by the
National Institute of Mental Health.
CONTRIBUTORS
Nicola Abba, DClinPsy Mark Hayward, DClinPsy, PhD

Southern Health NHS Foundation Sussex Partnership NHS
Trust Foundation Trust
Southampton, UK and
University of Sussex
Patricia Bach, PhD
Brighton, UK
Department of Psychology
University of Central Florida Emily Leickly, BA
Orlando, Florida Department of Psychiatry and
Behavioral Sciences
James Courtley, RMN
University of Washington
NTW NHS Foundation Trust
Seattle, Washington
Newcastle upon Tyne, UK
Michael McDonell, PhD
Lyn Ellett, PhD
Department of Psychiatry and
Department of Psychology
Behavioral Sciences
Royal Holloway University of London
University of Washington
Egham, UK
Seattle, Washington
John Farhall, PhD
Hamish J. McLeod, PhD
School of Psychological Science
Institute of Health and Wellbeing
La Trobe University
University of Glasgow
and
Glasgow, Scotland
NorthWestern Mental Health
Melbourne, Australia Kim T. Mueser, PhD
Center for Psychiatric Rehabilitation
Brandon A. Gaudiano, PhD
and
Department of Psychiatry & Human
Departments of Occupational
Behavior
Therapy, Psychology, and
The Warren Alpert Medical School of
Psychiatry
Brown University
Boston University
and
Boston, Massachusetts
Psychosocial Research Program
Butler Hospital
Providence, Rhode Island
xvi C ontributors
Katherine Newman Taylor, DClinPsy Douglas Turkington, MD

Southern Health NHS NTW NHS Foundation Trust
Foundation Trust and
and Newcastle University
University of Southampton Newcastle upon Tyne, UK
Southampton, UK
Roger Vilardaga, PhD
Richard Ries, MD Department of Psychiatry and
Department of Psychiatry and Behavioral Sciences
Behavioral Sciences University of Washington
University of Washington Seattle, Washington
Seattle, Washington
Ross G. White, PhD, DClinPsy
Frances Shawyer, PhD Institute of Health and Wellbeing
Department of Psychiatry University of Glasgow
School of Clinical Sciences at Glasgow, Scotland
Monash Health
Nicola Wright, PhD, CPsych
Monash University
Royal Ottawa Mental Health Centre
and
and
School of Psychological Science
School of Psychology
La Trobe University
University of Ottawa
Melbourne, Australia
Ottawa, Canada
Clara Strauss, DPhil, DClinPsych and
Sussex Partnership NHS Beck Institute of Cognitive
Foundation Trust Behavior Therapy
and Philadelphia, Pennsylvania
University of Sussex
Brighton, UK
Neil Thomas, DClinPsy
School of Health Sciences
Swinburne University of Technology
and
Monash Alfred Psychiatry
Research Centre
Melbourne, Australia
SECTION I
Introduction and Background

1
An Introduction to Mindfulness
and Acceptance Therapies
for Psychosis
BRANDON A. GAUDIANO ■
BAC KG R O U N D
Antipsychotic medications currently dominate the treatment of psychotic dis-

orders such as schizophrenia, given their efficacy for reducing hallucinations
and delusions. However, pharmacotherapy for psychosis has a multitude of
limitations in terms of safety, acceptability, and effectiveness (Lacro, Dunn,
Dolder, Leckband, & Jeste, 2002; Miyamoto, Duncan, Marx, & Lieberman,
2005; Moncrieff & Leo, 2010; Wunderink, Nieboer, Wiersma, Sytema, &
Nienhuis, 2013). A large body of research has demonstrated that antipsychot-
ics are clinically inadequate when used as the only treatment for psychosis
(Patterson & Leeuwenkamp, 2008). For many years, psychotherapy, or “talk
therapy,” was considered a questionable treatment for this clinical population
because it was believed to have very little impact on the illness. This cynicism
was reinforced by early studies of psychotherapy for psychosis using tradi-
tional psychoanalytic approaches, which reported limited effectiveness and
even potentially iatrogenic effects (Mueser & Berenbaum, 1990). However,
with the emergence of modern psychotherapeutic treatments, attention
once again turned to how psychotherapy could be adapted to treat psycho-
sis, with the aim of extending and complementing the benefits derived from
medications.
4 A c c e p t an c e and M i ndf u ln e ss i n t h e T r e a t m e n t o f P s y c h o s i s
In recent decades, a growing body of research has supported exciting new

developments in psychosocial treatments for schizophrenia and related psy-
choses. Clinical treatment guidelines for psychosis increasingly recommend
that patients be offered evidence-based psychosocial interventions in addition
to medications (Dixon et al., 2010; National Institute for Health and Clinical
Excellence, 2009). These recommendations are based on accumulating evidence
from numerous clinical trials showing that various individual and family-based
psychosocial interventions produce greater improvements in symptoms and
functioning and are better able to prevent relapses than medications alone
(Pilling Bebbington, Kuipers, Garety, Geddes, Martindale, et al., 2002; Pilling,
Bebbington, Kuipers, Garety, Geddes, Orbach, et al., 2002). Cognitive-behavioral
therapy (CBT) is one intervention class that has been shown to consistently pro-
duce these added benefits in the treatment of psychosis (Gaudiano, 2005; Wykes,
Steel, Everitt, & Tarrier, 2008).
I N C O R P O R AT I N G M I N D F U L N ES S A N D AC C EP TA N C E
I N TO T H E T R E AT M EN T O F PSYC H O S I S
In parallel with these recent advancements in the treatment of psychosis, the pre-
vious decade has witnessed an expansion in the way CBT is conceptualized and
implemented (Gaudiano, 2008). Increasingly, CBT interventions are incorpo-
rating novel strategies that promote psychological processes such as acceptance
and mindfulness (Tai & Turkington, 2009). Some have described these newer
acceptance- and mindfulness-based approaches as the “third wave” of behavior
therapy, with the first wave pertaining to the traditional behavior therapy move-
ment that developed in the 1950s, and the second wave representing the cognitive
therapy revolution that began in the 1970s (Hayes, 2004; Hayes, Villatte, Levin, &
Hildebrandt, 2011). Although debate in the field currently exists surrounding the
novel versus common elements of these interventions, third-wave therapies tend
to place a greater emphasis on acceptance than on change regarding psycho-
logical problems (Herbert & Forman, 2011). The justification for this approach
is based in part on research showing the often paradoxical or rebound effects
produced when individuals actively try to avoid or suppress unwanted thoughts
and feelings (Najmi & Wegner, 2008; Wegner, 1994; Wegner & Zanakos, 1994).
Acceptance does not imply mere resignation or “giving in” to symptoms but
instead represents a conscious choice on the part of the person to be willing
to experience difficult symptoms more fully if doing so serves that individual’s
valued goals (Hayes, Strosahl, & Wilson, 2012). Acceptance-based coping can
mitigate the paradoxical effects of avoidance and produce greater psychologi-
cal flexibility in responding to difficult symptoms (Levin, Hildebrandt, Lillis, &
Hayes, 2012). Related to the emphasis on acceptance are interventions that
train individuals to take a “mindful” stance toward their internal mental states.
Mindfulness involves bringing nonjudgmental awareness, curiosity, and open-
ness to one’s moment-to-moment experiences (Bishop et al., 2004). Practicing
Introduction to Mindfulness and Acceptance Therapies for Psychosis5
mindfulness has been shown to produce numerous benefits to people’s psycholog-

ical and physical well-being (Chiesa & Serretti, 2010; Hofmann, Sawyer, Witt, &
Oh, 2010; Keng, Smoski, & Robins, 2011).
Emerging research also suggests that the psychological processes of avoidance
and acceptance play an important role specifically in psychosis. Avoidance-based
coping styles (e.g., experiential avoidance, meaning the avoidance of internal
experiences causing impairment) have been implicated in the development and
maintenance of psychosis (Goldstone, Farhall, & Ong, 2011; Shawyer et al., 2007;
Udachina et al., 2009; Vorontsova, Garety, & Freeman, 2013; White et al., 2013).
Furthermore, research conducted to date points to the potential benefits of vari-
ous acceptance and mindfulness therapies for psychosis. For example, Bach and
Hayes (2002) conducted the first clinical trial of acceptance and commitment
therapy (ACT; Hayes et al., 2012) versus treatment as usual for hospitalized
patients with psychosis. Results showed greater reductions in believability and
distress related to psychotic symptoms and a 50% reduction in subsequent rehos-
pitalizations at 4-month follow-up compared with treatment as usual. This effect
on rehospitalization rates was maintained at 1 year post-discharge (Bach, Hayes, &
Gallop, 2012). My colleague James Herbert and I replicated and extended the Bach
and Hayes findings in a similar inpatient sample with psychosis (Gaudiano &
Herbert, 2006). We also demonstrated that changes in hallucination-related
believability targeted by ACT mediated the effects of the treatment on distress
at hospital discharge (Gaudiano, Herbert, & Hayes, 2010) and rehospitaliza-
tion rates at follow-up (Bach, Gaudiano, Hayes, & Herbert, 2013). Other more
recent studies also have supported the safety and efficacy of ACT for psychosis
(Shawyer et al., 2012; White et al., 2011). This research has led the American
Psychological Association (n.d.) to designate ACT as an empirically supported
therapy for psychosis.
In a separate but related line of research, Chadwick and colleagues (Chadwick,
Hughes, Russell, Russell, & Dagnan, 2009; Chadwick, Newman-Taylor, & Abba,
2005) reported that mindfulness meditation groups were effective for increasing
mindfulness and reducing symptoms in patients with current psychosis. Another
approach developed by Chadwick (2006), called person-based cognitive therapy
for distressing psychosis, combines more traditional cognitive-behavioral with
newer acceptance/mindfulness strategies and has shown promising results in
initial studies (Dannahy et al., 2011). Reviews of the literature on mindfulness
for psychosis are beginning to appear (e.g., Davis & Kurzban, 2012), and various
interventions that aim to foster acceptance and mindfulness are being devel-
oped and show promising initial results (Ashcroft, Barrow, Lee, & MacKinnon,
2012; Braehler et al., 2013; Chien & Lee, 2013; Davis, Strasburger, & Brown, 2007;
Gaudiano, Nowlan, Brown, Epstein-Lubow, & Miller, 2013; Johnson et al., 2011;
Laithwaite et al., 2009; Langer, Cangas, Salcedo, & Fuentes, 2012; Manjanath,
Varambally, Thirthalli, Basavaraddi, & Gangadhar, 2013; Razzaque, 2012; van
der Valk, van de Waerdt, Meijer, van den Hout, & de Haan, 2013). A recent
meta-analysis of initial studies demonstrated the benefits of various mindfulness
and acceptance therapies for psychosis and supported the hypothesis that they
work at least partly by changing the proposed mechanisms underlying psychosis

that are targeted by these interventions (Khoury et al., 2013).
R AT I O N A L E FO R T H E B O O K
Although there are a variety of acceptance and mindfulness approaches being

developed to address psychosis, currently there is no one dominant approach.
Furthermore, much confusion exists as to the quality of the research evidence
base supporting these newer interventions, and it is sometimes unclear what
their common and distinctive elements are. For this edited volume, I have asked
the leading researchers and clinicians developing acceptance and mindfulness
therapies for psychosis to compare and contrast these emerging interventions
and to discuss them within the context of the more traditional CBT approaches.
The book is designed to be relevant to both researchers and clinicians who are
interested in gaining a deeper understanding and appreciation of mindfulness
and acceptance therapies as part of the cutting edge of psychosocial treatment
for severe mental illness. The further aim of the volume is to stimulate discussion
and debate about these novel approaches to psychosis (both pro and con) and to
develop a coherent plan for moving research and practice in this area forward so
that it will have maximum impact on the field.
ST R U CT U R E O F T H E B O O K
This book is divided into three separate sections. Section I introduces the reader
to acceptance and mindfulness approaches for psychosis. Turkington and col-
leagues (Chapter 2) provide the historical context for this work by describing the
evolution of CBT for psychosis, from past to present. The authors start by tracing
the origins of CBT for psychosis and then discuss the expansion of this work
in recent years to include acceptance and mindfulness strategies. Their chapter
concludes by presenting an integrated model of cognitive-behavioral and mind-
fulness/acceptance strategies for psychosis. Vilardaga and colleagues (Chapter
3) discuss a novel assessment strategy that has the potential to further improve
and expand mindfulness and acceptance therapies for psychosis. These authors
describe the innovative use of mobile technologies (e.g., smartphones), also called
ecological momentary assessment (EMA), to study the wider context of experi-
ences of patients with psychosis in the community. They highlight important
new work demonstrating how EMA can be a used as a contextual method for
clarifying acceptance and mindfulness processes in psychosis, which then could
be employed in self-administered interventions via these same mobile devices.
Section II of the book reviews the variety of mindfulness and acceptance ther-
apies for psychosis that have been investigated in initial research to date. Each
chapter in this section (a) describes the treatment’s underlying theoretical model
and proposed mechanisms of change; (b) outlines the treatment approach,
including its essential techniques and strategies; (c) provides a clinical vignette

illustrating the application of this approach; (d) analyzes the proposed common
and distinctive elements of the treatment; (e) provides a summary of research
supporting the intervention; and (f) offers recommended directions for future
research. In the first chapter in this section (Chapter 4), Bach provides a detailed
description of ACT, which is the most studied mindfulness/acceptance-oriented
intervention for psychosis to date, as applied to hospitalized patients. Emerging
research focuses on the important role that self-compassion plays in understand-
ing and treating psychosis (Gumley, Braehler, Laithwaite, MacBeth, & Gilbert,
2010). White (Chapter 5) addresses compassion-focused therapy for psychosis
and discusses how it can be applied to treat emotional dysfunction following a
psychotic episode. Other work is being conducted that combines mindfulness/
acceptance and more traditional cognitive-behavioral strategies for psychosis.
Shawyer and Farhall (Chapter 6) discuss a novel intervention that they designed,
called TORCH, that integrates a wider range of CBT and ACT components to
treat those with persistent command hallucinations. These authors also discuss
the results and lessons learned from their randomized controlled trial compar-
ing TORCH to a supportive intervention. Hayward and colleagues (Chapter 7)
review person-based cognitive therapy for distressing psychosis; this approach
also combines more traditional elements from cognitive therapy with mindful-
ness meditation. The final chapter in this section, by Newman Taylor and Abba
(Chapter 8), describes how mindfulness meditation practices can be adapted
safely and effectively to treat psychosis.
Section III, the final part of the book, provides a synthesis and an analysis of
the work described in the previous section. In the first chapter in this section,
Thomas (Chapter 9) presents an acceptance- and mindfulness-informed theo-
retical model describing the development and maintenance of psychosis to guide
future intervention research. He emphasizes the role of avoidance and rumina-
tion in fostering the impairing preoccupation characteristic of psychosis, and
how acceptance and mindfulness processes can alter these maladaptive patterns,
leading to clinical improvement. McLeod (Chapter 10) addresses the dissemi-
nating and implementing of mindfulness and acceptance therapies for psycho-
sis, and how to do so in a responsible and empirically informed manner. He
makes specific recommendations for training clinicians in these interventions
so that they will be able to administer treatment reliably and competently. In the
final chapter of the book (Chapter 11), I summarize the current state of affairs
regarding mindfulness and acceptance therapies for psychosis. Suggestions are
given for future research and clinical work that might clarify and improve these
approaches, to make them more accessible to service users.
From the chapters in this book, it is clear that while work incorporating mind-
fulness and acceptance into various psychotherapies for psychosis is only just
beginning, already a considerable amount of theoretical, research, and clinical
support for these treatments has been amassed. It is hoped that by better under-
standing the diversity of ways in which mindfulness and acceptance strategies
are being applied to psychosis, we will be able to refine and clarify the most
effective components of these treatments, and harness them to support recov-

ery from psychosis. This book is one step toward reaching this important longer
term goal.
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2
The Evolution of
Cognitive-Behavioral
Therapy for Psychosis
The Path to Integrating Acceptance,
Compassion, and Mindfulness
D O U G L A S T U R K I N GTO N , N I C O L A W R I G H T,
AND JAMES COURTLEY ■
T H E 19 50 S: B EC K—FR O M PSYC H OA N A LYS I S TO

C O G N I T I V E- B EH AV I O R A L T H ER A PY FO R PSYC H O S I S
It is fair to date the genesis of cognitive-behavioral therapy (CBT) for psychosis to

a single case study (Beck, 1952). Aaron T. Beck had been trained as a classical psy-
choanalyst within a North American psychiatric training tradition. He began to
query the psychoanalytic models that he had been introduced to and investigated
these using a scientific methodology. He postulated that if dreams were “the royal
road” to the unconscious and that if depression was indeed aggression turned
against itself, then the dreams of patients suffering from depression should be full
of rage and anger. His investigation found, however, that their dream content only
contained depressive images, affects, and themes. He also queried the efficacy and
duration of classical transference-based interpretive psychoanalysis.
In his 1952 crucial, early case, Beck retained a psychodynamic formulation
but worked more directly on the psychotic content. His patient had an extensive
delusional system of Central Intelligence Agency persecution with prominent
anxiety and avoidance. Beck worked in a structured manner using collabora-
tive empiricism, guided discovery, and reality testing, and CBT for psychosis
(CBTp) was born. Through CBTp, Beck gradually reduced the patient’s anxiety
The Evolution of Cognitive-Behavioral Therapy for Psychosis13
and avoidance behaviors, and eventually through sustained, gradual reality

testing all persecutors were given up. Beck was then able to work with the guilt
underlying the delusion using a schema-based approach. The client’s recovery
was impressive and occurred with a classic experience and symptom of schizo-
phrenia (an entrenched delusional system). Up until this point, the commonly
held belief was that psychosis was resistant to all forms of treatment; antipsy-
chotic medication had not yet been introduced. Beck then dropped the psycho-
dynamic formulation and approach in favor of the more pragmatic cognitive
model, which he subsequently developed in relation to depression and anxiety
(Beck, Rush, Shaw, & Emery, 1979).
T H E 19 6 0 S: C BT P, T H E EM ER G EN C E O F
C O G N I T I V E R EM ED I AT I O N, A N D PR O G R ES S
I N B EH AV I O R A L A PPR OAC H ES
The psychological elegance of Beck’s original casework was submerged by a wave

of optimism surrounding the launch of the antipsychotics and the discovery
of the atypical antipsychotic clozapine. A more neurodevelopmental model of
psychosis became dominant and CBT took a remediative turn. Meichenbaum
(1969) developed cognitive remediation as a means to improve a client’s func-
tioning after behavioral therapy had produced some initial benefit. Allen and
Agus (1968) demonstrated that hyperventilation could trigger the development
of hallucinations, pointing the way to relaxation approaches, including progres-
sive muscular relaxation.
T H E 1970 S: C BT P ’S FO C U S O N R EM ED I AT I O N
In 1973, Meichenbaum and Cameron demonstrated that cognitive remediation

could improve attentional deficits. Beck’s original psychological model and case-
work of CBTp had gone largely unrecognized by the scientific community. However,
in 1974, Hole, Rush, and Beck (under the supervision of Beck) showed that cogni-
tive therapy in a brief format could have an impact on and improve various aspects
of the delusional experience in a case series of clients who experienced psychosis.
Milton, Patwa, and Häfner (1978) demonstrated that belief modification was more
effective than belief confrontation in treating clients with persistent delusions.
T H E 19 8 0 S: E X PLO S I O N O F I N T ER EST I N C O G N I T I V E

M O D ELS A N D T EC H N I Q U ES
In 1980, Jacobs described a cognitive approach to persistent delusions. By

the late 1980s an explosion of interest in CBTp was taking place around the
world. Important early work on reality-testing hallucinations was carried out
by Bentall and Slade, in 1985. In 1986, Hemsley and Garety described key
principles concerning delusion formation. Kaney and Bentall (1989) further
described attributions linked to the emergence of delusions. The first pub-
lished clinical report was from Umeå, Sweden, where Carlo Perris and his
team were using individual and group therapy for people experiencing per-
sonality disorders and psychosis with some success. Perris’s (1988) approach
incorporated CBT principles and techniques along with structured psycho-
dynamic work. At around the same time in the United Kingdom, Fowler and
Morley (1989) published an influential case series of patients undergoing CBT
for hallucinations and delusions.
A ground-breaking trial in 1989 by Romme and Escher described the com-
mon nature of patients’ voice-hearing experience. Romme and Escher described
how “voice-hearers” who were not in contact with psychiatric services were able
to cope with these experiences. At the end of the 1980s, in the Netherlands and
in Sweden, Marius Romme and Carlo Perris, respectively, were beginning a revo-
lution in CBTp. Meanwhile, in the United Kingdom, the CBTp revolution was
being led by Richard Bentall and David Fowler.
T H E 19 9 0 S: B LO S SO M I N G O F C BT FO R PSYC H O S I S
In 1990, Lowe and Chadwick published an influential paper on verbal control

of delusions. In 1991, psychological models for psychosis were described further
by Roberts, who highlighted the importance of the narrative (the beginnings of
the timeline) and the protective function of some primary delusions in relation
to matters disclosed in the narrative. Kingdon and Turkington (1991b) described
the critical importance of a normalizing explanation of psychotic “symptoms”
(experiences) to reduce stigma and enhance the therapeutic alliance. Their sub-
stantial case series showed the safety and acceptability of CBTp when empha-
sizing a normalizing rationale. Importantly, Kingdon and Turkington (1991b)
described an associated reduction in relapse, days of rehospitalization, and
polypharmacy.
In 1994 a CBT manual followed for the treatment of psychosis/schizophrenia
(Kingdon & Turkington, 1994). This manual described a rich therapeutic integra-
tion of CBT approaches including engagement; normalization; CBT strategies for
symptoms of anxiety and depression; coping strategy development; questioning
techniques; reality testing for delusions and hallucinations; and CBT approaches
for adherence, negative symptoms, schema-level work, and relapse prevention.
Kingdon and Turkington’s work provided the first description of a clear process
for CBTp in the literature.
Kingdon and Turkington’s (1994) work was closely followed by Fowler and col-
leagues’ manual in 1995 (Fowler, Garety, & Kuipers, 2005). The work of Fowler
and colleagues displayed a similar process of therapy but with a strong empha-
sis on the importance of the therapeutic alliance and a detailed description of
the importance of formulation and conceptualization. In 1996, an extremely
important book followed, by Chadwick, Birchwood, and Trower, entitled

Cognitive Therapy for Voices, Delusions and Paranoia. This work further devel-
oped the approaches described in the first two manuals.
By the mid-1990s, new CBT strategies for psychotic symptoms were being
regularly described and tested. An excellent example is Tarrier and colleagues’
(Tarrier, Harwood, Yusopoff, Beckett, & Baker, 1990) systematic evaluation of
coping strategy enhancement as an approach. In the late 1980s, Turkington and
Kingdon tested techniques for treating thought disorder in schizophrenia (e.g.,
thought linkage, clarification of themes, focus on the most affectively arousing
theme[s]‌, attention to nonverbal communication, and the challenge of neolo-
gisms) (Turkington & Kingdon, 1991). Large-scale, well-designed randomized
controlled trials were carried out to test the whole process of CBTp being devel-
oped by that time. Examples of this work include studies by Sensky et al. (2000)
and Tarrier et al. (2000), who tested their CBTp against the control conditions of
befriending and supportive therapy, respectively.
Also during this time, important breakthroughs were being made in the
measurement of psychotic symptoms, including development of the Psychotic
Symptoms Rating Scale, by Haddock, McCarron, Tarrier, and Faragher (1999),
and the Beliefs about Voices Questionnaire (Chadwick, Lees, & Birchwood,
2000). Regarding developments in cognitive remediation, Brenner, Hodel, Roder,
and Corrigan (1992) described an integrated psychological approach to a graded
development of remediative strategies. The elements of cognitive remediation
included cognitive differentiation, social perception, verbal communication,
social skills, and interpersonal problem-solving. Importantly, one of the limita-
tions emerging at this period of time was that the benefits of cognitive reme-
diation were not being shown to generalize to other settings (Wykes & Dunn,
1992) or to predict successful rehabilitation (Wykes, Sturt, & Katz, 1990).
T H E 21ST C EN T U RY: EM ER G EN C E O F
M I N D F U L N ES S, AC C EP TA N C E, A N D C O M M I T M EN T,
C O M PAS S I O N - FO C U S ED, A N D P O S I T I V E
PSYC H O LO GY– BAS ED A PPR OAC H ES
Subgroups of schizophrenia/psychosis were described by Kingdon and

Turkington in their new manual in 2005. They described subgroups of psychosis
with unique contributions to causation, symptomatology, and recovery trajec-
tory as once predicted by Bleuler (1911) in his Treatise on the Schizophrenias.
Kingdon and Turkington described traumatic psychosis, sensitivity disorder,
anxiety psychosis, and drug-induced psychosis, all with clear psychological
models, treatment pathways, and predicted psychological interventions based
on extended CBT approaches.
Chadwick and colleagues (2000) made a major contribution in their descrip-
tion of omnipotence and omniscience as a key parameter of command hal-
lucinations associated with very passive or high-risk behaviors. Their CBT
approach to command hallucinations based on social rank theory was described

by Byrne, Birchwood, Trower, and Meaden (2006). In later years, Grant et al.
(2012) described a CBT recovery approach for the most severely disabled people
with negative symptoms in schizophrenia. Their approach was based on graded
activity scheduling with mastery and pleasure recording. Grant and colleagues
also identified and worked with key underlying defeatist beliefs (e.g., failure and
achievement schemas) that seemed to underpin the maintenance of negative
symptoms.
Morrison and colleagues (2012) integrated Wells’ (2000) metacognitive the-
ory and techniques into their formulation-driven approach to psychosis. This
work seemed to develop and extend Morrison and Wixted’s (1989) model, which
described the maintenance of psychotic symptoms through appraisal, affect, and
safety behaviors. Morrison et al.’s newly developed model included a role for
meta-beliefs, such as “voices are supernatural,” “voices are dangerous,” “paranoia
will make me violent,” or “my mind is broken” (the latter highlighting the role of
a lack of cognitive confidence). Other mental behaviors described in the model
included worry linked to the meta-belief that “worrying will keep me safe” and
rumination linked to the meta-belief “If I ruminate I will be able to fight back.”
Another key meta-belief was “I should control my mind.” Importantly, attempts
to control thoughts were linked to avoidance and safety behaviors, including
persistent and repeated attempts at thought suppression leading to an increase in
paranoid ideation as well as to certain types of hallucinations.
The self-regulatory executive function model (Wells & Matthews, 1994) pre-
dicts the cognitive attentional state in which the mind is kept locked into cer-
tain presumed-to-be-fearful stimuli. Techniques such as evaluating the pros and
cons of worry, rumination, or thought suppression can provide the rationale for
therapeutic use of postponement strategies and the initiation of worry, rumina-
tion, or suppression periods for set times each day. In addition, attention-shifting
training can help to break up the cognitive attentional state in metacognitive
therapy linked to psychotic symptoms. The addition of a metacognitive element
to CBTp is showing prospects of being beneficial to at least a subgroup of clients
with these avoidance and safety behaviors.
Compassion-focused therapy (CFT) was introduced for the treatment of
depression by Paul Gilbert (2010). There is an obvious overlap between psychosis
and depression, as depression is common in those with psychosis. In addition,
the relatively high incidence of a history of childhood traumatization and sub-
sequent traumatization such as bullying or domestic violence can play a critical
role. Gilbert demonstrated the use of a variety of compassion-activating strate-
gies to activate the oxytocin-based compassion system in the brain. He described
the evolutionary function and interplay of the three emotional systems of drive,
soothing, and threat. Approaches used in CFT or compassionate mind train-
ing include developing a compassionate image or nurturer, compassionate
letter-writing, creation of a self-compassion box, carrying out compassionate
actions, and compassionate self-talk. Mindful compassion, or CFT, is increas-
ingly being implemented with those who experience psychosis (see Chapter 5 in
this book, as well as Braehler et al., 2013). Compassion toward the self, the hal-
lucinatory voices, and delusional persecutors can all be associated with reduced
distress and improved social functioning. Self-compassion can also lead to an
acceptance of the need to work with any medication benefits, ensuring improved
adherence, improved symptom control, and a reduced risk of relapse.
Acceptance and commitment did not appear as clear and valuable concepts
within CBTp until the description of the relational frame theory by Hayes,
Barnes-Holmes, and Roche in 2001. Its direct application to psychosis led to pub-
lications (Bach & Hayes, 2002; Gaudiano & Herbert, 2006) showing clear benefit
from acceptance and commitment therapy (ACT) for the distress caused by hal-
lucinations and a marked reduction in readmission and hospital bed days. The
key techniques used are acceptance of rather than an escape from the experience,
defusion from negative thoughts, present-moment awareness, self as observer,
and promotion of values and committed action to live a more values-consistent
life and work toward meaningful life goals. Valued goals (e.g., being a good
grandparent or being a kind person) are an excellent contribution toward focus-
ing on values and life goals, rather than on symptoms and problems; valued goals
serve to motivate change in the present moment and lead to enhanced function-
ing. Acceptance is, of course, complicated by the issue of insight and perceived
threat. Our clinical experience suggests that therapeutic work (such as develop-
ing alternative explanations through reality testing–based approaches) needs to
be done first in individuals with high levels of perceived threat, conviction, and
disability linked to hallucinations or delusions.
Mindfulness training was initially bought into therapeutic practice by
John Kabat-Zinn, in 1979, in order to treat people with chronic pain; mental
body scanning as well as sitting meditation were used to cope with pain (see
Kabat-Zinn, Lipworth, & Burney, 1985). Mindfulness can be a very useful
approach to integrate aspects of treatment for those who experience psychosis,
for a number of reasons. With practice, mindfulness can improve the ability to
notice without judgment thoughts, emotions, and other physiological sensa-
tions, thereby enhancing (1) defusion, (2) exposure to or coming into contact
with internal experiences, rather than avoidance, and (3) coping with distressing
affect, thoughts, and experiences.
In 2005, Chadwick, Newman-Taylor, and Abba described mindfulness for
people with psychosis. Early results were encouraging. In a similar group con-
trolled study, Chadwick et al. (Chadwick, Hughes, Russell, Russell, & Dagnan,
2009) showed some benefit with mindfulness treatment over treatment in the
control group. Modifications for mindfulness practice for those who experi-
ence psychosis include increased psychoeducation, shorter practice sessions,
enhanced processing of the mindfulness experience, and caveats for those who
have a history of trauma related to use of body scan exercises and prolonged
practice of the techniques.
Over the last 5 to 10 years, with the emergence of the positive psychology
movement, positive psychology principles and approaches have been introduced
within CBTp. Further research is required to evaluate the outcomes associated
with the incorporation of these strategies. Some examples of CBTp in which pos-
itive psychology is being applied are as follows:
• When a mini-formulation of maintenance is being collaboratively

developed, a proportion of the session is spent considering strengths and
assets that can be deployed to change the maintenance cycle (see Case
Formulation Worksheet, by Wright, Sudak, Turkington, & Thase, 2010,
pp. 63–79).
• During the production of a formulation timeline, negative life events,
experiences, and emotions are listed below the timeline, and positive
events, relationships, experiences, and emotions are placed above the
line. This approach can be hugely empowering, as often in a setting of
psychosis where trauma and loss is the rule rather than the exception,
these positive experiences can be minimized or dismissed. Therefore, in
each time period studied, the therapist searches for one or two nurturing
relationships and incidents linked to a positive affect (joy, serenity, peace,
elation). A “broaden and build” approach can be taken in future sessions.
• In relation to negative symptoms of schizophrenia, the concept of flow
activities can be very useful in activity scheduling with mastery and
pleasure recording. The only scientific testing of a positive psychology
technique in psychosis is that by van der Gaag et al. (2012). In a case series
of patients with distressing hallucinations, they used an induced positive
affect approach linked to positive affects discovered on the formulation
timeline. For example, a young man hearing very abusive voices with
linked sadness might activate a remembered effect of elation when, on the
school football team, he scored a goal in an important game. The positive
affect is then focused on with the help of linked imagery and behavior,
and the effect on the voice and depression is measured. The van der Gaag
trial showed clear benefits for this approach.
Example of Integrating Acceptance and Commitment,

Compassion, and Mindfulness into CBTp
In their book, Treating Psychosis: A Clinician’s Guide to Integrating Acceptance

and Commitment Therapy, Compassion-Focused Therapy and Mindfulness
Approaches within the Cognitive Behavior Therapy Tradition, Wright et al. (2014)
describe their treatment model and therapeutic protocol, which systematically
integrates many of the therapeutic processes described in the recent evolution of
CBTp. Their therapeutic approach to treating psychosis is driven by, and infused
with, a positive psychology and recovery-oriented approach to care. Integral to
this treatment approach is both a trauma- and culturally informed approach to
the understanding and treatment of those with lived experience of psychosis.
As outlined in Figure 2.1 the integrated treatment model is based on an inte-
gration of CBT, ACT, CFT, and mindfulness-based approaches with positive
History
Strengths & challenges
Core Beliefs
Self, Others, & Future
Compensatory Assumptions/Rules
Coping Strategies
Thoughts
Behaviors Emotions-
Physiological
sensations
ACT CFT
Positive Psychology
Compassionate
Values
Attention
Mindfulness
Metacognition
Goals
Living a more full
and meaningful life
Figure 2.1. Integrated treatment model.

psychology principles woven throughout. Beckian CBT with its focus on an

individualized conceptualization based on strengths and difficulties is integral
to the understanding and treatment approach. CBT (including metacognitive
approaches) is complemented by ACT and CFT, along with mindfulness-based
approaches implicitly part of the CBT, ACT, and CFT integration. Change in
and of itself (including cognitive change) is not necessarily the goal, but through
Socratic exploration, and processes such as contact with the present moment,
compassion-focused work, acceptance, and defusion may be part of the pro-
cess and outcome. The conceptualization is informed by the client’s life history,
including qualities, strengths, coping strategies, and resources as well as difficul-
ties and problems. Thus, to develop understanding of the individual, one needs
to consider helpful or healthy and not so helpful or healthy core beliefs, compen-
satory assumptions or rules, and coping strategies. The interplay of thoughts,
behaviors, and emotions and physiological sensations is explored to gain a
greater understanding of the client’s individualized conceptualization. ACT
processes such as values, committed action, acceptance, contact with the present
moment, self as context, and defusion are considered part of the conceptualiza-
tion, as well as an implicit part of the therapeutic processes involved in work with
psychosis. CFT and the three evolutionary-based emotional systems (threat,
drive, and soothing/compassion) are integrated in the conceptualization and
treatment. A compassion-focused approach is woven throughout the therapy,
including a compassionate stance by the therapist and work with compassion as
part of the therapeutic process. The compassion-focused approach is premised
on both the ubiquitous experience of problems and suffering and the desire to
alleviate suffering. The CFT approach involves development and enhancement
of compassion through care for well-being, a nonjudgmental stance, empathy,
sympathy, sensitivity, and distress tolerance. The compassion-focused skills
developed include compassionate attention, sensing, reasoning, imagery, feeling,
and behavior. Implicit in the treatment model and conceptualization is the goal
of compassion toward self and others, as well as through values and commit-
ted action the goals of living a more value consistent, full, and meaningful life.
Mindfulness is an integral approach in the therapy, involving such processes as
contact with the present moment, exposure, and the ability to notice thoughts,
feelings, and sensations with (as much as possible) nonjudgment and acceptance.
The therapy focuses on goals with symptoms addressed to the degree that they
get in the way of value-consistent living and meaningful goals. Work with nega-
tive symptoms is informed by behavioral activation approaches incorporating
values, valued activities, and committed action. Emotion regulation and emo-
tional resilience, informed by the emotion regulation literature and positive psy-
chology, are addressed early in the therapy to provide a stable base from which
to conduct therapeutic work and cope with the distress activated by therapy and
move toward valued goals as well as cope with other stressors. Stabilization is
also critical given the high levels of trauma histories in those who experience
psychosis. Stabilization is needed to enable working within a therapeutic win-
dow and prevent the experiencing of an overwhelming amount of affect.
C O N C LU D I N G T H O U G H TS
It is also important to note some caveats and limitations regarding CBTp.

Positive psychology, compassion, and metacognitive elements have gradually
entered the repertoire of approaches and processes available within CBTp, but
much more research evidence is needed to assess the therapeutic mechanisms
in CBTp. There are potential limitations of this treatment. Acceptance is depen-
dent on the nature, content, and severity of the aversive psychotic experiences.
Voices that are commanding and persistently abusive appear as both ego- and
schema-syntonic; therefore, we consider acceptance of the experience to be a
later stage goal of CBT. Coping and reality testing must be undertaken to allow
improved understanding of the nature and controllability of the psychotic expe-
riences. Committed action and work toward valued goals can be more difficult
for those clients with a predominant symptom burden and linked cognitive defi-
cits; therefore, individual adaptation is key. Failure of drive or reduced drive can
be a core symptom that is often linked to defeatist beliefs around mastery and
pleasure. Compassion-based approaches need to be implemented with awareness
and acumen to address the potential activation of distressing affect for those who
have had a history of trauma. Furthermore, metacognitive techniques focusing
on meta-beliefs and process rather than content can be extremely beneficial, but
they can be difficult to implement consistently. Furthermore, avoidance-based
thinking styles such as worry, rumination, and thought suppression used as
safety behaviors can be difficult to shift. Clearly, more work needs to be done in
this area. Additional studies are needed to assess variations in mindfulness-based
approaches for those with psychosis. Further research is required to evaluate
which therapeutic approaches or processes are most beneficial and for whom, as
well as to assess therapeutic mechanisms of change.
Despite the potential caveats and limitations and the still-developing state of
research, the evolution of CBTp has shown an exponential rise in its capacity
to address the great range of problems with which clients with psychosis can
present. CBTp has also been associated with an increase in subtlety and fluency
in conceptualizing people’s histories and harnessing their strengths to become
agents in their own recovery (Beck, 1995). The recovery movement itself has
grown alongside the development of improved psychological and neurobiologi-
cal understanding of the nature of the experiences of psychosis. The recovery
movement highlights choice, inclusion, empowerment, and a strengths focus.
Consistent with a focus on choice and enhanced awareness of the potential side
effects of medications, Morrison et al. (2012) have demonstrated that those with
psychosis who refuse antipsychotic medication but engage in CBTp have moder-
ately strong effect sizes with low levels of dropout. Attention now turns not only
to psychological recovery but also to physical recovery and the need to address
the appalling morbidity and mortality of those with psychosis. At this time of
rapid, extremely encouraging developments in all aspects of working therapeuti-
cally with those with lived experience of psychosis, this book stands as a beacon
to illuminate the path ahead.
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3
Ecological Momentary
Assessments in Psychosis
A Contextual Behavioral Approach to
Studying Mindfulness and Acceptance
ROGER VILARDAGA, MICHAEL MCDONELL,

E M I LY L E I C K LY, A N D R I C H A R D R I E S ■
W H Y C O N T E X T UA L B EH AV I O R A L
AS S ES S M EN T M E T H O DS?
Context Matters
Effective clinical behavior change begins with an assessment of an individual’s

context. An individual’s context usually contains directly manipulable variables
that can inform effective behavior change, such as levels of activity, relationship
patterns, or self-regulation strategies. This emphasis on context is the founda-
tion of the contextual behavioral science tradition (CBS; Hayes, Hayes, Reese, &
Sarbin, 1993; Vilardaga, Hayes, Levin, & Muto, 2009), for which context includes
not only an individual’s current situation but also how that situation unfolds
over time. In other words, context includes both the situational and historical
factors influencing an individual’s behavior.
In severe psychopathology (i.e., schizophrenia spectrum, bipolar and recur-
rent major depressive disorder), context may include a variety of factors: a his-
tory of childhood sexual abuse or trauma (Honig et al., 1998), stigmatization
(Norman, Windell, Lynch, & Manchanda, 2011), or an unsupportive social envi-
ronment (Norman et al., 2005). Other environmental factors, such as living in
an urban or rural environment (McGrath, Saha, Chant, & Welham, 2008), living
in a country with high levels of sugar intake (Peet, 2004), or prenatal influences
(King, St-Hilaire, & Heidkamp, 2010; Walker, Shapiro, Esterberg, & Trotman,
2010) have also been associated with severe psychopathology. However, from a
CBS standpoint, directly manipulable factors are most important. Talk therapy is
directly manipulable and can be part of an individual’s verbal context. For exam-
ple, a history of exposure to cognitive-behavioral therapy, including training in
self-regulation skills to cope with both private and environmental events, has been
linked to positive outcomes in people with psychosis (Wykes, Steel, Everitt, &
Tarrier, 2008).
All of these contextual factors can have a profound effect on behavior.
Furthermore, behavior itself exerts an influence on the external context, in turn
affecting the individual. A typical example is when individuals with psychotic
symptoms believe their voices are threatening, and thus take steps to mitigate,
distract from, or avoid situations in which the voices occurred in the past. As a
consequence, social withdrawal may occur, providing these individuals with less
access to social reinforcers.
Like any other living organism, individuals with severe psychopathology exert
and are exerted upon by a multitude of contextual factors that unfold over time.
Despite their complexity, these contexts can be sampled, examined, and inter-
preted separately in order to develop interventions that lead to effective clinical
behavior change.
Aren’t We Already Measuring Context?
When a patient attends one of our sessions, we are always directly observing
behavior in context. Through these routine observations we gather a variety
of information critical to planning our interventions, such as what the patient
thinks, feels, and wants (e.g., current verbal and emotional context). We also
gather more indirect information, such as the patient’s reactions to our questions
or repeated patterns of thinking, feeling, and wanting (e.g., historical verbal and
emotional context). Although these data can inform effective clinical behavior
change, it is only a small fraction of our patient’s historical and situational con-
text. Furthermore, from the moment we ask one of our patients, “How was your
childhood?”, “your last 5 years?”, or “your last week?”, we are entering the realm of
recall bias and interpretation.
Clinical behavioral sciences have experienced a lack of appropriate contex-
tual measurement tools nearly from their inception. Direct access to an indi-
vidual’s context was critical for early behavior therapists, since it provided the
ability to deliver direct contingencies (Dougher & Dougher, 2000). Fields such
as school, developmental, and organizational psychology often have access to
an individual’s context. However, such access to direct contingencies was not
always possible or feasible, resulting in a number of consequences. For one, it
hindered the progress of clinical behavioral science by undermining its abil-
ity to identify and target powerful independent variables leading to desired
Ecological Momentary Assessments in Psychosis27
outcomes. For example, the results of experimental research conducted in lab-

oratories could not be contextually validated in natural settings, which justi-
fied the mere use of interpretation and extrapolation of behavioral principles
(Vilardaga et al., 2009). Second, this problem contributed to the low scientific
status of clinical behavioral science within the larger scientific community,
since measures were primarily based on global self-reports. Third, clinical
behavioral researchers increasingly relied on measurement instruments rooted
in essentialist philosophical assumptions about the nature of human behavior
(e.g., underlying traits), which justified the use of global measurement tools,
such as global self-report scales or personality tests.
Up until today, the vast majority of the empirical literature in clinical psychol-
ogy has relied on the use of global self-report measures, direct observation (e.g.,
1-hour session, once a week), or collateral reports. Even though global self-reports
are a very practical method of gathering information about an individual’s con-
text, they have serious limitations. In clinical practice we typically find patients
describing their week as “bad” because some negative events occurred the day
before, regardless of having experienced prior days positively. In fact, research has
found that global self-reports are biased toward more recent events (e.g., Sato &
Kawahara, 2011).
The limitations of global self-report strategies do not have to lead to an “either/
or” solution. Global self-reports and clinical observation are important sources
of data. These assessment tools can point to specific contexts, response patterns,
and events. However, they are very limited for evaluating the intricate sequence
of events that occur on a daily basis, and they lack the precision of contextual
behavioral research conducted in the laboratory (e.g., Hughes, Barnes-Holmes, &
Vahey, 2012). Consequently, these measurement tools have serious limitations
in their capacity to establish meaningful and data-rich connections among con-
text, life events, and individuals’ responses to them in real-world settings.
Current Assessment Strategies Are Not Adequate

for Adults with Severe Psychopathology
Global self-report measures and interview data are particularly problematic

among individuals with severe psychopathology. When measured by perfor-
mance in neuropsychological tests, many individuals with severe psychopathol-
ogy have deficits in attention, concentration, working memory, processing speed,
and problem-solving skills (Dickinson, Iannone, Wilk, & Gold, 2004; Elvevåg &
Goldberg, 2000; Harvey, 2010). Studies suggest that these deficits cannot be
pinned down to specific cognitive abilities (Dickinson et al., 2004; Keefe et al.,
2006), and they tend to be stable over time (Rund, 1998). Cognitive deficits inevi-
tably have an effect on the ability of individuals with severe psychopathology to
process and report their experiences.
The cognitive deficits observed in severe psychopathology are associated with
poor functional outcomes in this population (Harvey, 2010; Harvey et al., 1998),
such as difficulties with work, poor interpersonal skills, and lack of engagement
in community activities (Bowie et al., 2008). These deficits often escape indi-
viduals’ self-awareness, as studies show that the results of formal cognitive tests
have little to no association with individuals’ perceived levels of disability in this
population (McKibbin, Patterson, & Jeste, 2004).
More directly related to the area of assessment, poor reporting among individ-
uals with severe psychopathology leads to bad clinical decision-making, medical
errors, and difficulties conducting a clinically useful functional analysis. Studies
of service utilization found that client self-report responses were a poor predic-
tor of visits on record in this population. Low utilizers tended to overstate their
number of visits, and high utilizers tended to understate them (Kashner, Suppes,
Rush, & Altshuler, 1999). Another study by Calsyn, Morse, Klinkenberg, and
Trusty (1997) found little agreement between reports by clients with severe psy-
chopathology and case managers regarding type and amount of mental health
and substance abuse services used. Additionally, adults with severe psycho-
pathology and a physical illness demonstrated less knowledge of their health
condition when compared to adults in the general population with the same
physical illness (Dickerson et al., 2005; Hinkin et al., 2002; McKinnon, Cournos,
Sugden, Guido, & Herman, 1996). Poor self-report can also misdirect therapy, in
that the intensity of negative and positive daily experiences of individuals with
severe psychopathology may be magnified retrospectively (Ben-Zeev, McHugo,
Xie, Dobbins, & Young, 2012). Among clinically depressed patients, Ben-Zeev,
Young, and Madsen (2009) found negative affect to be particularly emphasized
in retrospect. The overestimation of the intensity of such experiences makes it
difficult to accurately compute the variability of a patient’s experience over the
recall period. Since retrospective reporting may also be used to inform medica-
tion choice, experiences that are overestimated in their intensity may result in
unnecessary prescription or increased dosage of medications with potentially
unpleasant side effects (Ben-Zeev et al., 2012).
The prevalence of cognitive deficits in individuals with severe psychopathology,
together with the limitations of global self-report tools to measure clinically rele-
vant features of the individual’s context, warrants the use of measurement tools that
are sensitive to a broader range of contextual and environmental factors and less
reliant on an individual’s ability to retrospectively recall past events and circum-
stances. Such a method, called ecological momentary assessment (EMA), consists
in asking participants to take a moment several times per day to report on their own
experiences in real time (Csikszentmihalyi & Larson, 1987). EMAs (also known as
the experience sampling method) have been in use for a few decades now.
Affinity of EMAs to the Contextual Behavioral Tradition
From a contextual behavioral perspective, psychological events are under the

control of a unique set of contextual antecedents and consequences. The com-
bination of antecedents, behaviors, and consequences form a more meaningful
unit than traditionally “decontextualized” measures (e.g., global self-reports)

in which the individual’s responses are gathered in the vacuum of a laboratory
or artificial setting. EMAs can collect, for each measurement instance, the
specific external context (e.g., being alone), internal context (e.g., a psychotic
event), the individual’s psychological response to them (e.g., acceptance), and
a measure of the following consequences (e.g., affect). This method of assess-
ment circumvents the memory bias that comes with the “skewed averaging” of
experience that typically occurs when we are asked to provide a global evalu-
ation of our day or week.
In science, as well as in clinical practice, measurement is important, as good
scientific theories require precision as well as scope and depth (Hayes et al., 1993).
The small but critical improvements in the quality of the data collected by EMAs
can help contextual behavioral researchers examine rules of generalization (e.g.,
principles of change) with increased levels of precision. Furthermore, EMAs pro-
vide not only better measurement precision, but soon new mobile devices will
be able to measure the impact of behavioral interventions at different levels of
depth (e.g., physiological states; Kimhy, Sloan, Delespaul, & Malaspina, 2006). In
the long run, this may dramatically improve the contextual behavioral etiology
of severe psychopathology, by clarifying the psychological processes promoting
overall functioning and quality of life in this population. The prospect of achiev-
ing such clarity and improving patients’ quality of life seems to have contributed
to the rapid proliferation of EMA research, as the field has experienced an expo-
nential growth of related studies (e.g., Ben-Zeev, 2012; Kimhy, Myin-Germeys,
Palmier-Claus, & Swendsen, 2012; Oorschot, Lataster, Thewissen, Wichers, &
Myin-Germeys, 2012; Shiffman, Stone, & Hufford, 2008).
Another affinity of the EMA method with CBS is its challenging of tradi-
tional views with regard to measurement development. Most statistical and
psychometric theory starts off with the assumption that there is a “latent
structure” underlying psychological constructs that represents a stable qual-
ity of behavior that can be captured. This statistical assumption is contrary to
the contextual behavioral tradition, for which psychological events can only
be understood in context, and for which “truth” lies in pragmatic utility and
not in correspondence with a stable “latent structure” or reality (Vilardaga
et al., 2009). For example, from a CBS standpoint, the term acceptance is a ver-
bal construct that orients the listener (in this case, a researcher or clinician)
toward behaviors linked to general functioning. However, there is no assump-
tion about the stability of these patterns of behavior, as these behaviors can
fluctuate according to varying sequences of antecedents and consequences. In
fact, EMA developers have noted that this method is theoretically consistent
with the behavioral tradition (Hektner, Schmidt, & Csikszentmihalyi, 2007),
as the emphasis is placed on the identification of key environmental elements
underlying psychological states.
If we assume the utility of this new framework, psychometrics plays a second-
ary role in the development of EMA items from a CBS perspective. Having put
psychometric theory aside, we are left with important study design criteria, such
as theoretical coherence and appropriate survey design. For example, Kimhy

et al. (2012) argued that it is important to present more cognitively demand-
ing items (e.g., questions about internal state) at the beginning of a survey and
simpler items toward the end. Similarly, items should only address one construct
at a time and use sentences that are easy to comprehend (Kimhy et al., 2012).
Interestingly, these principles are seen in user-centered design (Fairbanks &
Caplan, 2004). Although this concept was not explicitly formulated in early EMA
studies, their designs were driven by the very same sensitivity. Therefore, when
it comes to selecting and adapting EMA items, relevant issues are acceptability,
wordings that are user-friendly, assessment burden, and appropriate conditional
branching. Surveys can also be branched so that specific items can only be trig-
gered when certain conditions are met (e.g., being alone). For a more thorough
description of theoretical, technical, and design considerations of EMA designs,
we recommend Hektner et al.’s (2007) book-length volume. A more contem-
porary description of the design of computerized EMA studies for adults with
severe psychopathology can be found in Kimhy et al. (2012).
Despite the fact that EMAs pose a new approach to item development and for-
mulation and that the measurement of momentary patterns of behavior and psy-
chological states is inherently unreliable (Hektner et al., 2007), EMAs arguably
have a number of psychometric advantages over traditional assessment methods.
For example, EMAs provide measurements of high external validity, since they
gather data directly from real-world settings. In addition, EMAs might provide
more internal validity than global self-report measures, since repeated measure-
ments avoid the bias of onetime reports and minimize the likelihood of a social
desirability bias (Zuzanek, 1999). Finally, random sampling of surveys through-
out the day provides a more representative sample of experiences than tradi-
tional global self-report measures (Hektner et al., 2007).
On the whole, researchers have found EMAs to be a rigorous approach to col-
lecting data in those experiencing psychosis and have been recommended in
light of the limitations of current clinical and performance measures available in
the field (Granholm, Loh, & Swendsen, 2008). Furthermore, some authors have
suggested that EMAs could be considered the new gold standard given their
high concurrent validity with traditional clinic-based measures and high levels
of compliance (Kimhy et al., 2012).
C O N T E X T UA L B EH AV I O R A L AS S ES S M EN T R ES E A R C H
I N S E V ER E PSYC H O PAT H O LO GY
Contextual behavioral assessments using EMAs have been developed by research-

ers for a few decades now (Csikszentmihalyi & Larson, 1987; Csikszentmihalyi,
Larson, & Prescott, 1977) and have been argued to have higher ecological valid-
ity than that of traditional global self-report methods (Shiffman et al., 2008;
Wenze & Miller, 2010). Surprisingly, within the CBS community, there are still
very few studies taking advantage of this assessment approach. In this section
we will describe studies using EMAs with a focus on individuals with severe
psychopathology.
EMA Studies in Psychosis
The first EMA researchers in the area of psychosis used pagers or programmable
watches to signal the use of a booklet with a series of questions about the individ-
ual’s current activity and experience (Delespaul & deVries, 1987). These prompts
had to be answered within 15 minutes and were provided during a period of
6 days. Researchers found that in this population social activities were enjoyed
as much as in the general population. However, individuals with severe psycho-
pathology had a tendency to daydream and be distracted from current activities
while alone. The kind of thoughts and activities that the clinical sample engaged
in were no different than those of the nonclinical group, but their mental states
(e.g., mood, motivation) were significantly worse. The authors also observed that
although both groups of individuals had similar levels of fluctuation in their
mental states, the clinical sample had greater reactivity to daily events.
Using a similar procedure, deVries and Delespaul (1989) studied a sample
of patients with schizophrenia in comparison to normal subjects and found
that the relationship between positive affect and being alone was curvilinear
in nature: Being in the presence of up to three individuals was associated with
greater positive affect. However, being in the presence of more than three indi-
viduals was associated with a decline in positive affect. Conversely, the relation-
ship between positive affect and social context was almost linear among normal
subjects. Some of the items used in this study are presented in Table 3.1.
EMAs have also been used to explore and refine specific psychological models.
For example, according to the self-esteem model, individuals experience para-
noid ideation as a defense against negative thoughts and emotions toward the self
(Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001). However, Thewissen
et al. (2008) found that negative emotions, in particular anxiety, can also lead to
paranoia. Another EMA study by Lardinois et al. (2007) suggested that develop-
ing a conscious appraisal of the distress of psychotic events and the use of coping
strategies might be beneficial to patients with psychosis. Verdoux and colleagues
(Verdoux, Gindre, Sorbara, Tournier, & Swendsen, 2003) found evidence against
the self-medication hypothesis by showing that cannabis use preceded psychotic
symptoms and not vice versa among individuals with high levels of social anhedo-
nia. The intensity of the emotional experiences was similar across individuals with
and without a psychotic disorder (Myin-Germeys, Delespaul, & deVries, 2000).
Similarly, consummatory pleasure (e.g., the enjoyment directly drawn from imme-
diate experiences) was similar between patients with psychotic symptoms and
normal controls. However, anticipatory pleasure (e.g., the anticipated enjoyment
drawn from future activities) was lacking among clinical samples, as they engaged
in less EMA-measured goal-directed activities (Gard, Kring, Gard, Horan, &
Green, 2007). With regard to reactivity to daily life events, Myin-Germeys et al.
Table 3.1. Examples of EMA Items Used in the Literature to

Assess Psychotic Symptoms
deVries & Delespaul (1989); 7-point Likert Scale

“I hear voices.” “I’m suspicious.”
“I cannot express my thoughts.” “My thoughts are influenced.”
“I feel unreal.” “I can’t get rid of my thoughts.”
Junginger et al. (1992); 7-point Likert Scale
“I’m preoccupied by my thoughts right now.” “My thoughts are suspicious.”
“My thoughts are being influenced.”
Myin-Germeys et al. (2005); 7-point Likert Scale
“Do you hear voices?” “Do you see things that others
cannot see?”
Kimhy, Sloan, et al. (2006); 7-point Likert Scale
“I see things (that other people can’t see).”
“I hear voices (that other people
can’t hear).”
“My thoughts are suspicious.” “I’m in control of my thoughts.”
“I can’t get rid of my thoughts.” “I fear I would lose control.”
“I feel unreal.” “My thoughts are difficult
to express.”
“This thought is confused.”
Granholm et al. (2008); 7-point Likert Scale
Since the last questionnaire:
“Have you had the impression that someone was spying on you or plotting against
you?”
“Have you had the impression that people could read your thoughts, or that you
could read theirs?”
“Have you felt you were possessed or that someone or something was putting
thoughts into your mind?”
“Have you felt that someone could communicate with you through the television or
radio?”
“Did you feel you had special powers to do something nobody else can do?”
“Have you heard things (such as voices), had visions, or seen things that others
could not see or hear?”
(2003) found that this relationship was moderated by cognitive ability. In a sepa-
rate study, the same authors found that social context, such as the presence of
family or acquaintances, reduced the likelihood of experiencing a delusional
experience at a later time (Myin-Germeys, Nicolson, & Delespaul, 2001).
Researchers have also conducted EMA studies to look at issues such as person-
ality disorders (Loewenstein, Hamilton, Alagna, Reid, & deVries, 1987), mood
Table 3.2. Examples of EMA Items Used in the

Literature to Assess Psychological States
Delespaul & deVries, (1989); 7-point Likert Scale

About the thoughts About mood
“I am alone” “Cheerful”
‘Pleasant” “Secure”
“Clear” “Social”
“Excited” “Relaxed”
“Normal” “Calm”
“Friendly”
Myin-Germeys et al. (2003); 7-point Likert Scale
Negative affect Positive affect
“Down” “Happy”
“Guilty” “Cheerful”
“Lonely” “Satisfied”
“Anxious”
“Angry”
Kimhy, Delespaul, et al. (2006); Visual Analog
“I feel stressed”
“I feel relaxed”
“My thoughts are going too fast”
“I feel sad/depressed”
“I feel irritated”
“I feel cheerful”
“I feel lonely”
and anxiety (Junginger, Barker, & Coe, 1992; Swendsen, 1997), and substance
abuse (Collins et al., 1998; Freedman, Lester, McNamara, Milby, & Schumacher,
2006). Table 3.2 summarizes some of the items used to assess mental states,
such as cognition, affect, and general well-being. A list of EMA items used to
assess situational context can be found in Table 3.3, which shows examples of
different items used by researchers over the years. Among all the EMA studies
reviewed, only two explored the impact of acceptance and mindfulness-based
processes on the occurrence of psychotic symptoms (Udachina et al., 2009;
Varese, Udachina, Myin-Germeys, Oorschot, & Bentall, 2011; see description
later in this chapter).
In summary, EMAs have great potential to test specific hypotheses about the
contextual behavioral etiology of symptoms in severe psychopathology as well
as provide a more precise measure of the effect of specific environmental factors
and/or interventions.
Table 3.3. Examples of EMA Items Used in the

Literature to Assess Situational Context
Delespaul et al. (2002) Box Check

Who am I with? What am I doing?
“I am alone” “Doing nothing”
“Family” “Self-care”
“Friends” “Work/study”
“Colleagues ” “Leisure”
“Strangers” “Health care”
“Travel”
Granholm et al. (2008) Box Check
Where are you right now?
“In my home”
“At home of relative or friend”
“At work or in class”
“Other inside (store, office ...)”
“Any outside (street, park)”
Who is with you at this moment?
“No one (you are alone)”
“Family, friends, or partner”
“Coworkers or classmates”
“Strangers”
“Other”
What are you doing at this moment?
“Inactive (TV, music, resting)”
“Eating, dressing, hygiene care”
“Shopping, chores, cooking”
“Work, school, or active leisure”
“Other”
Computerization of EMA Studies
While we will address the computerization of EMAs in later sections, here we

will simply mention that handheld computers such as portable digital assistants
(PDAs; e.g., PalmPilots) or cell phones with software capacity have increasingly
been adopted by researchers. Computerized EMAs can measure and collect data
in ways that offer many advantages over paper-and-pencil diaries (Ben-Zeev
et al., 2012; Granholm et al., 2008). Some of them include the stamping of data
with the time and date of collection, the potential to collect response time, easy
transfer of data to analytic software to be readily analyzed, and the possibility of
programming conditional rules upon specific answers (i.e., branching). Despite
the functional impairment typically observed among individuals with severe

psychopathology, the use of computerized EMAs has been shown to be as fea-
sible as paper-and-pencil EMAs (e.g., Granholm et al., 2008; Kimhy, Delespaul,
et al., 2006), and most studies now make use of these devices.
ST U D I ES T H AT E X A M I N E AC C EP TA N C E A N D
M I N D F U L N ES S - BAS ED PR O C ES S ES U S I N G EM AS
To our knowledge, only a handful of studies have explored acceptance and

mindfulness-based processes using EMA to investigate psychotic symptoms,
and only two used EMAs directly with individuals with severe psychopathol-
ogy. Varese et al. (2011) conducted a study in which EMAs were used to examine
the occurrence of auditory hallucinations. The authors found that both disso-
ciation and experiential avoidance had predictive effects, although only disso-
ciation remained significant after controlling for other paranoia. Udachina et al.
(2009) used paper-and-pencil EMAs to gather context and processes and a global
self-report questionnaire to measure experiential avoidance (e.g., Bond et al.,
2011). They found that individuals with high paranoia tended to experience poorer
self-esteem, as well as higher experiential avoidance and depression. Finally, one
study compared the relative effect of two distinct self-regulation strategies on
quality of life in a sample of individuals with severe psychopathology (Vilardaga,
Hayes, Atkins, Bresee, & Kambiz, 2013). In the following sections we will discuss
this study with the aim of illustrating the use of EMAs in this population.
EMA Study Comparing Self-Regulation Strategies

in Severe Psychopathology
Previous cognitive behavioral interventions for severe psychopathology have been

tested and have been demonstrated to have positive outcomes. Among them, accep-
tance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2011) reduced
number of hospitalizations (Bach, Gaudiano, Hayes, & Herbert, 2013; Bach & Hayes,
2002), distress, affective symptoms, and social impairment after discharge from an
inpatient unit (Gaudiano & Herbert, 2006a). ACT-based interventions for psychosis
also reduced mood symptoms and crisis contacts at follow-up (Gaudiano, Nowlan,
Brown, Epstein-Lubow, & Miller, 2013; White, 2011). Traditional cognitive-behavioral
therapy and ACT arguably target two different self-regulation strategies, cognitive
reappraisal and psychological acceptance, respectively. Research shows that the
impact of ACT on outcomes is mediated by reductions in levels of believability of
psychotic symptoms (Gaudiano & Herbert, 2006b). Despite this finding, none of
these studies conducted a more precise analysis of the interplay among specific con-
textual factors, individuals’ responses to them, and the resulting outcomes.
Next, we discuss the process of item development and selection of an EMA
study in which we compared the role of psychological acceptance with that of
cognitive reappraisal with regard to quality of life in a sample of individuals with
severe psychopathology. We will also outline some of the lessons learned while
conducting this study. A more thorough discussion of the results is published
elsewhere (Vilardaga et al., 2013).
Items Adaptation and Development

Keeping in mind the importance of theoretical coherence and design when
conducting EMA research (discussed in previous sections), we examined the
literature and selected items that addressed the contextual features, processes,
and outcomes of interest. For example, in order to assess situational factors, we
used items developed by Delespaul, deVries, and van Os (2002) and Granholm
et al. (2008). These questions covered a number of situational factors that were
important for understanding daily patterns of responding, such as being alone or
engaging in certain activities (see Table 3.3). In addition to situational factors we
selected items to assess the occurrence of internal events—in this case, psychotic
experiences. Table 3.4 includes these items. These items were adapted from a previ-
ous study by Granholm et al. (2008), who, in contrast to previous researchers (see
Table 3.1), developed items that covered the spectrum of psychotic experiences.
The items developed by Grandholm et al. (2008) were initially piloted in a
small sample of individuals with severe psychopathology. On the basis of their
feedback we decided to shorten the length of items, use more simple language,
and keep separate items for visual and auditory hallucinations.
This iterative process was achieved by using an open-source software devel-
oped at the University of Washington, called MyExperience (Froehlich, Chen,
Consolvo, Harrison, & Landay, 2007). This software enables the researcher to
manipulate an internal.xml file (see Figure 3.1) in order to modify the items,
the conditional rules to be implemented, and other EMA features. In our study
this included the type of sound we used to signal surveys, the number of times
it needed to be repeated, and the length of time lapse until the next reminder.
Before implementing this procedure with our final sample, it was tested by the
first author of the chapter (R.V.), then by research assistants, and finally by a
small sample of individuals with severe psychopathology.
To address psychological self-regulation strategies, we adapted items from
existing global self-report measures. Our EMA design strategy was such that
we programmed our devices so that when participants denied the occurrence
of a psychotic or stressful event they were presented directly with momentary
quality-of-life items. This branching reduced assessment burden.1 To select
items addressing our targeted self-regulation strategies, we examined global
self-report scales in the literature and picked specific items that had face valid-
ity and appropriate factor loadings. More specifically, to measure cognitive reap-
praisal, we picked Item 6 from the cognitive reappraisal subscale of the Emotion
Regulation Questionnaire (Gross & John, 2003). In order to measure cognitive
suppression, we used Item 7 from this very same questionnaire. Both items were
slightly modified and adapted, a common practice in these types of studies (e.g.,
Hatzenbuehler, Nolen-Hoeksema, & Dovidio, 2009; Kashdan, Barrios, Forsyth, &
Steger, 2006). To measure experiential acceptance, we picked Item 2 from the
Table 3.4. Sample of Items from Mindfulness- and Acceptance-Based Studies
Vilardaga et al. (2013); Since the last survey did any of the following
things happen to you? (Box Check)
“I heard things that others could not hear.” “I saw things that others could not
see.”
“I felt that someone was spying or plotting “I felt that people could read my
against me.” thoughts.”
“I felt that someone could communicate “None of the above.”
with me through the TV/radio.”
“I felt possessed or controlled by
someone or something.”
“I felt I had special powers to do
something nobody else could do.”
“I felt stressed.”
Vilardaga et al. (2013); How did you react? (7-point Likert Scale)
“I stopped doing the things I wanted to do.” (External avoidance)
“I tried to control my thoughts and feelings.” (Suppression)
“I made myself think about it in a (Cognitive reappraisal)
way to make me stay calm.”
“I simply noticed my feelings and continued (Experiential acceptance)
with what I was doing.”
Vilardaga et al. (2013); Which emotion do you feel most strongly
right now? (Box Check)
“Down” “Guilty”
“Relaxed” “Anxious”
“Happy” “Cheerful”
“Lonely” “Satisfied”
“None of the above”
Vilardaga et al. (2013); How are you doing right now?
(7-point Likert Scale)
“I enjoy what I’m doing.” (Anhedonia) “I feel competent.” (Self-esteem)
“I feel connected to others.” (Social support) “I feel free to act.” (Autonomy)
“I am comfortable with myself.” (Self-esteem) “I have energy.” (Physical well-being)
Udachina et al. (2009) and Varese et al. (2011); 7-point Likert Scale
“Since the last beep my emotions have got in the way of things which I wanted
to do.”
“Since the last beep I’ve tried to avoid painful memories.”
“Since the last beep I’ve tried to block negative thoughts out of my mind.”
NOTE: Context items were omitted from this table but were adapted from Granholm
et al. (2008). These items can be found in Vilardaga et al. (2013).
Figure 3.1. Example of .xml code from initial pilot versions.
Voices Acceptance and Action Scale (Farhall, Ratcliff, Shawyer, & Thomas, 2010;
Shawyer et al., 2007). The last coping item from Table 3.4 was designed to measure
overt avoidance, and we created it to fit the overall structure of the survey. Note
that this particular item could not have been possible without a survey design
that linked previous events (i.e., psychotic) to current response patterns. We ran-
domized the order in which these items were presented to avoid priming effects.
Although adding more items to assess each one of these processes (e.g., two items
per process) would have allowed us to calculate an internal Cronbach’s alpha,
pilot testing indicated that this may have increased assessment burden. Thus, we
chose to follow a single-item approach and focus on improving the face validity
of each item and its overall design fitness within the context of the overall survey.
The last part of the survey assessed moment-to-moment outcomes—in this
case, affect and quality of life. To asses current affect, we adapted items from
Myin-Germeys et al. (2003). Using a yes/no check box, we asked participants
to rate which word was most representative of their feelings at that moment.
Quality-of-life items were adapted from previous items of a quality-of-life
scale specifically tailored to individuals with schizophrenia (Short Quality
of Life Scale-18; Boyer et al., 2010). Each of these items targeted different
dimensions of quality of life: anhedonia, self-esteem, perceived social sup-
port, autonomy, and physical well-being. Since this was a central outcome
in our study, we asked participants to rate each of these items on a 7-point
Likert scale. A composite score of these items had a Cronbach’s alpha of .81 in
this sample.
Lessons Learned
The study showed that, in contrast to cognitive reappraisal, experiential accep-
tance had a stronger association with a range of indicators of quality of life
and functioning, which suggests that psychological acceptance might be a psy-
chologically “cost-effective” self-regulation strategy in this population when
experiencing psychotic symptoms. Other situational factors, such as “doing

something,” also had a strong association with positive outcomes (Vilardaga
et al., 2013). Use of EMAs in this study enabled not only comparison of specific
psychological regulation strategies in the context of the daily life of individuals
with severe psychopathology but also a “real-world” comparison of those pro-
cesses using a measure of higher precision.
We also learned a few lessons. At a technical level, we learned that a small
amount of software programming expertise can facilitate piloting and adapt-
ing EMA designs. In our case, this was achieved by using MyExperience
(Froehlich et al., 2007). We did not keep track of the number of modifications
we made to the myexperience.xml file; however, the number was very large. We
would emphasize that it was critical to have the minimal software and techni-
cal skills required to make small code adjustments. Such a study would not
have been feasible without the availability of this open-source software, as the
cost of hiring a software programmer is often too great. Hiring an external
programmer would also have limited the flexibility and speed of adaptations,
which could have diminished the total number of iterations and the adequacy
of the final procedure. However, this might not be an issue in funded stud-
ies. Some research centers already have interdisciplinary teams of behavioral
and computer scientists (e.g., Center for Behavioral Intervention Technologies
[CBITs], 2013).
Second, we learned that hardware matters. In this study, we trained par-
ticipants in use of the device. Following the initial training, we called par-
ticipants on a daily basis to monitor technical problems with the device.
On most occasions these calls were brief, but in some instances the patient
needed to be coached over the phone to recharge the device or to reset it.
Other times, the researcher had to meet face to face with the participant
and manually resolve the technical problem. As discussed by Kimhy et al.
(2012), electronic EMAs pose new technical challenges. The PDAs that we
used (Dell Axim X51) were brand new and had the appropriate hardware
capacity to run our software. However, they initially presented with “odd
behaviors;” for example, the device would turn off after a certain number of
signals. We solved this problem after finding out that the type of audio file
we were using to signal each survey was saturating the memory and forcing
the machine to turn off. This issue was resolved by including an audio file
of smaller size. Each mobile device will present specific software and hard-
ware challenges; it is very important to balance cost and potential technical
difficulties when deciding between different devices. These decisions can
have a serious impact on how the study is conducted and how participants
respond to it.
Third, recruiting individuals with specific diagnostic categories to partici-
pate in EMA studies can be challenging. For example, in our study, there was
a statistically significant difference between individuals with a diagnosis of
schizophrenia and those with any other psychotic disorder (i.e., schizoaffective
disorder, bipolar or depressive disorder with psychotic features). Participants
with schizophrenia gave a number of reasons to refuse participation. Some

simply indicated that they were not interested, others that they did not have
the time. One person stated that the EMA device was intrusive to his pri-
vacy, and another indicated that he had serious concerns about the possibil-
ity of breaking it. These individuals were not thoroughly interviewed about
their reasons for refusing, so we were unable to further explore their concerns
about participation. It is possible that these individuals’ psychotic symp-
toms (delusions) led them to feel suspicious about the use of a mobile device.
This situation calls for implementation of a tailored recruitment strategy to
approach individuals with schizophrenia differently than those with other psy-
chotic disorders; ample time needs to be taken to reassure potential partici-
pant’s concerns and thoroughly explain use of the EMA device and its role in
the study.
Finally, only 3 years after the study had been finalized, mobile devices had
evolved at such fast pace that we would no longer recommend using PDAs.
These devices have frequent software “bugs,” a weaker physical structure,
shorter battery life, and limited wireless connectivity. In contrast, current
mobile devices (e.g., smartphones) are smaller and have more reliable software
and greater capabilities (e.g., 4G, Internet access). In addition, they are less
intrusive as a research device, as smartphones are now an intrinsic part of
everyday life.
In the same way that introductory courses in chemistry include learning
about the technical features of a microscope, if EMAs eventually become the
gold standard in clinical behavioral science, we envision graduate courses
with a focus on basic programming skills and appropriate technical handling
of mobile devices.
N E W O PP O RT U N I T I ES, T EC H N O LO G I ES,
A N D C H A L L EN G ES
The use of contextual behavioral assessments, such as EMAs, combined with the
evolution of computerized mobile devices for commercial and leisure use, has
created new opportunities for research and clinical practice in this population.
Such opportunities come with new challenges, such as the need to develop new
strategies of “digesting” large volumes of information in order to produce mean-
ingful data. In the same way that over the decades a “symbiotic” relationship
emerged between statisticians and clinical researchers, emerging mobile tech-
nologies call for a similar relationship between the fields of behavioral science
and computer science (Roth, Vilardaga, Wolfe, Bricker, McDonell, in press). We
have already mentioned some research laboratories where this interdisciplin-
ary framework is taking place (e.g., CBITs, 2013). In the following sections we
will describe some of the opportunities, technologies, and challenges of this new
wave of clinical behavioral methods.
New Opportunities
Mobile Technology Adoption among Individuals

with Severe Psychopathology
The first opportunity for treatment development and clinical care comes from
the fact that an increasing number of people with severe psychopathology now
use mobile phones. A recent survey among 1,592 individuals with a diagnosis of
severe psychopathology reported that 72% had a mobile device, 33% of whom
used it to access the Internet and e-mail (Ben-Zeev, 2012). The rate of adoption
of mobile technology in this population, although lower than in the general
population, will continue to rise (Ben-Zeev, 2012). Thus the majority of young
individuals will be literate in using mobile devices as they develop a mental dis-
order (Ben-Zeev, 2012). Given this fact, the Center for Medicare and Medicaid is
expanding reimbursement procedures to include technologically based services
(Ben-Zeev, 2012).
The adoption of mobile technology by this population is not surprising, as
there are already 6.8 billion mobile phone subscribers in the world (International
Telecommunication Union, 2013), and it is expected that this number will
increase exponentially in subsequent years. Moore’s law stipulates that the num-
ber of transistors on a computer chip is expected to double approximately every
2 years (Moore, 1975). Consistent with this assertion, the capabilities and speed
of mobile devices will continue to increase. As the availability of these devices
rises and production costs shrink, they will become increasingly accessible and
affordable to people with severe psychopathology.
Understanding Mindfulness and Acceptance Processes

with Higher Precision
Another opportunity presented by the use of contextual behavioral assessment
methods is the possibility of exploring acceptance and mindfulness processes
using a more contextual and precise method of assessment. Understanding
processes and/or mechanisms of change has been a motif of recent emphasis in
the cognitive-behavioral therapy literature (e.g., Kazdin, 2007). However, most
processes of change have been examined using one-time global self-report mea-
sures. As discussed earlier, these assessments rely on memory recall and are thus
susceptible to retrospective bias. Retrospective bias is particularly problematic
in this population.
Using the EMA method we can accelerate our understanding of mindfulness-
and acceptance-based processes in both observational and experimental studies
in a more precise and context-specific fashion. For example, individuals’ levels
of mindfulness are often measured using global self-report measures that ask
individuals to evaluate the degree to which they present with certain patterns
of behaviors (e.g., “When I’m walking, I deliberately notice the sensations of my
body moving”; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). These global
mindfulness measures have improved our understanding of these processes;
however, the advantage of EMAs is that researchers can evaluate the anteced-
ents, self-regulation strategies, and consequences of specific events. For example,
in the study described earlier, the assessment of psychological acceptance strate-
gies (i.e., “I simply noticed my feelings and continued with what I was doing”)
was conducted only in the presence of a psychotic or stressful event (e.g. “I heard
things that others could not hear”). Following that question, participants were
asked about the emotional or functional consequences of this strategy (e.g., “I
feel connected to others”). Similarly, EMAs could be used to examine statisti-
cal mediation (e.g., MacKinnon, Fairchild, & Fritz, 2007) of mindfulness and
acceptance processes and help us understand the association between daily
fluctuations of mindfulness during the course of treatment and their impact on
outcomes. This could potentially improve our knowledge base about the spe-
cific strategies used by individuals diagnosed with severe psychopathology and
accelerate treatment development in this population. In addition to processes of
change, EMAs can also be used to measure the outcomes of mindfulness- and
acceptance-based interventions. Such studies are starting to emerge in the lit-
erature (e.g., Geschwind, Peeters, Drukker, van Os, & Wichers, 2011; Nosen &
Woody, 2013).
Improving Interventions
Computerized EMAs and mobile devices can be used to improve the delivery of
existing behavioral interventions. As mentioned earlier, mobile devices can be
used to counterbalance the barriers posed by cognitive deficits in this population
(Dickinson et al., 2004; Elvevåg & Goldberg, 2000; Harvey, 2010). These cognitive
deficits have been shown to undermine treatment engagement (McKee, Hull, &
Smith, 1997) and medication adherence (Jeste et al., 2003; Robinson et al., 2002).
This is not surprising, as face-to-face interventions rely on individuals’ ability to
describe their symptoms days or weeks later, remember long, delayed appoint-
ments (sometimes every 2 months), or use behavioral skills when most needed
(e.g., urges to use drugs). In addition, these technologies can deliver behavioral
interventions that are cost-effective, evidence-based, and tailored to each indi-
vidual’s needs (Choo, Ranney, Aggarwal, & Boudreaux, 2012). Mobile interven-
tions can help overcome these barriers by operating directly in the individual’s
environment, with prompts to use skills, attend meetings, self-monitor habits,
and take medication. A thorough description of the use of these methods for
intervention in this population is offered by Depp and colleagues (Depp et al.,
2010; Depp, Mausbach, de Dios, Ceglowski, & Granholm, 2012), who present
data about the use of mobile technologies as a means to enhance existing inter-
ventions or deliver new treatments.
New Technologies
The growth of mobile hardware (mobile devices) and software (apps) is so rapid
that any attempt to give a comprehensive review of existing devices and software
platforms would soon be outdated. The growth of evidence-based apps, however,

is rather anemic, and in no way parallels the commercial development of these
applications.
Mobile Apps
Presently, there are countless smartphone apps for tracking mood and other psy-
chological symptoms, and they represent a wide range of quality and sophistica-
tion. Apps with some level of empirical support include BeWell and Mobilyze!.
Although the focus of these apps is not on mindfulness and acceptance-based
strategies, they still share a number of commonalities with ACT and other forms
of cognitive-behavioral therapy. BeWell enables users to manage their physi-
cal well-being by monitoring physical activity, social interaction, and sleep pat-
terns. The app then provides summaries of the effects of each these behaviors on
well-being (Lane et al., 2012). Mobilyze! is a context-sensing app that predicts the
user’s mood based on phone sensors, including GPS, ambient light, and recent calls.
A corresponding website provides graphs correlating participant’s self-reported
mood states and provides information on behavioral activation (Burns et al., 2011).
DBT Coach is a mindfulness app that provides dialectical behavioral therapy
to help users identify emotions and associated action urges, determines if the
user is interested in practicing mindfulness skills, and suggests useful behaviors
for the user to engage in (Rizvi, Dimeff, Skutch, Carroll, & Linehan, 2011). An
example of a non-empirically tested app is ACT Companion, an app designed
to facilitate the relationship between a patient and his or her ACT therapist
(Berrick Psychology, n.d.). This app provides a range of well-crafted acceptance,
mindfulness, and commitment exercises that come with very useful follow-up
questions that can be readily shared via e-mail with the therapist. SmartQuit
is an ACT app designed to help individuals quit smoking. This app, developed
by Jonathan Bricker, PhD, at the Fred Hutchinson Cancer Research Center, has
been empirically tested with promising results in a pilot randomized controlled
trial (Bricker, Mull, Kientz, Vilardaga, Mercer, Akioka, Heffner, 2014). In addi-
tion to these apps, there are other ACT apps designed to target specific ACT
processes for the general public (e.g., Somatiq, n.d.).
In general, for mobile apps to be useful for clinical researchers and clinical
practice, they need to (a) be highly customizable and (b) include measurement
of contextual antecedents and consequences of mindfulness and acceptance
processes and practice. The majority of apps to date do not meet these require-
ments. Apps designed with this framework in mind would be more appealing
to researchers and clinicians. Despite the fact that most apps lack these features,
some mood-tracking apps can be useful in this regard. One is T2 Mood Tracker,
developed by The National Center for Telehealth and Technology (http://
t2health.org/). This app can be used to track a variety of mood states and can
be customized to some degree. (We will refer to this app in a later section of this
chapter.) The T2 Center has developed a number of mobile apps to improve the
psychological health of the U.S. military community; however, most of the apps
can be used for a variety of clinical purposes in non-military populations.
Smartphone Sensors
In addition to software, hardware innovation brings a wealth of new assess-
ment possibilities for contextual behavioral research and clinical care. More
specifically, new mobile devices are enabling the transition from self-reports to
auto-reports. Self-reports require a conscious and deliberate effort to evaluate cer-
tain emotional, situational, or behavioral states by the individual. Auto-reports,
by contrast, are created via the automatic collection of data by the mobile device
itself through the use of mobile sensors. Although the internal context of the
individual (e.g., emotional states) is subjective and not susceptible to automati-
zation (e.g., physiological data are not equivalent to subjective emotional states),
there are a number of situational and behavioral factors that can be measured
with mobile sensors, such as motion and audio detectors and GPS tracking, with
higher precision than that of self-reports. In order to fully understand the role
of mindfulness and acceptance processes in relation to individual’s functioning
and response patterns, these features of the environment are important to take
into account.
Furthermore, the interaction between self-reports and auto-reports can be
used in the new field of machine learning (e.g., Burns et al., 2011), the next step
in the development of treatments for this population. Machine learning will pro-
vide CBS researchers with tools to test specific behavioral learning hypotheses.
For example, we can envision research studies in which the occurrence of a cer-
tain sequence of antecedents (e.g., three micro-episodes of delusional thinking)
paired with physiological markers (e.g., heart rate variability) triggers prompts to
use acceptance skills. This could be followed by a measurement of self-reported
levels of well-being minutes or hours later, which would then be used to adjust
machine-learning algorithms that would inform future ratios of antecedents and
skills prompts. Similarly, the amount of time dedicated on a weekly basis to for-
mal mindfulness practice could be paired with daily EMA well-being ratings and
be used to inform the individual with personalized feedback about the most use-
ful levels of mindfulness practice. In other words, computer science offers great
possibilities to enhance the testing of scientific hypotheses and the development
of new mindfulness- and acceptance-based interventions in this population.
New Challenges
These hardware and software developments will come with new challenges for
behavioral scientists interested in the study of mindfulness- and acceptance-based
processes in this population. First, computerized EMAs can generate “big data.”
This term has been defined as “data of a very large size, typically to the extent
that its manipulation and management present significant logistical challenges”
(Oxford English Dictionary, 2013). Although the term big data is commonly
used in fields such as computer technology and biomedical research, it certainly
applies to data generated by ubiquitous information-sensing mobile devices,
such as smartphones (e.g., Kumar et al., 2013). Despite the fact that there is some
research using mobile sensors successfully among adults with severe psycho-
pathology (e.g., Kimhy, Sloan, et al., 2006), this technology nonetheless comes
with a wealth of data-analytic challenges and considerations. These will require
new statistical models for the analysis of intensive longitudinal data (Walls &
Schafer, 2006) and analytic tools with powerful visualization capabilities, such
as the programming language R (R Core Team, 2013).
Finally, the larger amounts of data provided by EMAs will enable mindfulness-
and acceptance-based researchers to implement single-case design experiments
(or ecological momentary experiments). This single-case design approach is con-
sistent with the inductive emphasis of the contextual behavioral science tradition
(e.g., Barlow, Hayes, & Nelson, 1984; Vilardaga et al., 2009), which can be then
combined with randomization tests (e.g., Edgington & Onghena, 2007; Ferron &
Ware, 1994), a statistical approach that does not require distributional assump-
tions (e.g., normal distribution).
In summary, a truly contextual behavioral study of mindfulness- and
acceptance-based processes in real time will involve addressing the large vol-
umes of data generated by these technological innovations and using more
sophisticated analytic tools to analyze them.
I N S I G H TS FR O M C L I N I CA L PR ACT I C E
The current availability of mobile devices for an increasing proportion of indi-

viduals with severe psychopathology (Ben-Zeev, 2012) provides clinicians with
exciting new opportunities to enhance their clinical practice with more con-
textually based assessment methods. For example, during the course of clinical
practice, one author of this chapter (R.V.) provided therapy to an individual with
a diagnosis of paranoid schizophrenia. This patient was in an advanced stage of
recovery and received a non-protocolized ACT intervention that covered all of
the ACT components (Hayes et al., 2011). As part of outpatient treatment, the
patient received case management and antipsychotic medication (intramuscular
risperidone). The main treatment goal was to improve the patient’s quality of life
and provide further self-regulation skills to deal with residual psychotic symp-
toms. During the first 2 months, the patient completed weekly measures of qual-
ity of life as measured by the Short Quality of Life Scale-18 (Boyer et al., 2010).
As a complement to these weekly overall ratings, we suggested that the patient
download the T2 Mood Tracker (National Center for Telehealth and Technology,
2013). This app has a number of predefined mood rating scales and offers the
possibility of customizing alternative targets based on a specific case formula-
tion. With our patient, we used two of the default categories to track anxiety and
well-being. The patient was then instructed to complete momentary assessments
twice a day for approximately 1 month. These assessments were not randomly
sampled throughout the day, as the T2 Mood Tracker tool does not allow for ran-
dom sampling of mood symptoms. Instead, they were scheduled at times when
they were less intrusive on the patient’s daily activities: at the end of the morning
and at the end of the evening. The quality-of-life scale and the EMA ratings did
not target the exact same outcomes; however, there was some degree of overlap
(e.g., feeling socially connected).
Figure 3.2 shows data for the global self-report measure; the data correspond
to the first month of treatment. We were not able to collect a baseline for this
measure. However, note that the patient’s levels of quality of life were very high
throughout this period. This was consistent with the patient’s life situation, level
of functioning, and clinical observation. Although the data from these global
self-reports were clinically useful, this chart lacked the measurement precision
to inform the patient’s functioning and treatment.
The chart in Figure 3.3 represents data from the EMA reports during the
first month, which corresponds to the same time period as the chart in Figure
3.2. Each dot in the chart corresponds to one momentary assessment of either
well-being or anxiety. Well-being or anxiety was rated on a 0 to 100 visual analog
scale. A score from 0 to 50 indicated a negative state (e.g., hopeless), whereas a
score from 50 to 100 indicated a positive state (e.g., hopeful). Other examples of
items included “unsafe” versus “safe,” “angry” versus “content,” “tired” versus
“energetic,” or “lonely” versus “connected.” Thus scores above 50 in the chart
indicate well-being and lack of anxiety, and scores below 50 indicate levels of
anxiety and lack of well-being. The specific content of each of these categories
can be found in the app itself, which is freely available (National Center for
Telehealth and Technology, 2013).
First, the graph shows that consistent with global measures of quality of life,
this patient had overall high levels of well-being and low levels of anxiety. Up
88
78
Quality of life scale
68
58
48
38
28
18
1
3
n
on
n
io
io
io
si
ss
ss
ss
es
se
se
se
ts
e
t
en
en
en
lin
tm
m
se
t
Ba
ea
ea
ea
Tr
Tr
Tr
Session type and number

Figure 3.2. Total scores on the Short Quality of Life Questionnaire.
100
High well-being/low
90
anxiety 80
70
60
50
40
Low well-being/high
30
anxiety
20
10
0
1 6 11 2 7 12 17 22 27 32 37 42 47 52 57 62
E MA EMA MA EMA EMA MA MA MA MA MA MA MA MA MA MA MA
ne ne e E n t n t tE tE tE tE tE tE tE tE tE tE tE
s eli seli elin tme tme men men men men men men men men men men men
Ba Ba Bas Trea Trea reat reat reat reat reat reat reat reat reat reat reat
T T T T T T T T T T T
Daily measurement type and number
Figure 3.3. Daily EMA scores of positive affect (above 50) and negative affect (below
50), using the T2 Mood Tracker app.
until the 15th EMA, about half of the ratings were within the 50–90 range, and
half within the 10–50 range. This pattern consistently changed afterward. At this
point, the patient started to report higher EMA ratings that topped 100 and a few
instances when the patient experienced very low levels of well-being and high
levels of anxiety. Higher ratings in the global self-report scale were consistent
with higher EMAs. However, at a clinical level, this fine-grained assessment of
the patient’s subjective experience of well-being allowed the discussion of spe-
cific daily situations and the furthering of ACT self-regulation skills. Thanks
to an EMA approach, what could have looked like an apparent lack of progress
turned out to be an obvious clinical improvement.
C O N C LU S I O N S
We hope that this chapter has provided the reader with a conceptual framework
for understanding the importance of contextual behavioral assessment methods
as applied to the research and clinical care of individuals with psychosis, and the
measurement of processes and outcomes of mindfulness- and acceptance-based
interventions. While clinical behavioral science has made great advances in the
last decades in understanding and treating severe psychopathology, we would
argue that a truly contextual behavioral assessment approach (e.g., EMAs) will
further advance the contextual behavioral etiology of psychosis and improve

mindfulness- and acceptance-based interventions. EMAs are measurement tools
that are consistent with the philosophical and theoretical assumptions of the
CBS framework. They can provide the measurement and conceptual precision
to evaluate the actual context in which individuals with severe psychopathology
live their lives. We believe that overcoming the challenges posed by a deeper
access to the contextual factors influencing the lives of individuals with severe
psychopathology will only strengthen the efficacy and effectiveness of clinical
behavioral science in this population.
N OT E
1. Of note, this strategy can potentially negatively reinforce skipping questions in

future occasions. Researchers recommend having branching strategies that are bal-
anced and offer equal amount of items.
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SECTION II
Specific Treatment Models

4
Acceptance and Commitment

Therapy for Psychosis
Applying Acceptance and Mindfulness in the
Context of an Inpatient Hospitalization
PAT R I C I A B AC H ■
T H E ACT A PPR OAC H
Psychosocial interventions including psychotherapy are increasingly recog-

nized to play an important role in the treatment of psychotic disorders (Dixon
et al., 2010). Medication is regarded as almost essential in the treatment of
psychotic disorders, and psychotherapy is increasingly regarded as a useful
adjunct. Cognitive-behavioral therapy (CBT) for psychotic disorders is associ-
ated with many important outcomes, including decreasing treatment resistance
(Turkington, Kingdon, & Weiden, 2006) and improving positive symptoms
(Wykes, Steel, Everitt, & Tarrier, 2008). CBT also has been shown to be useful
in treating early schizophrenia (Naeem, Kingdon, & Turkington, 2008) or pre-
venting those with prodromal symptoms from progressing to a full-blown psy-
chotic state (Kuipers et al., 2006). As empirical support for mindfulness-based
therapies grows, they are increasingly being applied to the treatment of psy-
chosis, and existing treatments are being modified to include practices such
as mindfulness meditation and decentering. Acceptance and commitment
therapy (ACT) is a functional contextual form of CBT that has been included
in the Substance Abuse and Mental Health Services Administration’s National
Registry of Evidence-Based Programs and Practices (2013), and the American
Psychological Association’s (n.d.) Society of Clinical Psychology (Division
12) has evaluated ACT as having modest support for its effectiveness in the
treatment of psychosis.
58 A cceptance and M i nd f u l ness i n the T reatment o f P s y ch o s i s
Since ACT was not developed for a specific disorder, it is a broadly focused
mindfulness-based treatment. The basic processes can be adapted to suit the
needs of a specific population or presenting complaint. ACT (Hayes, Strosahl,
& Wilson, 2011) uses six core processes: acceptance, defusion, contact with the
present moment, perspective taking, values, and committed action. The outcome
of interest is psychological flexibility, which refers to the ability to contact the
present moment more fully and without needless defense and, based on what the
situation affords, to persist in or change behavior in the service of chosen values
(Hayes et al., 2011). The core processes are introduced to clients through experi-
ential exercises, metaphors, values clarification, and behavior activation. Similar
to other cognitive-behavior therapies, the therapeutic alliance and homework
are important components of treatment.
ACT differs from most other CBT approaches in that the desired outcome in
ACT is not symptom reduction (though symptoms often do decrease following
ACT). The desired outcome is increased psychological flexibility, where the cli-
ent may persist in or change behavior in the service of attaining valued goals and
outcomes while accepting whatever thoughts and feelings (including symptoms)
show up.
ACT is based on the assumption that experiential avoidance is the core prob-
lem in most psychopathology. Experiential avoidance means avoiding unwanted
thoughts, feelings, sensations, and other private events. Avoiding unwanted
thoughts and feelings, unpleasant memories, negative self-judgments, or
negatively evaluated feelings such as depression or anger may seem desirable.
However, there is considerable evidence that attempts to suppress unwanted
private experience often fail and can paradoxically increase negative private
experience (Wenzlaff & Wegner, 2000) and lead to other types of avoidance that
cause even more problems, such as substance abuse, agoraphobia, or disassocia-
tion. In ACT, attempting to control private experience is seen as the problem
rather than the solution, and the core ACT processes are aimed at accepting
symptoms and defusing from them rather than reducing or eliminating them,
while behaving effectively in the service of chosen values. While a thorough
review of the core ACT processes is beyond the scope of this chapter (interested
readers are referred to Hayes et al., 2011), they will be briefly considered here
(see Figure 4.1).
Acceptance
Acceptance means having the willingness to experience what one is experienc-

ing, having whatever thoughts and feelings show up in the course of living “fully
and without defense” (Hayes, 1994). The ACT therapist helps the client explore
his or her history and see how avoidance may have costs and where acceptance
might be an alternative. Acceptance interventions are aimed at building willing-
ness to experience all private events—thoughts, feelings, and body sensations—
when avoiding them would have negative consequences or cause the client to
Acceptance and Commitment Therapy for Psychosis59
Commitment and Behavior Change Processes
Contact with the

Present Moment
Acceptance Values
Psychological
Flexibility
Defusion Committed
Action
Self as
Context
Mindfulness and Acceptance Processes

Figure 4.1. The ACT model of psychological flexibility.
miss out on opportunities for valued living. Note that accepting events does not
mean wanting them; one only needs to be willing to have them.
Defusion
Defusion strategies are therapy techniques that facilitate relating to thought con-
tent differently. The client practices noticing thoughts and seeing that our minds
produce a steady stream of verbal chatter including judgments, evaluations, mem-
ories about the past, thoughts about the future, and so on. The person who is fused
with thoughts takes them literally. The defused person sees them as mere mind
chatter. For instance, a person fused with the thought “something bad is going to
happen” might make preparations for some feared event. In contrast, the defused
person might notice the thought and move on from it with no need to take any
overt action. Fusion is a byproduct of language, and it is difficult for all of us to
remain defused from language all of the time (Hayes, Strosahl, & Wilson, 1999).
As Bach and Moran put it (2008), “Defusion frees the client to act on the basis of
values and the current environmental contingencies rather than on the basis of
fused verbal content.” The ACT therapist facilitates defusion through demonstra-
tions of how automatically most language processes occur, and through having
clients practice noticing thoughts and feelings as they show up.
Contact with the Present Moment
Contact with the present moment is synonymous with mindfulness. By most

definitions of mindfulness, the mindful person’s attention is fully in the pres-
ent moment, is nonjudgmental, and is accepting of experience (Baer, Smith,
Hopkins, Kreitemeyer, & Toney, 2006). The ACT therapist might use any num-
ber of mindfulness and meditative practices to facilitate contact with the pres-
ent moment. Further, acceptance and defusion also necessarily include being in
contact with the present moment.
Self-as-Perspective
Self-as-perspective, which may also be called self-as-context or the observing

self, involves experiencing the self as the place where one’s life unfolds. It is not
a verbal construct but an experience and can therefore be difficult to talk about.
Instead, the clinician has the client participate in guided experiential exercises
in which he or she observes memories, feelings, sensations, and thoughts, and
then is invited to notice “who” is having those experiences. For instance, a cli-
ent might notice the feeling of hunger and then be asked “notice who is having
that feeling of hunger” or “notice who is having that memory about the past” or
“notice who is thinking about tomorrow.” This sense of self is contrasted with
self-as-content—the things we know and say about ourselves, such as “I am
a woman” or “I have schizophrenia” or “I was born in Mexico.” Also, self-as-
perspective is contrasted with ongoing self-awareness, which is noticing what is
being experienced in the moment, for instance, noticing that “I feel tired” or “I
feel angry” or “I am thinking about lunch.” One way to put it is that content is
what one is thinking about, ongoing self-awareness is noticing that one is think-
ing, and self-as-perspective is experiencing that I am the person having these
thoughts here and now. The experience of self-as-perspective can be grounding
and can facilitate willingness and acceptance.
Values
Values are chosen life directions. As part of values clarification the ACT thera-
pist will ask the client the question, “What do you want your life to be about?”
(Hayes et al., 1999). Values are distinct from and contrasted with goals. The
metaphor of “moving East” might be used to characterize values, whereas goals,
in contrast, are more like a specific destination, such as New York. This distinc-
tion is important clinically, because even while goal setting and goal attain-
ment can be in the service of values, the problem with goals is that they are not
here and now and are often viewed in terms of what is missing from one’s life.
In contrast, values are linked to larger patterns of action that are always avail-
able. For instance, goals such as completing a college degree, getting married,
or losing 10 pounds may or may not be attainable in the future. However, val-
ues such as learning, helping others, or taking care of one’s health are always
feasible in the present. Values are also uniquely personal; no one can choose
another’s values. The ACT therapist will use various values clarification exer-
cises to help the client identify values and may point out that, whether verbal-
ized or not, the client is always moving in a direction, and perhaps a direction
that leads to negative outcomes. The therapist will then aid the client in setting
values-consistent goals and in identifying specific committed actions that fur-
ther valued living.
Committed Action
Committed action is behavior in the service of values. Committed action may

mean taking part in other therapeutic interventions, such as joining a skills
training group, taking medication, or doing exposure and response preven-
tion. Committed action may mean increasing values-consistent behavior, such
as spending time with one’s family or taking a class. Or committed action may
mean decreasing behaviors that interfere with values living, such as quitting
smoking or no longer avoiding anxiety. Carrying out committed actions entails
identifying barriers to committed action; here the client often needs to practice
acceptance and defusion and to be in contact with the present moment. Taken
together, acceptance, defusion, contact with the present, self-as-perspective, val-
ues, and committed action all increase psychological flexibility.
ACT ST R AT EG I ES A N D T EC H N I Q U ES
The ACT processes are taught to clients by use of metaphors, demonstrations,

experiential exercises, and homework. For example, metaphors such as playing
tug of war with a monster or a person struggling in quicksand might be used
to encourage acceptance (Hayes et al., 1999). If the client has difficulty with the
abstract nature of metaphors, they can be turned into demonstrations by playing
tug of war in the treatment room or struggling to get out of Chinese finger traps.
Cognitive defusion can be demonstrated and practiced by means of exercises
that encourage viewing thoughts from a distance, as if they are moving cars on
a road (Hayes & Smith, 2005) or through demonstrations of the automaticity of
language.
Guided imagery and exercises to increase contact with the present are com-
monly used to build flexible attention to the moment. For example, the clini-
cian might instruct the client to practice noticing the sights or sounds in the
room, or to pay attention to one’s body sensation using a body scan exercise.
Experiential exercises are used to establish more flexible perspective taking
and to decrease attachment to the conceptualized self. For example, clients
might be exposed to guided meditations in which they meet themselves as
children or imagine a future older self. Values in ACT are chosen life direc-
tions that establish reinforcers in the present and facilitate acceptance of
unwanted content and willingness to change behaviors. They are addressed
through values clarification exercises, and the rest of therapy is linked to
these values. Values work can be an especially useful starting point in work
with clients on an involuntary hospitalization status. The involuntary and
therapy-wise client may be motivated to participate in ACT if it is differenti-
ated from past approaches, and if it begins with an examination of goals and
values rather than beginning with why the client has been hospitalized or
otherwise placed on involuntary status (Bach, Gaudiano, Pankey, Herbert,
& Hayes, 2006). Committed action consists of traditional behavioral acti-
vation and skill development techniques, but the goal is to increase behav-
ioral flexibility linked to values in the presence of previously unwanted and
repertoire-narrowing stimuli. For the person with chronic mental illness
whose treatment adherence is a concern, medication adherence, attending
treatment sessions, and completing homework and other aspects of treatment
might themselves be regarded as committed actions and be part of moving in
a valued direction. The interested reader should search the literature, as there
is a growing number of books and other resources for learning ACT avail-
able to both clients and treatment providers, e.g., see Learning ACT (Luoma,
Walser, & Hayes, 2007) or Harris’ (2009) ACT Made Simple.
A N ACT M O D EL O F PSYC H OS I S
An ACT model psychopathology presumes that while pain in life is inevitable,

ordinary language processes can unnecessarily increase pain and suffering.
Experiential avoidance, that is, avoiding or attempting to avoid thoughts, feel-
ings, and other private events, paradoxically increases their frequency (Hayes
et al., 1999). Although some might find it difficult to regard symptoms such as
delusions and hallucinations as similar to more ordinary thoughts and percep-
tions, research findings suggest otherwise. Bach and Hayes (2002) hypothesized
that hallucinations and delusional beliefs are not necessarily problematic in
themselves, and instead that acting to avoid them or taking their content liter-
ally is more problematic than the symptoms per se. While traditional cogni-
tive therapies for psychosis of the time emphasized challenging beliefs, ACT for
psychosis emphasized acceptance of the symptoms and, in the words of Steven
C. Hayes (Hayes et al., 1999) “seeing them for what they are, and not what they
say they are.” That is, symptoms—like any thoughts—can be noticed or observed
with no need to act upon their content.
Functional contextual approaches to psychosis are based on a view of
continuity between “normal” beliefs and perceptual experiences along with
delusional beliefs and hallucinations. This view is not new (e.g., see Strauss,
1969) and is supported by recent research on hallucinations and delu-
sions. Support for this hypothesis can be found in data on the frequency of
hallucinations, which suggest that nearly 40% of the population experiences

hallucinations (Ohayon, 2000), yet most do not seek treatment for them.
Furthermore, most people occasionally misattribute or misidentify audi-
tory stimuli (Turkington & Siddle, 2000), for instance, when hearing one’s
name being called when no one is there. Interestingly, although hallucina-
tions appear to be relatively common in the general population, persons who
both report hallucinations and have a mental illness have stronger beliefs than
others that it is not normal to have intrusive or unwanted thoughts (Lobban,
Haddock, Kinderman, & Wells, 2002).
Delusional beliefs also appear to be widely distributed in the population.
The Peters Delusion Inventory (PDI) assesses 21 common delusional beliefs
(e.g., persecution, grandiosity, thought insertion, delusions of reference) on
the domains of distress, preoccupation, and conviction. A study compar-
ing more than 200 healthy controls to a sample of 33 inpatients with delu-
sions found significant overlap in the PDI scores of delusional inpatients and
healthy controls, with 11% of the controls scoring higher than the “deluded”
sample (Peters, Joseph, Day, & Garety, 2004). Both hallucinations and delu-
sions may be more common than most think, and it is becoming increasingly
clear that avoidance of these symptoms rather than the mere presence of them
can be problematic.
Avoidance
Avoidance strategies may appear to be successful at times, for instance, when

a socially anxious person avoids a social event and an evening of anxiety, or
a hallucinating individual drinks enough alcohol to quiet the voices. However,
such acts of avoidance often have negative consequences and tend to decrease
psychological flexibility over time or in the longer term. Recent basic research
findings support a relationship between paranoia and experiential avoidance.
Specifically, persons who engage in experiential avoidance may be more likely to
be paranoid and to have lower self-esteem. For example, research suggests that
paranoia may be a means of avoiding low self-esteem, for instance, in assuming
that “others are out to get me” rather than that “I have failed,” and that such
attempts to avoid low self-esteem paradoxically increase it (Udachina et al.,
2009). Similarly, Goldstone, Farhall, and Ong (2011) found that participants
who tended to avoid unwanted thoughts were more likely to experience distress-
ing delusions in response to stressful events regardless of whether or not they
had been diagnosed with a psychotic disorder. Taken together, these findings
suggest that, in the context of symptoms of psychosis, experiential avoidance
has negative consequences and can paradoxically exacerbate these symptoms.
Normalizing symptoms of psychosis, that is, noting their continuity with other
cognitive events, may reduce distress and increase willingness to experience and
report symptoms when they occur rather than trying to avoid them (Bach &
Hayes, 2002).
Cognitive Fusion
Cognitive fusion is related to experiential avoidance as well. The person who

is defused with thoughts feels no need to avoid them—they are seen as mere
verbal events that do not need to be eliminated. In contrast, the person fused
with thoughts takes their content literally. Having a thought that “no one likes
me” or “today is going to be a bad day” means that dire events are certain and
action must be taken to avoid negative outcomes or at least to stop the unwanted
thoughts. In the context of fusion, delusions are fused thoughts and not much
different from other sorts of thoughts. The use of defusion strategies is where
ACT most differs from therapies that aim to challenge delusional beliefs. Maher
(1988) pointed out that delusional beliefs and related overt behaviors are no more
difficult to modify than are beliefs and practices regarded as non-delusional, for
instance, political or spiritual beliefs. In ACT, there is no attempt to change
thought content directly. Instead, the client is encouraged to relate to his or her
thoughts differently. This can lead to increased disengagement from thoughts,
which is associated with greater detachment from them (Shawyer et al., 2007).
Deficits in Perspective Taking
Poor perspective taking may also play a role in the maintenance of both posi-
tive and negative symptoms of psychosis. Perspective taking is related to the
construct of theory of mind, which is known to be impaired in persons with
schizophrenia (Corcoran, 2001). The ability to relate oneself in time and space to
other persons, times, and places allows one to understand past events, consider
the future, including the consequences of past and present behavior, appreciate
the differences between one’s own perspective and the perspectives of others,
and respond to others in a socially appropriate manner. Poor perspective-taking
skills can have negative consequences and may be related to both positive and
negative symptoms (Bach, 2007).
A person who has limited ability to think about the future may show a lack of
motivation and have little concern with such things as keeping appointments or
thinking about future health or finances. A person who does not appreciate that
others have a perspective may be insensitive to the effect of his or her behavior
on others and fail to be concerned with matters such as personal hygiene and
grooming, and may misattribute the actions of others and believe that he or she
is being persecuted. A person who cannot properly relate events in the present
to the past or future may be more likely to misattribute events and be more sub-
ject to delusional beliefs. Recent research on perspective-taking ability suggests
that persons with schizophrenia make more errors in this ability than healthy
controls (Villatte, Monestes, McHugh, Esteve, & Loas, 2010). Facilitating contact
with the present moment can increase one’s ability to relate the present to the
future and the past, and values clarification exercises can improve attention to
future outcomes and consequences of behavior in the present.
Lack of Values Clarity
For persons with chronic and persistent mental illness, a lack of values clar-
ity may result from a combination of poor perspective-taking ability as well as
lack of opportunity to engage in thinking about values and goals. Persons with
frequent and lengthy hospitalizations may have difficulty making plans for the
future, and treatment planning is often limited to more immediate needs such
as housing and treatment arrangements. Values are important because they give
us a sense of purpose and meaning and help guide behavior. In ACT, values may
also function to increase willingness (Juarascio, Forman, & Herbert, 2010). That
is, one may be more willing to engage in behaviors likely to be accompanied by
unwanted thoughts or feelings when behavior is in the service of values. For
example, a person applying for a job may be more willing to accept rather than
avoid feelings of anxiety and fears of rejection if the behavior is in the service
of values such as self-sufficiency or taking care of others. Values clarification is
similar in some ways to motivational interviewing (Wagner & Sanchez, 2002),
which has been associated with improved insight and medication adherence in
persons with schizophrenia (Rusch & Corrigan, 2002).
Low Commitment
While some may have difficulty identifying values, others may have avoidant val-
ues. This occurs when behavior is in the service of avoiding unwanted thoughts and
feelings. A person who uses illicit substances to avoid anxiety or voices, or someone
who is nonadherent to treatment because they associate participation in treatment
with acceptance of mental illness, may be behaving on the basis of avoidance values.
Values clarification can help the individual identify behaviors that are values con-
sistent and can increase motivation for change, that is, increased committed action.
While the ACT model can be applied to the conceptualization and treatment
of psychosis, some modifications to standard ACT treatment protocols may be
needed for some persons with schizophrenia and other chronic and persistent
mental disorders.
A DA P T I N G ACT TO T H E T R E AT M EN T O F PER SO N S
W I T H PSYC H O S I S
Early studies of ACT for psychosis were followed by recommendations for adapt-
ing ACT to better meet the specific needs of this population (Bach et al., 2006).
Some of the more important modifications to standard ACT protocols include
increasing the amount of repetition while decreasing session duration; simplify-
ing metaphors and using physical metaphors; introducing values early in treat-
ment for involuntary patients; linking treatment adherence to values; and, where
applicable, educating staff and family members about the aims of ACT.
Cognitive deficits are common in schizophrenia and other chronic and per-
sistent mental illness (Penn, Combs, & Mohamed, 2001). Bach and colleagues
(2006) have recommended that a third of each session be spent reviewing previ-
ous material. Farhall and colleagues (Farhall, Thomas, Shawyer, & Hayes, 2010)
additionally recommend making audio recordings of all therapy sessions. They
provides their therapy clients with an audio CD at the end of each session. They
have found that listening to the recorded session between sessions is positively
associated with therapy outcome. Cognitive deficits may also be accommo-
dated by simplifying the presentation of some of the content in ACT. Popular
clinician guides to ACT include exemplars of many common ACT exercises.
Care can be taken to select and develop one’s own exercises that are shorter in
duration and that are less abstract. While metaphors are necessarily abstract,
they can be made easier to understand by using physical props and/or acting
them out, such as by putting thought content on paper and holding it close to
the client to illustrate fusion with verbal content, or pushing away index cards
with hallucinatory content written on them, to illustrate avoidance. However,
if a client is not motivated for treatment, even these modifications will not be
helpful.
Medication adherence is a sensitive concern for many diagnosed with psy-
chotic disorders. On the one hand, medication adherence tends to be lower than
is desirable. Data on the effectiveness of even so-called second-generation anti-
psychotics are mixed, with some studies showing that they are no more effec-
tive than older medications and have a limited impact on quality of life (Dixon
et al., 2010). Other studies suggest that addressing both the therapeutic alliance
and treatment adherence in treatment tends to improve medication adherence,
and that having a more positive attitude toward medication is associated with
improved adherence and better community functioning (Mohamed et al., 2009).
Further, Rose, Novitsky, and Dubin (2009) suggest the utility of addressing med-
ication adherence with strategies such as CBT and motivational interviewing,
in addition to providing psychoeducation, and spending time identifying and
addressing barriers to treatment adherence. During the committed action pro-
cess, the ACT therapist can help the client identify where medication nonadher-
ence, and indeed nonadherence to any form of treatment, might be a barrier to
attaining valued outcomes. Such strategies may improve willingness to engage in
treatment and promote better outcomes.
Many clients with psychotic disorders are treated on an involuntary basis, and
others, having voluntary status in a legal sense, may be disengaged from treat-
ment. In such cases it can be helpful to begin treatment with values clarification
(Bach et al., 2006). A more motivated client may be willing to practice accep-
tance and defusion; however, a less engaged client may be unwilling. Quickly
engaging the client around the larger context of values clarification can help to
focus and engage clients on the issue of relapse rather than the issue of getting
out of the hospital. Emphasizing what the client wants in his or her life can be
more helpful than focusing on problems first, as might occur if treatment were
to begin by exploring experiential avoidance and acceptance.
Once a client is engaged in treatment it may be helpful in some cases, depend-

ing on the particular situation of the client, to provide psychoeducation about
ACT to interdisciplinary treatment providers and/or to family members. While
mindfulness and acceptance-based treatments are becoming more common, to
many they remain outside of the mainstream or are associated with “alternative”
practices. Bach and Hayes (2002) found that inpatient participants exposed to
ACT were more likely to report symptoms of psychosis following exposure to
ACT. They interpreted this observation to mean that clients were more accept-
ing of and defused from symptoms, and thus were also more willing to report
them. Even while taking medications as prescribed, the majority of persons with
a diagnosis of schizophrenia continue to report positive symptoms, although
often in attenuated form. For instance, in a study of 6,642 patients, only a third
reported no or minimal positive symptoms or psychosis 3 years after begin-
ning treatment (Novick, Haro, Suarez, Vieta, & Naber, 2009). However, some
treatment providers and family members might find reports of such symptoms
concerning. In some cases reporting a symptom such as the presence of halluci-
nations may be grounds to keep a patient hospitalized, so it would be essential
for the ACT therapist to provide some education about ACT and to let important
others know that ACT is aimed at increasing acceptance of and defusion from
symptoms, and that this approach might be followed by an increase in reported
symptoms of psychosis. A case example is provided next to illustrate how ACT
in the treatment of psychosis might proceed.
ACT I N ACT I O N: CAS E V I G N E T T E O F

ACT FO R PSYC H O S I S
History
The case of Justin will be considered in order to illustrate the use of ACT in
the treatment of psychosis. Justin is a 38-year-old single white male diagnosed
with paranoid schizophrenia. His first hospitalization was at age 20 when he was
hospitalized for almost 3 months. He had persistent persecutory delusions that
people were plotting against him and wished to harm both him and his father.
Specifically, he believed that they were poisoning the water. He was admitted
for the first time after he made suicidal and homicidal threats. During periods
of remission Justin functioned rather well. He lived in an apartment with some
financial assistance from his father, he had completed some college and worked
part-time doing data entry. He had a close relationship with his father and one
of his sisters visited him regularly. When his symptoms were in remission he
took medication as prescribed and attended monthly visits with a case manager.
During acute episodes of his illness he typically became increasingly paranoid
over a period of several weeks, during which he usually ceased communica-
tion with all family members except for his father, who lived a quarter of a mile
away. His work attendance became sporadic, and his hygiene and grooming
deteriorated because he avoided showering and laundering his clothing, fear-

ing that the water was poisoned. He would also stop taking his medications and
experience increasingly persistent auditory hallucinations when unmedicated.
On each occasion, 11 times overall, Justin was hospitalized for 1 to 2 months. He
usually had significant symptoms of depression following each hospitalization
and took some time to return to premorbid levels of functioning.
Justin was first introduced to ACT while an inpatient, having been recently
hospitalized with paranoid delusions and auditory hallucinations. He was
approached about therapy a few days following his admission, after he had started
medication and his symptoms had remitted somewhat. Therapy was a standard
part of treatment on the unit, with about half of inpatients receiving individual
therapy in addition to participation in psychosocial groups. The specific therapy
approach varied by clinician. Justin had not heard of ACT specifically. He was
willing to participate in therapy and acknowledged that he had found therapy
helpful in the past. Justin and the therapist agreed that they would meet two or
three times a week for the duration of Justin’s hospitalization.
Justin had reasonable insight into the nature of his illness—a favorable predic-
tor of treatment outcome in schizophrenia (Mohamed et al., 2009), though also
associated with increased depression (Narvaez, Twamley, McKibbin, Heaton, &
Patterson, 2008). While he lacked insight into the delusional nature of his beliefs
when fully in the acute phase of the illness, most times he was able to acknowl-
edge that “sometimes I get paranoid.” His insight was important, for it made it
somewhat easier to describe and implement techniques for coping with delu-
sional beliefs and auditory hallucinations.
Like many individuals with schizophrenia, Justin had few close relationships
with others. He was especially close with his father, and he wanted his father’s
admiration and trust. He had a reasonably close relationship with one of his sis-
ters. He named his outpatient case manager, who had been working with him for
8 years, as someone he liked and trusted.
Treatment
The first two sessions were spent introducing the ACT model to Justin. The
clinician explored his attempts to cope with unwanted symptoms. He avoided
delusional thought content by staying indoors and avoiding even telephone and
Internet contact with others, with the exception of his father. He stopped going
to work and stopped participating in treatment. On occasions when his case
manager made a welfare check-in visit, he told her he was “fine” and asked her to
leave. He said that he did these things because he was afraid.
The therapist asked him if his actions helped stop his fearful thoughts and
feelings. Justin acknowledged that his fear usually increased with time, and that
all he could think about was the possibility of being poisoned. The therapist also
asked him about the consequences of his actions, reviewing the previous two
hospitalizations. Justin noted that on both occasions he was fired from his job,
he failed to meet financial obligations such as paying bills, and he stopped taking
medications, which increased his auditory hallucinations and general distress.
He said, “Now [while medicated] it seems dumb. I wish I didn’t have this [schizo-
phrenia], and I don’t know what else to do when it seems like people want to hurt
me.” He was able to see that his strategy for coping with his distress had negative
consequences, and he said that he was willing to try something new.
The idea of accepting symptoms and defusing from verbal content such as
delusional beliefs and hallucinatory content was new to Justin. He was skeptical
and said that he preferred to be rid of the symptoms. The therapist gave some
examples of how one can notice thoughts without “buying” them. For instance,
one could have a thought about eating and choose not to eat, or have a thought
about staying home from work and still go to work. Justin wondered if it was
okay to acknowledge thoughts instead of denying them, and the therapist had
him begin noticing and labeling his thoughts in session. He found it difficult not
to get caught up in his thoughts and that he was not confident he would be able to
“just notice” paranoid thoughts. The therapist assured him that this was difficult
for everyone to do, and that it would be important for him to practice between
sessions. At this point in his treatment, Justin was permitted access to the hos-
pital grounds; one homework exercise was for him to walk around the grounds
and practice labeling the things he saw (and later in treatment, he also practiced
labeling what he heard, as an alternate exercise). This allowed him to get in the
habit of focusing his attention and observing the present moment. He also was
able to notice how easy it is to become distracted, and that at any moment one
could redirect attention and resume noticing the present. After 1 week, Justin
began practicing noticing his thoughts, for 5 minutes twice a day. He completed
this assignment about half the time, saying that he sometimes “forgot.” He found
noticing and labeling his thoughts to be more difficult than labeling what he saw
and heard. He said that he often was distracted and that he did not want to notice
negative feelings and thoughts. The therapist used the standard intervention of
asking the client about his experience of avoidance—had he used avoidance
strategies before? When? How had they worked? Justin rather quickly acknowl-
edged that avoidance had not been helpful in the past. However, he continued to
maintain that delusional beliefs were “crazy” and should be gotten rid of.
Justin also noted that his father, sister, and case manager often inquired about
his symptoms, and stated that he often denied the presence of symptoms to oth-
ers. He expressed concern that his father or case manager might “send me here
again” if he reported to them that he was experiencing symptoms of psycho-
sis and “just accepting them.” Justin’s reaction to disclosing symptoms is not
uncommon—avoidance of unwanted thought content is common, and treat-
ment providers and family members routinely inquire about the presence of
symptoms. This information was important, since others might not be aware of
acceptance as a coping strategy and regard the presence of hallucinatory or delu-
sional content as “bad.” The therapist decided to include Justin’s father during a
later session to explain what they were trying to do—relate differently to symp-
toms rather than trying to eliminate them. The therapist also met with Justin’s
case manager, who knew a little about ACT, so that she would also be on board
with Justin’s new cognitive approach to working with symptoms. These conver-
sations were important for assuring Justin that it would be okay to acknowl-
edge the presence of symptoms to his father and to his case manager, and that
his treatment goal of accepting and defusing from verbal content would not be
undermined by his verbal community.
Even while Justin’s symptoms of psychosis were remitting and he appeared
to be coping with them, as occurs quite often in acute phases of schizophrenia,
his feelings of depression began to increase, leaving Justin to feel hopeless and
guilty. Although, as noted earlier, poor perspective-taking skills may be associ-
ated with symptoms of psychosis, this deficit appeared to increase Justin’s sense
of “badness,” as he judged himself harshly and presumed that others did too,
and he was convinced that “nothing will ever change.” Increased work on defus-
ing from judgments and other depressogenic thoughts was somewhat helpful to
Justin, and working on developing self-as-perspective skills was also introduced
at about this time. Justin participated in a modified version of the observing-self
exercise. In most versions of this exercise (e.g., see Bach & Moran, 2008; Hayes,
Strosahl, & Wilson, 2011; Zettle, 2007) individuals are invited to recall a moment
from the recent past and “see” themselves in their mind’s eye, as if they were an
observer, and to notice that even while it is the present moment, one can look
back at past moments. The exercise continues with the client being invited to
notice body sensations, roles, feelings, and thoughts . . . and to notice that he or
she is distinct from all of these things and experiences . . . that even while one has
a body, and has memories, and had thoughts, feelings, and sensations . . . there
is an important sense in that although one has feelings, thoughts, sensations . . .
one is not one’s thoughts, feelings, and sensations.
Work on perspective taking is necessarily abstract. The exercise was modi-
fied to begin with Justin imagining seeing words on a computer screen, specifi-
cally words that functioned as descriptions about him—for instance, reading the
words, “you are a bad person.” Could he read those words on a computer and
observe them and notice that even while they might seem to be about him, they
were not him and he was free to disregard them? By beginning the exercise with
a more concrete example of observing content, Justin was better able to under-
stand and participate in the later, more abstract parts of the exercise. Many cli-
ents find the exercise peaceful and experience the self as being at peace when not
being buffeted about by feelings and judgments about the self.
Justin was making good progress, and while his depressive symptoms remained,
his symptoms of psychosis were remitted somewhat as he was taking medication.
The next phase of treatment was values work. Values clarification was most impor-
tant for linking Justin’s unworkable behaviors—avoidance and medication non-
adherence—to his values and goals. He initially had difficulty identifying values,
so the therapist had him instead describe some of his goals. He was able to iden-
tify several goals, including finding employment (e.g., he was let go from his most
recent job just before his hospitalization), “not worrying his father,” and thinking
he might want to quit smoking. He thought he “maybe wanted a girlfriend,” and
he was unsure since he had not dated since being diagnosed with schizophrenia.
When he elaborated on these goals, they were more easily linked to some impor-
tant values for Justin. He valued being self-sufficient and self-supporting, valued
close family relationships, and did not want to be a financial or emotional burden
to his family. He wanted to explore romantic relationships but was unsure what
the outcome might be and lacked dating skills. He wanted to quit smoking in the
service of improving his health and in the interest of better managing his money.
These values were then linked to specific committed actions that Justin could take.
Justin did not mention medication adherence as a goal, and the therapist
wanted to link medication adherence to Justin’s values. Most of his hospitaliza-
tions had quickly followed periods of medication nonadherence. The therapist
revisited unworkable change agendas with Justin, and he was able to acknowledge
that discontinuing his medication was often associated with negative outcomes.
Most importantly, he recalled past hospitalizations and linked specific negative
consequences of medication nonadherence to his own experience, rather than
through persuasion on the part of the clinician. He committed to improving his
medication adherence, and both he and the clinician noted that this was espe-
cially difficult for him when his symptoms worsened. Justin agreed to sign an
advance directive authorizing his father and case manager to hospitalize him in
the event of medication nonadherence and the presence of significant symptoms
of psychosis. While this strategy might not prevent hospitalization completely, it
could very well lead to less severe consequences to Justin’s freedom, employment,
and finances. Justin also signed up to participate a dating skills group offered at
the community mental health center where he received outpatient treatment,
and he said he would work with his case manager on smoking cessation. He also
made a commitment to continue to do mindfulness exercises, such as noticing
and labeling his thoughts and feelings or things in the environment.
At this point in time Justin was engaged in discharge planning. His last few
therapy sessions were spent on exploring “barriers to values.” Specifically, he
and the clinician worked on troubleshooting what Justin perceived to be barri-
ers to completing his committed actions. He worried that he might not be able
to adhere to his plan if he became paranoid or if his symptoms of depression
worsened, and he acknowledged that he had attempted to quit smoking in the
past will little success. His plans for overcoming these barriers were to report
symptoms to his case manager, and to practice defusion when he encountered
paranoid or depressive thoughts. He noted that fear of failing was no reason
not to attempt quitting smoking, or dating, and that these were worth doing no
matter what the outcome might be. Justin was discharged after 7 weeks in the
hospital and 16 sessions of ACT.
Post-Discharge
Approximately 15 months later he experienced an exacerbation of his symptoms.

With the advance directive in place, his case manager had him hospitalized.
While Justin was initially furious, on later reflection he agreed that “it was a
good thing,” as he was quickly stabilized on medication and his hospitalization
was only 3 days in duration. He was discharged with his job and dignity intact.
During those 15 months he had quit smoking four times, had remained absti-
nent from smoking for up to 6 weeks, and vowed to persist in attempting to
attain complete smoking cessation. He completed the dating skills course and
decided that while he felt he had learned useful skills, he did not really want to
date, and that dating would in fact be in the service of pleasing others rather than
doing something that truly interested him at the time. Overall, he evaluated his
course of therapy as helping him to “figure out what I want and hopefully stay
out of the hospital so I can do what I want.”
R ES E A R C H S U PP O RT FO R AC C EP TA N C E A N D
C O M M I T M EN T T H ER A PY FO R PSYC H O S I S
Justin’s course of treatment is fairly typical with respect to the course of ACT
for psychosis. The first study of ACT for symptoms of psychosis was published
in 2002 (Bach & Hayes). The participants were inpatients at a state psychiatric
hospital in Nevada. The inclusion criteria were the presence of hallucinations or
delusional beliefs at intake, and that the client was able to consent to participate.
Exclusion criteria were having a legal guardian, a diagnosis of substance-induced
psychosis, or comorbid mental retardation. Most who agreed to participate had
a long history of treatment at the facility including multiple hospitalizations;
individuals who had not been hospitalized before tended to decline to partici-
pate. The majority of the 80 participants recruited for the study had a diagnosis
of schizophrenia (N = 43), and others had diagnoses of schizoaffective disor-
der, mood disorder with psychotic features, psychotic disorder not otherwise
specified (NOS), or delusional disorder. The primary outcome measure was time
(days) to rehospitalization. The treatment group participated in four sessions of
ACT plus treatment as usual (TAU), while a control group received TAU only.
The results were that 20% of the ACT participants and 40% of the TAU par-
ticipants were rehospitalized during a 120-day follow-up. Considered as a group,
ACT participants remained out of the hospital an average of 22 days longer than
TAU participants. These differences were statistically significant, and the differ-
ence remained significant at 1 year follow-up and after controlling for previous
hospitalization and duration of hospital stay (Bach, Hayes, & Gallop, 2012). ACT
participants also showed greater reductions in believability of symptom content
as measured by a Likert-type rating scale created for the study. Interestingly,
the ACT participants were twice as likely as TAU participants to report symp-
toms of psychosis at follow-up. The authors suggested that this finding may have
been due to ACT participants becoming more accepting of symptoms and thus
more likely to acknowledge their presence post-treatment. While not a direct
measure of acceptance, those who reported symptoms reported significantly
reduced symptom-related distress at follow-up. In contrast, an individual who
is avoiding symptoms might deny their presence even while they are occurring
(Bach & Hayes, 2002). Indeed, Waters (2010) subsequently found that symptom
underreporting is common in persons with psychotic disorders because of the
negative consequences of reporting symptoms. Limitations of Bach and Hayes’
(2002) study were that diagnoses were not assigned in a standardized manner
and treatment integrity was not assessed. Also, a TAU comparison group is
less than ideal, compared to an active treatment comparison group. The sample
was also less likely to have a diagnosis of secondary substance abuse and more
likely to be fully or partially medication adherent than the average person with
a chronic and persistent mental illness, so the results may not generalize to all
persons with psychotic disorders. That said, given the high social and economic
costs associated with hospitalization, the results may be regarded as meaning-
ful: rehospitalization was reduced, and results were consistent with the ACT
model of psychopathology.
Gaudiano and Herbert (2006) completed a replication and extension of the
Bach and Hayes (2002) study. Their study was completed at an inpatient facility
in Philadelphia. Participants received an average of three sessions of ACT, the
exact number of sessions being determined by length of participant hospital-
ization. This study improved on some of the limitations of the Bach and Hayes
(2002) study. For instance, Gaudiano and Herbert (2006) used an enhanced
treatment as usual (ETAU) comparison condition in which the number of
contact hours of treatment was controlled and equal for participants in each
condition, and they administered standardized measures of symptom sever-
ity and global functioning, such as the Brief Psychiatric Rating Scale (Overall
& Gorham, 1962), at baseline and post-treatment. Although the results did
not reach statistical significance in uncontrolled analyses, they were similar
to results of the first study, with rehospitalization rates of 45% for the TAU
group compared to 28% for the ACT group. Additionally, the ACT partici-
pants had lower symptom believability and greater reductions in psychiatric
symptoms, social impairment, and hallucination-related distress as compared
to the ETAU group (Gaudiano & Herbert, 2006). A later follow-up analysis
showed that the ACT group had a significantly longer time to rehospitaliza-
tion than that for the ETAU group after controlling for baseline symptoms
severity (Bach, Gaudiano, Hayes, & Herbert, 2013). Gaudiano, Herbert, and
Hayes (2010) followed up this study with a mediation analysis and found that
symptom believability at post-treatment mediated the relationship between
treatment condition and symptom-related distress. In a further mediation
analysis, the data from the two ACT for psychosis studies were combined so
as to achieve greater statistical power; it was found that post-treatment symp-
tom believability mediated the effect of treatment condition on hospitalization
(Bach et al., 2012). Further, neither symptom frequency nor symptom-related
distress mediated the outcome. These mediation studies provide support for
the proposed mechanism of ACT—that relating differently to symptoms can
reduce negative consequences attributed to their presence, even when symp-
tom frequency remains high.
Since the first randomized controlled trials of ACT were completed there
have been additional trials of ACT for psychosis. ACT was also recently applied
in order to assess its feasibility for treating depression in persons with psychotic
disorders. Depression is common in persons with schizophrenia and is asso-
ciated with poorer outcome. Analysis of a large-scale study on the effective-
ness of both pharmacological and psychosocial treatments for schizophrenia
included the recommendation that there be more study on the effectiveness of
CBT for depression in persons with schizophrenia (Dixon et al., 2010). White
and colleagues (2011) completed a feasibility study of ACT for emotional dys-
function following psychosis. They found that in a sample of 27 participants
who met criteria for a psychotic disorder and scored high on a measure of
depression, ACT participants were more likely than TAU participants to have
their status change from depressed to non-depressed, showed greater reduc-
tions in negative symptoms, and demonstrated increases in mindfulness skills.
These findings are particularly encouraging, given that depression is common
in schizophrenia and is associated with poorer quality of life (Narvaez et al.,
2008). In addition to the research studies described here, there are a few pub-
lished case studies documenting the utility of ACT for schizophrenia (e.g.,
Garcia-Montes, Luciano, Hernandez, & Zaldivar, 2004; Veiga, Perez, & Garcia,
2008), and a recent open trial of ACT delivered in a group treatment format
(Morris & Oliver, 2008) resulted in improved recovery following a first episode
of psychosis.
Patients’ evaluations of ACT have also been assessed. Bacon, Farhall, and
Fossey (2014) specifically studied clients’ perceptions of ACT through adminis-
tering a semi-structured interview to nine participants diagnosed with schizo-
phrenia. They found that all of the participants found ACT helpful and would
recommend it to others; participants also reported that, as predicted by the ACT
model, symptom frequency did not change, while symptom intensity and associ-
ated distress were reduced. Acceptance, defusion, mindfulness, and values work
were described as the most useful components of treatment.
There have also been some attempts to combine components of ACT with
other treatments, and the results have been mixed. One study combined ele-
ments of ACT and more traditional CBT for command hallucinations. Patients
were taught both how to modify beliefs and work on accepting hallucinations as
part of a 15-session intervention called treatment of resistant command halluci-
nations (TORCH). This treatment was compared to befriending, a manualized
control treatment that provides similar therapist engagement to CBT, and to a
waitlist condition. On the one hand, participants in the TORCH group showed
more improvement than the waitlist group. On the other hand, the TORCH and
befriending groups had similar outcomes across several variables. Although
both groups reported at post-treatment that they felt they would be better able
to resist command hallucinations, these gains were not maintained at follow-up.
However, there were some group differences in several variables. For instance,
the TORCH group showed greater symptom reduction at follow-up and the
befriending group showed greater decreases in symptom-associated distress.
The TORCH participants were also more likely to show gains and maintain
improvements at follow-up, whereas befriending participants reported most
gains post-treatment and not all were maintained at follow-up. The authors
pointed out that the study was small (N = 44) and to the possibility that com-
bining techniques of both CBT and ACT may have created some confusion
(Shawyer et al., 2012).
Another study combining treatment approaches attained more success-
ful outcomes. Cognitive-behavioral therapies including ACT have been
applied and studied in persons with depression and, more recently, albeit
to a lesser extent in persons with psychotic disorders. Gaudiano and col-
leagues (Gaudiano, Nowlan, Brown, Epstein-Lubow, & Miller, 2013) have
combined these approaches and published the results of the first open trial
of acceptance-based depression and psychosis treatment (ADAPT) for per-
sons with psychotic depression. Their treatment combined behavior activa-
tion with ACT. They provided up to 6 months of ADAPT combined with
medication to 14 individuals diagnosed with depression with psychotic fea-
tures. The 11 participants that completed treatment had improved depressive
and psychotic symptoms. Further, their scores on measures related to ACT
processes also improved. Specifically, there were large effect size improve-
ments on measures of psychological flexibility, values-consistent behaviors,
and mindfulness.
C O M M O N VS. D I ST I N CT I V E EL EM EN TS O F ACT
ACT is often described as a “stance” toward treatment, rather than a treat-

ment per se. This is in part because specific interventions of many varieties
can be applied as part of the committed action process, while acceptance, con-
tact with the present moment, and values clarification might be used to bol-
ster willingness to actively participate in behavior change activities through
committed actions.
ACT is most incompatible with conventional cognitive therapy strategies
in the specific areas of acceptance and defusion vs. cognitive restructuring.
Acceptance and defusion exercises teach clients to notice their thoughts as they
are, and to accept and be willing to have whatever thoughts, feelings, and sensa-
tions show up. In contrast, many cognitive restructuring techniques are aimed at
changing thought content, which is at odds with the notion of accepting thought
content. In spite of this area of conflict, other interventions appear to be more
compatible, and the practice of combining treatment strategies is on the rise. For
instance, mindfulness techniques and values clarification are being combined
with other approaches such as the addition of values clarification to behavior
activation (Kanter et al., 2010) and the addition of mindfulness techniques to
treatments as diverse as eye movement desensitization and reprocessing (EMDR)
and relapse prevention for alcohol and substance abuse (Witkiewitz, Marlatt, &
Walker, 2005).
F U T U R E R ES E A R C H D I R ECT I O N S
Research on ACT for psychosis has been promising thus far. However, more
research is needed. Three aspects of research on ACT for psychosis that must
be enhanced are samples and sample sizes, the specificity of ACT for psychosis
treatment protocols, and outcome measures. The largest controlled trial included
80 participants; all other trials of ACT for psychosis have had fewer than 40
participants. Trials with larger numbers of participants are needed. Further,
both of the two largest trials included samples that were mixed with regard to
diagnosis, and those that were limited to participants with the same diagnosis
include case studies and/or small samples with protocols that combined ACT
with other interventions. Larger studies with samples that are more homogenous
with regard to diagnosis can refine knowledge about the effectiveness of ACT
for psychosis.
A second area for future research is to provide more clearly specified treat-
ment protocols with treatment integrity evaluated. The two largest trials to date
(Bach & Hayes, 2002; Gaudiano & Herbert, 2006) both had poorly specified
treatment protocols, making replication difficult. It is encouraging that media-
tional analyses of ACT for psychosis have supported the proposed mechanism
of change (Bach et al., 2012; Gaudiano et al., 2010), and further studies of large
samples of persons with symptoms of psychosis are needed in order to determine
if the results hold for persons with different disorders and different demographic
characteristics.
Future studies of ACT for psychosis will also benefit from improved outcome
measures. In the last decade since the first trials of ACT for psychosis were com-
pleted, measures of important ACT processes and outcomes have been devel-
oped and/or improved (e.g., see Bond et al., 2011), and a measure specific to
acceptance of symptoms of psychosis has been developed (Shawyer et al., 2007).
These advances will allow for improved assessment of effectiveness and media-
tion. Fortunately, the future is now; at the time of this writing, larger clinical
trials of ACT for psychosis are being developed or are underway.
C O N C LU S I O N
While medications have traditionally been the treatment of choice for persons
with symptoms of psychosis, there is growing awareness that although medica-
tions can be helpful for reducing symptoms, they are frequently not sufficient for
significant functional improvement and recovery. There is growing evidence that
psychotherapy can be a useful part of treatment for persons with symptoms of
psychosis (Dixon et al., 2010). ACT is one psychosocial approach to the treatment
of psychotic symptoms. ACT may be particularly useful because specific interven-
tions can be adapted to low functioning and involuntary clients, and ACT can
be used alone or it can be integrated with the interdisciplinary treatments com-
monly used in inpatient and other intensive settings. ACT is not aimed at reducing
symptoms of psychosis; in fact, most participants in ACT for psychosis continue to

acknowledge experiencing hallucinations and/or delusions. However, the believ-
ability of their symptoms is greatly reduced, which appears to mediate treatment
outcomes and may contribute to lower rates of relapse and rehospitalization and
to decreases in subjective distress associated with symptoms (Bach et al., 2006;
Gaudiano et al., 2010). The emphasis in ACT on engaging in committed actions
that are consistent with chosen values while accepting or allowing the occurrence
of psychotic symptoms is a departure from other common treatment approaches
that aim to reduce or eliminate positive symptoms. In contrast, the ACT thera-
pist aims to enhance client motivation to change behaviors, including adherence
to treatment, while working toward values-consistent goals, rather than acting in
accordance with their symptoms or engaging in detrimental behaviors in the ser-
vice of avoiding or escaping symptoms. On the whole, the body of evidence for
the effectiveness of ACT for psychosis remains small but encouraging. Research
results suggest that ACT may be useful for decreasing hospitalization and reducing
symptom-associated distress. Further, mediation studies suggest that ACT for psy-
chosis works through the mechanism posited by contextual scientific theory, and
specifically through decreasing symptom believability and related attachment to
reducing symptom frequency. More studies are certainly needed, and the evidence
that ACT can be an effective treatment for persons with psychosis is growing.
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5
Treating Depression in Psychosis

Self-Compassion as a Valued Life Direction
ROSS G. WHITE ■
OV ERV I E W
Depression occurring in the context of psychosis is recognized as a clinically

important issue. Rates of depression following psychosis can be as high as
50% in first-episode populations and 33% in individuals with established psy-
chosis (Whitehead, Moss, Cardno, Lewis, 2002). The experience of depres-
sion has been highlighted as one of the major factors contributing to poorer
quality of life among individuals with psychotic disorders generally (Saarni
et al., 2010) and schizophrenia specifically (Meijer, Koeter, Sprangers, Schene,
2009; Narvaez, Twamley, McKibbin, Heaton, & Patterson, 2008). The asso-
ciation between depression and psychosis also appears to predate the emer-
gence of the psychosis. Research has indicated that 83% of individuals with
first-episode psychosis have previously experienced an episode of depres-
sion (Häfner et al., 2005). In an attempt to understand the phenomenology
of depression that occurs following the experience of psychosis, Birchwood
and colleagues (Birchwood, Mason, MacMillan, & Healy, 1993; Birchwood,
Iqbal, Chadwick, & Trower, 2000; Iqbal, Birchwood, Chadwick, & Trower,
2000) found that depression emerges independently of positive and negative
symptom severity and is associated with appraisals of loss (e.g., the ending of
friendships, aspirations for the future), entrapment (worrying that the psy-
chosis will recur), and humiliation (feeling embarrassed and stigmatized by
the experience of psychosis).
This chapter builds on the work of White (2013) to highlight how acceptance
and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) can be used to
treat depression occurring in the context of psychosis. The chapter will outline
the role that threat-focused appraisals (relating to themes such as loss, entrap-
ment, and humiliation) play in activating what has been termed the social rank
mentality—an evolutionary derived set of psychological, behavioral, and biologi-
cal responses that serve to alert the individual to threat from others and internal-
ized self-generated threat (i.e., internalized stigma and/or self-criticism) (Gilbert,
2009). Although the social rank mentality can serve the adaptive function of
protecting the individual from harm, we propose that it also promotes excessive
cognitive fusion with the content of threat-focused appraisals, which leads to
rigid and avoidant patterns of responding that deprive the individual of oppor-
tunities to experience positive affect. The case will be made for supplementing
an ACT protocol with strategies that specifically aim to reduce the influence of
the social rank mentality. A vignette of an individual presenting with depres-
sion occurring in the context of psychosis will also be described. The chapter
will then describe a therapy protocol that can be used to address this important
clinical issue.
T R E AT I N G D EPR ES S I O N I N T H E C O N T E X T
O F PSYC H O S I S
Drawing on research highlighting the important role that rumination can play
in the emergence and maintenance of depression (Cribb, Moulds, & Carter,
2006; Nolen-Hoeksema, 2000; Nolen-Hoeksema, Morrow, & Fredrickson, 1993;
Watkins & Moulds, 2005), I have previously proposed that depression occur-
ring in the context of psychosis is the result of psychological and behavioral
rigidity that serves to minimize exposure to further sources of threat and/or
the possibility of being overwhelmed by levels of affect (White, 2013). In this
sense, we believe that it is inappropriate to think about “depression” as a tan-
gible entity in its own right. Instead, we propose that depression be regarded as
a process—a means to an end, rather than an end in itself. Rather than focusing
on the noun depression it might therefore be more helpful for us to consider the
verb to depress. From an ACT perspective, the principal therapeutic focus will
be the avoidant patterns of thinking, feeling, and behaving that are depressing
the individual’s capacity to engage with personally held values. This maladap-
tive attempt to minimize threat serves to also minimize opportunities to expe-
rience positive affect.
Our feasibility study of ACT for emotional dysfunction following psy-
chosis found that a significantly greater proportion of individuals receiv-
ing ACT, compared to those receiving treatment as usual, changed from
being depressed at the time of entry into the study to not being depressed at
3-month post-baseline follow-up (White et al., 2011). These results are con-
sistent with those of Gaudiano and Herbert (2006), who found a marginally
significant impact of ACT, relative to enhanced treatment as usual (TAU), on
mood as assessed by the Brief Psychiatric Rating Scale (BPRS) affect subscore.
More recently, Gaudiano, Nowlan, Brown, Epstein-Lubow, & Miller (2013)
Treating Depression in Psychosis83
conducted a trial in which 14 participants with major depressive disorder with

psychotic features were provided up to 6 months of acceptance and commit-
ment therapy. Clinically significant and persisting improvements in psycho-
social functioning and both depressive and psychotic symptoms were noted
through post-treatment follow-up. Furthermore, changes in ACT-related
processes (acceptance, mindfulness, and values) were significantly correlated
with changes in symptoms (Gaudiano et al., 2013). Building on this existing
research, we have commenced a pilot randomized controlled trial of ACT for
post-psychotic depression. This chapter will reflect on the development of a
therapy protocol for this ACT for Depression After Psychosis (ADAPT) trial
and the specific adaptations that can be made to ACT protocols that could
optimize the effectiveness of treatments for depression occurring in the con-
text of psychosis.
The development of ACT has coincided with the emergence of another inno-
vation in psychological therapy, called compassion-focused therapy (CFT;
Gilbert, 2010). ACT and CFT share some important features. For example,
both approaches place emphasis on the importance of evolutionary factors
as contributing to the maintenance of human suffering, and both approaches
stress the importance of mindful acceptance. In light of these commonalities,
it is unsurprising that there is continued dialogue between the originators
of both approaches, and that ACT and CFT have been referred to as “fellow
travelers” by the originators of the approaches. To date, however, little attempt
has been made to explore the possibility of integrating ACT and CFT proto-
cols. I believe that a strong case can be made for specifically emphasizing the
prominent role that compassion-focused work can play in addressing depres-
sion that can occur in the context of psychosis. In particular, I will present
the case for tackling depression occurring in the context of psychosis by using
an ACT framework, to help individuals develop self-compassion as a valued
life direction.
SO C I A L M EN TA L I T I ES A N D
C O M PAS S I O N - FO C U S ED T H ER A PY
Social mentality theory (Gilbert, 2001; 2005) proposes that evolutionary-derived

systems lead to the interplay between emotional, motivational, cognitive, and
behavioral processes that shape relationships between the self and others.
Social mentalities are context dependent. For example, the toning down of
positive emotion, confidence, and explorative behavior (features of the clini-
cal presentation of depression) may be adaptive when suffering a major defeat
or loss of attachment, but not under other circumstances. It is suggested that
social mentalities play an important role in appraising threat, enhancing safe-
ness, and regulating the affect associated with these evolutionary challenges
(MacBeth, Schwannauer, & Gumley, 2008). Building on the work of Panksepp
(1998), Depue and Morrone-Strupinsky (2005), and others, Gilbert (2009) has
proposed that three interacting and competing systems are responsible for reg-
ulating emotions:
1. The threat system: This is associated with threat detection and defensive

responses.
2. The drive system: This is linked to reward seeking. Dopamine has been
highlighted as an important neurotransmitter for the regulation of drive.
3. The soothing/affiliative system: The action of opiates and oxytocin appear
to be important for the experience of soothing.
Early experiences and attachment history appear to play an important role in

the maturation, organization, and preferential use of social mentalities (Chaffin
Hanson, Saunders, et al., 2006; Gilbert, 2005; 2010). Through relational expe-
riences children can construct working models of others as safe, helpful, and
supportive, which enable the individual to experience themselves as lovable and
able to internalize self-soothing and compassionate behaviors (Gillath, Shaver,
& Mikulincer, 2005; Mikulincer & Shaver, 2007). In times of managing distress,
these individuals are more likely to have an improved capacity to self-soothe.
This is referred to as the as the caring social mentality. However, experiencing
primary caregivers as abusive or neglectful will lead to children experienc-
ing fewer experiences of soothing and calming in interpersonal relationships.
Consequently, the caring social mentality may be poorly developed. In its place,
a social mentality better suited for dealing with social threats (i.e., the social rank
mentality) takes precedence and focuses individuals’ attention on the potential
power of others. When the social rank mentality is activated, “we turn our atten-
tion to our social position in a social hierarchy, to think about our relationships
in terms of hierarchies and social comparisons . . . and to behave in ways appro-
priate to hierarchies” (Gilbert, 2009, p. 108).
Research has indicated that the social rank mentality may be implicated
in the auditory hallucinations that individuals diagnosed with psycho-
sis can experience. For example, a study by Birchwood, Meaden, Trower,
Gilbert, and Plaistow (2000) concluded that the power imbalance between
an individual and the hallucinatory voice that he or she was experiencing
is associated with the appraisal that the individual makes of his or her own
social rank relative to the standing of other people generally. There is also
indirect support for the social rank mentality playing a role in the emer-
gence of depression in the context of psychosis. For example, individuals
diagnosed with psychosis who meet criteria for depression have been shown
to have greater problems in family relationships (Mino, Inoue, Shimodera,
Tanaka, Tsuda, & Yamamoto, 1998; Rocca et al., 2005); early life trauma and
stressful life events (Scheller-Gilkey, Thomas, Woolwine, & Miller, 2002;
Ventura, Nuechterlein, Subotnik, Gutkind, & Gilbert, 2000); and greater
actual experiences of stigma, particularly with respect to accessing val-
ued social roles (Angermeyer, Matschinger, & Corrigan, 2004). Stigma has
been defined as a set of culture-wide beliefs that indicate how particular
attributes of people should be judged and treated (Kurzban & Leary, 2001).
The experience of psychosis can be highly stigmatizing (Haghighat, 2001).
Individuals with psychosis can internalize this stigma and suffer shame and
reduced self-esteem (Birchwood, Mason, MacMillan, Healy, 1993, Corrigan,
1998; Corrigan & Kleinlein, 2005). Gilbert et al. (2001) have pointed out
that the threat system that has developed to infer some survival advantage
turns on itself when the individual engages in internal attacks, which trigger
subordinate defenses. It is suggested that internal interactions of this type
might play an important role in major depressive disorder and the depres-
sion experienced by individuals who hear malevolent auditory hallucina-
tions (Gilbert et al., 2001).
There is a cruel irony about the possibility that threat-focused thoughts and
emotions that may emerge through an individual’s life (and the activation of
the social rank mentality that this can trigger) may lead to the emergence of
psychosis, and that the experience of psychosis (including the symptoms and
stigmatizing societal attitudes) in turn can serve to keep the social rank men-
tality activated. We propose that it is not merely the presence of threat-focused
appraisals that precipitates the emergence of depression in the context of psy-
chosis, it is the fusion with the content of these appraisals and the chronic over-
activation of the social rank mentality that gives rise to rigid, avoidant patterns
of behaving that serve to minimize opportunities of experiencing positive affect.
We have previously argued that if this pattern of responding occurs over a suf-
ficiently long period, it can lead to a shutting down of affect in the individual to
protect against the potentially toxic effects of the chronic overactivation of the
threat system, and that this manifests itself in the form of the negative symptoms
of psychosis (White, Laithwaite, & Gilbert, 2013).
When a therapist discusses the social rank mentality (or a differently worded
version of this concept) with an individual, it is important to appreciate that
threat-focused appraisals can serve an adaptive function. For example, it may
be that awareness of personal shortcomings serves to facilitate opportunities for
self-improvement that may ultimately improve an individual’s capacity to func-
tion harmoniously with others (e.g., Heine, 2003; Heine et al., 2001; Kitayama &
Karasawa, 1997). Difficulties may, however, emerge when the social rank mental-
ity leads to overactivation of the threat system and an associated down-grading
of the soothing/affiliative mentality.
Compassion-focused therapy (CFT; Gilbert 2000, 2009, 2010) has been spe-
cifically developed to promote affiliative behavior. The approach employs com-
passionate imagery and compassion-focused exercises to tone down threat
processing by preferentially activating the soothing/affiliative mentality. From
a CFT perspective, the concept of compassion encompasses being motivated to
care, attentive to suffering, tolerant of distress, empathic toward causes of suffer-
ing, non-condemning, and mindful of experiences (Braehler, Harper, & Gilbert,
2012). Research findings suggest that CFT can stimulate positive affect and
greater social connectedness (Fredrickson, Cohn, Coffey, Pek & Finkel, 2008;
Hutcherson, Seppala & Gross, 2008).
PSYC H OS I S A N D C O M PAS S I O N - FO C U S ED T H ER A PY
Research has shown that threat processing is problematic for people with psycho-
sis (Braehler, Gumley, et al., 2012) and that threat emotions such as fear, anxiety,
and anger contribute to paranoid delusions (Freeman & Garety, 2003; Freeman
& Garety, 2004), hallucinations (Gilbert et al., 2001), and feelings of external and
internal shame (Birchwood, Trower, et al., 2007). In applying CFT to individuals
with psychosis, Gilbert and Procter (2006) demonstrated that the approach can
be used with a day-hospital population to reduce shame, self-criticism, depres-
sion, anxiety, and stress. Mayhew and Gilbert (2008) found that in a small pilot
study of three voice-hearers, compassion training significantly benefited two of
them, with the third finding it helpful but limited because he felt he did not
deserve compassion (possibly because of undisclosed shame-linked fantasies).
Specifically, auditory hallucinations became less malevolent, less persecutory,
and more reassuring. In studying potential barriers to engaging individuals with
psychosis in this work, Laithwaite et al. (2009) found that individuals who were
struggling to cope with elevated levels of positive symptoms of psychosis were
more likely to disengage from the compassion-focused intervention and were
less likely to benefit from it.
Gumley et al. (Gumley, Braehler, Laithwaite, MacBeth, & Gilbert, 2010) pro-
posed a compassion-focused model of recovery after psychosis. They suggested
that a compassion-focused approach can provide a developmentally and inter-
personally sensitive approach to promoting recovery following psychosis.
Johnson, Penn et al. (2011) used loving-kindness meditation in 18 outpatients
experiencing persistent negative symptoms. Their findings indicated that the
intervention was feasible and associated with decreased negative symptoms and
increased positive emotions and psychological recovery. More recently, Braehler,
Gumley, et al. (2012) conducted a feasibility randomized controlled trial of CFT
for psychosis. They found that CFT was deemed to be highly acceptable by those
who received it, was not associated with any adverse events, and had low attrition
rates. Relative to the TAU group, increases in compassion in the CFT group were
significantly associated with reductions in depression and in perceived social
marginalization (Braehler, Gumley, et al., 2012).
Self-Compassion
A key aim of CFT is to enhance individuals’ capacity to be self-compassionate.

Self-compassion has been defined as “being open to and moved by one’s own suf-
fering, experiencing feelings of caring and kindness toward oneself, taking an
understanding, nonjudgmental attitude toward one’s inadequacies and failures,
and recognizing that one’s experience is part of the common human experience”
(Neff, 2003a, p. 224). Neff (2003a,b) has proposed that there are three theoreti-
cal facets to self-compassion which can be represented by three sets of opposing
poles: self-kindness and self-judgment, common humanity and isolation, and
mindfulness and overidentification. In terms of exploring these different facets

of self-compassion, Van Dam, Sheppard, Forsyth, and Earleywine (2011) have
suggested that the self-kindness aspect represents an alternative to self-criticism,
self-condemnation, and ruminative thinking styles that are characteristic of
depression (see Beck, Rush, Shaw, & Emery, 1979) and other forms of psychopa-
thology (e.g., anxiety disorders; Forsyth & Eifert, 2008). The common-humanity
facet of self-compassion represents a recognition that one’s suffering does not
occur in isolation but is inherent to the nature of life and intimately related to
the suffering of others (Van Dam et al., 2011). Finally, the mindfulness facet
represents a stance of equanimity toward difficult and uncomfortable thoughts
and experiences rather than overidentification or excessive fixation (Van Dam
et al., 2011). Research conducted with Masters-level counseling psychology stu-
dents found that mindfulness-based interventions resulted in participants dem-
onstrating an improved capacity to be self-compassionate (Shapiro, Brown, &
Biegel 2007). However, it is not clear whether this is consistently the case across
different populations. It may be that some individuals (such as those diagnosed
with psychosis) derive additional benefit from the use of compassion-focused
exercises over that from mindfulness exercises alone.
Confusion can arise among therapists and individuals about the difference
between self-compassion and self-esteem. Research suggests that self-compassion
attenuates people’s reactions to negative events (involving failure, rejection,
and/or embarrassment) in distinct and potentially more beneficial ways than
self-esteem (Leary, Tate, Adams, Allen, & Hancock, 2007; Neff & Vonk, 2009).
Whereas self-compassion promotes emotional regulation, self-esteem has been
linked to self-centeredness, distorted self-perceptions, downward social com-
parisons, and aggression under conditions of ego threat (Baumeister, Campbell,
Krueger, & Vohs, 2003; Crocker & Park, 2004; Leary et al., 2007). Self-compassion
can lessen feelings of self-loathing without requiring that one adopt an unrealis-
tically positive view of oneself (Leary, Adams, & Tate, 2005). Put simply, whereas
compassion is about sensitivity to suffering, self-esteem is not. Self-esteem can
predispose people to thinking that they are only doing well if they are achieving.
Reactivating the attachment system using self-compassion may serve to
reactivate emotional memories of events that originally shut down the attach-
ment system (emotional conflicts, neglect, or abuse) (Gilbert, McEwan, Matos,
& Rivis, 2011). The reemergence of these difficulties and feelings can underpin
fears of compassion and be major blocks to recovery, especially for people with
high shame and self-criticism. This fear of self-compassion can be marked, espe-
cially if people come from low affection or abusive backgrounds (Bowlby, 1980;
Gilbert, 2007; Mikulincer & Shaver, 2007), and for those who have high levels of
self-criticism (Gilbert et al., 2011; Gilbert & Procter, 2006; Mayhew & Gilbert,
2008; Rockliff, Gilbert, McEwan, Lightman, & Glover, 2008). Gilbert and Procter
(2006) found that the fears about self-compassion experienced by a group of
chronic mental health patients were linked to doubting whether compassion
was deserved, thinking of it as a weakness, being unfamiliar with it, and simply
never considering the value of self-compassion. Other research has highlighted
that individuals may be reluctant to exercise self-compassion out of fear of being

adjudged to be self-indulgent (Neff, 2003b). An important issue to be aware of is
that feelings of warmth associated with compassion from the self and others can
activate feelings of grief from wanting but not receiving affection and care from
significant others, with an increased awareness of inner loneliness and a yearn-
ing for close and accepting, valuing relationships (Bowlby, 1980; Gilbert, 2010;
Gilbert & Proctor, 2006). It is important to take time when working to enhance
individuals’ capacity to be self-compassionate, in order to determine what the
concept of compassion means to the individual.
Research has indicated that developing therapeutic techniques to engage with
and help people resolve their fears of and resistance to compassion can have
important therapeutic effects (Gilbert & Procter, 2006; Laithwaite et al., 2009).
Gilbert (2005) proposed that self-compassion enhances well-being because it
helps individuals feel cared for, connected, and emotionally calm. Leary et al.’s
(2007) series of experimental studies showed that self-compassion was associ-
ated with lower negative emotions in the face of real, remembered, and imagined
events and with patterns of thoughts that generally facilitate people’s abilities
to cope with negative events (involving failure, rejection, and/or embarrass-
ment). Interestingly, individuals with higher levels of self-compassion more
readily accept undesirable aspects of their character and behavior than do those
with lower levels of self-compassion. Importantly, however, they do this without
obsessing over them, becoming defensive, or feeling badly (Leary et al., 2007).
Other research studies have suggested that helping people develop compas-
sion for themselves and for others has a powerful impact on not only reducing
negative affect but also promoting positive affect and psychological strengths
(Lutz, Greischar, Rawlings, Ricard, & Davidson, 2004; Neff, Kirkpatrick, &
Rude, 2007). Raque-Bogdan et al. (Raque-Bogdan, Ericson, Jackson, Martin, &
Bryan, 2011) noted that self-compassion mediated the relationship between
attachment and mental health. In a meta-analysis exploring the associations
that self-compassion has with psychopathology, MacBeth and Gumley (2012)
concluded that self-compassion is an important explanatory variable in under-
standing mental health and resilience. The authors note, however, that the cur-
rent evidence does not permit definitive conclusions to be made about the causal
relationship between self-compassion and psychopathology; it may be that lower
levels of psychopathology lead to higher levels of self-compassion. Longitudinal
data sets on changes in self-compassion over time and/or across treatment are
urgently required (MacBeth & Gumley, 2012).
We recently conducted a study investigating correlates of depression in
individuals diagnosed with schizophrenia (Gumley et al., in press). The study
recruited individuals from a secondary-care mental health service in Glasgow.
The findings indicated that Self Compassion Scale (SCS; Neff, 2003) total scores
had highly significant negative correlations with the psychological flexibility
as assessed by the Acceptance and Action Questionnaire (AAQ-II; Bond et al.,
2011), the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith,
1983) Anxiety and Depression subscales, the Calgary Depression Scale for
Schizophrenia (CDSS; Addington, Addington, & Maticka-Tyndale, 1993), and

the Hated-Self subscale of the Forms of Self-criticism/attacking Reassurance
Scale (Gilbert, Clark, Hempel, Miles, & Irons, 2004). Those individuals diag-
nosed with schizophrenia who had clinically important levels of depression, rel-
ative to those who did not, had significantly lower levels of both self-compassion
(as assessed by the SCS) and psychological flexibility (as assessed by the AAQ-II)
(Gumley et al., in press).
I N T EG R AT I N G C F T A PPR OAC H ES I N TO ACT
In light of the prominent role that the process of fusing with the content of rumi-
native thought patterns might play in the emergence of depression experienced
by those with psychosis, we propose that various facets of self-compassion can
serve to undermine the influence of threat-focused appraisals (including nega-
tive self-cognitions) and the behavioral rigidity that can stem from these. These
processes overlap with and are complementary to those advocated by ACT theo-
rists and practitioners. In particular, the explicit focus that ACT places on values
exploration and on the importance of engaging in action consistent with these
values provides an opportunity to allocate an explicit focus on self-compassion.
ACT uses acceptance-based approaches to help optimize individuals’ capacity
to notice the content of their cognitions without getting caught up in reacting to
these cognitions. ACT protocols tend to incorporate exercises aimed at enhanc-
ing mindful acceptance, highlighting conceptual overlap between ACT and
mindfulness-based approaches (such as mindfulness-based cognitive therapy;
MBCT). Mindfulness has been defined as a state of nonjudgmental awareness
that involves the clear seeing and acceptance of mental and emotional phenom-
ena as they arise in the present moment (Baer, 2003). Researchers and theorists
have also sought to explore the relationship between compassion-focused strat-
egies and mindfulness. As mentioned previously, the SCS has a subscale that
assesses mindfulness ability. From a traditional mindfulness perspective, com-
passion is considered to be “a kind of pilot light for the other virtues” (Rosch,
2007, p. 260). It has been suggested that mindful objectivity helps provide the
right amount of distance from one’s emotions so that self-compassion might
be feasible (Neff, Kirkpatrick, & Rude, 2007). In this sense, mindfulness is an
important starting point in that it facilitates individuals to notice the tendency
to have threat-focused thoughts and feelings and the suffering that can be asso-
ciated with this. Research evidence suggests that self-compassion can be devel-
oped indirectly through mindfulness practice (e.g., Shapiro, Astin, Bishop, &
Cordova, 2005; Shapiro, Brown, & Biegel, 2007). Both mindfulness and
self-compassion skills have been identified as potentially important processes
of change in the reduction of depression and anxiety. For example, Kuyken et al.
(2010) reported that both self-compassion and mindfulness mediated the effect
of MBCT for depression, with increased self-compassion during treatment
significantly associated with lower depressive symptoms at follow-up. Shapiro
et al. (2005) demonstrated that self-compassion mediated reductions in stress

associated with a mindfulness-based stress reduction program. More recently,
Van Dam at al. (2011) have suggested that, relative to dispositional mindfulness
as measured by the Mindfulness Attention Awareness Scale (MAAS; Brown &
Ryan, 2003), self-compassion (as measured by the SCS) is a more robust predic-
tor of depressive and anxious symptomatology and quality of life. So, although
mindfulness can help free us from the yoke of our busy minds, it is also impor-
tant for the heart to be involved through the adoption of a compassionate mode
of mind. In this sense, mindfulness is a necessary but not sufficient process
for enhancing mental health and well-being. A “compass” analogy can be
used to elaborate on this point: mindfulness skills (like the needle on a com-
pass) can help to orientate individuals to a particular point (i.e., the present
moment), but the orientation of a compass needle is not much use if there are
no bearings marked on the compass. Compassion can represent an important
compass-bearing that serves to help individuals orientate to how they are going
to progress in their journey.
VIGNET TE
Ben is a 42-year-old man. His first psychotic episode occurred when he was 31,
in the context of a number of life problems. He had lost his father 14 months
before. He was employed in two stressful jobs and was getting very little sleep.
He felt irritable and strained, and was taking recreational drugs from time
to time to relax and “blow off steam,” which led to some tension and argu-
ments with friends and family. He lost his day job after an argument with his
employer and became reliant on working night shifts for his source of income.
As a result, he spent very little time with family and friends and began to feel
quite isolated. His first episode of psychosis lasted for 6 weeks and he was hos-
pitalized for a month during this time. He has been hospitalized on two other
occasions over the past 10 years when he was unable to cope with the voices
he was hearing and began responding to them. He has been taking different
combinations and dosages of antipsychotic medications since that time and
now also takes antidepressants. Ben continues to hear voices that narrate his
behavior and are sometimes very critical of him, but he feels that he is better at
dealing with them now.
Ben currently has a good relationship with his mother and sister and visits
his mother every week. However, he feels uncomfortable meeting new people
and being in more crowded places. Although he has attempted to join walking
groups and other group activities as recommended by his occupational therapist,
he usually only attends on one or two occasions before he stops going. He worries
about the voices commenting on the people in the group and is anxious that oth-
ers might be able to hear what the voices say about them. He spends a lot of time
alone. He likes to play guitar and to write short stories but feels unable to do this
at times because he believes that the voices prevent him from doing so. He would
like to go back to work but fears that he will be distracted by the voices and that
he will have problems making friends with colleagues. He worries about disclos-
ing his illness to others and what they will think of him.
Ben is usually quite critical of himself. He often feels worthless compared to
others and feels that other people are doing much better than him in general. He
finds it difficult to be kind to himself and is frustrated by his lack of friends and
opportunities. He has said that he feels guilty about not working, on a number
of occasions. He reports that his life has become the same pattern of sleeping,
plodding through the day, and waiting to go to bed. He often feels low and dis-
heartened and that he is physically and mentally slowed down. He feels that he
does not have a future, and when he feels particularly sad, he can start to feel
suicidal—although he has made no plans or attempts to end his life. At times he
can feel very overwhelmed by feelings of entrapment and loss.
T R E AT M EN T PR OTO C O L
White (2013) outlined a protocol for treating emotional dysfunction following

psychosis. This protocol has been developed further with the commencement of
the ADAPT trial, which focuses specifically on treating depression occurring in
the context of psychosis. In this protocol, individuals receive up to 5 months (20
sessions) of individual ACT for depression in psychosis (ACTdp). The aims of the
ACTdp therapy protocol are to identify threat-focused appraisals; highlight how
attempts to avoid these appraisals can paradoxically increase their frequency;
develop individuals’ ability to accept appraisals rather than get caught up react-
ing to them; facilitate understanding about how distress can inform personally
held values; explore valued life domains; and help individuals to commit to
behaviors consistent with these valued life domains.
The compassionate mode of mind can be diametrically contrasted with
the mode of mind that individuals with psychosis adopt when they are expe-
riencing threat-focused appraisals. Mary Welford’s (2013) book, The Power of
Self-Compassion, is an excellent resource that provides practical skills and
techniques for enhancing individuals’ capacity to be more self-compassionate.
A number of these techniques have been incorporated into the ACTdp pro-
tocol. A key role of the therapist is to create a safe and sensitive interpersonal
environment (Gilbert, 2010). By adopting characteristics such as being warm,
empathic, open, and nonjudgmental, therapists can model compassion to clients.
Therapists should compassionately acknowledge the functionality of the client’s
coping strategies as their best attempt to deal with the suffering that they have
been experiencing. Therapists and recipients of therapy alike should be careful
not to view threat-focused appraisals as something to be avoided or eliminated.
The emphasis is instead on helping the individual understand why he or she gets
drawn into relating so much to the content of these appraisals.
The ACTdp therapy protocol is divided into three broad phases (see Table 5.1
for a summary).
Table 5.1. Summary of ACT for Depression after Psychosis (ACTdp) Protocol
Phase Focus of Therapy

Phase 1 Socialization to the model, assessment, and formulation (Sessions 1–4)
• Reflecting on how being sensitive to sources of threat can be functional.
Discussions also explore the life-limiting effect that avoidant strategies can have
in valued life domains.
• Using the matrix approach to gather and organize relevant information about
the individual’s life. This information can be used to populate the four quadrants
of the matrix:
• Threat-focused appraisals and emotions including aspects of the experience of
psychosis (i.e., sources of threat)
• Strategies the individual has employed to combat these difficulties (i.e.,
attempts to resolve threat)
• Themes and principles that guide the individual’s behavior (values)
• Goals that the person can work toward that are consistent with these values
(valued action)
• The completed matrix represents a diagrammatic formulation that is shared with
the individual and modified over the course of treatment.
• The rationale for treatment focuses on the tension between struggling to move
away from threat on the one hand and moving toward a valued and meaningful
life on the other.
Phase 2 Progressing with the ACT intervention (Sessions 5–15)
• The individual is supported to adopt a nonjudgmental curiosity about threat-focused
appraisals (including critical self-cognitions) and bring a quality of self-kindness to
committing to behaviors that are consistent with valued life domains.
• Mindful acceptance: Mindfulness exercises are used to develop the individual’s
capacity to show up to distressing thoughts and emotions without getting caught
up in reacting to them or trying to avoid them.
• Defusion: Strategies are used to help reduce the extent to which individuals relate
to the verbal content of their thoughts.
• Introducing the compassionate mode of mind: Helping the individual to bring an
attitude of warmth and kindness to how he or she relates to the self.
• Understanding the function of threat-focused appraisals: Exploring how the
distress that individuals experience in life can communicate to us what it is
important (their values).
• Valued life direction: Clarifying valued life directions that can help promote
wellness (e.g., being self-compassionate, being able to support others, feeling
relaxed and refreshed, being creative). Emphasis is placed on supporting the
person to engage in behaviors consistent with these particular values.
Phase 3 Looking to beyond the ACT intervention (Sessions 16–20)
• Reviewing completed work and preparing the individual for the end of therapy.
Individuals may wish to have a friend or family member present during these
sessions. This will help promote a shared understanding of values-consistent
goals that they has identified.
• Linking the individual to organizations or groups in the community that are
consistent with his or her values and areas of interest.
Phase 1: Socialization to the Model, Assessment

and Formulation (Sessions 1–4)
In socializing individuals to the ACTdp intervention, it is important for thera-

pists to emphasize how functional it is for human beings to be sensitive to threat.
Explaining how this has been beneficial for the evolution of humankind will help
validate the individual’s attention to threat in a way that promotes a normalizing,
shared-humanity perspective on these experiences. Discussions with the individ-
ual should highlight that psychosis is an experience that can be characterized by a
sense of ongoing threat. For example, an individual might be experiencing ongo-
ing residual positive symptoms (malevolent hallucinatory voices or delusions) that
promote a sense of threat; have distressing memories of previous symptoms and/or
aspects of their treatment; feel stigmatized by the diagnosis they have been given;
or have self-critical thoughts about their perceived inability to cope. The thera-
pist should empathize with the individual’s attempts to minimize or avoid these
threats. The focus of the discussions should not be on the individual being broken
but instead on how he or she got stuck in avoidant patterns of responding to threat.
The possibility should be explored that avoidant patterns of responding may not
be the most workable for the individual living a life that feels vital and fulfilling.
In socializing individuals to the intervention, it is also important to touch on the
power of human language. Consistent with the focus on human evolution, discus-
sions can highlight how human language developed as a way to promote coopera-
tion between humans, which enabled collaborative efforts to respond to sources
of threat. The individual should, however, be helped to see that problems can arise
when language is applied to the self in the form of judgmental self-categorizations
(i.e., self-criticism). These categorizations may be particularly prominent in those
who have been subjected to high levels of interpersonal threat during their lives,
where the critical language of others was internalized. In such circumstances, this
internalized verbal content (in the form of self-critical thoughts) can itself become
a source of threat. Essentially, the therapist’s aim is to convey the cruel irony that,
on the one hand, language has provided us with incredible capacities for solving
problems while, on the other hand, it can also lead to individuals seeing them-
selves as a problem to solve. The therapist should highlight to the individual that
self-criticism will be a particular focus of the intervention, and that together they
will explore alternative ways of responding to threats of this type that do not
involve avoidance. Self-compassion can be introduced as an alternative mode of
mind that involves employing strength and courage as the individual works to be
sensitive to, and tolerate, his or her distress and that of others.
An amended version of the matrix approach (see Figure 5.1), originally devel-
oped by Kevin Polk and colleagues (Polk, Hambright, & Webster, 2009; http://
drkevinpolk.blogspot.com/), can be used to explain the rationale for the ACTdp
intervention to participants. The matrix is formed from two axes (one distin-
guishing between five-sense experience and inner experience, the other distin-
guishing between threat and valued life direction). The matrix is divided into
four quadrants (see Figure 5.1) that can be used as points of focus during the
assessment process:
• Difficult thoughts and emotions related to the experience of psychosis

(Sources of threat)
• Strategies that the individual has employed to combat these difficulties
(Attempts to resolve threat)
• Themes and principles that guide the individuals behavior (Values)
• Goals that the person can work towards that are consistent with these
values (Committed action).
Our amended version of the matrix places particular emphasis on the role
that sources of threat in individuals’ lives can play in the formulation. As
Birchwood, Iqbal, et al. (2000) highlighted, appraisals related to themes such as
loss, entrapment, and humiliation are important potential sources of threat. To
elicit information about threat-related stressors, to continue with our vignette,
Ben should be encouraged to reflect on a recent occasion when he experienced
a strong emotion such as sadness, anxiety, or anger. He should then be asked to
describe what thoughts he was having at that time about himself, other people,
and the future.
Over the course of the assessment phase, relevant information is added to each
of the four quadrants of the ACT matrix. This will culminate in the completion
of a diagrammatic representation of the individual’s formulation. The matrix
helps to highlight the tension that exists between struggling to move away from
Five Sense Experience
Attempts to resolve
Committed action
threat
Threat Valued Life

Direction
Sources of threat Values
Inner Experience
Figure 5.1. The Matrix (Adapted from Polk, Hambright, & Webster, 2009).
threat on the one hand and moving toward a valued life direction on the other.
Ben should be encouraged to understand ACTdp as an approach aimed at facili-
tating him to shift from trying to avoid threat (on the left of the diagram in
Figure 5.1) to moving toward his valued life direction (on the right of the dia-
gram in Figure 5.1).
Phase 2: Progressing with the ACT Intervention (Sessions 5–15)
Showing up to Distress
Over the course of therapy, an important issue will be to address Ben’s avoidant
patterns of behavior by supporting him to show up to his distress. The therapist
should compassionately empathize with Ben’s attempts to avoid threat, while
simultaneously working with him to explore the life-limiting effect that avoid-
ance has had on his ability to pursue valued life domains. This phase of the
intervention permits a specific focus on threat-focused appraisals (i.e., critical
thoughts that Ben has about himself, his experience of psychosis and how other
people see him). Ben should be supported to (a) engage with these threat-focused
appraisals in a step-by-step way and (b) develop an empathic understanding
about the maladaptive function that these threat appraisals may serve. Helping
Ben to physicalize and embody the experience of this threat is a key strategy for
promoting acceptance of the emotional experience that can accompany these
appraisals.
Mindful Acceptance
Mindfulness exercises are an important way of supporting Ben to show up to
and explore his distress. Ben can be helped to develop his capacity to notice dif-
ficult thoughts and emotions without getting caught up in reacting to them or
struggling to avoid them. The practice of allowing distressing thoughts to come
and go while simultaneously bringing awareness back to the sensations of the
breath through mindfulness exercises has been shown to be safe and acceptable
for individuals with psychosis (Chadwick, Hughes, Russell, Russell, & Dagnan,
2009; White et al., 2011).
Defusion
Once Ben has started to explore in greater depth the threat-focused appraisals
and associated emotions, this can create a context for relating to these experi-
ences in a different way. Defusion is a process that helps individuals to notice
that they can have thoughts without necessarily getting caught up in reacting
to the content of these thoughts (Hayes, Strosahl, & Wilson, 2011). An example
of a defusion exercise is the mind check analogy. For this exercise, Ben is invited
to hold a particular threat-focused appraisal that he has recently experienced in
his mind. He is asked to buy into that thought for a moment. He is then asked
to imagine that he has typed this thought as a sentence into word-processing
software so that it now appears on a computer screen. Similar to how the

spell-check function of word-processing packages places a red zig-zag line
under incorrectly spelled words, Ben is then asked to imagine that a purple
zig-zag line appears underneath the sentence he typed on the screen. This pur-
ple zig-zag line represents mind-check. Through mind-checking, Ben can learn
that it is his mind generating this appraisal and that appraisals are not facts.
Introducing the Individual to the Compassionate Mode of Mind

The rationale for the use of compassionate mind strategies in the protocol can be
justified as an attempt to develop a more balanced set of feelings by choosing to
cultivate compassion, which serves to activate the soothing/affiliation mentality
while simultaneously reducing the influence of the social rank mentality. Citing
the work of Paul Gilbert, Welford (2013) highlighted six qualities of compassion
that can be enhanced in individuals: care for well-being, sensitivity to distress,
sympathy, empathy, nonjudgment, and distress tolerance. When discussing the
concept of compassion with Ben, it will be important to emphasize that adopting
a compassionate mode of mind takes both training and practice.
Both Kristin Neff and Paul Gilbert have emphasized the importance of using
touch and speech to reinforce the compassionate mode of mind. So, for example,
Ben might adopt a self-compassionate posture such as placing a hand over his
heart. He should be encouraged to connect with the feeling of his heart while
saying a phrase such as, “This is really hard right now. Suffering is part of human
life, may I be kind to myself in this moment, may I give myself compassion.” It
has been suggested that practices such as this can be as useful for developing a
compassionate mode of mind as more formal meditation techniques. The follow-
ing exercises provide examples of compassionate mind strategies that could be
integrated into the ACTdp protocol.
Exercise 1
The aim of this exercise (adapted from Welford, 2013) is to help individuals
exercise acceptance by exploring the quality of the self-critical attitude that
they can adopt.
The individual should be encouraged to think about a recent situation
when they were being self-critical. They should be asked the following ques-
tions: (1) If the self-critical thoughts took on the appearance of an actual
person, what would that person look like? (2) What would the facial expres-
sion be like? (3) Does this person seem to be physically bigger or smaller than
you? (4) Describe their tone of voice. (5) What posture does this person seem
to be adopting? (6) What emotions is this person directing at you? (7) Does
this remind you of anyone?
Exercise 2
The aim of this exercise is to help individuals connect with their body,
become playful with facial expressions, and speak in a kind voice to
themselves. Through the exercise the individual begins to appreciate that

the mind and body are linked.
The individual should be encouraged to notice the breath and to allow the
breathing to slow a little. This has the effect of engaging the parasympa-
thetic nervous system. The individual should be advised to notice five or six
breaths. This will help calm the person down and become centered in the
body. With each out breath the individual should be encouraged to focus
on the words “slowing down.” The individual should then be instructed to
adopt a neutral facial expression for five or six breaths. The person should
then adopt a friendly facial expression. Imagining being with someone he
or she cares about can be helpful for this. The person should then revert
back to a neutral face, before returning to a friendly face (the duration of
each phase should again be five or six breaths). The exercise culminates
with the individual saying hello to themselves on the out-breath in the neu-
tral face, and then repeating this for five or six voices with a kind voice.
Encouraging the person to elaborate on how the kind voice would sound
(tone, content, volume) can be helpful. The exercise concludes with the
individual being asked to notice his or her emotions and thoughts with a
curious, welcoming, kind attitude. If people notice distress or pain, they
are invited to ask themselves what is the kindest thing they could do for
themselves at that point.
Exercise 3
The aim of this exercise is to explore potential fears that individuals might
have about being self-compassionate (adapted from Welford, 2013).
Individuals should be encouraged to imagine for a moment that they could
take away their self-criticism. They should be asked the following ques-
tions: (1) Do you have any fears or worries about giving up your self-criti-
cism? (2) What do you think might happen if you were to let it go? (3) How
much do you genuinely think that your self-critic has your best interests at
heart? (4) Does the critic really care about you and want you to do well? (5) If
your self-critic does have your self-interests at heart, is it going about it the
right way?
Utilizing subtle shifts in perspective during guided exercises (as is advo-

cated by the deictic framing strategies espoused in relational frame theory
[Hayes, Barnes -Holmes, & Roche, 2001] and by ACT practitioners) can also
be effective for helping individuals access the compassionate mode of mind.
For example, Ben might be guided to imagine a child coming to him express-
ing the types of threat-focused appraisals that he had been experiencing. How
would he react? Would he react unfavorably or aggressively toward the child
because of this? An alternative way of switching perspectives that is used in
compassion-focused approaches is to generate an imagined ideal compassion-
ate entity, or perfect nurturer (Lee, 2005). This would involve Ben describing
in detail what his ideal compassionate entity would look like, how it would
sound, and the things that it would say to bring comfort to him. He would
be encouraged to bring this imagined entity to mind when he was feeling
elevated levels of threat.
Understanding the Function of Threat-Focused Appraisals

Appraisals related to themes such as loss, entrapment, and humiliation are spe-
cifically addressed during this phase. Ben will be supported to understand how
these threat appraisals trigger the social rank mentality. The therapist can help
Ben understand that his preoccupation with particular themes is potentially a
messenger communicating to him how much he values having a future that will
afford him the opportunity to live a full and meaningful life. Rather than strug-
gling to avoid threat-focused appraisals that relate primarily to aspects of mental
illness, Ben should be supported to explore ways in which he can work toward
optimizing mental wellness (e.g., being able to help and support others, feeling
relaxed and refreshed, being creative). This is a valued life direction that is shared
by the vast majority of people and is a unifying, non-stigmatizing approach that
enhances feelings of affiliation with others rather than feelings of being dif-
ferent from others. This serves to bolster the common-humanity aspect of the
self-compassion work.
Valued Life Direction

As individuals explore valued life directions, it is inevitable that threat-focused
appraisals will emerge when individuals consider the possibility of commit-
ting to action that is consistent with these values. In this context, White
(2013) highlighted the inextricable link that exists between suffering and val-
ues. Optimizing individuals’ capacity to be self-compassionate may serve to
enhance their capacity to be open to experiencing the sense of vulnerabil-
ity that can emerge when attempting to commit to behaviors consistent with
their values. For this reason, it is important to discuss the possibility of the
individual working to promote self-compassion as a valued life direction in its
own right. Individuals should be encouraged to consider the possibility that
our suffering provides important insights into what it is that we care about.
Discussions with Ben might explore the risk that in making our suffering our
enemy, we by default also make our capacity to care our enemy. Ben should
be supported to consider the possibility that vulnerability is the bridge that
links suffering and values. This can help create a context in which he can build
a willingness to lean into this suffering, so that he might better understand
what it is he values. The therapy can then center on supporting Ben to use
self-compassion as he works toward engaging in behaviors consistent with his
values.
Welford (2013, p. 212) outlined a particular exercise that can be used to pre-
pare individuals for what she terms compassionate behavioral experiments. This
exercise involves a worksheet on which individuals are encouraged to state the
valued action they are going to commit to (e.g., going to a walking group for the
first time); things they can do to prepare for this and potential obstacles that
might arise; steps they can take to negotiate these obstacles; things that would be
helpful for them to remember just before and during performance of the valued
action; and compassionate messages that the individual can say to themselves
before, during, and after completion of the action. It is believed that using com-
passionate mind strategies to activate the soothing/faciliatory mentality in this
way will reduce fusion with threat-focused appraisals and increase the likeli-
hood of the individual engaging in valued action.
Phase 3: Looking to Beyond the ACT Intervention

(Sessions 16–20)
This phase of treatment provides an opportunity to review the work completed

during therapy and prepare the client, in this case Ben, for the end of therapy.
The therapist and Ben will work together to prepare a written summary of the
work completed. Writing a compassionate letter to oneself has been shown to
improve coping with life events and reduce depression (Leary et al., 2007). In the
letter, Ben could be encouraged to reflect compassionately on how the agenda
of his life has been set by struggles to avoid threat. The letter can highlight how
these struggles have affected his capacity to move toward his values. Finally,
the letter can compassionately deal with worries and fears that may arise as he
considers committing to action that is consistent with his life values. Welford
(2013) provides further information about the process of writing a compassion-
ate letter.
During this phase of the intervention, the therapist should ask Ben if he would
like to have a friend or a family member present during the sessions. In hearing
a review of the work that the therapist and Ben have completed together, the
individual can help support Ben to use ACTdp strategies in order to engage in
value-consistent behavior after the completion of the therapy sessions. Liaising
with community organizations and vocational programs can also be invaluable
for helping Ben to identify goals in various activities he values, such as music,
physical exercise, and gardening.
R EFL ECT I O N S O N T H E B EN EFI TS O F I N T EG R AT I N G

C O M PAS S I O N - FO C U S ED T EC H N I Q U ES I N TO ACT
Throughout the course of this chapter I have sought to emphasize the benefits
of integrating compassion-focused techniques into an ACT protocol over those
from using either approach on its own. Although adopting a compassionate stance
is an implicit part of being an ACT therapist, traditionally there has not been
an explicit focus on enhancing the level of self-compassion experienced by the
individual receiving the therapy. By integrating compassion-focused techniques
into ACT protocols, it may be possible to foster a particular quality of action
that individuals can bring to values-consistent behaviors. For example, individu-

als can be supported to interact lovingly with significant others in their lives,
or react more kindly to worries they might experience. On the other hand, the
functional pragmatism of ACT can bring added value to a compassion-focused
approach. For example, for individuals who report high levels of self-criticism,
willingness to change can be built by exploring the longer term workability of
self-criticism. It may be pertinent to ask individuals to reflect on whether they
can in effect “hate themselves happier.”
Some caution is warranted, however, when integrating compassion-focused
techniques into ACT protocols. It is important to watch for individuals using
strategies aimed at enhancing self-compassion as a form of avoidant coping.
Efforts to enhance self-compassion should never supersede or replace mind-
ful exploration and acceptance of threat-focused appraisals. Instead, boost-
ing self-compassion should be seen as an opportunity to bring an attitude
of warmth and kindness to efforts to engage in behaviors consistent with
one’s values. In this sense, enhancing self-compassion is a disposition that
enhances the capacity to stay present with the fear, anxiety, and doubt that
might arise as the individual engages in behaviors consistent with other val-
ued life domains.
Meta-analytic reviews have reported that higher levels of self-compassion

(MacBeth & Gumley, 2012) and psychological flexibility (Levin, Hildebrandt,
Lillis, & Hayes, 2012) are associated with lower levels of symptoms across a range
of mental health difficulties. Feasibility studies using randomized controlled
trial methodologies have indicated that ACT and CFT offer hope for treating
depression occurring in the context of psychosis (Braehler, Gumley, et al., 2012;
White et al., 2011). However, the sample sizes recruited to these trials were small.
Consequently, further large-scale randomized controlled trials of these inter-
ventions are required.
In general, there is a need for research to investigate how individuals
diagnosed with psychosis describe the experience of engaging in strategies
aimed at enhancing self-compassion. Previous research has shown that
compassion-focused exercises are acceptable to individuals diagnosed with
psychosis (Braehler, Gumley, et al., 2012; Laithwaite et al., 2009), but further
research employing qualitative methodologies is required, to help provide
information regarding specific barriers and facilitation to the experience of
self-compassion in the context of psychosis.
This chapter has proposed that integrating compassion-focused approaches
into ACT protocols is particularly beneficial to treating depression in the con-
text of psychosis. This claim is based on the assertion that distress and avoidant
behaviors associated with threat-focused appraisals can be reduced through
efforts to increase levels of (1) psychological flexibility and (2) self-compassion.
The possibility of an interaction between these theoretically distinct potential

mechanisms of change for depression is an interesting area for future research.
In particular, it may be advantageous for research efforts to focus on devel-
oping an assessment tool specifically tailored to assess the extent to which
individuals can be psychologically flexible to uncompassionate and unsympa-
thetic appraisals. The Acceptance and Action Questionnaire (AAQ-II; Bond
et al., 2011) represents a general measure of psychological flexibility, which
may lack sensitivity for use in certain clinical populations. It is likely that a
measure that focuses instead on assessing psychological flexibility in relation
to uncompassionate and unsympathetic appraisals would have particular rel-
evance for various forms of mental health difficulties including depression,
psychosis, and eating disorders.
Moving forward, it will be important to determine the comparative strength
of potential mechanisms of change for treating depression in the context of psy-
chosis. This will be hugely important for the refinement and development of psy-
chotherapy aimed at bringing about optimal change in depression occurring in
the context of psychosis. To investigate the relative importance of psychological
flexibility and compassion-focused interventions, component analysis research
could be conducted to isolate and compare the efficacy of ACT vs. CFT strat-
egies for reducing levels of depression. Crossover designs could be employed
to vary the phasing of particular intervention strategies to determine whether
self-compassion or psychological flexibility exerts the greatest influence on levels
of depression.
This chapter has proposed that the integration of compassion-focused
strategies into ACT protocols can be helpful for treating depression occur-
ring in the context of psychosis. However, it is possible that this integration
may also be useful for alleviating distress associated with other aspects of
the experience of psychosis, including hallucinatory voices and delusional
beliefs. Clinical trials are required to investigate how changes in the capacity
to be self-compassionate or, indeed, how changes in the ability to be psycho-
logically flexible in response to threat-focused appraisals are associated with
changes in distress and believability associated with hallucinatory voices or
delusional beliefs.
Over the course of this chapter I have described how fusion with threat-focused
appraisals experienced by individuals with psychosis can lead to the chronic
overactivation of the social rank mentality that serves to limit the willingness
of individuals to engage in values-consistent and potentially mood-elevating
behavior. We have presented a case for integrating compassion-focused strategies
into ACT protocols to help individuals defuse from threat-focused appraisals
and increase the likelihood of committing to valued action. We have described
how compassion-focused strategies can be incorporated into an ACT protocol.
We believe these approaches are compatible and that this integration infers
advantages over using either of these approaches in isolation. Future longitudi-
nal research should explore the potential role that processes like self-compassion
(as well as other associated indices of the soothing/affiliative mentality) play in
bringing about shifts in the distress experienced by individuals with psycho-
sis. Preliminary investigations into this issue have been promising (see Braehler,
Gumley, et al., 2012). Future clinical trials investigating ACT intervention for
depression would also benefit from including measures of self-compassion as a
potential process of change measure.
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6
Acceptance-Based CBT for

Command Hallucinations
Rationale, Implementation, and
Outcomes of the TORCH Project
FRANCES SHAW YER AND JOHN FARHALL ■
BAC KG R O U N D A N D R AT I O N A L E
Auditory hallucinations (AHs), often experienced as “voices,” are heterogeneous

experiences that can occur across a wide variety of conditions and illnesses.
Although most commonly associated with schizophrenia, they can also occur in
psychiatrically and medically well individuals in the general population, where
the experience is usually transient with benign content (Barrett & Caylor, 1998;
Choong, Hunter, & Woodruff, 2007; Gierlicz, 1998; Grimby, 1993; Junginger &
Frame, 1985; Mott, Small, & Anderson, 1965; Posey & Losch, 1983–1984).
Exclusively positive voices are experienced by some individuals with a diagno-
sis of schizophrenia; however, these occur only in a minority of cases (Sanjuan,
Gonzalez, Aguilar, Leal, & van Os, 2004). For example, surveys of AHs in people
with schizophrenia typically find that voices are described as predominantly
negative, distressing (Carter, Mackinnon, & Copolov, 1996; Close & Garety, 1998;
Copolov, Mackinnon, & Trauer, 2004; Johns, 2002; Oulis, Mavreas, Mamounas, &
Stefanis, 1995), and subjectively powerful (Chadwick & Birchwood, 1994; Close &
Garety, 1998).
Auditory hallucinations occur in over two-thirds of individuals with a diag-
nosis of schizophrenia. Roughly half of such individuals will have command
hallucinations (CHs), that is, voices that direct them to perform particular
actions (Shawyer, Mackinnon, Farhall, Trauer, & Copolov, 2003). Command
hallucinations are a particularly stressful form of AH (Mackinnon, Copolov, &
Acceptance-Based CBT for Command Hallucinations109
Trauer, 2004), and individuals with psychotic disorders who experience them
often feel under a powerful obligation to carry out the commands, sometimes
with devastating consequences to either themselves or others. The personal and
social costs of complying with CHs—especially harmful CHs—have been well
documented. Numerous case studies indicate that CHs can be an important
factor in many seriously destructive behaviors (Friedman, Hrouda, Holden,
Noffsinger, & Resnick, 2005; Mancinelli et al., 2004; Manfredi et al., 2010;
Ozan, Deveci, Oral, Yazici, & Kirpinar, 2010; Sarkar & Barhara, 2012), and
controlled investigations have found harmful CHs to be a significant predictor
of violent behavior toward self (P. Rogers, Watt, Gray, MacCulloch, & Gournay,
2002) and others (Green, Schramm, Chiu, McVie, & Hay, 2009; McNeil, Eisner, &
Binder, 2000).
The problem of CHs is not restricted to acts of compliance. There is evidence
to suggest that the pressure to comply with CHs produces distress that is addi-
tional to that of the mental illness or the AHs alone. Rogers, Gillis, Turner,
and Frise-Smith (1990) found that the content of AHs in a group of people
with CHs (n = 25) was more aggressive and self-punishing than that of a com-
parison group with non-command AHs (n = 24). Those experiencing CHs also
showed more dependency on their hallucinations and had a greater sense of
helplessness. Romme, Honig, Noorthoorn, and Escher (1992) reported that
voice hearers who said that they coped poorly with their voices were more
likely to experience CHs than those who said they coped well (62% vs. 26%).
As part of previous work investigating AHs, some members of our team ear-
lier compared the phenomenology of hallucinations with and without CHs,
using the Mental Health Unusual Perceptions Scale (MUPS). The MUPS is
a semi-structured interview that investigates many aspects of AHs (Carter
et al., 1996; Carter, Mackinnon, Howard, Zeegers, & Copolov, 1995). Using
this instrument our colleagues interviewed 199 patients with AHs, including
47 who never heard CHs and 130 who reported CHs “sometimes” or “often.”
They found that, compared to those experiencing non-command AHs, indi-
viduals who heard CHs described their AHs more negatively, felt more con-
trolled by them, and reported greater distress and worry about their voices.
Participants also used more coping methods—a finding typically associated
with more severe AHs (Escher, Delespaul, Romme, Buiks, & van os, 2003;
Falloon & Talbot, 1981; O’Sullivan, 1994)—reflecting the high emotional
impact of CHs and greater personal burden associated with them (Mackinnon
et al., 2004). Although conventional treatments, including pharmacotherapy,
are valuable in the treatment of psychoses, a significant minority of patients
remain symptomatic.
Treatment of resistant command hallucinations (TORCH) is a psychologi-
cal treatment developed to assist people to better manage problematic CHs.
Like others (Linehan, 1993; Segal, Williams, & Teasdale, 2002, 2013), we
attempted to integrate the newer acceptance-based approaches with traditional
cognitive-behavioral therapy (CBT), which has demonstrated but limited effi-
cacy in treating psychosis. In our own work (Farhall & Gehrke, 1997; Farhall &
Voudouris, 1996) and in the AH literature more broadly (e.g., Cohen & Berk,
1985; Romme & Escher, 1989), the theme of “accepting voices” has been a persis-
tent and intriguing indicator of better coping and adaptation to voices for many
years. There has lacked, however, a clear and well-validated technology for how
this could be developed. So, although TORCH was initially designed within a
CBT framework (Shawyer et al., 2003), when the first paper describing acceptance
and commitment therapy (ACT) for psychosis was published, describing very
encouraging outcomes (Bach & Hayes, 2002), we immediately saw the promise
therein. Taking up the authors’ recommendation to try to integrate acceptance
procedures into other comprehensive packages of CBT, we undertook training in
ACT and mindfulness and incorporated these methods into TORCH.
In this chapter we present in detail the particular problems associated with
the common responses of individuals to their CHs and why, theoretically, we
expected that an acceptance-based CBT intervention would be a particularly
helpful adjunct to CBT in addressing these problems. We then describe the
TORCH trial and consider, in the absence of clear superiority to a comparison
treatment that did not contain elements of our acceptance-based CBT pro-
tocol, why the promise was not realized as expected. Finally, we discuss the
direction the work has taken us, consider broader issues of evaluation in rela-
tion to ACT for psychosis, and suggest potentially fruitful avenues of research
for the future.
C O G N I T I V E M O D ELS
Cognitive models have proven to be a fruitful source of therapeutic innova-

tion for many years. In 1994, Chadwick and Birchwood published a cogni-
tive model for the maintenance of auditory and command hallucinations,
proposing that the reactions of individuals to hearing voices is linked not
just to their form and content but also to the beliefs they hold about them
(Chadwick & Birchwood, 1994). The beliefs identified in this model as most
critically influencing problem behavior and distress were the power of the
voice, and whether voices were perceived as benevolent or malevolent—that
is, as having good or evil intent. Engagement and resistance were identified
as the two main forms of response. Engagement involves willingly listening
to the voices and accepting what they say, including willing compliance with
commands. Resistance involves efforts to regulate or control the voices in
order to eliminate them or reduce their impact, including reluctance to obey
them. Chadwick and Birchwood found that participants who believed their
voices to be benevolent engaged with them, whereas those who believed them
to be malevolent resisted them.
An instrument called the Beliefs about Voices Questionnaire (BAVQ)
was subsequently developed in order to test this model further (Chadwick
& Birchwood, 1995). The BAVQ is a 30-item questionnaire that includes
items assessing the key beliefs people hold about their voice(s), including
benevolence, malevolence and omnipotence, as well as engagement and resis-

tance. Resistance comprises items relating to behavioral resistance, (e.g., “I
tell it to leave me alone,” “I am reluctant to obey it,” “I do things to prevent it
talking,” “I try and take my mind off it”) and a negative emotional response
to voices (e.g., “My voice makes me feel angry,” “My voice makes me feel anx-
ious”). Engagement comprises items relating to behavioral engagement (e.g.,
“I listen to it because I want to,” “I willingly follow what my voice tells me
to do,” “I seek the advice of my voice”) and a positive emotional response to
voices (e.g., “My voice makes me feel confident,” “My voice makes me feel
calm”). To improve its sensitivity and range of application, the BAVQ was
later revised, replacing the two-point “yes” or “no” response on the BAVQ
with a four-point scale (disagree, unsure, agree slightly, agree strongly) and
adding five items to the original single omnipotence item in the BAVQ to form
an omnipotence subscale (BAVQ-R—Chadwick, Lees, & Birchwood, 2000).
The measures were found to be reliable and valid and the predicted posi-
tive correlations between malevolence and resistance, and benevolence and
engagement were confirmed (Chadwick & Birchwood, 1995; Chadwick, Lees,
et al., 2000). However, while engagement and resistance appear to be natural
and common reactions to viewing voices as either good or evil, they are also
potentially problematic when it comes to responding to CHs.
EN G AG EM EN T A N D C O M M A N D H A L LU C I N AT I O N S
Given the definition of engagement and its links with perceived benevolence
of voices, it is not surprising to find that viewing the voices as positive and
engaging with them is associated with compliance with CHs. This is clearly a
problem in relation to harmful CHs. Beck-Sander, Birchwood, and Chadwick
(1997) examined compliance with both harmful and nonharmful CHs using
the BAVQ and found that benevolent voices were associated with engage-
ment and compliance with both innocuous and harmful commands, though
not with commands to self-harm. In a later study examining factors related
to compliance with harmful CHs, Fox, Gray, and Lewis (2004) compared
responses on the BAVQ between a group of compliers (n = 24) and noncom-
pliers (n = 8). They showed that those who showed higher levels of engagement
were more likely to comply with harmful CHs. We also examined the role of
various risk factors in predicting compliance to harmful CHs in a sample of
75 people with psychoses (Shawyer et al., 2008). Participants were assessed
specifically, albeit retrospectively, at the point of response to the most seri-
ous CH experienced since the age of 18 years. We found that viewing voices
issuing the harmful command as positive and engaging with them were both
predictors of compliance. In fact, when we examined the incremental value
of combining significant univariate predictors of compliance using multiple
ordinal regression, viewing the voices as positive emerged as the most signifi-
cant predictor of compliance.
R ES I STA N C E A N D C O M M A N D H A L LU C I N AT I O N S
While it would not be surprising for both patients and mental health profes-
sionals to assume that making efforts to resist CHs rather than engage with
them is desirable, there is substantial evidence to suggest that this response is
not only ineffectual but also contributes to the malignancy associated with this
symptom. Although concepts of resistance and noncompliance are sometimes
conflated in relation to CHs, resistance in this context is most usefully thought
of as the degree to which a person wishes or attempts to oppose a command,
whereas noncompliance is the degree to which a person does not do what the
command urges. Although it might be expected that measures of resistance and
measures of noncompliance would largely overlap, the evidence suggests oth-
erwise. In the study by Beck-Sander et al. (1997) described earlier, the authors
found that although a belief in the malevolence of the voice was associated with
resistance, it was not associated with compliance, leading them to speculate that
the relationships here are more complex than those of engagement and compli-
ance. Similarly, Fox, Gray, and Lewis (2004) found that there were high levels of
resistance in both the complier and noncomplier groups and that these were sta-
tistically indistinguishable. Fox et al. noted that “despite the high levels of resis-
tance reported, the majority of people within this study had a strong tendency to
act upon their commands” (p. 526). The authors did acknowledge, however, that
the relationship between resistance and compliance was investigated at a general
level only—it may be that although participants usually resisted their voices, at
the point of compliance they did not. Another difficulty noted with the study
was the small sample size, particularly in the noncompliance condition. These
issues were addressed to a large extent in our project examining a number of risk
factors for compliance with harmful CHs (Shawyer et al., 2008) and, unlike Fox
et al., we did find resistance and noncompliance to be related. However, the over-
lap between these two factors was by no means complete, explaining just 19%
of the variance. By separating affective resistance from behavioral resistance we
also found behavioral resistance to be strongly related to negative affect, whereas
the level of actual compliance was not.
The evidence reviewed in the previous paragraph suggests that a resistance
response style is often ineffective in preventing compliance. Findings from the
general AH literature may help explain why this is the case. In the broader lit-
erature, resistance has been noted to be generally ineffective as a coping strat-
egy: It seems to compound the problems associated with voices and tends to
increase distress, which further exacerbates hallucinations. As an interpersonal
response to threatening voices, Gilbert et al. (2001) usefully divided resistance
into the fundamental reactions of “fight” or “flight” and found that both these
responses were associated with feeling depressed and trapped. For example,
“fight” strategies such as shouting at or arguing with the voices have been shown
repeatedly to be ineffective coping methods (Falloon & Talbot, 1981; Farhall &
Voudouris, 1996; McInnis & Marks, 1990; Romme & Escher, 1989), and we have
found these to be linked to poor control of emotion (Farhall & Gehrke, 1997).
Indeed, Farhall and Voudouris (1996) asked a group of 35 hospitalized hallucina-

tors to rate degree of success for each coping strategy that they had tried from
a list of 29 alternatives for voices they did not like. The coping strategy “yell
or argue back to them” was ranked lowest with “doing exactly what the voices
want.” Thus, directly fighting unwanted voices appears to be as unhelpful as fully
complying with them. There is reason to believe that “flight” strategies, such as
attempts at avoidance or suppression, may be equally unhelpful, by having the
effect of maintaining the power of AHs in the longer term (Hacker, Birchwood,
Tudway, Meaden, & Amphlett, 2008; Morrison & Haddock, 1997), by contribut-
ing to depression (Escher et al., 2003), distress (Hacker et al., 2008), poor cop-
ing (Romme et al., 1992), and low self-esteem (Haddock, Slade, Bentall, Reid, &
Faragher, 1998), and by preventing assessment of true risk through the use of
safety behaviors (Hacker et al., 2008; Morrison, 1998; Morrison & Renton, 2001;
Yusupoff & Tarrier, 1996).
Overall, resistance approaches to AHs have been associated with negative
affect and appear to be relatively ineffective ways of coping with voices, includ-
ing CHs. It has been suggested that actively hostile, negative, and non-accepting
attitudes toward voices may contribute to increases in voice frequency and
reduced coping, possibly as a result of increased physiological arousal (Al-Issa,
1995; Chadwick & Birchwood, 1994; Delespaul, deVries, & van Os, 2002; Gilbert
et al., 2001; Romme & Escher, 1989; Slade, 1976). The role of stress and arousal in
aggravating AHs has been postulated for some decades (Slade, 1972, 1973, 1976).
There is evidence to suggest that anxiety predicts the intensity of hallucinations
(Delespaul et al., 2002) and that emotions increase the bias toward the external
attribution of thoughts, a process thought to be central to the formation of AHs
(Mertin & O’Brien, 2013; Morrison & Haddock, 1997).
AC C EP TA N C E A N D C O M M A N D H A L LU C I N AT I O N S
Taken together, the findings described here indicate that while engagement and
compliance are of major concern in relation to CHs, particularly harmful CHs,
active attempts to resist them are also of limited effectiveness in preventing com-
pliance and may add to distress and the sense of feeling trapped. As noted by
Gilbert et al. (2001), “voice hearers probably do not think they can easily defeat
their voices, but also do not willingly or affiliatively subordinate themselves to
their voices and may feel more like angry subordinates” (p. 1122).
Given the problems associated with engagement and resistance, we consid-
ered that a third, orthogonal response involving acceptance may lead to better
outcomes. Nearly 30 years ago, Cohen and Berk (1985) identified acceptance as
a nonreactive or “do nothing” response that seemed to assist some patients with
schizophrenia to live with their voices. This style of response was distinguished
from a less useful “do nothing” response that involved helplessness and giv-
ing up. Theoretically and pragmatically, acceptance of the reality of a stressful
experience is likely to be most adaptive where a stressor is both ongoing and
not amenable to change—as in the case of medication-resistant AHs (Carver,

Scheier, & Weintraub, 1989; Farhall & Gehrke, 1997; Suls & Fletcher, 1985). Since
Cohen and Berk’s study, acceptance has been identified as a potentially help-
ful approach for managing AHs within several different frameworks, includ-
ing coping, consumer-based, and CBT-based frameworks. In the next sections
we describe the forms of acceptance developed within these frameworks, before
proposing mindful acceptance as a potentially more useful alternative.
Engaged Acceptance
In the coping literature, a form of acceptance has been described that is nar-
rowly confined to the level of voice content: The term acceptance in this context
has often been used synonymously with engagement (Birchwood & Chadwick,
1997; Farhall & Voudouris, 1996; Lucas & Wade, 2001; Pembroke, 1998). This
form of acceptance, which we have termed engaged acceptance, has been identi-
fied as a reasonably useful natural coping strategy that is potentially associated
with reduced distress and improved control of hallucinations (Falloon & Talbot,
1981; Farhall & Gehrke, 1997; Farhall & Voudouris, 1996; Frederick & Cotanch,
1995). However, as already discussed, this form of acceptance has clear dangers
for those who experience harmful CHs.
A more sophisticated form of engaged acceptance has been pioneered in the
work of Romme, Escher, and colleagues (Romme & Escher, 1989, 1993; Romme
et al., 1992), who argue for the value of developing personalized and meaningful
explanations for voices. These explanations may include mysticism, parapsychol-
ogy, psychodynamics, and natural medicine and religion, each of which is linked
to a certain method of coping. Based on an analysis of material obtained from
voice-hearing respondents to a television talk show, Romme and Escher (1989)
described what appeared to be stages toward developing an ultimately meaning-
ful and adaptive frame of reference for AHs—one that was not necessarily one
of “pathology” and that appeared to assist in their management. In particular,
they noted:
[P]‌eople who learned to cope with the voices developed a kind of balance . . .
the individuals saw the voices as part of themselves. The voices are part of
life and self, and they can have a positive influence . . . Coping success . . .
appears to entail reaching some sort of peaceful accommodation and accep-
tance of the voice as “part of me.” (pp. 212–213)
The work of Romme and colleagues has inspired some consumer (service user)
groups, such as the UK Hearing Voices Network, to promote a theme of accept-
ing voices, including via mutual support groups (Romme, 2009) and self-help
publications (Baker, 1995; Coleman & Smith, 2002). The focus of this work is
on acceptance of voices through normalization of voices as part of the range of
human experience, a personal exploration of their content and meaning, a focus
on their positive aspects, and the development of coping strategies. Acceptance is

suggested as a first step toward learning to live with voices. From a cross-cultural
perspective, Al-Issa (1995) and Castillo (2003) have expressed similar points of
view. They suggest that rational Western cultures that make a rigid distinction
between fantasy and reality tend to foster negative attitudes about hallucinations
and associate them with pathology.
If personally meaningful, less pathological and more benevolent construc-
tions of the voice experience lower distress, improve coping, and reduce avoid-
ance, then these developments would appear to have promise and are likely to be
helpful for some people. However, some caution is necessary when considering
these approaches in psychosis. It might be noted that Romme et al.’s (1992) study
was a cross-sectional study in which 39% of the participants were not psychiatric
patients. Moreover, those who coped well were less likely to be in psychiatric
care. What appears to be a staged development in acceptance may be a reflection
of different hallucinatory experiences across the patient and nonpatient groups.
Certainly, those who coped well were more likely to hear positive voices and less
likely to hear negative ones. Again, as noted in the introduction, there are impor-
tant differences between voices experienced in the general population and those
experienced as a symptom of schizophrenia. A suitable acceptance approach for
a person who experiences AHs in a “mystical” or parapsychology context may
be different to those who experience AHs as part of a psychotic illness and who
are likely to have other symptom(s), such as delusions or disorganized thinking.
Again, in the case of the latter, the risks associated with increasing engagement
with voices apply.
More broadly, it has been argued that engaging with voices can become overly
“intimate” and have hidden costs in terms of privacy, confidence, flexibility,
social adaptation, and adherence to treatment (Benjamin, 1989; Birchwood &
Chadwick, 1997; Falloon & Talbot, 1981; Favrod, Grasset, Spreng, Grossenbacher,
& Hodé, 2004). As well, Vaughan and Fowler (2004) found a strong positive cor-
relation between belief in the benevolence of the voice and voice hearer helpless-
ness and dependency on their voice.
Disengaged Acceptance
Insight Acceptance
An alternative form of acceptance also considers focusing on the value of expla-
nation but here in relation to acceptance of voices as part of an illness or “insight.”
This form of acceptance has been central to some forms of cognitive-behavioral
therapy (CBT) for psychosis (Kingdon & Turkington, 1991, 1994; Morrison &
Renton, 2001; Sensky et al., 2000). The delusional attribution of voices as alien
and real has been described as possibly the most important characteristic of
voices in psychosis (Bentall, Haddock, & Slade, 1994; Junginger & Frame, 1985)
and may be what distinguishes those who do from those who do not have a men-
tal illness (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001; Johns, 2002;
Krabbendam et al., 2004; Millham & Easton, 1998; Morrison, Nothard, Bowe, &
Wells, 2004). In the case of CHs, such attributions have been identified as impor-
tant contributors to compliance (Erkwoh, Willmes, Eming-Erdmann, & Kunert,
2002; Junginger, 1990, 1995). CBT interventions for voices typically include
normalizing explanations for voices, emphasizing the continuity between “nor-
mal” experience and psychosis, nonconfrontational and personalized discus-
sions of alternative illness-based models, and other efforts to challenge beliefs
about voices and ultimately reattribute voices to the self using belief modifica-
tion techniques (Bentall et al., 1994; Garety, Fowler, & Kuipers, 2000; Kingdon
& Turkington, 1991).
Unlike the engaged forms of acceptance previously described, this form of
acceptance seeks to foster improved adaptation through disengagement with
voices (Chadwick & Birchwood, 1994). In relation to CHs, there is some evi-
dence that disengagement with voices may be associated with better outcomes
in terms of both distress and compliance. Beck-Sander et al. (1997) found that
when participants were “disengaged” from their voices (i.e., believed them to
be neither benevolent nor malevolent), their primary emotional response was
“neutral” regardless of the content of the command. In turn, a neutral emotional
response—indifference—has been associated with a lower predisposition to obey
the voices (Erkwoh et al., 2002).
While CBT for psychosis has had some success, around half the patients who
enter CBT treatment fail to attain and sustain clinically significant benefits in
symptoms (Garety et al., 2000). Failure to respond to CBT has been associated
with pre-therapy measures of resistance to considering alternatives to delusions
(Chadwick & Lowe, 1990; Freeman, Garety, McGuire, & Kuipers, 2005; Sharp
et al., 1996), denying any possibility of being mistaken (Garety et al., 1997), and
the patient failing to engage with the therapist’s model of reality during the ther-
apy process (McGowan, Lavender, & Garety, 2005). Taken together, these obser-
vations suggest that the partial effectiveness of CBT may arise from some patients
not being amenable to the process of belief modification with respect to their
symptoms. Certainly, many voice hearers with medication-resistant psychosis
find it difficult to reattribute their voices as coming from themselves rather than
from external sources, even in the face of the plausible alternatives (Bentall, 1990;
Bentall et al., 1994; Hemsley & Garety, 1986). The available data suggest that,
despite CBT interventions, improvements in insight often either fail to occur
(Chadwick, Sambrooke, Rasch, & Davies, 2000; Newton et al., 2005), fluctuate
(Bentall et al., 1994) or are not maintained (Valmaggia, van der Gaag, Tarrier,
Pijnenborg, & Slooff, 2005). There may be a number of reasons for this, such
as cognitive inflexibility (Garety et al., 1997; McGowan et al., 2005) or defense
of self-esteem (Bentall, 1990). However, illness models and self-attribution may
be resisted fundamentally because they do not tally with the compelling nature
of the ongoing, subjective experience of AHs. Such hallucinations are thought
to be underpinned biologically by dysregulated dopamine transmission lead-
ing to the aberrant assignment of salience to mental events (Kapur, 2003). Thus,
even where an illness model is accepted to some degree, the subjective sense of
the reality and power of the experience is such that allegiance to the delusional
explanation may persist.
Mindful Acceptance
Given the risks associated with engagement, the costs associated with resistance,
and the limits to acceptance approaches to AHs to date, we were extremely inter-
ested when Bach and Hayes (2002) published their first paper describing quite
astounding results for people with psychosis using ACT, particularly in relation
to AHs. Bach and Hayes assessed the impact of a brief version of ACT on symp-
toms and rehospitalization in a population of 80 inpatients with positive psy-
chotic symptoms. Treatment involved just four 45-minute sessions. The authors
found that, compared with a treatment-as-usual control group, participants in
the ACT group had half the rate of rehospitalization over a follow-up period
of 4 months and rated their symptoms as less believable. Greatly inspired by
these findings, we thus began our journey to investigate whether the TORCH
intervention might benefit from mindful acceptance, the form of acceptance
described by the so-called third generation of behavior therapy, of which key
examples include mindfulness-based stress reduction (MBSR—Kabat-Zinn,
1982), mindfulness-based cognitive therapy (MBCT—Segal et al., 2002, 2013),
dialectical behavior therapy (DBT—Linehan, 1993), and ACT (Hayes, Strosahl, &
Wilson, 1999, 2013).
We hypothesized that the methods involved could directly facilitate adap-
tive attitude change to CHs by providing a direct route to a new form of dis-
engaged acceptance—that is, acceptance without the risks of engagement but
also without the difficulties in attempting to cultivate insight. Acceptance of
this kind is composed of (a) metacognitive awareness or the ability to disen-
gage or “decenter” from one’s immediate experience (Segal et al., 2002) and
(b) the willingness to have ongoing experience just as it is, including aversive
and previously avoided private experience. This form of acceptance can be
developed via the application of a number of methods, particularly mindful-
ness and cognitive defusion techniques through which the client is taught
to take the detached stance of an objective observer of his or her own expe-
rience (Hayes et al., 1999). Most broadly defined, mindfulness is a way of
being that is cultivated by a number of practices that encourage “deliberate,
non-evaluative contact with events that are here and now” (Hayes & Wilson,
2003, p. 163) or “seeing things the way they really are” (Marlett et al., 2004,
p. 267). Mindful acceptance is thus process focused (Epstein & Leiff, 1981);
the same non-evaluative stance is taken in the “here and now” regardless
of content. Acceptance occurs at an experiential level, divorced from both
content and explanation. ACT is a treatment approach that emphasizes the
mindful acceptance of thoughts, emotions, and perceptions while reducing
flight-or-fight responses—avoidance or over-management of difficult private
events. While the goal is similar to mindfulness, the techniques used are more
wide-ranging and the work is set in the context of the explicit articulation and
commitment to personal values and goals.
T R E AT M EN T O F R ES I STA N T C O M M A N D
H A L LU C I N AT I O N S ( TO R C H )
The original aim of TORCH was to reduce the distress, worry, and harmful or
self-defeating behavior associated with CHs by arming the patient with effective
strategies that would reduce the distress and problematic compliance with CHs.
Treatment was not restricted to harmful CHs because (a) it has been shown that
nonharmful CHs cause distress (Honig, 1991) and (b) development of attitudes
and behaviors that reduce compliance to nonharmful CHs may assist in cop-
ing with dangerous CHs should they occur in the future (Rudnick, 1999). The
structure of the TORCH approach was influenced by the Fowler model (Fowler,
Garety, & Kuipers, 1995) used also in our previous work in recovery therapy
(Farhall, Freeman, Shawyer, & Trauer, 2009), whereby a broad range of thera-
peutic resources are made available to the therapist to draw on in an individu-
alized formulation-based approach. As a consequence, it was not difficult to
supplement the standard CBT methods of the original TORCH protocol with
(1) strategies aimed at cultivating mindful acceptance as an alternative to strat-
egies aimed at fighting, suppressing, or avoiding CHs and (2) consideration of
valued action rather than CHs as a guide to behavior. Figure 6.1 provides an
elaboration of the model of intervention we initially developed for the project,
with some contextual terminology added from Ong, Ulmer, and Manber (2012).
Ong et al. usefully distinguish first-order or direct change strategies (partic-
ularly belief modification) from second-order change strategies which target
metacognitive processes or the stance one takes toward experiences (mindful
acceptance interventions). These processes interact to appreciably broaden the
focus of change.
Main Components of TORCH
The main components of TORCH are described in the following sections.
Engagement and Assessment

The first three sessions of TORCH are geared toward engaging the client by
conveying that his or her problems are being taken seriously and that specific
concerns will be addressed in therapy. The therapist explains what to expect in
therapy and conveys hope for improvement. The assessment clarifies the experi-
ence of CHs and associated problems noted by the client. During these sessions a
case formulation is developed which takes into account the most critical features
of the participant’s experience of CHs and their explanatory model and goals.
It includes an assessment of predisposing or vulnerability factors, preventive or
protective factors, precipitating factors, perpetuating factors and potential for
therapy. The most relevant TORCH components are identified on the basis of
this information.
First order change: belief modification
Non-psychotic Beliefs about CHs

beliefs (self, - power Beliefs about the
Thinking deficits Delusional relationship with
others, the - compliance
and/or biases beliefs the voice
Misattribution world) - intent
- reasoning biases
to external - abstraction
source - thought disorder
Perceived as Appraisal Coping +/–Stress

Thought a voice Stress Reappraisal Coping etc.
(CH)
Aberrant
assignment
of salience Metacognitive stance: engulfment, fusion, and automatically reacting
vs. decentering, defusion, and consciously responding
Second-order change: mindful acceptance Values and commitment
Figure 6.1. The TORCH model of voices and associated features of psychosis (for further details on theoretical aspects of the model, see Shawyer,
Thomas, Morris, & Farhall, 2013).
Belief Modification
In this second component, established belief modification techniques are applied
to the beliefs people hold about their hallucinations that lead to distress, resis-
tance, or problematic compliance. Beliefs that might be addressed include the
following:
• The power or omnipotence of the voice

• The supposed intent of the voice to do “good”
• Consequences of compliance and noncompliance
• Beliefs about self that amplify the CHs
• Delusions that are associated with or reinforce CHs
A belief of primary concern in CHs is the omnipotence of the voices. People

with psychotic illnesses and AHs frequently experience their voices to be extraor-
dinarily powerful (Chadwick & Birchwood, 1994; Nayani & David, 1996) and
this increases the risk of compliance (Fox et al., 2004), particularly for those
with threatening voices (Shawyer et al., 2008). The perceived power of the voices
is challenged through collaborative and systematic attempts to modify beliefs
about them. Interventions will differ according to whether the voices are benevo-
lent or malevolent. Belief modification also addresses beliefs about the conse-
quences of compliance. As well as addressing beliefs related to the power and
importance of CHs, work may involve associated beliefs about self and delusions,
since findings from our work and others have shown that congruent delusions
and beliefs about self are important factors in compliance (Shawyer et al., 2008).
Therapy is conducted in a climate of “collaborative empiricism” (Beck, Rush,
Shaw, & Emery, 1979), in which both therapist and patient are embarking on a
joint enterprise to understand better the situations the patient has experienced.
Beliefs are regarded as possibilities that may or may not be reasonable (Chadwick
& Birchwood, 1994). Three basic techniques are aimed at weakening beliefs. Each
technique occurs in the context of the availability and prominence of an alterna-
tive, more adaptive way of understanding the circumstances that the client gives
as evidence for their belief. The analysis of evidence technique elicits the main
reasons given for a particular belief, then gently challenges them, noting how the
alternative belief still remains possible. Direct challenge of beliefs occurs where
engagement is at least moderate, and consists of the raising of internal inconsis-
tencies and irrationalities in the person’s belief system, again, in the context of a
viable alternative explanation. Reality tests may be devised to cap off a period of
discussion of alternative ways of interpreting a situation.
ACT and Mindfulness

The aim of TORCH was to target not only the beliefs underpinning responses
through traditional cognitive therapy but also more directly target the responses
themselves through developing a broader metacognitive stance of awareness
and acceptance. As discussed in detail earlier, we considered that the more tra-
ditional CBT procedures would be enhanced by the capacity to detach from
CH-related phenomena through acceptance and mindfulness methods. We

speculated that undermining key beliefs about the voices would facilitate the
adoption of acceptance strategies. This is because the fusion experienced with
delusional beliefs combined with the aberrant perceptual experience of hearing
voices is more compelling than that experienced in the general population with
ordinary thoughts (Kapur, 2003). It seemed reasonable to suppose, for exam-
ple, that defusing thoughts and content associated with CHs or observing these
experiences mindfully might be more effective if the belief that the voice is very
powerful and can harm them if they don’t comply has already been weakened.
The main components of ACT as applied in TORCH were broadly based on the
session framework described in the original Bach and Hayes trial and included
the following:
• Accepting voices even though one may not like them (core
process: acceptance)
• Cultivating capacity to just notice voices and associated thoughts rather
than believe and act on them (core processes: defusion, contact with the
present moment, self-as-context)
• Accomplishing valued goals in context of ongoing voices (core
process: values and committed action) (Bach & Hayes, 2002)
It might be noted that the ACT framework does not ultimately dictate a par-
ticular response as being right or wrong. For example, although compliance with
harmful CHs is likely to be unhelpful by definition, this is not necessarily the
case with nonharmful CHs (see, for example, the ACT and mindfulness clinical
vignette presented later in the chapter). As we have noted elsewhere (Shawyer,
Thomas, Morris, & Farhall, 2013), engagement and resistance responses, though
often unhelpful in relation to CHs experienced by people with psychosis, are also
not necessarily “bad,” as illustrated by the work of the hearing voices network
and the many people who have benefitted from exploring the personal meaning
of their voices (Unger, 2013). A particular strength of the ACT perspective is that
it provides a broader, pragmatic lens from which to consider one’s response: Do
my actions in response to voices help me live my chosen way of life (Shawyer
et al., 2013)? The aim is for the client to move from being engulfed by their voices
and automatically reacting to CHs to being able to stand back from them to
enable a more considered and adaptive response, in line with values and goals.
Simple mindfulness exercises were introduced from early on in therapy with
practice encouraged at home. This was carefully monitored, since at the time
of the trial few controlled studies had been conducted evaluating the impact of
mindfulness on Axis I disorders (Baer, 2003), and, to our knowledge, no ran-
domized controlled trial (RCT) had been published that had directly applied
mindfulness to psychotic symptoms, although there had been a number of
case studies published over the preceding decades. General mindfulness skills
were taught (e.g., raisin exercise: Kabat-Zinn, 1991, pp. 27–28) before applying
these to CHs.
To provide the context for most usefully responding to CHs, including the
rationale, motivation, and direction for alternative actions to obeying harm-
ful CHs, exercises identifying values and goals were commenced in the early
to middle stages of therapy. Examples include identifying top 10 values using
a values card sort, or completing a worksheet identifying core values in key
domains of life. The swamp metaphor (Hayes et al., 1999, p. 248) was com-
monly used to illustrate commitment to a valued direction in the presence of
difficult internal experience (if you want to reach a beautiful mountain you
may have to accept the need to go through an unpleasant swamp). In later ses-
sions, defusion techniques were included to undermine the verbal impact of
the content of CHs and associated thoughts—for example, repeating a difficult
thought or CH over and over again, or saying it in silly voices until it loses its
meaning, or writing the content of thoughts or CHs on cards backwards or
jumbled and then reading it aloud. Comparisons were made with the many
thoughts we have that are not acted on (e.g., thinking about yelling at someone
but not doing it, thinking about eating when there is no food around) (Bach &
Hayes, 2002).
The “take your mind for a walk” (Hayes et al., 1999) exercise was a central
exercise in TORCH that lent itself to creative adaptations to foster dispassion-
ate observation of verbal events: “taking your voices for a walk” or having a
dialogue with the clients, with one person talking and the other person describ-
ing the process of what is being said. We found that the “taking your voices
for a walk” exercise was best done toward the end of therapy (but not in the
last session) as a way of consolidating and applying skills already developed.
It needs to be done with caution, as it can lead to distress: (a) clients can easily
fuse with the content (forgetting it is a role-play) or (b) voices can be triggered.
Good preparation is essential, including informed consent and agreement up
front regarding the content that will be role-played, commencing with neutral
material so that the clients know clearly what to expect with more challenging
material, and doing the exercise in very short bursts (e.g., 30 seconds) before
stopping and debriefing. Going for a walk to a destination chosen by the cli-
ent while the therapist passes the client the content of CHs written on cards or
with voice content written on bits of paper placed in the client’s shoe are milder
forms of this exercise that illustrate the idea that one can experience CHs but
choose to act autonomously.
Plan of Action
In a similar way to relapse prevention plans developed more generally in psycho-
sis, therapy culminated in an “action plan” for dealing with CHs in the future.
The action plan was based on the formulation and approach to CHs developed
throughout therapy and consolidated learning into a take-home summary
record. It might include the following:
1. A formulation of the CHs as generated collaboratively during treatment;

2. Minimizing the occurrence of problem voices;
3. Effective coping mechanisms (that do not interfere with achieving valued

goals);
4. Coping statements;
5. Mindfully accepting the presence of commands and doing what works;
and
6. Danger signs and seeking support and help when bothered by CHs.
An example of a simple action plan is illustrated in Box 6.1.
Support Modules for TORCH
A number of optional supporting modules were included to address other prom-

inent therapeutic needs where indicated through individual formulations and
are discussed in the next sections.
Techniques from Motivational Interviewing

Engaging and retaining patients with a psychotic disorder can present signifi-
cant challenges. It is critical to pay attention to the client’s underlying motivation
Box 6.1.
Action plan for command hallucinations: What I can do when
I hear voices telling me to do things
Step 1. Observe, be mindful.

Stand back and observe the voice and my reactions (thoughts, body sensations).
Try to observe what is happening and accept it without judging it as either good
or bad or trying to get rid of it.
Remind myself that:
• I can hear voices without necessarily believing or acting on them.
• This experience will pass.
Step 2. Remind myself that what I am hearing from voices are just
words, not necessarily helpful or the truth.
Consider:
• Defusing upsetting or commanding words (not taking them literally)
• The evidence: Is what I am hearing a guess or a fact?
• Is what I fear really likely to happen?
• Testing out fears by not doing what the voices say
• Talking about it with other people—I don’t have to do it on my own.
Step 3. Use my values and goals to help me decide what is the right
thing for me to do.
to engage actively in therapy and to change during the assessment phase and
also throughout therapy. Where appropriate, techniques from motivational
interviewing were incorporated during the assessment and intervention phases
to enhance behavior change. For example, a critical part of both motivational
interviewing and ACT is identifying the core attitudes, goals, beliefs that the cli-
ent holds. How do CHs relate to these? What are the pros and cons of compliance
with CHs? How do the clients’ strategies for managing CHs get in the way of liv-
ing out values and goals? If a discrepancy was apparent, this could be highlighted
by drawing out how doing what the voices say conflicts with the attitudes, values,
beliefs, and self-image of the person.
Personalized Psychoeducation
Like many cognitive-behavioral therapies, TORCH assumed a continuum
model including AHs experienced by people who have intact mental health
as well as those of people experiencing psychosis. Reminding the client of this
model can be used as a stigma-reducing strategy, by suggesting that unusual
experiences (voices in bereavement, paranoid under stress) are common in
the general population. Sharing such information with patients in a format
they can digest can be extremely useful. As noted by Morrison and Renton
(2001), the provision of normalizing information can ensure that the patient
is not left with unhelpful choices, such as “either the devil is talking to me or
I am mad” (p. 150).
Enhancing Self-Efficacy
Self-efficacy has been defined as “beliefs in one’s capabilities to organize and exe-
cute the courses of action required to produce the given attainments” (Bandura,
1997, p. 3). To enhance self-efficacy with respect to voices a number of methods
can be employed (e.g., recall of past success) that together aim to build the skills
and confidence needed to manage CHs adaptively, in particular to not comply
with them where they may cause harm.
Coping Strategy Enhancement

Coping is an early intervention that can provide immediate relief from the
distress associated with symptoms. As well as reducing distress, having effec-
tive coping strategies can strengthen self-efficacy and weaken the power
differential. Coping may be aimed at managing negative emotions (e.g., by
reducing tension) or at reducing the hallucination itself (e.g., through audi-
tory competition). It is not necessary for the client to understand and adopt
any particular model of hallucinations for basic coping strategies to be insti-
tuted—they may be suggested on the basis of common sense or as ideas imple-
mented by others that the client may wish to try. Coping approaches are best
implemented by assessing the person’s current automatic and deliberate cop-
ing efforts, then building on them by testing out several different types of
coping strategies.
Assertiveness
We found previously that individuals with high trait anger were significantly
less likely to comply with dangerous commands than those with lower levels
of trait anger (Shawyer et al., 2008). We hypothesized that a robust capacity for
anger (and therefore self-protection), directed toward the voice, might be an
effective psychological antidote for the feelings of powerlessness and of being
controlled that are engendered by the voice. However, given that strategies
such as shouting back at the voices or arguing with the voices are poor coping
responses, and that arousal in general is likely to make the voices worse, we
were interested here in cultivating an assertive rather than aggressive response
to voices. The focus of this component was to enable anger and distress gener-
ated by CHs to be channeled into self-efficacious action. There is evidence that
a person’s relationship with their voice may be reflective of other relationships
in the person’s life, especially those in which the person has been subordinated
(Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000; Gilbert et al., 2001).
Thus, the general approach in this module is to link strategies used with people
and authority figures to those that can be used with voices. For example, com-
mands from a malevolent voice can be labeled as bullying, leading to an exami-
nation of how the person has coped with bullies in the past or what is likely to
be helpful in dealing with bullies (e.g., reducing the sense of isolation by telling
others, accessing support).
Sequencing TORCH Interventions
In terms of sequencing, skills training and belief modification are structured in

a logical sequence for implementation. Thus, coping and assertion strategies may
provide more practical, immediate relief as well as provide some useful evidence for
belief modification approaches. Weakened beliefs about voices may allow for addi-
tional changes to metacognitive beliefs about CHs. In parallel, ACT strategies are
also progressively implemented. However, for any particular case, implementation
of steps is flexible. Like the approach used by Freeston, Léger, and Ladouceur (2001),
the general strategy is to find a middle ground between a manualized treatment and
an individualized case-formulation approach. The range of factors believed to be
associated with problematic CHs are assessed in a standardized manner, then an
individualized approach is provided within the framework provided.
C L I N I CA L V I G N E T T ES
The following vignettes provide examples of how belief modification and ACT/
mindfulness components were implemented in practice. Personal details and
some aspects of presentation have been changed to protect privacy.
Belief Modification
Katrina is a 28-year-old single woman who was first diagnosed with schizo-
phrenia at the age of 21. Katrina reported hearing two equally malevolent and
critical voices: an old man and a middle-aged woman who both had no con-
nection to her past. Her voices generated a negative running commentary on
whatever she was doing and had a tendency to focus on the futility of Katrina’s
life. Katrina said that the voices tried to dictate her behavior by screaming and
shouting abuse at her. Katrina would regularly hear commands telling her to
smash windows, for example, “Break all the windows, go wild. You have to
show people how ill you are, you have to show people our power.” On average
Katrina heard voices approximately 10 times a day; this could be far higher on
bad days and she was aware that they were worse when her general arousal level
was high. Katrina believed that the aim of the voices was to take her over and
did not question the negative comments about her as being a true reflection of
her lack of personal worth. Her main coping strategies were taking medica-
tion and sleeping. Katrina often tried to argue with the voices, although she
was aware that this led to a greater level of distress. CBT was used in a variety
of ways:
1. Katrina had a number of underlying beliefs that were contributing to her

arousal and distress and therefore exacerbating the voices. One of these
was an excessive need for approval, so that when she experienced voices
in social situations and found it hard to concentrate and communicate,
she would then also get caught up with concerns that others would think
her rude or dull. Katrina’s need for approval was challenged by exploring
situations where she had experienced disapproval and survived and
noting that disapproval from others is inevitable in life because everyone
is different, but it is not catastrophic.
2. In relation to the voices, Katrina’s assumption that the voices saying
negative things about her means she is a bad person was challenged.
As well as contributing to her distress, taking on board the voices’
comments about her increased their perceived relative power. Katrina
was asked to describe some positive and negative characteristics of
herself that she felt were stable. After emphasizing the stability of these
characteristics compared to the temporal nature of voices, the idea that
these characteristics suddenly change when the voices call her useless was
challenged through Socratic dialogue. Some alternative responses were
generated: “I don’t believe what you are saying.” “I don’t need to believe
what I am hearing.” “I don’t have to take the content of the voices to mean
that I am a bad person.”
3. In relation to her CHs, Katrina was asked whether she had ever acted
on the CHs to break windows. Katrina initially said rarely but when
asked for specific times it emerged that she had never in fact acted on
the CHs, although she viewed these commands as evidence that the
voices were trying to take control of her mind and felt very distressed by
the possibility. The therapist noted that Katrina had been very good at
not giving in to the voices and used this as evidence that she was more
powerful than the voices:
T: What does that tell you about power?

K: That I am stronger. But sometimes I get so close.
T: Yes but you don’t. And even if you were to, what would that say
about you?
K: I’m not sure.
T: It would only prove you are human.
As a result of these interventions, Katrina started to see her beliefs associated

with the voices as a bad habit. She became aware of the role she played in the
magnification of her responsiveness to the voice content and her responsibility
for her emotional states.
ACT and Mindfulness
Michael is a single, overweight 40-year-old man with a diagnosis of schizophre-

nia, living alone in private accommodation. He saw a private psychiatrist for
his medication. Michael had completed a university degree in the past; he was
not currently working. He presented as somewhat unkempt but reliably attended
appointments. He had difficulty concentrating occasionally and was sometimes
low in mood but diligently completed homework tasks.
Michael’s onset of AHs occurred at the age of 26. He described his voices as a
constant loud whisper coming from outside his head. He heard several voices, the
most dominant being an older male. In the past, Michael had experienced severe
CHs telling him to kill himself and why he deserved this fate. However, his CHs
at the time of the trial were generally nonharmful, such as “do the dishes,” “go
down this street.” Nevertheless, he viewed his voices as having malevolent intent,
wanting to either control or upset his mind. Although Michael was not con-
cerned that anything bad would happen if he defied the voice he was determined
to defy the voice at all times, as he was wanted to stop the voices “invading my
mind and taking over as they seem to want to.” He felt it was a struggle between
him and the voices and was concerned that the voices might win. While he was
successful in defying them most of the time, this did not stop him from feeling
distressed and annoyed in response to the CHs. Michael described the experi-
ence as “like being in a boxing match all the time . . . it starts as soon as I wake
up—if I can’t get back to sleep I have to get up and watch TV for a while or put the
radio on to block it out. That’s why it’s so tiring because I have to be constantly
vigilant to block it out. . . . [If they weren’t there] I’d have a rest from fighting it
all the time and defending my self-esteem all the time against it. I could just be
me rather than a fighter. It would be a weight off my mind.”
Not surprisingly, Michael displayed a very strong resistant style of coping

and had a range of strategies geared around avoiding or fighting the voices in
some way. Michael’s resistance extended to refusing to comply with CHs that
he thought were actually a good idea because he felt that this would mean that
the voice would be in control. He expressed considerable frustration and annoy-
ance at this “no-win” situation. As well as deliberately resisting all CHs, Michael
would get caught up in the content of these as well as derogatory comments, try-
ing to work out what to do and defending himself against insults.
One aim of treatment was to strengthen the “acceptance” and “disengage-
ment” arms of Michael’s coping repertoire, without removing any of his own
coping techniques that he found effective, in order to reduce the impact of his
CHs on his capacity to live out his values and goals. Metaphors and exercises
were used to attempt to explain the nature of acceptance and how sometimes the
struggle against an ongoing problem can lead to greater difficulty. For example,
Michael was asked to try to pull his fingers out of a Chinese finger trap to illus-
trate how sometimes the more you struggle, the more stuck you become. The tug
of war with a monster was also enacted to illustrate the alternative of dropping
the rope rather than continuing with the battle:
T: If your job is not to win the battle, what might it be?

M: Maybe to ignore the monster?
T: It sounds like that has been more of the battle for you.
M: I have read stuff about hallucinations where they say sometimes it helps to
make friends with the voice rather than be on bad terms with it. . . . But
I don’t want to be friendly with something that’s always putting me down.
I don’t think that’s the answer for me.
T: And it may be a bit like part of the battle again.
M: If it’s not winning the tug of war I don’t know what the answer is.
T: One suggestion might be to drop the rope.
M: That would be good—I’d love to drop the rope. It just sort of has its way—
it just says what it wants to say and I’ve got so little control over it—that’s
the hard part.
T: So you’ve got no control over the other end.
M: It could be a technique. . . . I’m willing to try these things—even if just
telling myself don’t fight it, drop the rope. If that helps a bit that’s good.
T: The trick is not to use it as just another strategy—as part of the battle.
Mindfulness techniques were taught to help him develop the capacity to

observe experiences such as voices without attaching any judgment (such
as it being “bad” or “terrible,” or something that needed to be avoided or
acted on). Initially these exercises focused on breathing, body sensations,
and external sounds, and then they graduated to thoughts and eventually to
auditory and command hallucinations. Michael was encouraged to practice
mindfulness exercises between sessions and was provided with audiotapes to
guide him.
Acceptance was also supported by cognitive defusion exercises to highlight

the difference between words and reality—for example, describing a chair vs.
sitting on a real chair, and quickly repeating a word until it becomes meaning-
less sound (Titchener’s exercise) (Hayes et al., 2013). Other tasks required that
Michael go for a walk to a location chosen by him despite hearing interfering
thoughts, then later, when “hearing” CHs (role-played by the therapist) and, as
homework, that he go about his daily activities despite carrying potentially dif-
ficult or interfering CHs written on cards with him. These tasks illustrated the
idea that it is possible to let voices be without believing or acting on them and to
continue to live out a value or goal, as reflected in the following dialogue:
M: I thought of [the cards] every now and again, that I had those cards in my
bag. They’re not doing me any harm, just sitting there.
T: So, did they stop you from doing anything?
M: No, they didn’t—I suppose I’m learning that these things can’t really
harm me.
T: So your conclusion from that is . . .
M: They can be there but they are not necessarily doing you any harm. If
I could take that to the voice and let it say what it says without letting it do
me any harm, that would be good.
Important values and goals were identified through narrative description, dis-
cussion, and an exercise in which he imagined the sorts of speeches he would
like to hear about himself at his own 80th birthday. Linked to the idea that voices
cannot cause action, this part of the work was important for motivating commit-
ment to act according to values rather than according to transient perceptions
such as voices.
By the end of therapy, Michael was regularly practicing mindfulness, applying
these skills to voices, and experiencing considerably reduced distress. He felt he
was stronger in his capacity to manage his feelings and more positive about deal-
ing with life issues in general.
He found the work related to values and goals of benefit, particularly the con-
cept that one can still move forward despite having voices or bad thoughts and
feelings. He also understood that acting on a helpful idea from the voices did
not mean he was being controlled: At the final session he noted that “if you get
something that is really helpful [from the voices] and then you try and go against
it there is too much conflict—you think you are fighting someone else but you
are really fighting yourself. Better to be a bit mindful about it, observe it a bit but
still take the good advice.”
C O M M O N A N D D I ST I N CT I V E EL EM EN TS O F TO R C H
The use of acceptance approaches in TORCH evolved from a broad literature

related to auditory and command hallucinations, including cognitive and
coping frameworks. As noted earlier, the structure of the approach was influ-
enced by the Fowler model (Fowler et al., 1995) used also in our previous work
in recovery therapy (Farhall et al., 2009), whereby a broad range of therapeutic
resources are made available to the therapist to draw on in an individualized
formulation-based approach. Acceptance was introduced as an additional and
potentially valuable element rather than being the central platform for treat-
ment. While the use of acceptance-based interventions, including standard ACT
and mindfulness interventions, is common to the interventions in this book,
their combination with CBT, together with a range of other support modules,
marks TORCH as distinctive—and ambitious.
TO R C H E VA LUAT I O N: T R I A L I M PL EM EN TAT I O N

A N D O U TC O M ES
TORCH was evaluated in a 4-year RCT by comparison with a control condition

called “befriending.” Recruitment commenced July 2003 and the final assess-
ment was completed in August 2006. For a more detailed report on study meth-
odology and outcomes refer to Shawyer et al. (2012).
Hypotheses
The predicted outcomes were that, compared to befriending, participants receiv-

ing TORCH would demonstrate increased confidence to resist obeying harmful
CHs and increased confidence in coping with CHs. We also hypothesized that
participants would demonstrate reduced compliance with harmful CHs; how-
ever, low compliance rates at baseline ultimately precluded using this as a viable
outcome measure.
In secondary hypotheses, we expected that TORCH participants would show
reduced illness severity, distress, and disruption to life and improved functioning
and quality of life. We predicted that these outcomes would occur via improved
insight, lower conviction in key beliefs related to CHs, improved acceptance of
auditory and command hallucinations, and reduced involvement with them. We
expected that these changes would occur by the end of therapy and be main-
tained at follow-up.
Method
Participants
We recruited 43 adults (mean age 39, range 22–64) with a diagnosis of schizo-
phrenia or other psychotic disorder with medication-resistant CHs causing dis-
tress or dysfunction. Exclusion criteria included having a significant neurological
disorder, an IQ less than 70, inadequate fluency in English, current treatment of
drug or alcohol abuse, and inability to give informed consent. Participants were
recruited from a large number of public and private mental health services in
Victoria, Australia, and were typically experiencing serious symptoms and/or
serious impairment in functioning on entry to the trial, as rated on the Modified
Global Assessment of Functioning (Hall, 1995a, 1995b).
Randomization
Following the initial baseline assessment, participants were randomly allocated
to either TORCH or the control treatment, befriending. A subsample of par-
ticipants were randomly allocated to a 4-month waitlist prior to their treatment
allocation so that both treatments could be compared with treatment as usual
(TAU). Treatment for both groups involved 15 weekly sessions of approximately
50 minutes’ duration. Two additional follow-up sessions were also offered dur-
ing the 6-month follow-up period. Therapy was delivered by five psychologists
trained in CBT, ACT, and mindfulness.
Control Intervention
Befriending is a manualized intervention that primarily involves social con-
versation about positive or neutral topics, but with allowance of activities par-
ticularly for those who struggle with dialogue (Bendall, Killackey, Jackson, &
Gleeson, 2003). In the form of befriending used in this trial, participants were
advised that problems and symptoms could not be discussed in befriending: the
explicit focus on topics that are positive or of interest to the participant forms
the rationale for treatment. Befriending has been used in several trials as a con-
trol for treatment expectancy and therapist contact (Jackson et al., 2008; Sensky
et al., 2000; Turkington & Kingdon, 2000).
Measures
Outcome Measures
The primary outcome measures of confidence to resist obeying harmful CHs
and confidence in coping with CHs were measured using a rating scale of
0–100. For the secondary outcome measures, illness severity was measured
using the Positive and Negative Syndrome Scale (PANSS—Kay, 1991). Symptom
severity was assessed using items from the Psychotic Symptom Rating Scales
(PSYRATS—Haddock, McCarron, Tarrier, & Faragher, 1999) and the Single
Hallucination Episode Record (SHER—Farhall, 2005). Quality of life was assessed
using the Quality of Life Enjoyment and Satisfaction Questionnaire (Endicott,
Nee, & Harrison, 1993) and functioning was assessed with the Modified Global
Assessment of Functioning Scale (Modified GAF—Hall, 1995b).
Process Measures
Involvement with voices issuing commands (preoccupation, engagement, and
resistance) and beliefs about them (reality and power) were assessed using rel-
evant items from the SHER and the BAVQ-R. Insight was measured using the
Insight Scale (Birchwood et al., 1994). The Voices Acceptance and Action Scale
(VAAS) was developed in parallel with the TORCH trial and was used to assess
acceptance of CHs and AHs, since no such measure existed at the time. Given
its special relevance to the subject matter of this book, the VAAS is described in
more detail later in this chapter. A more detailed description of the other mea-
sures is provided by Shawyer et al. (2012).
The VAAS is a 31-item instrument that was modeled on the BAVQ-R and
includes two theoretically derived subscales: Acceptance and Action. The first 12
items of the scale (Section A) were designed to be applicable to AHs in general,
with the remaining items (Section B) applying specially to CHs. Examples of
acceptance items are “I have learned to live with my voices” and “I struggle with
my voices.” Examples of action items are “My voices stop me doing the things
I want to do” and “I decide what I do, not my voices.” The initial psychometric
evaluation using TORCH baseline data showed satisfactory internal consistency
and test-retest reliability. The validity of the measure also looked promising. The
VAAS was correlated negatively with measures of depression and positively with
quality of life and coping with CHs. Those who reported no compliance with
harmful CHs in the previous 6 months showed higher scores on the Action sub-
scale than those who did comply. Correlations also showed that acceptance was
unrelated to engagement, indicating successful discrimination of the two con-
structs (Shawyer et al., 2007).
Results
Quality Control
A considerable amount of effort was spent ensuring that the TORCH trial
was tightly run in terms of both design and implementation. Randomization
was conducted independently of trial staff, and the vast majority of assess-
ments were successfully blinded. Attrition was low (n = 3; 7%), and there
were no significant differences in therapeutic alliance as rated by participants
or engagement with therapy as rated by therapists. Participants in the both
treatment conditions received similar “doses” of therapy in terms of session
length, number of months of therapy, number of sessions, and number of
follow-ups. An audit of a random sample of audiotaped therapy sessions indi-
cated that the content of therapy was appropriate to the applicable treatment
manual with no overlap on the core therapeutic interventions (Figures 6.2
and 6.3). As Figure 6.2 indicates, acceptance-based interventions were most
prominent among the mix of interventions provided in TORCH. Although all
the support modules were used at times, they were largely imbedded within
the broader ACT-CBT framework. Only 4.1% of sessions were rated by the
therapists as having a support module as the main approach for a given ses-
sion including motivational interviewing (1.4%), psychoeducation (0.3%), and
coping enhancement (2.4%). Enhancing self-efficacy and assertion were never
identified as the main intervention for a given session. The TORCH study was
45
40
35
30
Percentage
25
20
15
10
5
0
Engagement Acceptance Belief Future Support
and modification planning & module
Assessment review
Figure 6.2. Content of TORCH sessions (n = 295).
100
90
80
70
Percentage
60
50
40
30
20
10
0
Neutral topics Neutral activities
Figure 6.3. Content of befriending sessions (n = 297).
independently rated on a measure of research trial quality, the Clinical Trials

Assessment Measure (CTAM—Wykes, Steel, Everitt, & Tarrier, 2008), gaining
a score of 88/100.
Outcomes
Subjective feedback from participants showed that, whereas both therapies
helped participants to feel better, mean ratings for TORCH participants on
improving the problem of CHs were significantly higher than those for befriend-
ing participants (see Figures 6.4 and 6.5). However, this did not translate into
differences between TORCH and befriending on any of the outcome or process
measures. An examination of comparisons between the combined TORCH and
befriending group with waitlist suggested, however, that both groups showed
substantial improvements in confidence in coping with CHs, overall symptom
severity, and quality of life. Within-group comparisons indicated that TORCH
60
50
40
Percentage
30
TORCH
20 Befriending
10
0
Felt Felt Felt no Felt Felt
much better different worse much
better worse
Figure 6.4. Percent ratings of emotional response to therapy.
60
50
40
Percentage
30
TORCH
20
Befriending
10
0
Problem Problem Problem Problem Problem
is much is better is no is worse is much
better different worse
Figure 6.5. Percent ratings of problem change from therapy.
participants improved significantly in terms of overall severity of illness (PANSS),

symptom-related functioning (modified GAF, PSYRATS disruption to life),
and quality of life over the longer term, whereas the befriending group showed
significant improvement regarding distress related to auditory and c ommand
hallucinations in the short term. In relation to process measures, both groups
showed improvement on acceptance of voices (VAAS) and reduction in belief in
the voices’ power (BAVQ-R Omnipotence scale). Responses to CHs in terms of
preoccupation, engagement, and resistance did not significantly alter in either
group.
Discussion
There was no strong evidence from the TORCH trial that a combined ACT-CBT
treatment involving 15 sessions targeting CHs was superior to befriending
treatment. Despite our efforts to run a high-quality trial, there were a num-
ber of methodological concerns that may have contributed to the null effect,
as described in Shawyer et al.’s (2012) report. The most important of these was
the sample size. Despite recruiting through a large number of services, the n of
43 was somewhat lower than the 60 indicated by our power analysis conducted
prior to the trial and a great deal lower than what would now be considered
advisable based on effect sizes published after the trial’s completion (e.g., Lynch,
Laws, & McKenna, 2010; Wykes, Steel, Everitt, & Tarrier, 2007). Compounding
this problem were baseline differences in several clinical factors with potential
to influence outcomes—a risk in small trials where randomization is not strati-
fied (Kernan, Viscoli, Makuch, Brass, & Horwitz, 1999). In particular, those
allocated to the TORCH condition had significantly worse negative symptoms
at baseline, a factor we later identified to be a strong predictor of poorer out-
come in CBT for voices at a specialist clinic (Thomas, Rossell, Farhall, Shawyer,
& Castle, 2011).
However, had a very strong signal for the efficacy of TORCH been present,
these methodological concerns would not necessarily have prevented this sig-
nal from being detected. Our results appear therefore to stand in some contrast
to the original Bach and Hayes (2002) trial, which after only four sessions of
ACT alone demonstrated a halving of the rehospitalization rate over a 4-month
follow-up period compared to TAU. Moreover, in March 2006, which was toward
the end of the TORCH recruitment period, a second RCT of ACT for psychosis
was published in which an enhanced treatment as usual (ETAU) group was com-
pared to a control group for amount of therapist contact (Gaudiano & Herbert,
2006). Unlike the Bach and Hayes study, validated symptom measures were
included, such as the Brief Psychiatric Rating Scale (BPRS) and the Clinical
Global Impressions Scale (CGI). ETAU largely involved more thorough assess-
ment in addition to TAU and control for treatment contact time. On average,
three sessions of ACT were provided in this trial. Unlike the Bach and Hayes
trial, there was no significant between-group difference in rate of rehospitaliza-
tion or believability of hallucinations (delusions were not reported), although
a later analysis of pooled data from both trials supported the original reduced
hospitalization result and demonstrated its mediation by reduced believability
of symptoms (Bach, Gaudiano, Hayes, & Herbert, 2013). There were, however,
significant between-group differences in favor of ACT for hallucination distress,
and there was a marginally significant difference on the CGI post-treatment.
Although there were no group differences on the BPRS scale, more participants
in the ACT group showed a clinically significant improvement. From pretest to
follow-up, half of the participants in the ACT condition improved two standard
deviations or more on the BPRS, while only about 10% of the enhanced treat-
ment as usual group did so.
Several fundamental differences between the TORCH trial and the two
ACT trials mean that making direct comparisons is difficult. While TORCH
was focused on chronic symptoms in outpatients with problematic CHs within
the Australian healthcare system, using a combined ACT-CBT protocol and
an active comparison condition, the two ACT trials targeted general psychotic
symptoms in an acute inpatient setting in the U.S. healthcare system, using an
ACT-only protocol. Unlike the two ACT trials, the assessments in TORCH were
blinded. It is possible that the apparent effect in the two previous ACT trials is
nonspecific. Although there is some mediator evidence for ACT processes, in the
absence of a direct comparison with a control, this provides only limited sup-
port, since our befriending results suggest that the same mediators may work in
other treatment modalities. Befriending as well as TORCH was associated not
only with changes in dimensions of psychotic symptoms but also in the puta-
tive mediators for CBT (power) and ACT (acceptance) despite these not being
directly targeted in befriending. Thus, in the absence of a nonspecific control
treatment, it is not possible to be sure that mediation analysis in uncontrolled
studies is direct evidence for the ACT model. However, TORCH also may not
be working as expected, given, for example, that there were no exclusive VAAS
changes or changes in engagement and resistance.
In addition to the ACT trials, a trial conducted by Trower et al. (2004) has
provided strong evidence that cognitive therapy (CT) is effective in reducing
compliance in relation to CHs. Again, there are multiple differences between the
TORCH trial and the Trower et al. trial, making direct comparisons difficult.
While TORCH flexibly applied a combination of ACT, mindfulness, and CBT
to a varied presentation of CHs in a nonforensic sample, Trower et al. delivered
CT strongly focused on power of voices to a more severe but symptomatically
homogenous sample of participants, as all patients in the trial were required to
have had a recent history of compliance with or appeasement to severe CHs.
The simplicity of the therapy and the clear model used in this trial may be of
particular relevance: It is possible that the complexity of TORCH combined with
the varied symptom profile may have contributed to the weak results. The broad
scope of TORCH, while allowing for an individualized formulation and flexible
delivery of treatment, has some important drawbacks in terms of (a) the range
of material that the therapist and the client need to get their head around and
(b) the provision of a coherent model for the client (see Figure 6.1). It does not
lend itself to providing the client with a neat explanatory framework and model
for therapy. More pragmatically, the breadth of possible treatment focus can also
lead to different outcomes for different participants, diluting measures.
Is ACT better than simpler alternatives like befriending? Beyond the TORCH
trial, there is evidence that befriending may be an active and specific interven-
tion in its own right: As a comparison condition it has performed nearly as well
as traditional CBT (Jackson et al., 2008; Samarasekera et al., 2007; Sensky et al.,
2000; Turkington & Kingdon, 2000). People experiencing psychotic disorders
usually present with life-changing difficulties, including the characteristic symp-
toms of schizophrenia both positive and negative, and, in addition, difficulties
with thinking, concentration, attention, abstract reasoning, social cognition,

and verbal memory (Tandon, Keshavan, & Nasrallah, 2008). The breadth and
degree of difficulty of factors that may need addressing for symptoms or func-
tioning to improve through a psychological therapy, and the degree to which
both symptoms and cognitive functioning may be barriers to the progress of
therapy each suggest that the potency of cognitive and behavioral therapies is
tempered by the nature and number of impairments in psychosis. That is, think-
ing and emotional overload can readily occur in talking therapies for psychosis.
ACT ideally attempts to engender experience as the primary vehicle of change,
rather than trying to achieve understanding as the vehicle through explanation.
In considering the application of ACT to psychosis, to what extent is cognitive
reflection and understanding useful? In our view, having some understanding is
helpful and may prevent distorted applications, as illustrated in the qualitative
study of Bacon, Farhall, and Fossey (2014), which found both absence of under-
standing and some fundamental misunderstandings about core interventions,
including mindfulness and defusion, among some participants in our current
trial of ACT for psychosis. Moreover, difficulty understanding, even if “normal-
ized” as part of ACT, can result in negative effects, such as feeling stupid and
frustrated. For maximum impact in chronic psychosis, therapy needs to be kept
as simple as possible. It is possible that the difference between any credible com-
parison treatments is not very much and that a better service response may be to
save money on expensive training and focus on simple services such as befriend-
ing. Further study of befriending therapy in psychosis to replicate possible gen-
eral and specific treatment effects is warranted. Attention to theorized change
processes in both treatments would be of great interest. However, it is equally
important to test ACT on its own, as having two therapeutic modalities in the
one treatment may have been too complex.
Our experience with the TORCH trial suggested a number of priorities for future
research. We briefly outline these here and indicate the extent to which they have
been implemented in our current trial—Lifengage.
Simpler Treatment Interventions
Arguably, there are significant overlaps and synergies between CBT and ACT
(Ciarrrochi & Bailey, 2008), as well as potential value in exploring their synergies
and intersections further. Nevertheless, we argue on both research and clinical
grounds that ACT-only interventions are a greater research priority than inte-
grated ACT-CBT treatments such as TORCH.
First, research evidence for the efficacy of ACT in psychosis (ACTp) as a
stand-alone intervention is promising (Bach et al., 2013; Bach & Hayes, 2002;
Gaudiano & Herbert, 2006; White et al., 2011) but preliminary at present. As
we argue later in this chapter, further studies with improved measures and trial
quality are needed, and the only evidence for the hypothesized mechanisms of
ACT being evident in psychosis is also preliminary in nature. More firmly estab-
lishing the efficacy of ACT in treating psychosis is essential. In this context, com-
bined treatments such as TORCH inevitably have a greater breadth of possible
change targets and mechanisms which are likely to dilute treatment and process
effects on any one measure and make interpretation of ACT-specific treatment
effects more difficult.
Second, we argue that an ACT-only intervention is the research priority at
this stage on clinical grounds. As outlined in the Discussion, our multicom-
ponent therapy added complexity for clinicians and possibly clients. In retro-
spect, we believe our therapists in this trial had more to offer than was wise or
necessary. Broad therapy resource manuals are available for CBT for psycho-
sis—for example, the classic contribution of Fowler, Garety, and Kuipers (1996).
However, a risk of breadth is less clarity and coherence for the consumer (even if
the therapist can neatly integrate it all). In addition, as the promising results of
befriending therapy in psychosis nicely illustrate, benefit to the consumer is not
necessarily dependent on complex therapies.
Attention to Trial Quality
In the pursuit of evidence-based clinical interventions, questions of treatment

efficacy are best addressed via tightly conducted trials. The CONSORT (Moher,
Schulz, & Altman, 2001) criteria for RCTs are now standard, although vari-
ous forms of clinical trials that fall short of a well-controlled RCT can have an
important place in the mix of research. Given that ACT positions itself firmly
in a science paradigm, and that trial quality has been a concern of critics (e.g.,
Ost, 2008), high-quality studies both address these concerns and ensure robust
results. Compared with other ACTp trials, the TORCH study did well in this
regard, and its score on the CTAM measure of research trial quality (Tarrier &
Wykes, 2004) was superior to all but 2 of the 35 trials reported in the review of
CBTp conducted by Wykes et al. (2008).
Methodological improvements over previous ACTp trials included having
a rigorous process for checking that assessors were blind to condition, and
an alternative psychological treatment condition (befriending therapy) with
known efficacy. The TORCH trial was the first ACTp study to employ a known
active comparison treatment. Although tighter methodology may enhance
the likelihood of substantive funding from medical research bodies, a balanc-
ing issue is that key features of trial quality add substantially to the funding
required—active control treatments, larger sample sizes to ensure adequate
power, and independent assessments of outcome and fidelity can be expensive.
A disincentive is that such improvements may, of course, make significant
results less common—as illustrated by Wykes et al.’s (2008) demonstration of
an inverse relationship between trial quality and the effect size of the primary
outcome measures.
Adequate Sample
Our obtained sample was disappointing, but it raises the question of what sam-
ple sizes might be needed for future treatment trials. Obviously, this depends on
the number of groups to be compared and the potency of the interventions. To
demonstrate superior efficacy over a comparison therapy rather than just TAU
is likely to require substantially more participants than the 43 we randomized.
A cautionary finding from the Wykes et al. (2008) CBT meta-analysis was that
the effect size for the target symptom fell to 0.22 after selecting only those stud-
ies whose methodology was rated as “rigorous.” For this effect size a two-group
F-test would require a sample of 203 to reliably detect a difference. On these
grounds, future well-controlled studies should be cautious about expected effect
size when calculating sample sizes.
Improved Measurement
Measurement of outcomes in ACTp needs to address both standard outcome

measures focused on improvements in clinical presentation such as the BPRS (as
used by Gaudiano & Herbert) or PANSS (used in TORCH), as well as theoreti-
cally important outcome targets, such as the preoccupation dimension of psy-
chotic symptoms, and the domain of valued living. In addition, to achieve status
as a fully evidence-based treatment for psychosis, ACT will need to demonstrate
the mediation of such outcomes by theoretically predicted mechanisms. A first
step in this has been the demonstration of believability as a mediator of hospi-
talization outcome in the first two ACTp trials (Bacon et al., 2014). However,
the measurement of the “believability” construct is confounded with that of the
construct of “conviction” (Farhall, Shawyer, Thomas, & Morris, 2013), which
is traditionally used as an outcome measure (a component of severity). This
measurement problem, along with the absence so far of any other theoretically
relevant mediating variable as a mediator of change in psychotic symptoms in
psychosis studies, means that this domain of research is critical to improve. As
we noted earlier, meditational analyses need to be done in controlled trials if the
intended argument is to support the intervention (as opposed to demonstrating
the process).
The VAAS, of course, was developed in order to measure acceptance of CHs
and AHs as a key mechanism of change. Although the initial psychometric
results were promising (Shawyer et al., 2007), this instrument requires further
development and assessment including its sensitivity to change. It is important
to note that the measure was both developed and assessed in the same sample
and one which was likely unusually severe; hence, cross-validation in a new
sample is essential. As well, the wording of some items is complex, which may
affect its performance: Simplification of items is likely to be helpful especially
in reducing the double negatives for longer items. The construct of acceptance
is not an easy one to convey, and the challenge is to reduce the complexity of
items while still conveying its true meaning, rather than common but incorrect
connotations such as resignation or engagement. For example, in some further
psychometric evaluation of Section A of the VAAS, conducted as part of a doc-
toral dissertation (Ratcliff, 2010), a poor association of the item “I accept the fact
that I hear voices” was found with other items; this may be because multiple
interpretations of “accept” are possible. We are aware of independent researchers
using the instrument; further data to better evaluate its performance are likely
to be published.
Other measurement issues in this field are partly psychosis related, particu-
larly the likely impact on reliability and validity of common cognitive difficul-
ties, and partly more general—for example, the difficulties in baseline rating of
mindfulness in the absence of having experienced the process. These issues are
discussed in more detail in Farhall et al. (2013).
Our Next Step—Lifengage RCT of ACT vs. Befriending
These priorities for research have shaped our current trial. To begin with, our
choice of sample reflects the argument above. Community-residing patients
with a diagnosis of schizophrenia or schizoaffective disorder and who have
medication-resistant psychotic symptoms were chosen on the basis of having
high levels of need and being a priority for research funding. Consistent with
the desirability of researching simpler interventions than TORCH, we have set
aside further development of a combined ACT-CBT intervention in favor of an
eight-session ACT treatment. The treatment is a further development of Bach’s
approach, with additional attention to accommodating cognitive deficits associ-
ated with psychosis through choice of, as well as simplification of, metaphors and
exercises, and the whole influenced by further development of our theoretical
ideas (Shawyer et al., 2013).
Tightening trial quality has been addressed by aiming to meet most of the
CONSORT criteria for RCTs. We have again used befriending as an active con-
trol, employed careful procedures to ensure blind assessments, demonstrated
fidelity, and relied on validated measures. The 96 participants randomized fell
a little below our calculated target of 106, but is greater than any ACTp study to
date. We included the AAQ as a standard ACT process measure as well as the
VAAS to measure acceptance and independent action in relation to hallucinated
voices, and the Thought Action Fusion measure as a proxy for fusion/defusion.
We also sought other windows into understanding the processes of ACT with
this population, with one add-on study in which qualitative interviews of partic-
ipants are conducted (Bacon et al., 2014), and another study, yet to be published,
extending to psychosis the Hesser et al. (Hesser, Westin, Hayes, & Andersson,
2009) method of rating in-session verbal behaviors reflecting client response to

CT interventions by the therapist. At the time of writing, all data have been col-
lected and analysis is underway.
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7
Person-Based Cognitive Therapy

for Distressing Psychosis
Integrating a Mindfulness-Based Approach
with Cognitive Therapy
M A R K H AY W A R D , LY N E L L E T T, A N D C L A R A S T R A U S S ■
I N T R O D U CT I O N
Person-based cognitive therapy for distressing psychosis (PBCT, Chadwick,

2006) is an integration of cognitive theory and therapy, mindfulness, and
Rogerian principles (particularly acceptance). The emphasis in PBCT is on under-
standing and reducing distress, and on promoting strengths and well-being. This
chapter provides an integrated summary of the PBCT approach and starts with
an overview of the zone of proximal development—the central theoretical model
used in PBCT. This includes a summary of each of the four zones with integrated
discussion of the associated main therapeutic techniques. A clinical vignette is
then provided, and the chapter concludes with a summary of current research
supporting the approach and future research directions.
OV ERV I E W O F T H EO R E T I CA L M O D EL I N PB CT:
T H E ZO N E O F PR OX I M A L D E V ELO PM EN T
The zone of proximal development (ZoPD; Vygotsky, 1978) is the central for-
mulation model in PBCT; it is a conceptualization of collaborative learning and
represents a dynamic interpersonal therapeutic process. It is used to formulate
both distress and strengths/positive characteristics. It consists of four indi-
vidual zones (see Figure 7.1): symptomatic meaning, relationship with experi-
ence, schemata, and symbolic self, and is defined as “a social process, whereby
Person-Based Cognitive Therapy for Distressing Psychosis151
Relationship with Internal Experience

Symptomatic Meaning
Case Formulation: ABC Framework Case Formulation: Mindfulness-based formulation of
Main Techniques: Exploring goodness of fit of beliefs; distress
embracing doubt & uncertainty; assessing usefulness &
impact; behavioral experiments
Main Techniques: Mindfulness Practice
Radical Collaboration
Schemata Symbolic Self
Case Formulation: Negative self-schema (NSS) Case Formulation: Integration of NSS & PSS
Positive self-schema (PSS)
Main Techniques: Two-Chair Method Main Techniques: Two Chair Method
Figure 7.1. Summary of the four zones of proximal development.

Adapted from P. Chadwick, Person-Based Cognitive Therapy for Distressing Psychosis.
Wiley-Blackwell, 2006, p. 10.
with the support of a radically collaborative and skilled therapist, a client eases
distress, develops metacognitive insight and achieves self-acceptance through
proximal development in all four domains” (Chadwick, 2006, p. 11). Proximal
development occurs through a social and collaborative process; client and
therapist work together in each of the four zones, with equal emphasis placed
on working with strengths and distress. The zones are intentionally positioned
alongside each other, promoting flexibility and movement between zones dur-
ing therapy, rather than having to “work through” each one hierarchically.
Figure 7.1 is a summary of the ZoPD, which is intended mainly for therapists
to help them structure PBCT; case formulation materials that are used with cli-
ents, and main techniques, are listed in each zone. Radical collaboration (RC) is
at the heart of PBCT and is infused within each of the four zones.
R A D I CA L C O L L A B O R AT I O N
In PBCT, the client is positioned at the heart of the therapeutic process, thus the
centrality of a person-centered relationship is essential to the process of therapy.
In PBCT, the primary task from the outset is to develop and establish a relation-
ship that is radically collaborative and enables clients to formulate their goals
within the context of an open, supportive, and collaborative relationship. There
are a number of characteristics that support radical collaboration, including
active listening, Socratic dialogue, and open discussion of important issues such
as responsibility and choice. In developing and establishing a radically collab-
orative relationship, the therapist “meets the person” rather than their problem
or symptoms. Therefore, it is essential that the therapeutic relationship be char-
acterized by openness and collaboration. The practice of PBCT and RC is thus
supported by several positive assumptions about people with psychosis and the
process of therapy. Chadwick (2006) identifies five such assumptions: the core of
people with psychosis is essentially positive; psychotic experience is continuous
with ordinary experience; the therapist’s responsibility is to radical collaboration
and acceptance; effective therapy depends on understanding sources of distress,
not sources of psychosis; and therapists aim to be themselves more fully with
clients. RC thus supports a person-centered approach to examining sources of
distress and potential for proximal development.
What follows is a summary of each of the four zones of proximal development,
including essential techniques associated with each zone.
T H E FO U R ZO N ES O F PR OX I M A L D E V ELO PM EN T
Symptomatic Meaning
This domain involves working directly with beliefs about symptoms, such as
paranoia and voices (Chadwick, Birchwood, & Trower, 1996). Working within
this domain involves collaboratively exploring an individual’s ability to decen-
ter from their psychotic experiences, which allows the individual to develop not
only awareness of how their beliefs about symptoms affect behavior and generate
distress, but also new meanings that enhance well-being. The aim is to explore
collaboratively an individual’s capacity for proximal development in this domain,
instead of trying to force change to occur. When working with symptomatic
meaning, it can be helpful for therapists to bear in mind that many clients may
not have considered their beliefs in depth before, and that working in this domain
is likely to involve small change, rather than substantial shifts in beliefs.
Main Techniques
Within the zone of symptomatic meaning, the key techniques are exploring
goodness of fit (evidence) of beliefs about symptoms (e.g., beliefs about voices),
including exploring doubt and generating alternatives; assessing usefulness and
impact; and planning and conducting behavioral experiments. These are all com-
mon cognitive-behavioral therapy (CBT) techniques and will be briefly summa-
rized here, as they are discussed extensively elsewhere (see Chadwick et al., 1996).
Goodness of Fit (“Evidence”) and Generating Alternative

Symptomatic Meaning
Goodness of fit concerns examining the extent to which an individual’s belief, or
belief system, captures the entirety of their experience. Within PBCT, the start-
ing point for assessing goodness of fit is always examining reasons that support
individuals’ beliefs (evidence for the belief). Only when a full understanding of
evidence for the belief has been gained would attention then be turned to explor-
ing facets of experience that are less consistent with beliefs (evidence against
the belief). Part of exploring goodness of fit, or “evidence,” involves collabora-
tively exploring doubt with clients. This process begins by examining the client’s
capacity for doubt, and includes the client and therapist offering hypothetical
contradictions (offered tentatively), thereby facilitating development of alterna-
tive symptomatic meaning. The symptomatic belief and alternative are assessed
for consistency with the available evidence (i.e., goodness of fit) and usefulness
(i.e., advantages and disadvantages of each). Within PBCT, it is important to
encourage clients to fully consider both alternatives.
Accepting Fixity
Therapists are often faced with the situation of a client’s belief being fixed. At
these times, it is helpful for therapists to accept this—in PBCT, acceptance
applies to the whole person, which includes their fixed beliefs. Although fixity
can often be frustrating for therapists, it is actually informative—it reveals to the
therapist that in this particular moment, proximal development in the symp-
tomatic meaning zone is not possible. This is not to say that future proximal
development in this zone will not occur, but rather, at this particular point in
therapy, it may be better to turn attention toward working in one of the other
domains. This supports the conceptualization of the four zones as sitting along-
side each other, rather than being “worked through” hierarchically, and allows
for more flexibility and fluidity within the therapeutic process.
Relationship with Internal Experience
Within PBCT, mindfulness is used as the primary method for working within
the relationship domain of the ZoPD. Mindfulness can be used within indi-
vidual therapy and also within the context of mindfulness groups. By engaging
in mindfulness practice, individuals learn to respond mindfully to psychotic
experiences, rather than getting lost in reacting to them; being more aware
of psychotic experiences and their impact allows individuals to let go of their
usual reactions (e.g., experiential avoidance, rumination), which produce dis-
tress. Two main processes support the reduction of distress and enhancement
of well-being through mindfulness practice: (1) decentered awareness (Segal,
Teasdale, Williams, & Gemar, 2002) and (2) acceptance of present-moment
experience. This is facilitated by reflective learning (in which the role of the
therapist is to draw out metacognitive insights) and guided discovery both
prior to and following mindfulness practice, as well as by use of specific
guidance during practice. Guidance during practice and reflective learning
both highlight key aspects of experience during mindfulness practice—for
example, that sensations come and go, and that nothing stays in awareness
permanently. This facilitates the acquisition of metacognitive insights, as the
therapist draws out what the client notices about the nature of sensations and
his or her reactions to them. This helps clients to gain awareness of how their
relationship to (psychotic) sensations has a direct impact on current emo-
tional state. Both decentered awareness and metacognitive insights form the
collaborative learning process and enable clients to realize proximal develop-
ment within the relationship domain of the ZoPD.
Main Techniques
Mindfulness Practice
Mindfulness practice in PBCT starts by bringing awareness to sensations in the
body, starting with noticing points of contact, such as the feeling of the back
against the chair, or soles of feet on the floor. The individual is then guided to
move awareness up through the body (as in a body scan), noticing whatever
sensations are present (pleasant, unpleasant or neutral) and any tension that
is present. Having moved up through the body, awareness then moves to the
breathing—individuals are asked to find a place in the body where the sensations
of breathing are most accessible and comfortable (e.g., tips of the nostrils, rise
and fall of the chest). Breathing helps to anchor awareness, because each breath
occurs in the body in the present moment, not in the past or future. Mindful
awareness of breathing continues for the remainder of the practice, and individ-
uals are gently guided to notice when their mind has wandered (e.g., to distress-
ing voices or images) and are guided to bring awareness back to the sensations of
breathing. At the end of the practice, individuals are gently guided to open their
eyes and settle back into the room.
Adaptations for Psychosis

Although mindfulness-based therapies have proliferated in recent years (e.g.,
Segal, Williams, & Teasdale, 2002), several adaptations to mindfulness prac-
tice have been suggested for working with people with distressing psycho-
sis (Chadwick, 2006; Chadwick, Hughes, Russell, Russell & Dagnan, 2009;
Chadwick, Newman-Taylor, & Abba, 2005; Dannahy et al., 2011). Chadwick
(2006) has identified three main adaptations to mindfulness practice for indi-
viduals with psychosis. First, practice time is limited to 10 minutes maximum,
as many clients find this is the most that they can manage. Second, extended
silences during practices are avoided—therapists give brief guidance or com-
ments every 1–2 minutes. This is an important grounding method, as it helps
clients to decenter from voices and rumination and to reconnect with present
experience with clearer awareness. Third, practice outside sessions is not an
essential requirement—audiotapes of 10-minute guided practices are provided,
and practice is encouraged.
Schemata
In PBCT, working within the schemata domain involves reducing distress directly
linked to the individual’s negative schema of self and others, and enhancing over-
all well-being by developing positive self-schemata. In PBCT, there are four aims
when working with negative schemata. First, individuals increase awareness of
the nature and characteristics of their negative self-schematic experience (NSS).
Second, both the client and therapist accept the NSS, although it is also impor-
tant to acknowledge that there will be future times when the person’s experience
of self is overwhelmingly negative and all-consuming. The third aim is to gain
metacognitive insight about the NSS, that it forms one aspect of the self, not the
entire self. The fourth is to reduce fear associated with negative schematic expe-
rience. Taken together, these four aims allow a new relationship with NSS to be
developed. When working with positive self-schemata (PSS), the aim is to col-
laboratively draw out, maintain, and generalize positive schematic experience.
Main Techniques
In PBCT, a range of experiential approaches are used for working with schemata,
which include (1) mindfulness, (2) shame attacking, (3) experiential role-plays,
and (4) two-chair methods. Mindfulness has already been described. Shame
attacking (repeated voluntary exposure to schematic distress to facilitate toler-
ance and habituation) and experiential role-plays (typically with critical voices
to facilitate challenging of the global, stable felt sense of negative schemata)
are both common CBT techniques. The focus here will be on discussion of the
two-chair method (Chadwick, 2003).
Two-Chair Method
When the rationale and process of the two-chair method has been outlined, and
clients have decided they want to experience it, the first step in the process is for
the client to briefly enact the NSS. Following the client’s enactment, the therapist
then provides an empathic summary of this negative experience of self. The client
is then invited to move to the second chair; at this point the therapist emphasizes
that the NSS stays in the first chair. Following movement to the second chair, the
client then articulates and “lives” a PSS. The therapist then facilitates Rogerian
acceptance of both schemata, and client and therapist together explore the com-
plex and changing nature of the symbolic self. At the end of the two-chair pro-
cess, it is important that the therapist check in with the client, to ensure there are
no continuing effects when the client returns to the chair in which the NSS was
enacted. To support metacognitive insight, maintenance, and generalization, the
two-chair method needs to be seen as a flexible process, rather than a one-time
task, which will often be used many times during therapy.
Symbolic Self
In PBCT, the symbolic self is a metacognitive model of self, which represents

an integration of both positive and negative schematic experiences of self. The
symbolic self brings awareness to and facilitates acceptance of the complex and
changing nature of the experience of self. Most of us probably have moments of
negative self-schematic experience, but this does not tend to dominate or over-
whelm the symbolic self. However, the more the person’s experience of self is
dominated by negative schematic experience, the more the focus of the sym-
bolic self becomes restricted and overly negative—what Chadwick (2006) refers
to as “one-dimensional.” It is common for the symbolic self of individuals with
distressing psychosis to be one-dimensional at the start of therapy. Proximal
development in this domain therefore involves bringing negative schematic

experience into balance and elaborating and enhancing positive schematic expe-
rience, thereby “opening out” the symbolic self and bringing awareness to, and
acceptance of, the complex and changing nature of the self.
Main Techniques
Working with the dynamic nature of the symbolic self is achieved by (1) bring-
ing experientially into awareness the current focus of the symbolic self on the
all-consuming nature of the NSS; (2) enhancing and elaborating on positive
self-schematic experience; (3) supporting acceptance of both NSS and PSS as
valid experiences of self; and (4) working directly to modify the symbolic self so
that it is not solely defined by negative self-schematic experience, but also incor-
porates positive schemata of self and others. The purpose of working within the
domain of the symbolic self is not to get rid of or change the NSS in any way, but
rather to experience the NSS as simply one aspect of self, not the entire self. By
bringing the PSS more into focus, therapists can facilitate reflection on and expe-
rience of the changing nature of the symbolic self. Therapists then emphasize
that the client can either continue to be defined solely by their NSS or commit to
further development of the positive aspects of the symbolic self. This is mainly
achieved using the two-chair method.
C L I N I CA L V I G N E T T E W I T H U S E O F T H E A PPR OAC H
PBCT can be offered individually or in a group format, and it can be syndrome

(psychosis) or symptom (delusional beliefs or distressing voices) focused. This
section provides an overview of offering group PBCT to people who hear dis-
tressing voices.
Therapy Context
Group PBCT is offered over twelve 90-minute sessions, typically with 4–12 peo-
ple per group. Groups are typically facilitated by two therapists and follow the
same format:
1. 5- to 10-minute mindfulness practice

2. 15- to 20-minute discussion and reflection on practice
3. 10-minute break
4. 30- to 35-minute CBT focus
5. 10-minute reflection and homework
The predictability of the format is emphasized to promote the containment of anx-

iety and the collaborative nature of the therapeutic process. The sessions always
begin with the brief mindfulness practice described earlier. The remainder of the
first part of the session is dedicated to reflection on and discussion of experiences

during the mindfulness practice, guided by Socratic questioning (“relationship
with internal experience”). A break is always welcomed by members and is essen-
tial for this client group. The second part of the session utilizes techniques from
cognitive therapy to explore beliefs about voices (symptomatic meaning), beliefs
about the self (schemata), and the changing nature of self (symbolic self). Material
and evidence from the mindfulness practice and from homework are used to
evaluate the accuracy of beliefs. Each session concludes with a brief reflection on
the learning from the session and assignment of the homework.
Therapy through its Phases
Mindfulness Practices
The same practice is offered at the beginning of each session—a 10-minute sit-
ting practice. The same therapist leads the practice and verbally guides members
through a body scan and a focus on the breath. The guidance includes instruc-
tion to bring awareness to the full range of cognitive and emotional experience—
thoughts, feelings, voices, images—and invites group members to notice their
minds wandering and bring their attention back to the breath if they wish to do
so. In this respect, noticing is emphasized as the first part of a two-part process—
and one that creates a choice about whether to allow oneself to be caught up in
internal experience or to bring attention back to the breath. This conceptualiza-
tion is consistent with the radically collaborative stance of the therapists, as it
encourages group members to exercise agency and make their own decisions.
Group members typically engage well with the practices from the outset and
readily accept the central role of mindfulness within the therapy. The initial prac-
tices can offer a novel experience to group members, and this can sometimes gener-
ate concerns about not practicing “the right way” or “not getting it.” Such concerns
can be reflected on during the extended reflection and normalized. Following the
practice, members are invited to offer reflections on their experience. This typi-
cally involves description of their experience during the practice—often describ-
ing a sense of relaxation. Socratic questioning is used to help members locate such
feelings in their bodies. Voices are often active during practices, and members are
invited to describe the process of noticing voices and their subsequent response.
Participants typically report that when they are able to focus their attention on
their breathing during the mindfulness practice, voices tend to fade into the back-
ground. This is often accompanied by feelings of calm and peacefulness.
ABC Model (Sessions 2–3)

During sessions 2 and 3, the focus is on collaborative discussion of feelings
and behaviors that are commonly associated with hearing voices, including the
impact of beliefs about voices and beliefs about self. This is discussed Socratically,
with examples being grounded in participants’ own experiences, and formulated
using the ABC model. An example follows.
Activating Event A Beliefs and Thoughts B Consequences C

Voice comments Beliefs about voices: Feelings:
“Voices are powerful.” Anxious
“Voices have control.” Low in mood
Beliefs about me: Behavior:
“I have no control.” Stop doing the things
“I am weak.” I want to do
Subsequent discussion is then focused on how different beliefs and thoughts

about the same experience (i.e., hearing a voice) can result in different conse-
quences. This is again formulated using the ABC model; following is an example:
Activating Event A Beliefs and Thoughts B Consequences C

Voices start talking Beliefs about voices: Feelings:
“Voices don’t have total Proud of myself
control.” Enjoyment
Beliefs about me: Behavior:
“I am strong.” Go to work
“I have some control.” Spend time with friends
Read a good book
Personal Control (Sessions 4–6)

The focus during sessions 4–6 is on collaborative discussion of the belief that
voices have control over us. Socratic dialogue is used to help assess the accuracy
of this belief, using questions such as the following:
1. What is the evidence that the voices have control over us?
2. Is there any evidence that the voices do not have control over us?
“Voices have control over us.”

Evidence supporting this idea Evidence not supporting this idea
Last week voices told me not to Yesterday I went shopping even though voices
go shopping and I didn’t go. told me not to go.
Voices told me not to call my Voices made threats that something bad would
friend last night and I didn’t. happen if I went out on Tuesday but I went
out anyway and nothing bad happened.
Voices told me I was stupid and Voices told me that my friends didn’t like me
should stop reading my book, and not to bother calling them, but I picked
and I stopped reading it. up the phone and called them. They seemed
really pleased to hear from me and we met up
for a coffee.
Further evidence is gathered that voices do not always have control:
Belief: “Voices do not always have control over us.”

Evidence supporting this belief:
• Voices told me not to go shopping or something bad would happen. I went
shopping anyway and everything was OK.
• I went to a party even though voices told me not to and I had a good time.
• Voices told me to harm myself but I said no and felt proud of myself.
• I called my friend even though voices said that she didn’t like me. She was really
pleased to hear from me and suggested meeting for coffee.
All the evidence gathered is then reviewed, and group members are asked
to reflect on what this evidence might mean about themselves and voices.
Through collaborative reviewing of the evidence and Socratic dialogue, par-
ticipants develop the insight that they do have some personal control, even
when voices are around. This can subsequently be used to examine the differ-
ence between believing that voices have total control and believing that par-
ticipants themselves have some control, which is again illustrated using the
ABC framework.
A (Antecedent Event) B (Beliefs and Thoughts) C (Consequences)

Hear a distressing voice “I have some personal Feelings:
control even when the Proud, enjoyment
voices are around.” Behaviors:
Go out; see friends; do
things I enjoy
Voices are around “Voices have control over Feelings:
me.” Anxious, depressed, angry
Behaviors:
Stay at home; avoid seeing
people; lie in bed
Members are guided to consider how their day-to-day lives might be different if
they began to believe they had some personal control and act in accordance with
this belief. Individuals are encouraged to plan activities to do outside of therapy
that they enjoy (e.g., going to the shops, seeing friends) and which support the
belief that they have some personal control even when voices are around. It is
important that the activities planned feel manageable; they should be formulated
with each individual within the group context.
Positive Self-Schemata (Sessions 7–10)

Sessions 7–10 focus on individuals’ experience of the self. Individuals are intro-
duced to some of the cognitive biases that can maintain negative self-schemata
and are encouraged to notice and reflect on examples based on their own
experiences:
1. Noticing evidence and experiences that fit with negative beliefs about
ourselves.
Example: We have an argument with a friend and blame ourselves and
think, “It’s all my fault.”
2. Ignoring or “bouncing off” evidence or experiences that don’t fit with
negative beliefs about ourselves.
Example: We go shopping despite voices and we don’t give ourselves any
credit.
3. Distorting positive experiences so that they fit with negative beliefs.
Example: A friend gives us a compliment and we think they “ just feel sorry
for me.”
Members are also encouraged to recollect positive beliefs about themselves, or

times when they have felt okay about themselves. This can be very difficult for
some individuals, particularly when their view of the self is dominated by nega-
tive self-schemata. However, working in a group means that only one member
needs to offer a positive experience for the group to have new material to reflect
on. When asking participants to reflect on times when they felt okay about them-
selves, it can be helpful to ask:
• What was happening? (e.g., helping a friend with something)

• How did you feel? (e.g., feeling proud)
• What did this experience mean about you as a person? (e.g., “I am a good
person,” “I am valued,” “I am helpful”)
This facilitates development of and reflection on positive experiences of self. In

addition, mindfulness can be a helpful way to bring full awareness to positive
experiences, even though such experiences may be infrequent, at least to start
with. This process becomes easier and more fluid as participants gain more expe-
rience of noticing positive experiences of self.
When members reflect on a positive experience of self, there is often a sense
of them visually growing in stature and confidence—sitting upright, smiling,
seeming “bigger” somehow. These changes are highlighted to the group and
reflected back to the individual. Socratic dialogue of positive experiences of
self enables individuals to develop and reflect on positive beliefs about the self.
Typical examples might include the following:
• I am good enough.

• I am an okay person.
• I am a helpful person.
• I am capable.
• I am likeable.
The two-chair technique can be used in a group format to facilitate discussion of

the different ways that we can experience the self at different times. The two chairs
are first introduced to the group, as is done when using the technique in individual
therapy. Group members are often very aware of their negative experiences of self,
therefore the focus is on articulating and experiencing the PSS. Group members
are each invited to sit in the positive chair, so that individuals get some sense of
what this other (positive) way of experiencing the self feels like. During this pro-
cess, individuals develop awareness that we sometimes see ourselves in a positive
way and sometimes we see ourselves in a negative way (symbolic self). When we
are in the negative chair it can feel as if it is always going to be like this (i.e., drawing
out the global and stable qualities of the NSS). Mindfulness skills can be used to
notice when we are sitting in the negative chair and remind ourselves that it won’t
always be this way. When participants become aware of feeling okay about them-
selves, mindfulness skills can be used to bring full awareness to how this feels,
what they are thinking, and what they notice physically in their body. When using
the two-chair technique, the following questions can be used to guide reflection:
• What happens to voices when I am sitting in the positive chair?

• How do I view myself as a person when I am sitting in the positive chair?
• What activities am I doing when I experience myself as an okay person?
• What activities could I do this week that might help me to sit in the
positive chair?
• What have I learned about myself from sitting in the positive chair?
• What have I learned about voices from sitting in the positive chair?
Looking Back and Forward (Sessions 11–12)

During the final two sessions, individuals are invited to discuss what they each
learned from therapy and what they plan to take forward into their daily lives.
Discussion and responses can be mapped onto the four domains of proximal
development. Some typical examples are as follows:
1. Mindfulness
• Listening to the mindfulness practice every day or as often as seems
helpful.
• Listening to the mindfulness practice when we are sitting in the
negative chair.
• Using mindfulness skills in our daily lives (e.g., when we are shopping).
2. I have some personal control even when voices are around.

• Reminding ourselves of the evidence from our own lives that we
sometimes have control even when voices are around.
• Doing what we want to do and not what voices tell us to do.
3. I have positive qualities.

• Remembering a positive chair experience when I felt okay about myself
as a person.
• Asking ourselves: “How do I see myself as a person when I am sitting

in the positive chair?”
• Doing things that can help us to sit in the positive chair (e.g., spending
time with friends).
4. We all have negative and positive views of ourselves at different times.

• Noticing when we are sitting in the negative chair (using our
mindfulness skills).
• Reminding ourselves that the negative chair isn’t all there is; we have
positive chair experiences too.
Summary of Clinical Vignette
PBCT is a 12-week therapy program that can be offered in a group format to

people who hear distressing voices. The clinical vignette presented here is
intended as one possible example of how PBCT can be structured and imple-
mented. Therapists are encouraged to use the main techniques flexibly and to
work collaboratively with clients within each of the four domains of proximal
development.
C O M M O N VS. D I ST I N CT I V E EL EM EN TS O F PB CT
PBCT has elements that are both similar to and distinctive from those of CBT and
mindfulness-based cognitive therapy (MBCT; Segal, Williams, Teasdale, 2002).
Like CBT for psychosis (CBTp), PBCT involves working directly with beliefs about
symptoms, such as paranoia and voices, to develop new meanings that enhance
well-being. Within the zone of symptomatic meaning, key techniques are used
that are also common CBT techniques, for example, exploring goodness of fit
(evidence) and beliefs about symptoms (e.g., beliefs about voices). For MBCT, the
similarity of PBCT relates to the integration of cognitive therapy techniques and
a mindfulness-based approach. By engaging in mindfulness practice, individu-
als learn to respond mindfully to psychotic experiences, rather than getting lost
in reacting to them. Through facilitated reflective learning and guided discovery
the acquisition of metacognitive insights helps clients gain awareness of how their
relationship to (psychotic) sensations directly affects their current emotional state.
The distinctiveness of PBCT is threefold. In relation to MBCT, PBCT empha-
sizes adaptations to mindfulness practice for working with people with distress-
ing psychosis (e.g., practice time is limited to 10 minutes maximum; extended
silences during practices are avoided; and practice outside sessions is not an
essential requirement). In relation to CBTp, PBCT foregrounds and works more
extensively on self-schema. CBTp has always included an element of self-esteem
work—but arguably such work has not been driven by a specific conceptual-
ization of schemata, their influence, and how they can be modified. In PBCT,
working within the schemata domain involves a model-driven conceptualiza-

tion of negative and positive self-schemata and dedicates a number of sessions
to the reduction of distress directly linked to the individual’s negative schema
of self and others and enhancing overall well-being by developing positive
self-schemata.
The final distinctive element involves the balancing of NSS and PSS. In PBCT,
the symbolic self is a metacognitive model of self, which represents an integra-
tion of both positive and negative schematic experience of self. The symbolic
self brings awareness to, and facilitates acceptance of, the complex and changing
nature of the experience of self. Proximal development in this domain therefore
involves bringing negative schematic experience into balance and elaborating
and enhancing positive schematic experience, thereby opening out the symbolic
self and bringing awareness to and acceptance of the complex and changing
nature of the self.
PBCT FOR DISTRESSING PSYCHOSIS: WHAT IS THE EVIDENCE?
PBCT is an integrative therapy combining CBTp with a mindfulness-based ther-

apy for psychosis (MBTp) approach. Therefore, when considering the evidence
for effectiveness of PBCT, it is important to review evidence for effectiveness of
its constituent parts (CBTp and MBTp), as well as evidence for effectiveness of
the integrated whole—PBCT. Evidence for CBTp is summarized next, followed
by a review of the evidence for MBTp. A review of the evidence for PBCT is then
provided. This section ends with conclusions drawn from the evidence to date
and setting the agenda for future research.
Cognitive-Behavioral Therapy for Psychosis
A review of the evidence for CBTp is covered in Chapter 2 in this volume and
so will only be briefly summarized here. A meta-analysis of CBTp random-
ized controlled trials (RCTs) was conducted by Wykes and colleagues (Wykes,
Steel, Everitt, & Tarrier, 2008). They included 34 trials in their analysis and
found a between-group Cohen’s d effect size on target symptoms of 0.4, which
is in the small to medium range. A similar effect size (d = 0.37) was found for
positive symptom outcomes for the 32 trials that included a measure of posi-
tive symptoms. However, this meta-analysis included trials with nonactive
control conditions, so it is not possible to rule out the effects of nonspecific
therapy factors.
To control for nonspecific therapy factors, Lynch, Laws and McKenna. (2010)
conducted a meta-analysis of nine RCTs that compared CBTp to active control
conditions (supportive counseling or therapy, befriending, psychoeducation,
recreational therapy, and social activity therapy). They found no difference
between CBTp and active control conditions for symptoms (d = 0.08), suggesting
that CBTp is no more effective than other active interventions in reducing symp-
toms of psychosis.
In summary, while CBTp provides modest benefits in comparison to inac-
tive control conditions, it does not appear to be more effective than other active
interventions such as supportive counseling or therapy. These findings all point
to the need to refine CBTp to improve benefits and PBCT is a possible candidate
in this respect.
Mindfulness-Based Therapy for Psychosis
Evaluation of mindfulness-based therapies for psychosis are still in their

infancy. We have conducted a systematic review of the individual and group
MBTp literature (Shore, 2013), where MBTp was defined as an intervention
that foregrounded mindfulness, mindfulness practice was included in ther-
apy sessions, and mindfulness home practice was encouraged. This defini-
tion was adopted in an attempt to bring MBTp in line with well-established
mindfulness-based interventions such as mindfulness-based cognitive therapy
(MBCT; Segal, Williams, et al., 2002) and mindfulness-based stress-reduction
(MBSR; Kabat-Zinn, 1990).
The systematic review of the individual and group MBTp literature included
three qualitative studies of MBTp (Abba, Chadwick, & Stevenson, 2008; Ashcroft,
Barrow, Lee, & MacKinnon, 2012; Brown, Davis, LaRocco, & Strasburger, 2010),
three case series (Davis, Strasburger, & Brown, 2007; Ellett, 2013; Newman
Taylor, Harper, & Chadwick, 2009), two uncontrolled trials (Chadwick et al.,
2005; van der Valk, van de Waerdt, Meijer, van den Hout, & de Haan, 2012), and
five controlled trials (Chadwick et al., 2009; Lalova et al., 2013; Langer, Cangas,
Salcedo, & Fuentes, 2012; Shawyer et al., 2012; White et al., 2011). What follows is
a summary of findings from the uncontrolled and controlled trials of MBTp that
were identified in the systematic review.
Uncontrolled MBTp Studies

Two uncontrolled pre-post studies of MBTp were found (Chadwick et al., 2005;
van der Valk et al., 2012). Across the studies 30% of participants dropped out.
Both studies found significant pre- to post-therapy improvements on measures
of psychological health or mental health. Neither of these studies evaluated
symptoms of psychosis. These two studies provide evidence that MBTp for psy-
chosis is associated with improvements in psychological health and decreases in
mental health symptoms. However, as these studies were uncontrolled, it is not
possible to rule out the possibility that these improvements may have occurred
over time without the intervention.
Controlled Trials
Five controlled trials of MBTp were identified in the systematic review (Chadwick
et al., 2009; Lalova et al., 2013; Langer et al., 2012; Shawyer et al., 2012; White
et al., 2011). While the study by Shawyer et al. (2012) was of a therapy that inte-
grated CBT with acceptance and commitment therapy (ACT) for psychosis (see
Chapter 4 if this volume for a description of ACT), mindfulness practice was
included in sessions and home practice was encouraged. The study by White
et al. (2011) was of ACT as well, but included the PBCT mindfulness practice
developed by Chadwick (2006).
Over the five trials only 9% of people dropped out of the intervention arm,
which might be taken as an indication of the acceptability of the intervention
approach. However, there were few significant between-group post-intervention
differences.
Chadwick et al. (2009) found a nonsignificant difference between groups
on a measure of psychological health, albeit with a medium effect size in the
hypothesized direction. In their RCT of ACT for psychosis, White et al. (2012)
found no significant between-group differences on measures of depression or
anxiety or on a measure of positive symptoms. However, they did find significant
between-group differences with large effect sizes on measures of negative symp-
toms and on a measure of mindfulness skills. Shawyer et al. (2012) found no sig-
nificant between-group differences on any measure, and effect sizes were small
in their RCT comparing acceptance-based CBT to an active control intervention
(befriending). In their pseudo-randomized trial with “insight” as the primary
outcome, Lalova et al. (2013) found no differences between MBTp and cognitive
remediation therapy (CRT) on four of their five insight subscales (CRT targets
neurocognitive processes associated with psychosis such as attention and work-
ing memory). They did, however, find that MBTp participants showed greater
improvement on the symptomatic attribution subscale in comparison to CRT.
Finally, Langer et al. (2012) found no significant between-group differences on
their measure of symptoms, although they did find significant between-group
differences in the expected direction on their measure of mindfulness.
Findings across these five studies were mixed, with a general failure to find
consistent benefits of MBTp in comparison to control conditions. However, all of
the studies were underpowered to find anything other than large between-group
effect sizes, so it is difficult to draw firm conclusions from the findings. Perhaps
one of the more interesting results from these studies is that only 9% of par-
ticipants dropped out from the MBTp arm, which, given the caution sometimes
expressed about mindfulness-based interventions for people experiencing psy-
chosis, suggests the acceptability of MBTp to these individuals. Although con-
trolled trials represent an important development in the methodological rigor of
MBTp evaluation, what is required is a fully randomized controlled trial in order
to elucidate the effectiveness of MBTp.
Person-Based Cognitive Therapy for Distressing Psychosis
What we have seen so far is evidence that effectiveness of CBTp may be limited
in comparison to nonactive control conditions and that CBTp may be no more
effective than other active interventions. Evidence for MBTp appears tentatively
promising. PBCT integrates these two approaches. This review now turns to
evaluating the evidence for effectiveness of this integrative approach.
One quantitative and two qualitative studies of PBCT for psychosis have been
published to date (Dannahy et al., 2011; Goodliffe, Hayward, Brown, Turton, &
Dannahy, 2010; May, Strauss, Coyle, & Hayward, 2014). Dannahy et al. (2011)
reported on our uncontrolled trial with 62 participants (40 female, 22 male),
all of whom were hearing distressing voices. There were significant pre- to
post-therapy improvements on a measure of psychological health, with a medium
effect size (d = 0.57) on ratings of distress in relation to hearing voices (d = 0.75)
and on ratings of beliefs about voice control (d = 0.62). These improvements were
maintained at 1-month follow-up. Although this study offers initial support for
PBCT in terms of clinical benefits and acceptability (18% dropped out), the lack
of a control group does not allow us to attribute benefits to the therapy with any
certainty, as observed improvements may have occurred without intervention.
The qualitative studies by Goodliffe et al. (2010) and May et al. (2014) both cor-
roborate the acceptability of PBCT for participants (who were drawn from the
Dannahy et al., 2011 study). In a thematic analysis from transcripts of interviews
with 10 participants, May et al. (2014) identified three themes, which all involved
a change in relating: relating differently to voices, relating differently to self, and
relating differently to others. These three themes corroborate the emphasis in
PBCT on altering how we relate to our experiences. The three themes identified
by May et al. (2014) also lend support to the four domains of the PBCT model
(see Figure 7.1). Participants described (1) changing beliefs about voice power
and control, so that they no longer perceived voices as having complete control
(symptomatic-meaning domain); (2) relating to experiences, including voices,
with acceptance (relationship with internal experiences domain); (3) acknowl-
edging and strengthening positive self-schema (schemata domain); and (4) let-
ting go of a fixed sense of (negative) self (symbolic self domain). Thus, findings
from May et al. (2014) suggest that all four domains of the PBCT model were
valued by participants as facilitating meaningful change.
Future Research
Although findings from these three studies of PBCT offer early support for the
approach, what is needed is an adequately powered RCT. Our research team is
currently conducting an RCT of PBCT that will enable us to evaluate PBCT in
comparison to treatment as usual on a range of important outcomes, including
psychological well-being, depression and anxiety symptoms, self-esteem, posi-
tive symptoms, and recovery.
Depending on the findings from this initial RCT, future research of PBCT
should include an active control condition in order to control for nonspecific
therapeutic factors. Indeed, while the meta-analysis by Wykes and colleagues
(2008) found a modest effect for CBTp in comparison to control conditions,
no differences between CBTp and active control conditions were found in the
meta-analysis by Lynch and colleagues (2010). This highlights the potential role
of nonspecific therapeutic factors in facilitating improvements and the need for
comparison conditions that control for these factors.
In addition to adopting robust designs to evaluate effectiveness, future
research should focus on identifying potential mechanisms of therapeu-
tic change during PBCT, in order to elucidate the active ingredients of
change. In the MBCT literature, for example, improved mindfulness skills
and self-compassion have been identified as mediators of clinical outcome
(Kuyken et al., 2010), and mediation analyses should be extended to PBCT
research. According to the PBCT model (see Figure 7.1), potential mediators
of outcome would include beliefs about psychotic experiences, beliefs about
self and others (schemata), mindfulness skills, and symbolic self. Measures of
these constructs could be included in future PBCT research in order to iden-
tify which of these factors contribute to outcome.
Qualitative research can also help to elucidate potential mechanisms of
change, by exploring participant experiences of the therapy. Future PBCT
research could build on the studies by Goodliffe et al. (2010) and May et al.
(2014) in order to explore in more depth the PBCT change process. Identifying
mechanisms of change will allow us to better understand the active ingredients
of PBCT and then to refine the therapy to more effectively target these active
ingredients.
C O N C LU S I O N
Person-based cognitive therapy for distressing psychosis (Chadwick, 2006) inte-

grates CBTp with a mindfulness-based therapy (MBTp). Four domains of thera-
peutic change are suggested to occur within a radically collaborative therapeutic
relationship: (1) symptomatic meaning, (2) self-schemata, (3) relationship to
internal experience, and (4) symbolic self. Although there is evidence for the
effectiveness of CBTp in comparison to inactive control conditions, it does not
appear to be any more effective than other active interventions. There is evidence
from uncontrolled and controlled trials suggesting that MBTp may be effective
at improving psychological well-being and mental health. There is emerging evi-
dence that PBCT, as an approach that integrates CBTp with MBTp, is effective in
improving psychological well-being and is acceptable to participants. The four
domains of PBCT were corroborated through a qualitative study of the therapy,
which suggested that each domain may be important in facilitating therapeutic
change. An adequately powered RCT of PBCT is currently underway; it is hoped
that this study will enable us to comment with more clarity on the potential
benefits of PBCT for people who are experiencing distressing psychosis. Future
research should include comparison conditions that control for nonspecific ther-
apeutic factors, and would benefit from a focus on identifying potential mecha-
nisms of therapeutic change.
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49(12), 901–907.
Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behaviour ther-
apy for schizophrenia: Effect sizes, clinical models and methodological rigour.
Schizophrenia Bulletin, 34(3), 523–537.
8
Mindfulness Meditation
in Cognitive-Behavioral Therapy
for Psychosis
K AT H E R I N E N E W M A N TAY LO R A N D N I C O L A A B B A ■
The use of mindfulness meditation in mental health settings has developed rap-
idly over the last two decades. In a secular context, mindfulness is taught as
a skill that may be valuable for people with long-standing or recurrent mental
health problems. The therapeutic aim is to teach people to step back, or “decen-
ter,” from habitual patterns of distressing internal experience and to respond
with acceptance and a compassionate curiosity rather than with rumination and
avoidance. In learning to respond mindfully, people may no longer be domi-
nated by overwhelming fears, despair, memories, voices, and so on, and start to
engage more effectively in the lives they wish to lead (see Kabat-Zinn, 1990; 2003;
Teasdale et al., 2000; 2002;3; Teasdale, Segal, & Williams, 1995; Williams, 2008).
The growing evidence for mindfulness-based interventions, while not unequiv-
ocal, suggests that these approaches may be effective in alleviating distress and
reducing risk of relapse in people with depression and anxiety as well as physi-
cal health problems (see Baer, 2003; Grossman, Niemann, Schmidt, & Walach,
2004; Hofmann, Sawyer, Witt, & Oh, 2010; Piet & Hougaard, 2011, for reviews).
There is also some preliminary support for the use of mindfulness meditation
with people with psychosis (Abba, Chadwick, & Stevenson, 2008; Chadwick,
Hughes, Russell, Russell & Dagnan, 2009; Chadwick, Newman Taylor, & Abba,
2005; Ellett, 2013; Newman Taylor, Harper, & Chadwick, 2009), though some
have expressed concerns about the possibility of causing harm with this group.
In our work as clinical psychologists and cognitive-behavioral therapists, we
use mindfulness meditation with people with psychosis. Our practice is firmly
Mindfulness Meditation in Cognitive-Behavioral Therapy for Psychosis171
embedded in a cognitive-behavioral therapy (CBT) understanding of voices,

paranoia, and other delusions, and we introduce mindfulness when indicated
by a person’s individualized formulation of the specific processes likely to be
maintaining distress (following Teasdale, Segal, & Williams, 2003). In this chap-
ter, we aim to place mindfulness for psychosis in the context of CBT theory and
practice. The reasons why mindfulness may be helpful for people with psychosis
are described, as well as possible reasons for caution. Given the overarching aim
of this book, we discuss common and distinctive elements of this approach in
order to contrast emerging models in the area. A review of the research indicates
promising but preliminary evidence. Arguably, it is only with a detailed under-
standing of the mechanisms of change that we are able to offer the most effective
psychological interventions. Future research, therefore, needs to address ques-
tions of therapeutic process, as well as larger efficacy studies, if we are to deliver
mindfulness-based interventions that enable people to live well with psychosis.
T H EO R E T I CA L M O D EL A N D PR O P O S ED M EC H A N I S M S
OF CHANGE
A Cognitive Approach to Psychosis
The aim of CBT1 for psychosis is to support people’s recovery by decreasing dis-
tress, reducing risk of relapse, and improving quality of life. Therapy focuses on
working collaboratively to understand the psychological processes involved in
the development and maintenance of distressing psychosis and then support the
person to make changes in line with his or her goals and aspirations.
The cognitive model (Beck, 1976; Beck, Emery, & Greenberg, 1985; Beck,
Rush, Shaw, & Emery, 1979) assumes that distress and disability are often cog-
nitively mediated. For example, we know that many people in the nonclinical
population hear voices (Beavan, Read, & Cartwright, 2011; Johns et al., 2004,
Johns & van Os, 2001; Romme & Escher, 2006), and that those who have come
to believe that their voices are powerful and malevolent are likely to feel dis-
tressed (Chadwick & Birchwood, 1994; 1995). Similarly, studies show that para-
noia is a common experience in the general population (Bebbington et al., 2013;
Freeman et al., 2008; Johns et al., 2004) and that severity of paranoid thinking
is strongly associated with poorer mental and physical health and social func-
tioning (Freeman et al., 2011). Although there are a number of cognitive behav-
ioral models of psychosis, differing somewhat in focus and emphasis, there is
broad agreement that it is not the voices, other perceptual anomalies, or even
automatic paranoid thoughts that are necessarily problematic, but the develop-
ment and maintenance of causal explanations that are distressing and behav-
iorally disturbing. These beliefs are likely to have been influenced by emotional
and psychosis-specific processes, as well as a person’s early learning history (see
Bentall, 2003; Chadwick, 2006; Freeman, 2007; Freeman & Garety, 2004; Garety,
Kuipers, Fowler, Freeman, & Bebbington, 2001; Gumley & Schwannauer, 2006;
Morrison, 2001). The recent outcome data indicate moderate effects of CBT on
psychotic symptoms, functioning, and mood associated with psychosis, not-
withstanding issues of methodological rigor (Pfammatter, Junghan, & Brenner,
2006; Wykes, Steel, Everitt, & Tarrier, 2008; Zimmermann, Favrod, Trieu, &
Pomini, 2005). While encouraging, comparison studies suggest that CBT may
not yet be any more efficacious than other less intensive interventions such as
befriending (Jones, Hacker, Cormac, Meaden, & Irving, 2012), again indicating
the need to identify key mechanisms of change if these therapies are to be most
useful (Gaudiano, 2006).
Mechanisms of Change in CBT
Early descriptions of CBT emphasized the role of both cognitive content and pro-
cess in the treatment of mental health problems. The cognitive model assumes
that three aspects of our thinking contribute to the maintenance of depression
and anxiety: (1) automatic thoughts and images about oneself, others, and the
future; (2) schemas (i.e., stable cognitive structures that govern information pro-
cessing and behavior—usually described as core beliefs and underlying assump-
tions); and (3) information-processing patterns (e.g., “black and white thinking”
and “personalization” of events) (Beck, 1976; Beck et al., 1979; 1985). It is clear
that we are expected to attend to both what people are thinking and how they are
thinking if we are to be effective cognitive therapists.
It is a commonly held view that CBT places greater emphasis on addressing
the content rather than the process of thought. An examination of the literature
does not support this assumption. This is most evident in the development of
problem-specific models for the anxiety disorders over the last 30 years. As well
as differences in cognitive content, the models of obsessive-compulsive disorder
(Salkovskis, 1985), panic (Clark, 1986), health anxiety (Warwick & Salkovskis,
1990), social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997), general-
ized anxiety disorder (Wells, 1995), and post-traumatic stress disorder (Ehlers &
Clark, 2000) highlight the role of specific attentional, ruminative, and avoidance
processes in the maintenance of anxiety, and means of addressing these in order
to effect therapeutic change.
Teasdale, Williams, and colleagues have examined the mechanisms of change
in CBT for depression. These authors argue that a lack of “decentered awareness”
contributes to the maintenance of depression, whereby thoughts and feelings
are assumed to be necessarily accurate representations of the self and the world.
They propose that CBT is effective not through changes in what we think (for
example “I am bad” → “I am of value”) but through changes in how we think,
and specifically our relationship with internal experience (for example, “I am
bad” → “I am having a thought that ‘I am bad’”); that is, change in process rather
than content of cognition leads to the therapeutic benefits of CBT (Teasdale,
1999; Teasdale et al., 1995, 2000, 2002). This is supported by evidence that vul-
nerability to depression is associated with poorer decentered awareness, and that
when cognitive therapy (as well as mindfulness-based cognitive therapy) reduces

risk of relapse in residually depressed patients, this is associated with improved
decentered awareness (Teasdale et al., 2002). Williams (2008) concludes that a
“doing mode of mind” constitutes a specific vulnerability to depression. Modes
of mind describe whole patterns of processing, incorporating thinking, feeling,
behavioral urges, and physical sensations that are linked and shift together. The
doing mode of mind is characterized by automatic discrepancy-based process-
ing, an assumption that thoughts necessarily reflect reality, and the avoidance
of unwanted internal experience. The alternative “being mode” involves accep-
tance of difficult thoughts and feelings, an intentional “turning toward” these
sensations, and then allowing them to pass as transient mental events. Williams
(2008, 2013) distinguishes the doing and being modes of mind in terms of seven
contrasting characteristics: striving vs. non-striving; avoidance vs. approach;
thoughts as “real” vs. thoughts as mental events; living in the past and future
vs. living in the present moment; representational (often language based) vs.
direct experience; automatic vs. intentional; and depleting vs. nourishing. In
information-processing terms, it is the activation of a being mode of mind,
which may be cultivated through mindfulness meditation, that is hypothesized
to reduce likelihood of depression.
Interestingly, Wells and colleagues have examined the mechanisms of change
in CBT for anxiety and draw very similar conclusions, albeit from a differ-
ent theoretical framework. In their self-regulatory executive function model
(S-REF), Wells and Matthews (1994; Wells, 2000) argue that mental health
problems result from a particular pattern of information processing described
as “object mode” and characterized by increased self-focused attention, perse-
verative self-referent processing (worry and rumination), and the assumption
that thoughts depict reality and must be acted on to evaluate and reduce threat.
Responses such as avoidance and selective attention to threat cues are activated
in order to control or eliminate unwanted thoughts and feelings but maintain
distress through the usual confirmatory and disconfirmatory processes. By
contrast, a “metacognitive mode” recognizes that thoughts are events that can
be evaluated and replaces threat-based behaviors with “metacognitive control
behaviors,” such as suspending worry and redirecting attention. The few studies
of attentional training to date support the role of self-focused processing rou-
tines in the maintenance and alleviation of anxiety (Schmidt, Richey, Buckner,
& Timpano, 2009; Wells, 1990; Wells & Papageorgiou, 1998; Wells, White, &
Carter, 1997). Comparable to the hypothesized mechanisms of change in CBT
for depression, it is the activation of this metacognitive mode of mind that is
assumed to reduce likelihood of anxiety.
These accounts of the mechanisms of change in CBT are rooted in different
theoretical models, and described in somewhat different language. Nonetheless,
there is clear agreement that the ability to experience difficult thoughts and
feelings as transient mental events, and allow these to come and go rather than
respond with habitual patterns of rumination or avoidance, is likely to be associ-
ated with improved mental health.
The Rationale for Mindfulness Meditation with Psychosis
Mindfulness meditation is used as a means of facilitating a decentered awareness

of internal experience. Comparable to the doing or object modes of mind posited
by Williams (2008) and Wells (2000), respectively, people with psychosis may be
“lost in reaction” to unpleasant voices, paranoid thoughts, and images, which
are experienced as intolerable and trigger strategies designed to eliminate them
(e.g., rumination, worry, confrontation and experiential avoidance) (Chadwick
et al., 2005). In the same way that people with depression and anxiety get stuck
in problematic processing patterns, the person unwittingly becomes embroiled
in reaction, thereby exacerbating the distressing psychosis. Mindfulness medi-
tation may be taught as an alternative; a mindful response involves learning to
accept the presence of voices, images, and paranoid thoughts, and allowing these
to come into conscious awareness and then pass.
In summary, the cognitive model and current theories of the mechanisms
of change in CBT indicate that there is good reason to think that mindfulness
meditation may be useful to people with psychosis. Just as mindfulness has been
beneficial to others struggling with enduring mental health problems, this may
be an effective way of decentering from internal psychotic experience rather than
becoming caught up in understandable but unhelpful reactions that maintain
distress. There is a small body of literature, however, that raises concerns about
the use of mindfulness with psychosis.
Cautions—Might Mindfulness Be Harmful?
A small number of studies suggest that some meditation practices may trigger
psychosis. These are typically uncontrolled and retrospective case studies and
describe psychotic episodes following periods of intensive yoga or meditation,
sometimes over a number of days. Most, but not all, describe transient psychosis
in people with a history or other vulnerability to psychosis (see Kuijpers, van
der Heijden, Tuinier, & Verhoeven, 2007; Lu & Pierre, 2007; Naveen & Telles,
2003; Sethi & Bhargava, 2003). There are, of course, limits to the conclusions
that can be drawn from retrospective accounts. Nevertheless, it may be that
certain forms of intensive meditation and yoga can trigger psychotic episodes
and that this is more likely for people vulnerable to psychosis and when lengthy
sessions of concentration are combined with sensory, sleep, or food deprivation.
As Chadwick (2006) states, “the question raised by the literature is, perhaps,
how mindfulness can safely and therapeutically be introduced to people with
distressing psychosis” (p. 81).
In answering this question, we suggest that it is essential to distinguish
overt behaviors from internal psychological processes when talking about
mindfulness. That is, the practice of sitting quietly while listening to anoth-
er’s guidance is distinct from how we respond internally. Attending a guided
session is not the same as, and does not necessarily lead to the development
of, decentered awareness. The term mindfulness has been used to mean both
practice and psychological process in the literature, and this has led to confu-
sion. Paradoxically, it may be that some intensive meditation practices trigger
unmindful and distressing responses in vulnerable individuals under cer-
tain conditions. It is of note that cognitive and behavioral practitioners using
mindfulness with this group emphasize adaptations—in particular the impor-
tance of grounding, relatively short sessions, and frequent guidance from the
facilitator (Chadwick, 2006; Chadwick et al., 2005; Thomas, Morris, Shawyer,
& Farhall, 2013). It is essential that we repeatedly seek to clarify the degree to
which a person is developing skill in decentering from voices and paranoid
thoughts, and the impact of doing so, through careful inquiry following the
guided practice.
M I N D F U L N ES S M ED I TAT I O N I N C L I N I CA L PR ACT I C E
Introducing Mindfulness Meditation
We follow a particular sequence when introducing mindfulness within a CBT

approach, based on Chadwick et al. (2005) and Chadwick (2006):
1. Establish a specific role for mindfulness based on an individualized

formulation of the person’s distress linked to his or her psychotic
experience.
2. Explain the rationale using guided discovery to draw out existing coping
strategies and associated problems, and then introduce an alternative
strategy—mindful responding.
3. Carry out a short practice to enable the person to make an informed
choice about whether or not to pursue this intervention.
4. Check understanding, clarifying any misconceptions about the use of
mindfulness in a secular mental health setting.
5. Agree on plans for regular practice in individual or group setting.
Subsequent sessions then follow a broadly consistent pattern—a review of the

previous week; a brief mindfulness practice with guided feedback; discussion
of a specific aspect of mindful relating to voices and paranoia; a second practice
with guided feedback; and planning for the following week.
1. When to introduce mindfulness? Establish a specific

role for mindfulness.
We consider introducing mindfulness when this is indicated by the person’s
formulation. When a person is “caught in the power” of the other (whether a
voice or an assumed persecutor), mindfulness can facilitate a sense of auton-
omy from what is often an oppressive and tyrannical relationship (Abba et al.,
2008). When people describe a current coping repertoire characterized by
strategies such as rumination, worry, judgment, confrontation, and experien-

tial avoidance, mindfulness may be introduced as a more skillful response to
psychotic experience.
Keith, in his 40s, had a history of severe and disabling psychosis since his late
teens. He heard two voices, one always preceding another more frightening voice.
Keith’s formulation indicated that the first voice triggered anticipatory anxiety
about the second, and that he quickly became lost in worry, which intensified his
anxiety and increased the likelihood of the second voice occurring. In the context
of a wider cognitive behavioral therapy, mindfulness was introduced as a way of
decentering from the first voice and habitual worry that maintained his fear of the
second, more malevolent voice. Over time, this reduced the frequency of the second
voice and increased Keith’s ability to experience both voices without previous levels
of struggle and distress.
2. How to introduce mindfulness? Explain the rationale.

We aim to introduce mindfulness in relation to the person’s direct experience.
The rationale is derived from the shared formulation, noting the very common
desire to avoid contact with psychotic sensations and associated affect. The effect
of rumination, experiential avoidance, and other strategies are elicited using
guided discovery, for example by asking, “And what happens to the voice when
you shout back?” and “What is it like to be constantly on your guard against
them?” We are interested in drawing out the short-term and longer term con-
sequences of responding in these habitual patterns. A sense of relief is a com-
mon immediate advantage of avoidance but tends to be short-lived. Believing
oneself to be resisting voices by trying to block them or shout back can give a
sense of strength and self-esteem. It is important to validate current reactions
as understandable (and often highly reinforcing) responses and to explore the
longer term disadvantages.
Jonathon, a young man with a diagnosis of schizophrenia characterized by gran-
diose beliefs, felt an immediate sense of well-being from listening to his voices and
thinking about how special they made him feel. This was in stark contrast to the
shame and hopelessness associated with his then present reality of being detained
in the hospital and homeless once again. Although the voices lifted Jonathon’s
mood in the short term, he spent several hours listening to them each day and was
becoming dissatisfied with the limited social contact and purposeful activity in his
life. Jonathon decided to use mindfulness as a way of disengaging from the voices
so that he could spend more time focusing on the practical steps of being discharged
from the hospital and getting on with his life.
It is important to be clear that mindfulness is not intended to eliminate voices,
paranoid thoughts, or other psychotic sensations. This is disappointing for many.
We acknowledge this, saying that we recognize that the person would like to get
rid of the voices and troubling thoughts, but that we are unable to do this. What
we can offer is a way of responding that is likely to be less distressing and would
allow the person to (re)engage in activities that are valued and pleasurable or give
a sense of achievement.
3. How to get started? Carry out a short practice.

Although we can talk about mindfulness in detail, it is only through direct expe-
rience that the person is able to start to appreciate what is involved. A brief guided
practice is useful at this point, and allows the person to make an informed choice
about whether or not to pursue this intervention. A shortened version (3–5 min-
utes) of the longer 8- to 10-minute standard practice is used (as described later
in the chapter).
4. How to talk about the initial practice? Check understanding.

Inquiry after the practice is as important as the guided mindfulness. This involves
asking people about their experience in such a way as to facilitate decentered
awareness. After the first short session, the inquiry can clarify any initial mis-
conceptions about the use of mindfulness in mental health services, confirming,
for example, that this is not a religious or mystical practice and is not designed
to get rid of psychotic experience. Any moments in which the person has recog-
nized unhelpful habitual patterns, such as rumination and avoidance, are noted
as a first step in decentering from these internal behaviors.
Jan, a young woman with disturbing voices, images, and paranoia, and with a
history of serious substance misuse, stated that an early practice was no good—
she just couldn’t relax or get rid of the voices. Guided discussion helped clarify the
intended purpose of the intervention in relation to Jan’s distress and goals. Jan
decided not to pursue mindfulness at that time.
5. Agree on plans for regular mindfulness practice.

Mindfulness may be planned on an individual or group basis and may consti-
tute one component of a more comprehensive cognitive-behavioral therapy or
a stand-alone intervention. In line with routine CBT practice, we agree on the
number and duration of sessions in advance, and discuss any questions and con-
cerns the person may have.
Ongoing Mindfulness Meditation Sessions
1. Format and content of sessions

Mindfulness meditation sessions typically run for 6 to 8 weeks, each consist-
ing of two guided practices followed by inquiry. In a group setting, the first
session includes agreement on ground rules and a review of the rationale for
mindfulness.
We teach mindfulness of the body and breath each session in order to develop
familiarity and mastery in a particular routine. The breath is used as a point of
focus, not to exclude other experience but to facilitate an ability and willingness
to “turn toward” all experience in the present moment, including psychotic sen-
sations. Following one or two introductory practices, we emphasize particular
aspects of mindfulness in a certain order: letting go of reactions to psychotic
experience; opening awareness and turning toward unpleasant sensations; and
accepting psychotic experience and the self without judgment (see Chadwick,
2006; Chadwick et al., 2005).
2. Adaptations for people with psychosis

Certain adaptations to traditional practice are recommended for people with
current distressing psychosis or vulnerability to psychosis (Chadwick, 2006;
Chadwick et al., 2005; Thomas et al., 2013). The practice is conducted in a therapy
setting and construed as a therapeutic intervention rather than as skills develop-
ment in a class. We have found that asking people to accept and respond differ-
ently to psychotic experience requires a sound therapeutic relationship.
The guided practice itself is usually kept to approximately 10 minutes rather
than the longer periods of up to 45 minutes used in mindfulness-based cognitive
therapy (MBCT; Segal et al., 2002), mindfulness-based stress reduction (MBSR;
Kabat-Zinn, 1990), and traditional meditation. In our experience, 10 minutes has
been the limit for useful practice for people with current psychosis.
Practice is always guided by the therapist, who makes comments every few
seconds to prompt people to disengage from any habitual and distressing reac-
tions. Hearing the therapist’s voice acts as a reminder to bring the focus of atten-
tion back to present experience, thereby decentering from reaction to voices,
thoughts, memories, and other sensations, and grounding awareness back in the
breath and body.
We do not require practice between sessions. This is largely a pragmatic
response to the often overwhelming experience of psychosis for most of the peo-
ple with whom we work. People are given an audio recording of a 10-minute
guided practice and encouraged to use this independently, but many prefer to
restrict their formal practice to the group or individual sessions. We also teach
the “3-minute breathing space” (Segal, et al., 2002) and routinely ask for exam-
ples of spontaneous use of mindfulness at the start of each session to encourage
between-session practice. We look for opportunities to facilitate generalization
of learning, and have found that people with psychosis often make use of mind-
fulness in this more ad hoc way.
3. Guiding practice

Every practice commences with instructions to ground awareness in the body
and breath, using physical points of contact such as the soles of the feet on the
ground, and the rise and fall of the breath. We remind people that the intention
is not to control the breath but simply to notice the sensations as they arise, and
where these are most salient, such as the tips of the nostrils or the stomach. We
encourage a gentle concentration on the breath, emphasizing that there is no
need to strive for any particular goal, nothing to achieve. The task is simply to
turn toward the sensations of the body, breath, and whatever comes to awareness
with a compassionate curiosity, and then to let these pass.
It can be useful to anticipate difficulties that may arise, particularly if the per-
son is new to mindfulness—for example, feeling self-conscious or noticing unfa-
miliar sensations.
Jan, the young woman with voices and paranoia, became highly self-conscious
simply by focusing on her breath and relaxing her avoidance of troubling thoughts.
This was aversive for Jan, who chose to pursue other approaches to living with her
psychosis rather than mindfulness.
Many people find it helpful to name and normalize the experiences that arise
(silently noting “a thought” or “a voice”) and observing that these pass. In this
way, we are encouraging a recognition of these sensations as mental events rather
than necessarily accurate reflections of the self or reality (“just a thought” and
“just a voice”) (following Teasdale, 1999; Teasdale et al., 1995, 2000), a key com-
ponent of decentered awareness (Williams, 2008).
The ability to let paranoid thoughts, voices, and judgments come and go can
be understood as a flow of attention in which we allow our focus to rest on the
breath until another sensation comes into awareness, at which point the focus
gently rests on this sensation until it passes, and then returns to the body and
breath until the next sensation arises. We highlight and normalize the mind’s
tendency to wander and engage in more familiar (often language-based) patterns
of responding. The very act of noticing periods of avoidance and rumination,
however, involves a momentary decentered awareness, which can be noted. The
person then has the choice of whether to re-engage in the usual reaction or con-
tinue to observe passing sensations, including those that are unpleasant, bring-
ing the attention back to the breath once these have passed. We draw people’s
attention to the impact of letting voices and paranoia come and go, as distinct
from their more usual responses, as beneficial (or “nourishing”) rather than
depleting (following Williams, 2013).
At the outset, we tell people that they can stop the practice (and open their eyes
if closed) at any point, and to leave the room if uncomfortable in a group session.
We have found that this is welcomed and rarely used.
4. Inquiry into the practice

Equal weight is given to experiential practice and inquiry. We start by inviting
general feedback and observations. Therapists also comment; it can be valuable
for people to hear that we are no different in the ways we learn to relate to inter-
nal experience.
The inquiry enables a guided discovery approach to learning about the impact
of habitual and mindful responding. We are particularly interested in any exam-
ples of how people have responded in a nonjudgmental and accepting manner to
their experience, even if just momentarily. In line with the preceding practice,
the focus is on a non-striving acceptance of psychotic experience, turning toward
unpleasant sensations in the moments that they arise, and letting go of habitual
language-based reactions. In this way we can assess whether the person is learn-
ing to respond mindfully to their psychotic sensations, without re-engaging with
other habitual and harmful processes maintaining distress.
It is important to attend to the ways in which unmindful responding can lead
to seemingly positive effects. For cognitive-behavioral therapists, this may be
comparable to fulfilling criteria for underlying assumptions. For example, a
person who believes “If I don’t have bad thoughts then I’m OK” may report a
sense of achievement: ‘It really worked today, I felt totally relaxed and the bad
thoughts didn’t come.” Physical relaxation may well reduce frequency of voices
and paranoia, but this person is not yet developing a mindful response to psy-
chotic sensations.
We have also found that an important component of inquiry is to be clear
about the meaning of “accepting” voices, thoughts, and images. People with
psychosis may feel utterly besieged by their voices and assumed oppressors, and
overcome with fear, hopelessness, or humiliation. When we talk about accepting
psychotic experience we are not in any way agreeing with the voices, approving
of them, or suggesting passive defeat in the face of oppression. We are asking
people to accept that “these are the sensations I am experiencing right now,” and
observe the impact of doing so. This is contrasted with the often exhausting and
demoralizing impact of people’s more usual responses. The sensations are pres-
ent; the choice is how to respond. One of the participants in the grounded theory
study (Abba et al., 2008) described his experience of persistent voices:
It won’t let you go, it just won’t let you lie there and rest, they’re always at
you, they’re at you 24 hours of the bloody day. You can either let them go or
after 20 minutes you’re going to be screaming, breaking windows, throwing
your shoes against the wall, banging your fists against the wall. Which one
is preferable?”
For further discussion of common problems in mindfulness meditation with

people with psychosis, see Chadwick (2006).
Therapist Requirements—Do We Need Our Own Practice?
When using mindfulness with people with psychosis, we rely on both our clini-
cal CBT skills and our own mindfulness practice. It is essential that the therapist
has a sound theoretical and experiential understanding of mindfulness in order
to guide practices and talk accurately and helpfully with people during inquiry.
Opinion is divided on whether therapists need their own practice in order to teach
mindfulness to others. Our experience is that it is only through our own regular
personal practice that we have been able to use mindfulness effectively with people
with psychosis. We aspire to daily practice of 20–45 minutes and at times fall short.
I N T EG R AT I N G C BT A N D M I N D F U L N ES S M ED I TAT I O N
Formulation-based CBT identifies a number of linked components of experience

involved in the maintenance of mental health problems. Affective, behavioral, and
cognitive processes all contribute to distressing psychosis and may be targeted to
alleviate distress and improve quality of life. Mindfulness meditation is one way to
facilitate change in metacognition, that is, in our relationship to internal experience.
Just as we may encourage people to use behavioral interventions to address

overt avoidance and use of safety behaviors, and traditional cognitive inter-
ventions to explore specific concerns or fears, mindfulness meditation may be
used to note and then disengage from ruminative or worry-based processing
and decenter from troubling internal experience, thereby allowing the person to
choose how to respond.
From the age of 12, Daniel was systematically bullied by a small group of chil-
dren at his school. Over the following years he became increasingly isolated and
withdrawn. As a young gay man, he started to hear the taunts of these bullies as
voices. Daniel became suspicious of other men and hypervigilant to the minutia of
their speech, facial expressions, and actions, anticipating imminent threat of being
beaten and killed. Although these assumptions and behaviors may have protected
him from the brutality of others as a child, these same processes crystallized into
and maintained his paranoia as an adult. In social situations, he would quickly
jump to the conclusion that unknown men necessarily posed a threat and that he
was too weak to protect himself. He learned to manage feelings of fear and humili-
ation by avoiding social contact, worrying about being harmed, and ruminating
self-critically. He was leading a life that had become restricted and impoverished.
Daniel sought CBT for help with his voices and paranoia.
Cognitive behavioral formulation involved mapping out the formative influ-
ences and current emotional, behavioral, and cognitive processes maintaining his
distress, as the basis for collaborative treatment planning. Behavioral interventions
were valuable in enabling Daniel to tackle his avoidance of other men and learning
that most people do not pose a threat, and that he could assert himself in inter-
personally difficult situations. The formulation itself and cognitive re-evaluation
work proved useful in reattributing certain beliefs about the voices. By recognizing
that these echoed his memories and worst fears of being bullied, the voices started
to seem less powerful and less relevant to his adult life. Mindfulness was intro-
duced as an alternative way of responding to the voices, fears, and humiliation.
With practice, Daniel found that he was able to hear the voices and note the para-
noid fears that continued to arise, and start to allow these to come and go without
reaction. While this did not eliminate the psychotic sensations, it did provide the
opportunity for Daniel to start to engage in activities that gave him a sense of mas-
tery or pleasure, in a way that had not been possible when caught up in the voices
and paranoia that had dominated his adult life.
While we see mindfulness meditation as entirely consistent with CBT in the-
oretical terms, there are certainly times when a traditional CBT approach might
follow one therapeutic path while a focus on mindfulness might take another.
These are clinical decision points, and the choice made at any one time will
depend on the particular focus of the session and the therapist’s judgment about
most beneficial learning. As cognitive therapists, we often attend to the content
and meaning of people’s accounts. This is valuable when we are addressing the
impact and alternatives to particular ideas and beliefs. At other times, the key
learning may be better facilitated by a focus on mindful responding to thinking.
These clinical decision points frequently arise in the inquiry following guided
practice. It is important to be quite clear about the purpose of these discussions,
which is to facilitate a compassionate curiosity toward one’s internal experience,

and a willingness to turn toward the voices, paranoia, and other sensations and
then allow these to pass. For example, if a person says, “The voice was going on
and on, calling me a loser,” rather than asking questions such as “How do you
feel when the voice says that?” and “What does it mean to you, being called a
loser?” we might instead ask, “And how did you react, in your mind, when you
heard the voice calling you a loser?” and “What impact did that have?” The focus
is on the person’s relationship with their internal experience and elucidating the
impact of habitual and mindful responses.
Similarly, we seek to create and take opportunities that arise in more tradi-
tional CBT work on the content or meaning of psychotic experience to notice
and reflect on the process of thinking (whether ruminative or avoidant) and the
impact on the person’s mood and beliefs as another means of stepping back and
effecting decentered awareness.
On a practical note, given the time taken to learn and benefit from mindful-
ness meditation, we often introduce this early in a course of CBT so that the
person has sufficient opportunity to develop this skill over a longer period. In
individual therapy, this may involve six to eight sessions in which the focus is
primarily on mindfulness, followed by a brief guided practice and inquiry to
start subsequent sessions of the full therapy.
C L I N I CA L I L LU ST R AT I O N
Background and Presenting Problems
Rachel2 described a chaotic home life and disrupted attachments from as far
back as she could recall. Throughout her early years, she and her older brother
witnessed a highly volatile relationship between their parents, characterized by
verbal and at times physical aggression. Given their own learning histories, her
parents relied heavily on alcohol to manage their difficulties. Rachel’s father left
the family home briefly on two occasions, and both times her mother responded
by attacking him physically. Rachel was bullied for the first 2 years of secondary
school and became gradually more disruptive herself over this time. Her teach-
ers struggled to engage her or manage her challenging behavior, and she spent
increasing periods skipping school with friends. Rachel described her first sexual
partner as controlling and dominating, and quickly learned to rely on alcohol as a
means of managing her fears, shame, and despair. Rachel had been attacked and
raped on two occasions as an adult; despite police involvement neither man had
been convicted.
Rachel presented with paranoia, low mood, and anger. She had a diagnosis of
psychotic depression characterized by persecutory delusions. She had addressed
her alcohol addiction after many years attempting to do so, and she now wanted
to understand her past and lead her life more fully. Psychological assessment
indicated both psychotic and traumatic processes maintaining current distress

and constituting an enduring vulnerability to her mental health problems.
Formulation
In the context of her early learning history, Rachel had come to believe that
she was worthless and that others were dangerous and unpredictable. Intense
emotions were also unsafe. She managed these beliefs by avoiding emotion-
ally intimate relationships and intense emotion as much as possible. Over her
adult life she had become ever more wary of others, and this stance devel-
oped into clear paranoia over the period of her first sexual relationship. At
the time of assessment, Rachel was overwhelmed by fears that she would
be attacked and killed. Social contact with unknown men triggered a set of
linked responses, driven by a potent sense of herself under threat. This “felt
sense” initiated and was maintained by her feelings, thinking, and behav-
ioral ways of coping. A diagrammatic formulation (Figure 8.1) was helpful
Triggers:
Social contact, intrusive
thoughts and images
Activates beliefs and assumptions:

I’m useless, worthless; others are dangerous and unpredictable
If I trust people, they’ll leave me or harm me
Feelings are dangerous – I must get rid of them or be overwhelmed
Perceived danger:
They’re watching me,
they’re going to kill me
Self under threat:

Intense self-consciousness,
see self being attacked and
humiliated
Feeling: Coping:
Terror, fury, shame, Avoid other people, express
nausea, tension unchecked fury at parents,
don’t look after myself
Thinking:
Always on the lookout for threat
Ruminating or blocking intrusions
Jumping to conclusions about what
others are thinking
Figure 8.1. CBT formulation for Rachel.

in supporting Rachel to make sense of these understandable but unhelpful

responses.
Therapeutic Options
This formulation allowed us to consider a range of possible therapeutic options

for Rachel, as shown in Figure 8.2.
Treatment Plan
Rachel described a sense of despair that she was “stuck” and unable to move
on with her life. Her priorities were to (1) understand her problems, (2) be able
to cope day to day, and (3) be able to cope with the memories of the attacks.
A cognitive-behavioral therapy plan was agreed on, targeting the processes that
prevented her from achieving these goals (Figure 8.3). Mindfulness meditation was
included as one component of the therapy, as an alternative to the ruminative and
avoidant patterns of thinking that contributed to the maintenance of her paranoia.
Triggers: Functional analysis; trauma work

Social contact, intrusive
thoughts and images
Activates beliefs and assumptions:

I’m useless, worthless; others are dangerous and unpredictable
If I trust people, they’ll leave me or harm me
Feelings are dangerous – I must get rid of them or be overwhelmed
Schema and assumption work
Perceived danger:
They’re watching me,
they’re going to kill me
Cognitive re‐evaluation
Develop sense of safety and interpersonal

Self under threat: trust; develop metacognitive awareness
Intense self-consciousness,
see self being attacked and
Feeling: humiliated
Coping:
Terror, fury, shame, Avoid other people, express
nausea, tension unchecked fury at parents,
Arousal management don’t look after myself
Thinking: Graded exposure; anger

Always on the lookout for threat management; practical self‐care
Ruminating or blocking intrusions
Jumping to conclusions about what
others are thinking
Alternatives to thought control strategies and
jumping to conclusions; attentional focus work
Figure 8.2. Therapeutic options for Rachel.

Goals Key processes Intervention

Understand my All Formulation to recognize
problems overwhelming sense of vulnerability
and threat, and how this drives
all areas of experience – feeling,
thinking and behaving
Be able to cope Self neglect Behavioral work to improve diet, sleep
day to day and exercise
Avoidance Behavioral work to address paranoia-
based avoidance
Perceived danger Cognitive re-evaluation to start to
consider alternative explanations
of events
Thinking patterns Mindfulness meditation as an
alternative to rumination,
‘blocking’ internal experience,
and hyper-vigilance; as a means of
developing metacognitive awareness
Be able to cope Trauma-based Low arousal trauma work – grounding
with the attacks intrusions and distress tolerance skills in first
instance
Avoidance of activity ‘Reclaiming my life’ – re-engaging
associated with with valued activity
mastery / pleasure
Core beliefs and Schema work to address enduring
assumptions vulnerability; to develop sense of
safety and inter-personal trust
Figure 8.3. Rachel’s treatment plan.
Example Script: Introducing Mindfulness Meditation
The following script (see Table 8.1) demonstrates an early use of guided medita-
tion with Rachel and inquiry after the practice. Williams’s3 (2008) model is used
to structure the guidance, giving point-in-time aims in line with a being mode
of mind.
C O M M O N A N D D I ST I N CT I V E EL EM EN TS
A detailed comparison of acceptance and mindfulness approaches across cur-

rent models of psychosis is beyond the scope of this chapter, and will be cov-
ered elsewhere (Section 3, this volume). Here we seek to identify key areas of
Table 8.1. Script to Guide Mindfulness Meditation
Guided Practice
Aim Guidance
Grounding in the body—starting to To begin, sit comfortably with your feet flat on the floor, back straight and slightly away from the back of
focus on direct experience the chair, shoulders relaxed, hands folded on your lap or resting on the thighs or chair, head tilted slightly
forward to extend your spine, and your tongue resting comfortably on the roof of your mouth. You can
keep your eyes open or closed; if you open your eyes then let your gaze fall on a spot a little way in front of
you.
Anticipating difficulties You may feel self-conscious. It may be uncomfortable if you’re used to keeping your thoughts and feelings
out of mind. If at any time you want to open your eyes or stop the practice, that’s fine.
Focusing on direct experience— First we are going to bring our attention to our bodies. Start by bringing your attention to your feet, noticing
bodily sensations the sensations in the soles of the feet where they come into contact with the floor, just noticing any
sensations or lack of sensation there. Now move your awareness up through your body, notice where your
body comes into contact with the chair, bringing your attention to the weight of your body in the chair, the
feeling of your clothes on your skin, the warmth (or coolness) of the air in the room. Bring your awareness
to your shoulders, noticing any tension you may be holding there, and as best you can, let that go.
Focusing on direct experience— Now, bring your awareness to your breathing, noticing the sensations of your breath right now as you
bodily sensations of the breath breathe in and out.
Non-striving There is no need to change your breathing in any way; simply notice the sensations of the breath as you
breathe in (pause) and out (pause). We can tune in to the sensations of the breath at the tips of the
Intentional present-moment nostrils—as you take a breath in, notice the cool air passing into your body and the slightly warmer air
awareness as you breathe out. Or place a hand on your stomach and feel the gentle rise and fall as you breathe in
(pause) and out (pause) in this moment.
Thoughts as mental events If you find that your mind has wandered, that’s OK, that’s what our minds do. When you realize this, just
Approaching/turning toward notice where your mind has wandered—perhaps to thoughts, feelings, voices—even if these are difficult or
psychotic and other sensations unpleasant.
Intentional present-moment When these sensations have passed, and when you’re ready, breathe in, and as you breathe out, gently bring
awareness your awareness back to the breath and the sensations in your body as you breathe in and out. In and out.
Focusing on direct experience
Approaching/turning toward When thoughts, feelings, or voices come up, as best you can, bring your awareness to these sensations.
psychotic and other sensations Perhaps label them “thoughts” or “feelings” or “voices” and notice any reactions. When these have passed,
Thoughts as mental events gently bring the attention back to the breath.
Thoughts as mental events You may notice that your mind has got caught up with worries, judgments, or trying to push thoughts and
Focusing on direct experience feelings out of mind. Again, as best you can, just notice what your mind is doing. It can be useful to label
this—“worry” or “judgment,” for example. Then when you are ready, letting go of the worry or judgments,
gently bring your attention back to the breath.
Non-striving Continue to let your attention rest gently on the breath, noticing the sensations of your breath right now as
Focusing on direct experience you breathe in and out.
Approaching/turning toward Notice any unpleasant thoughts, feelings, voices, or images. Are there any moments when you’re able to turn
psychotic and other sensations toward these sensations? As best you can, notice how this feels.
Focusing on direct experience— Notice any judgments and, as best you can, let go of any judgments that arise.
noting tendency to judgments
Focusing on direct experience— For the last minute or so, see if you can let your attention rest on the sensations of the breath as we breathe
bodily sensations of the breath in and out. In and out.
Focusing on direct experience— Just before we finish, bring your attention to the room, to the sensations in your body, the soles of your feet
bodily sensations on the floor, pressure of the chair under the weight of your body.
Ending the practice Now, you can relax your concentration, bringing your awareness back into the room. And when you’re
ready, end your mindfulness practice and gently open your eyes.
(Continued)
Table 8.1. Continued
Facilitated Inquiry
Process targeted Inquiry
Opening discussion Therapist (Th). What was that like? How did you find the practice?
Client (C). I thought I was going to go to sleep—I feel so tired. I hadn’t noticed I was so tired.
Focusing on direct experience— Th. That’s interesting, so you noticed that you are physically very tired—what did you notice in your body?
bodily sensations C. I just felt really heavy, like I was going to fall asleep.
Focusing on direct experience— Th. I see. And what was that like—the heaviness, the sensation that you were going to fall asleep?
bodily sensations C. Quite relaxing, really. I stopped worrying about everything and just felt quite relaxed.
Intentional present moment Th. Right, so for a few moments you were able to pause from the worries about the future and thinking about the
awareness past, and just notice how you were feeling right now?
C. Yes (smiles).
Non-striving Th. Hmmm. And that sounds quite different from the usual busyness in your head—the worries, the fears.
Impact is nourishing What was that like, just pausing for breath, so to speak?
C. A relief, really. But then you said to notice if my mind had wandered and it had. All the worries came
back and I couldn’t stop it.
Intentional present-moment Th. OK, so it was a relief to pause for a moment, to focus on what was happening right now rather than on your
awareness usual worries and fears, but then it all came flooding back.
C. Yes, and I couldn’t stop it.
Avoidance vs. approach Th. I see, so did you find yourself trying to stop it?
C. Well, yes, I try to stop it but it just goes on and on.
Focusing on direct Th. OK, and when you noticed your mind getting caught up in these thoughts, what did you do?
experience—thinking C. Well, like I said, I tried to stop it, but I couldn’t. I started thinking about the man I saw in town the other
day—I’m sure he was watching me.
Thoughts as mental events Th. So the familiar fears came back. And do you find that you start believing these ideas—do they seem very
real when you focus on them?
C. Well, yes. He seemed to be watching me. Just sitting there on the park bench watching me.
Focusing on direct Th. OK, so some of the time you try to stop these frightening ideas coming to mind, and some of the time you
experience—thinking get caught up in them, trying to work out whether this is real or not. Is that right?
Thoughts as mental events C. Mmmm. Yes, I think so.
Avoidance and striving Th. And what is it like when you try to stop the worries and fears, or get caught up in them trying to work
Impact is depleting out what’s really going on?
C. Exhausting. It’s exhausting. I can’t bear it.
Thoughts as mental events Th. It does sound exhausting. And it seemed like it was unbearable. Is that something you were saying to
yourself, “I can’t bear it”?
C. Mmmm, yes. It’s awful.
Thoughts as mental events Th. I see, and what was the impact of that—telling yourself that you can’t bear it?
Impact is depleting C. I don’t know really. It’s stupid. I got quite tense. It’s ridiculous. It’s just too much sometimes.
Representational vs. direct Th. Yes. I can see that it feels overwhelming at times. So you were telling yourself that you couldn’t bear it,
experience and it sounds like you were starting to become quite critical of yourself (and we know your mind is very
Focusing on direct experience— good at that!) and the judging was making you feel more tense, more frustrated. Is that right? (C. nods.)
bodily sensations Were there any moments when you were able just to notice these fears and judgments and then let them
Non-striving and approaching/ go, even for just a moment?
turning toward psychotic and C. I’m not sure—maybe for just a moment, when you were saying to come back to the breath, but then they
other sensations come back.
Non-striving and approaching/ Th. I see, and what is it like when you are able just to notice them and then let them go and come back to the
turning toward psychotic and breath?
other sensations C. I don’t know really. Strange. A bit of a relief. But then they just came back.
(Continued)
Facilitated Inquiry
Process targeted Inquiry
Thoughts as mental events Th. Yes, and that’s OK. It’s interesting—sometimes people think that they are not being mindful when their
Intentional present moment minds are busy, or keep wandering, or go back to familiar fears, memories, and other ideas, but this is
awareness what minds do. You noticed your mind was wandering and there were one or two moments when you
Remaining hopeful about were able to bring your awareness back to your breath. Each time you do that, each time you notice where
developing mindfulness together your attention has wandered and gently bring it back to the present moment, you are starting to respond
mindfully to all that your mind is bringing up. I wonder if with more practice you can start to notice
the times when you are able to have these difficult thoughts, feelings, and memories, and step back from
them—see if there are moments when you’re able to let them come and go without judgment or struggle.
We can practice that together.
commonality and difference in the use of mindfulness meditation to inform this

wider synthesis.
Mindfulness Meditation in CBT and Person-Based

Cognitive Therapy
Mindfulness is conceptualized and used similarly in traditional CBT and

person-based cognitive therapy (PBCT; Chadwick, 2006). PBCT was developed
for people with psychosis and integrates cognitive theory and therapy, mindful-
ness meditation, and Rogerian acceptance. Both CBT and PBCT assume that
distress and well-being are improved through the cultivation of decentered
awareness and acceptance of present-moment experience. In both, mindfulness
is taught as a means of facilitating these key processes in relation to psychotic
and other experiences. The teaching of mindfulness is also similar across these
approaches, and focuses on the body and breath in order that people have the
opportunity to become skilled in one particular method.
We would suggest that the differences in the use of mindfulness meditation
in traditional CBT and PBCT lie in theoretical emphasis rather than purported
mechanisms of change, or clinical application. A CBT approach to recovery is
based on an individualized formulation of the psychological processes involved
in the development and maintenance of distressing psychosis. This may follow
Beck and colleagues’ (1976; Beck et al., 1979) original developmental formula-
tion, as applied to psychosis, or one of the more recent problem-specific models.
PBCT adopts Vygotsky’s (1978) “zone of proximal development” as the central
organizing framework to describe sources of distress and potential well-being
in psychosis. A PBCT approach separates content (“symptomatic meaning” and
“schema”) and process factors (“relationship with experience” and “symbolic
self”). These four domains constitute areas in which a person may be supported
to effect therapeutic change. Mindfulness is the key means of facilitating change
in the relationship with experience domain, and gains here are woven together
with those in the other areas of symptomatic meaning, schema, and symbolic
self (see Chapter 7, this volume).
Mindfulness Meditation in CBT and Acceptance and

Commitment Therapy
In acceptance and commitment therapy (ACT; Hayes, Stroshal, & Wilson,

1999), distress is understood as the consequence of unproductive struggle with
thoughts and feelings, and mindfulness is used as a way of addressing this
“unworkable” relationship with internal experience. In ACT, mindfulness is one
of a number of ways of assisting a person to disengage with this struggle and to
focus instead on living day to day in line with his or her values and goals. ACT
assumes a cross-diagnostic conceptualization of psychopathology associated
with psychological inflexibility. The processes of experiential acceptance, defu-

sion, self as context, and present-moment focus are emphasized to cultivate
the capacity simply to notice and accept sensations such as voices, images, and
thoughts (whether pleasant or unpleasant), and accomplish valued goals in the
context of ongoing psychosis. Again, there are differences in theoretical empha-
sis, but the proposed mechanisms of change appear similar.
There are differences in the clinical application of acceptance methods,
including mindfulness, in CBT and ACT. CBT formulation is replaced with the
“hexaflex” in ACT, and a range of experiential exercises are employed to facilitate
mindful acceptance of difficult experience. ACT tends to use traditional mind-
fulness meditation less than some other approaches and makes strong use of
metaphors and other defusion techniques (see Chapter 4, this volume).
Mindfulness Meditation in CBT and Compassion-

Focused Therapy
Compassion-focused therapy (CFT; Gilbert, 2009) is another “third-wave”

approach that has been adapted for people with psychosis (Braehler et al., 2013;
Gumley, Braehler, Laithwaite, MacBeth, & Gilbert, 2010; Laithwaite et al., 2009;
Mayhew & Gilbert, 2008). CFT assumes that mental health problems are associ-
ated with the overactivation of normal threat responses, and the aim of therapy
is to stimulate an individual’s capacity for self-soothing and affiliation to self
and others as a way of regulating this threat system and thereby reduce distress
(Gilbert, 2009). This approach draws on evidence that affiliation regulates threat
processing by developing a sense of social safeness. Therapy focuses on creating
experiences of safe and reliable relationships external to the person, and then
teaching him or her to develop a more compassionate and attuned relationship
with the self and difficult internal experiences (Braehler et al., 2013). This is
intended to contrast with and attenuate self-critical and persecutory attitudes
toward the self and experiences that are associated with fear and shame (Gumley
et al., 2010). Mindfulness exercises are used as one way of promoting affiliation
and self-soothing.
To date, CFT for psychosis has focused on the promotion of emotional recov-
ery after psychosis rather than address current distress. Common emotional
consequences such as feelings of shame, humiliation, depression, entrapment,
traumatic reexperiencing of psychosis, and fear of recurrence are identified as
key factors likely to be contributing to risk of relapse and are targeted in ther-
apy. As before, mindfulness is used in CFT as a way of enabling a person to be
in direct contact with difficult feelings, thoughts, memories, and so on, rather
than avoiding them, and to do so from a position of decentered awareness (see
Chapter 5, this volume). The proposed mechanisms of change appear strikingly
similar across CBT, PBCT, ACT and CFT.
C U R R EN T R ES E A R C H E V I D EN C E A N D
F U T U R E D I R ECT I O N S
Research investigating the value of mindfulness for people with psychosis is in

its infancy. Studies include those examining the impact of mindfulness medi-
tation specifically and evaluations of combined interventions, of which mind-
fulness is one component. Here we focus on the former for people struggling
with the “positive symptoms” of voices, paranoia, and other delusions, but
note promising early findings for combination interventions including MBCT
(Langer, Cangas, Salcedo & Fuentes, 2012), PBCT (Dannahy et al., 2011), ACT
(Bach & Hayes, 2002; Bach, Hayes & Gallop, 2012; Gaudiano & Herbert, 2006;
Shawyer et al., 2012; White et al., 2011), the related but distinct “attentional
training technique” developed by Wells (1990) (Hatashita-Wong & Silverstein,
2003; Valmaggia, Bouman, & Schuurman, 2007), and initial studies of mind-
fulness for “negative symptoms” of psychosis, such as anhedonia and avolition
(Johnson et al., 2009, 2011).
An uncontrolled pilot study of mindfulness groups for people with psychosis
found increases in mindful responding to internal experience and improvements
in broad psychological well-being (Chadwick et al., 2005). This study assessed
the impact of a six-session group mindfulness training alongside treatment as
usual for people with distressing psychosis. All participants had been routinely
referred to the local psychological therapies service and described unremitting,
distressing psychosis of at least 2 years’ duration. All met diagnostic criteria
for paranoid schizophrenia or schizoaffective disorder (American Psychiatric
Association [APA], 1994) characterized by paranoid beliefs. People were taught
mindfulness of the breath and encouraged to make use of this skill between ses-
sions. The Clinical Outcomes in Routine Evaluation (CORE) self-assessment of
mental well-being assesses well-being, problems and symptoms, functioning,
and risk. The CORE was developed for use in routine clinical practice, where
it has been found to be both reliable and valid (Evans et al., 2000). Significant
reductions in total CORE scores indicated improved mental well-being following
the group intervention. Secondary qualitative data assessed the value of particu-
lar therapeutic factors and identified the subjective importance of mindfulness
to the group process. This initial study was encouraging but did not examine
mechanisms of change; there was no assessment of whether mindfulness train-
ing led to improved mindfulness skills and whether any such improvement in
skill was associated with therapeutic benefit.
A second study extended the first uncontrolled pilot, to assess the feasibility of
a randomized evaluation, replicate clinical gains, and measure changes in mind-
fulness (Chadwick et al., 2009). Twenty-two people with distressing psychosis
were randomly allocated to group-based mindfulness training or waitlist control
for a period of 10 weeks. At the end of this time, the control group also received
the active intervention. All met diagnostic criteria for schizophrenia (APA,
1994). The intervention comprised twice-weekly group sessions for 5 weeks.
Participants were encouraged to practice between sessions (but as before, this

was not required) and independently for 5 weeks following the group. Despite
trends in the expected direction, there were no significant differences between
intervention and waitlist participants. This may have been due to the study being
underpowered. When the data from both groups were combined, mindfulness
training again yielded significant improvements in clinical functioning (as mea-
sured by CORE).
The Southampton Mindfulness Questionnaire (Chadwick et al., 2008) was
designed to assess the degree to which people respond mindfully to distress-
ing thoughts and images and has been validated for people with psychosis.
A parallel version for voices has also been validated (Chadwick, Barnbrook,
& Newman-Taylor, 2007). Interestingly, the combined group data showed
improvements in mindfulness of distressing thoughts and images, but not of
voices. No significant differences were found on the Psychiatric Symptom Rating
Scale (PSYRATS; Haddock, McCarron, Tarrier, & Faragher, 1999) for sever-
ity and intensity of dimensions of delusions and voices, or on the Beliefs about
Voices Questionnaire–revised (BAVQ-R; Chadwick, Lees, & Birchwood, 2000),
which assesses beliefs, feelings, and responses to voices. The authors concluded
that the replication of previous clinical benefits indicates that contemporary
mindfulness-based interventions are safe and therapeutic for people with dis-
tressing psychosis and noted the improvement in mindfulness of thoughts and
images, but not voices. This specificity of effect is curious and warrants further
scrutiny.
In an attempt to examine the effects of mindfulness more closely, two con-
trolled single-case studies examined the impact of mindfulness training on
affect and cognition associated with voices (Newman-Taylor et al., 2009). The
two men met diagnostic criteria for paranoid schizophrenia (APA, 1994) and
were referred through routine clinical pathways. The men were taught mindful-
ness of the breath and completed twice-weekly analogue scales of belief convic-
tion and distress associated with their voices through baseline and mindfulness
intervention. Both men showed reductions in belief conviction and distress fol-
lowing 8 weeks of mindfulness meditation practice. Mindfulness scores were
higher post-treatment for both. It was concluded that mindfulness meditation
had an impact on cognition and affect specifically associated with voices and
thereby altered the relationship with voices for these two men (Newman Taylor
et al., 2009).
Using a similar design, Ellett (2013) assessed the impact of mindfulness for
people with persecutory delusions. In two single-case studies, self-ratings of cog-
nition and affect linked to paranoid beliefs reduced following mindfulness train-
ing. Self-rated mindfulness of distressing thoughts and images increased over
the same period. These gains were maintained at 1-month follow-up and suggest
that mindfulness meditation may have an impact on cognition and affect linked
specifically to paranoia. The impact of mindfulness meditation on people’s dis-
tress and thinking linked to psychotic experience can now be investigated using
more rigorous methods.
Abba and colleagues (2008) used grounded theory to examine the psychologi-
cal processes involved in responding mindfully to psychotic experience and iden-
tified the tyrannical relationship with psychosis as a key problem. Mindfulness
was adopted in three stages. Initially, people were able to develop a moment-to-
moment awareness of the immediate experience of their voices, thoughts, and
images. Second, some people started to allow these sensations to come and go
without reaction or struggle. Finally, a number of the group were able to reclaim
a powerful sense of self-determination through acceptance of self and a “defla-
tion” of the psychosis (Abba et al., 2008).
These early studies suggest that mindfulness meditation may be useful to
people with psychosis, and the grounded theory analysis in particular identifies
how this may evolve over time. However, these benefits have not yet been demon-
strated sufficiently, and the likely mechanisms remain largely untested. Based on
the hypothesis that distressing psychosis may be alleviated by the development
of a mindful response or “mode of mind” in the context of troubling internal
experience, perhaps the most important questions at this time focus on these
processes, and the therapeutic impact:
1. How can we support people to develop a decentered awareness of their

distressing psychosis?
2. Is mindfulness meditation an effective means of facilitating decentered
awareness?
3. Does a decentered awareness lead to improved recovery-based outcomes
for people with psychosis—including reduced distress, improved quality
of life, and reduced risk of relapse?
C O N C LU S I O N
Mindfulness meditation may be valuable for people with psychosis. Voices, para-
noia, and other psychotic sensations can elicit considerable distress and lead to
severe social disability. We would argue that learning to decenter from habit-
ual patterns that maintain distress, such as rumination and avoidance, and to
respond instead with a compassionate curiosity to internal experience is entirely
consistent with a CBT approach to psychosis.
There is emerging agreement on the likely mechanisms of change across
current models, despite differences in theoretical frameworks on the one hand
and clinical application on the other. It may be that some approaches prove
more effective than others in facilitating a decentered awareness and thereby
effecting therapeutic outcomes. Alternatively, if a range of approaches are
found to be beneficial, this would allow for a welcome diversity of clinical
provision.
Finally, we note the speed with which third-wave approaches have been
adopted for people with psychosis. This is in contrast to the usual pace of theo-
retical and clinical advances for this group. It may be that the stigma associ-
ated with psychosis has reduced. While undoubtedly true to a modest degree,
we remain unconvinced that this fully explains these developments. We suggest
that clinicians and researchers working in this area recognize that process-based
approaches, such as mindfulness, have a particular relevance to people strug-
gling in the grip of voices and paranoia and with the compelling sense of shame,
fear, and humiliation that often accompany psychosis. Stepping back from this
struggle in the ways promoted by these approaches is likely to be the very thing
that is both most needed and most difficult. It is vital, therefore, that we under-
stand the mechanisms of change involved, in order to optimize these interven-
tions and support people to free themselves from the tyranny of distressing
psychosis.
N OT ES
This chapter is partially adapted from Newman Taylor, K., & Abba, N. (2013).
Achtsamkeit bei Psychosen. In M. Hammer & A. Knuf (Eds.), Die Entdeckung der
Achtsamkeit in der Arbeit mit psychisch erkrankten Menschen. Cologne: Psychiatrie
Verlag, with permission.
1. In line with much of the current literature, the terms cognitive therapy and
cognitive-behavioral therapy are used interchangeably in this chapter.
2. Some details regarding Rachel (and the others described in this chapter) have been
changed to preserve anonymity.
3. Contrasting characteristics of the “doing” and “being” modes of mind are as fol-
lows: striving vs. non-striving; avoidance vs. approach; thoughts as “real” vs.
thoughts as mental events; living in the past and future vs. living in the present
moment; representational (often language based) vs. direct experience; automatic
vs. intentional; and depleting vs. nourishing (Williams, 2008, 2013).
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SECTION III
Synthesis and Analysis

9
A Model for the Development of

Acceptance- and Mindfulness-
Based Therapies
Preoccupation with Psychotic Experiences
as a Treatment Target
NEIL THOMAS ■
The loss of contact with reality that characterizes psychosis is most often consid-
ered in terms of the content of the person’s beliefs and experiences. This can be
operationalized in terms of a misalignment of what someone believes or experi-
ences with consensual reality: Individuals may come to believe in plots against
them regarded by others as false, they may report that their actions are under
the control of others, and they may talk of hearing voices others cannot hear.
This aspect of loss of contact with reality is that which has been most focused
on in research and treatment. For example, the dominant psychological therapy
modality of cognitive-behavioral therapy for psychosis (CBTp) focuses in partic-
ular on helping the person to develop an alternative, reality-based formulation of
their experiences in place of delusional explanations, and on helping the person
reconsider whether hallucinatory experiences are real or possess power over the
hearer (Morrison & Barratt, 2010).
This chapter focuses on another aspect of loss of contact with reality that char-
acterizes psychosis, providing an alternate and complementary target in psycho-
logical intervention. This is the extent to which individuals become immersed
in an internal psychotic world—how much they spend time thinking about the
possible plots against them, how much they become preoccupied with whether
their actions are being controlled, and how much they listen to and interact with
their hallucinated voices. This reflects processes involving both attention and
204 A cc e p ta n c e a n d M i n d f u l n e s s i n t h e T r e atm e n t o f P s y c h o s i s
internal verbalization, in particular in the form of verbal thinking processes

associated with delusional ideation and interaction with voices. A focus on these
elements of psychotic experience parallels that found in literatures on depres-
sion and anxiety, which highlight processes such as rumination and worry as
factors that maintain negative affect and impaired social function and that have
become important targets for therapy. The chapter also considers ways in which
attentional and verbal engagement with psychotic experiences develop and
how this may provide a specific target for acceptance- and mindfulness-based
interventions.
PH EN O M EN O LO GY O F PSYC H O S I S
The positive symptoms of psychosis are frequently equated with delusions and
hallucinations. This, of course, is oversimplifying the vast range of unusual sub-
jective experiences encountered in psychosis, but there is evidence that these are
the main symptoms in a distinct reality distortion cluster of symptoms, separate
from negative symptoms (e.g., avolition, social withdrawal, anhedonia) and dis-
organization symptoms (e.g., formal thought disorder) (e.g., Liddle, 1987). It is
this reality distortion cluster that captures the essence of psychosis, being used
to define a range of schizophrenia-like, affective, and organic disorders as “psy-
chotic,” and is the focus of this chapter.
Delusions are often labeled as “false” beliefs, usually defined by the person
possessing a significantly distressing and/or disabling belief not shared with oth-
ers in their culture, usually with high conviction. Meanwhile, hallucinations are
often referred to as “false” perceptions. These are mental events defined by their
experiential quality of seeming to be true perceptions originating autonomously
in the external world via the senses, as opposed to an internal mental event
such as a thought or memory (Bentall, 1990). Hallucinations arise in all sensory
modalities (auditory, visual, olfactory, gustatory, somatosensory), but the most
commonly reported ones are auditory hallucinations, which are nearly always
in the form of human speech, an experience commonly referred to as “hearing
voices.” These two key phenomena are now considered in turn.
D ELU S I O N S
Delusions as Multidimensional Phenomena
The term delusion is used broadly to capture a range of experiences in people

with psychotic disorders; although it is most often defined as a type of “belief”
(e.g., see American Psychiatric Association, 2013), it is apparent that typi-
cal delusional content relates to a spectrum of associated experiences. These
range from stable beliefs (e.g., a belief that you are being monitored and fol-
lowed, believing that there is a microchip in your brain controlling your body
A Model for the Development of Acceptance- and Mindfulness-Based Therapies205
and mind), to moment-to-moment thoughts (e.g., a thought that a stranger is

watching you, thinking that a particular action was under external control),
to more sensation-like experiences (e.g., a feeling of being in danger from oth-
ers when outside, feeling as if one’s actions are not under one’s voluntary con-
trol). Although originally defined as characterized by absolute conviction, there
appears to be distinct variability here, with some people reporting experiences
that dominate their thinking throughout the day but that they recognize as being
a product of their own mind, whereas others seem to infrequently talk or think
about a delusional belief but retain absolute conviction in it (Garety & Hemsley,
1987; Steel et al., 2007; Strauss, 1969).
In understanding this variability in experiences, it has become common to
conceptualize delusions dimensionally. A first aspect of this conceptualization
is that there is not a clear dividing line between the delusions held by people
with psychotic disorders and beliefs held by people in nonpsychotic popula-
tions (Strauss, 1969). Beliefs with similar content to delusional themes are often
reported in nonclinical samples, including persecutory beliefs, beliefs in super-
natural phenomena, and telepathy (Freeman, 2006). For example, in contrast
between psychotic and nonclinical populations, Peters, Joseph, and Garety
(1999) highlighted that the 40 most common delusional themes included in a
structured interview schedule for psychotic disorders were quite frequently
endorsed by people in a nonclinical sample, with adapted versions of each theme
being endorsed on average by one in four persons. This has been interpreted
as delusions falling along a continuum with normal cognition, and rather than
being characterized by qualitatively abnormal content, differ quantitatively from
normal-range beliefs as part of a continuum (Freeman, 2006; Garety & Hemsley,
1987; Johns & Van Os, 2001; Strauss, 1969).
A second aspect of a dimensional conceptualization of delusions is that a
number of dimensions may be needed to understand the differences between
psychotic and nonpsychotic cognition (Strauss, 1969). Dimensions that have
been proposed to understand delusions include both content-related dimen-
sions (conviction, bizarreness, systematization) and non-content-related dimen-
sions (preoccupation, distress, interference with functioning) (e.g., Garety &
Hemsley, 1987; Haddock, McCarron, Tarrier, & Farragher, 1999; Kendler, Glazer,
& Morgenstern, 1983; Jørgensen, 1995; Mizrahi et al., 2006; Peters et al., 1999;
Strauss, 1969; Wessely et al., 1993). Content-related dimensions alone seem inad-
equate in distinguishing between delusions and normal thought, as they overlap
considerably with normal beliefs (Strauss, 1969), highlighting the importance of
non-content aspects in characterizing delusional thinking.
A further aspect of this conceptualization is that the non-content characteris-
tics of delusions proposed appear largely orthogonal. The dimensions that have
been described appear only modestly correlated with each other (Appelbaum,
Robbins, & Roth, 1999; Garety & Hemsley, 1987; Kendler et al., 1983; Steel et al.,
2007) and appear to vary independently of each other over time (Brett-Jones,
Garety, & Hemsley, 1987; Hole, Rush, & Beck, 1979; Sharp et al., 1996). This sug-
gests that they potentially reflect the involvement of multiple cognitive processes
in delusion formation and maintenance. Indeed, the jumping-to-conclusions

bias on probabilistic reasoning tasks (Huq, Garety, & Hemsley, 1988), which is
probably the most frequently reported cognitive process linked with delusions,
appears to relate specifically to conviction but not to preoccupation (Garety
et al., 2005), suggesting that different processes are involved.
Delusions and Anomalous Experience
Additionally, a distinction is often made between delusions as beliefs and asso-

ciated anomalous experiences. Maher (1988) proposed that delusions could be
understood as attempts by the person to make sense of perceptual anomalies
arising in psychosis, an idea included in most contemporary models of delu-
sions (e.g., Frith, 1992; Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001;
Morrison, 2001). For instance, hearing a negative voice commenting on you and
other people may lead you to believe that you are being tormented by a demon,
and having experiences of thought insertion may lead to explanations in terms
of telepathic communications. The precise content of delusional beliefs is also
influenced by cultural background, prior life experiences, broader representa-
tions of oneself and the world, and ongoing concerns (e.g., Rhodes & Jakes, 2000,
2010; Smith et al., 2006; Thomas, Farhall, & Shawyer, 2013), which may account
for individual variability in their manifestation.
A number of delusional themes appear to correspond directly with distur-
bances of experience, such as delusions of control (being controlled by an external
entity) with passivity experiences (actions not seeming to be under one’s volun-
tary control) and delusions of reference (being referred to in the media, etc.) with
the feeling that certain experiences are of personal significance (Frith, 1992).
The breakdown of the usual boundaries between self and the external world,
or ability to accurately recognize this distinction, is often referred to in models
attempting to explain these phenomena (e.g., Bentall, 1990; Fowler, 2000; Frith,
1992; Garety et al., 2001). Other models have highlighted potentially related dif-
ficulties in screening out or inhibiting irrelevant information, leading to them
appearing unusually novel or salient (Gray, Feldon, Rawlins, Hemsley, & Smith,
1991; Kapur, 2003). Delusional experiences may be further added to by affective
disturbance such as anxiety contributing to interpretations of threat, dyspho-
ria to negative beliefs about self, and mania to grandiosity (Garety et al., 2001).
Affective experience has been proposed as sufficient in itself to act as a trigger for
delusion formation in the absence of perceptual disturbance (Freeman, Garety,
Kuipers, Fowler, & Bebbington, 2002).
Overall, these models of delusions converge on the idea that delusions are
associated with a verbally mediated cognitive process of trying to assimilate
conscious perceptual (e.g., hallucinatory, somatosensory, monitoring of motor
activity) and/or affective (e.g., feelings of threat) experiences. Considering the
proposed multidimensionality of delusions, this process can be conceptualized
not only in terms of belief content and associated strength of conviction but also
in terms of the amount of time in which cognitive representations of the experi-

ence are a focus of consciousness, both during a search for meaning and after
explanations have been developed. This is typically labeled as “delusional pre-
occupation” (e.g., Haddock et al., 1999; Peters et al., 1999; Wessely et al., 1993).
Episodes of delusional preoccupation can be prolonged—for example, in data
presented by Steel et al. (2007) on people during acute relapse, the median rated
duration of delusional preoccupation was rated as “at least one hour,” with 26%
of people for “several hours.”
Delusional Preoccupation
Cross-sectionally, delusional preoccupation appears to be particularly relevant

in understanding the differences between psychotic and nonpsychotic think-
ing, and the associated impacts on distress and functioning. Lincoln (2007)
contrasted schizophrenia patients and nonclinical controls on self-ratings
for 40 common delusion themes. Data reported from this study indicated
preoccupation performed better than conviction in distinguishing groups.
Similarly, in examining dimensions of delusions during psychotic relapse,
data presented by Steel et al. (2007) indicated that indices of preoccupation
with the person’s most prominent delusion were associated with both distress
and interference with functioning, whereas conviction showed no relation-
ship with these variables.
A small number of studies have longitudinally tracked preoccupation during
onset of and recovery from delusions, which further illustrates the potential role
that preoccupation may play. Based on interviews with people with a first episode
of psychosis, Moller and Husby (2000) identified two core experiential elements
of the psychosis prodrome being a disturbance of perception of self, combined
with an “extreme preoccupation by and withdrawal to overvalued ideas” (p. 223).
These authors describe this preoccupation as developing from an idea that is
ascribed importance as a focus for the person’s thoughts, and see development
of delusional conviction as an endpoint of a period of increasing preoccupation
with it. Meanwhile, in considering dimensional change during recovery, longi-
tudinal studies by Jørgensen (1995), Drury (1992), and Mizrahi et al. (2006) have
tracked people during recovery from an acute episode. These studies each found
evidence that, during recovery, changes in preoccupation tended to be first to
occur, preceding changes in conviction.
Among people with persisting delusions, there appears to be fluctuation in the
degree to which thoughts concern delusions. Experience sampling studies have
suggested that delusional ideation is present only in a minority of time points
(e.g., Myin-Germeys, Nicolson, & Delespaul, 2001), and, when present, there are
variable degrees of distress, interference, conviction, and duration of preoccupa-
tion (Peters et al., 2012). Peters et al. (2012) further found that delusional ideas
being described as going “round and round” were more strongly associated with
distress and interference than conviction.
Overall, these findings suggest that the extent to which delusional ideation is
represented in consciousness tends to fluctuate relatively independently of the
degree of conviction, but with closer associations with distress and interference.
Hence both cross-sectionally and longitudinally, preoccupation appears to rep-
resent a distinct process and potentially a key target for intervention.
What Fuels Delusional Preoccupation?
If delusions are formed to explain anomalous experiences, delusional cognitive

structures may continue to be activated when the person continues to have such
experiences. This has not been studied definitively—although, in an experience
sampling study, Ben-Zeev, Ellington, Swendsen, and Granholm (2011) did not
find that variability in hallucinatory activity proved to be a good predictor of
subsequent occurrences of delusional ideation. It could be that variations in a
range of anomalous experiences broader than frank hallucinations may be more
predictive, such as perceptual disturbances, affective disturbances, and experi-
ences of events as personally salient. However, if preoccupation merely arose as
an attempt to explain anomalous experience, one would expect that once a delu-
sional explanation has been established, the duration of delusional preoccupa-
tion would decrease. This is contrary to observations of the prolonged nature of
episodes of delusional preoccupation, particularly in people with well-formed
delusional explanations for their experiences. Indeed, expression of absolute
certainty in delusional beliefs, suggestive that the person has reached closure
in explaining their experiences, predicts greater rather than less preoccupation
(Garety et al., 2005). This suggests that other processes are likely to contribute to
the persistence of delusional ideation.
The antecedents to episodes of delusional ideation found most consistently in
experience sampling studies have been emotional disturbances, with variations
in anxiety, dysphoria, and low self-esteem robustly predicting subsequent delu-
sional ideation and paranoia in clinical and nonclinical samples (Ben-Zeev et al.,
2011; Thewissen, Bentall, Lecomte, van Os & Myin-Germeys, 2008; Thewissen
et al., 2011). This suggests that emotion-related processes may be important in
contributing to ongoing immersion in psychosis.
Ruminative Thinking Processes

In emotional disorders, the importance of repetitive thinking processes has
been highlighted in maintaining the representation of sources of concern within
consciousness for extended periods of thinking. Nolen-Hoeksema (1991) high-
lighted the role of rumination in maintaining depression. She proposed rumi-
nation as a response style to dysphoria, in which the person engages in trying
to identify the causes of his or her mood using an unproductive self-focused
brooding style. Depressive rumination is of particular significance, as induction
of rumination in experimental procedures predicts greater dysphoria, and indi-
vidual differences in trait rumination predict risk of relapse (Nolen-Hoeksema,
Wisco, & Lyubomirsky, 2008). Rumination has been proposed to maintain nega-
tive mood states by leading to persisting activation of depression-related cogni-
tive networks (e.g., Teasdale & Barnard, 1993).
A number of other patterns of repetitive thinking have been described in the
context of other diagnoses and in nonclinical populations, leading to unpro-
ductive negative thinking being proposed as a transdiagnostic construct (e.g.,
Harvey, Watkins, Mansell, & Shafran, 2004; Watkins, 2008). In particular, worry
appears to be a similar, but future-focused, process significant in maintaining
anxiety (e.g., Borkovec, Ray & Stöber, 1998). It has been proposed that rumi-
nation functions in order to resolve perceived discrepancies between current
and desired goal states (Martin & Tesser, 1996; Pyszcynski & Greenberg, 1987),
which suggests that it could also be triggered as an attempt to resolve the pres-
ence of unwanted intrusive anomalous experiences.
Although there is evidence of rumination occurring in people with psychotic
disorders (e.g., Thomas, Ribaux, & Phillips, 2014), there has been relatively
limited examination of the role of repetitive thinking in delusions. Thomas,
Labuschangne, and Rossell (2013) found that persons prone to delusion-like ide-
ation in a nonclinical population endorsed greater preoccupation with delusional
themes if they had higher levels of repetitive thinking in general. There have
also been a number of studies specifically focused on the relationship between
paranoia and repetitive thinking. In these, worry has consistently predicted the
presence of both nonclinical paranoia and persecutory delusions (Freeman et al.,
2008; Freeman, Pugh, Vorontsova, Antley, & Slater, 2010; Morrison & Wells,
2007; Startup, Freeman, & Garety, 2007) and preoccupation with persecutory
delusions (Bassett, Sperlinger, & Freeman, 2009; Startup et al., 2007). Worry also
prospectively predicts the persistence of delusions at follow-up (Startup et al.,
2007). Likewise, rumination is predictive of nonclinical trait paranoia (Simpson,
MacGregor, Cavanagh, & Dudley, 2012), and following a paranoia induction,
nonclinical participants instructed to ruminate reported greater persistence of
paranoia (Martinelli, Cavanagh, & Dudley, 2013). Although we await a definitive
study of repetitive thinking in relation across the range of delusional themes in
people with psychosis and further examination of associated processes, these
initial studies suggest that processes akin to rumination and worry may contrib-
ute to persisting preoccupation with delusions.
Avoidance
A second process that may contribute to preoccupation with psychosis is avoid-
ance. The possibility that immersion in psychosis may have a defensive func-
tion has long been hypothesized, with psychosis initially being construed as a
defense in line with a psychodynamic tradition (Hingley, 1997), but in more
recent conceptualizations, irrespective of the origins of psychosis, its persistence
may be contributed to by defensive avoidance (e.g., Bentall, Corcoran, Howard,
Blackwood, & Kinderman, 2001; Freeman et al., 2002). One form of avoidance
proposed is that against threats to self: Engaging with paranoid and grandiose
thought content may serve to protect the person from thoughts about personal
failings or low social status—often challenges within the population of people

with psychotic disorders. Some support for this comes from studies of attribu-
tion in relation to persecutory delusions. Persecutory delusions are associated
with an attributional bias toward attributing the cause for negative events to the
actions of other people and for positive events to oneself (e.g., Bentall, Kaney, &
Dewey, 1991). Alongside this pattern there have been observations on disguised
tasks designed to assess implicit attributions, that reverse bias was present—
attributing the cause of negative events to oneself—suggesting that there may
be an underlying negative view of self which is defended against in conscious
thought by focusing on others as the cause of difficulties (Lyon, Kaney, & Bentall,
1994). Although originating in research on persecutory delusions, other studies
have suggested that these results are not specific to persecutory delusions and
are associated with psychosis more broadly (Humphreys & Barrowclough, 2006).
Findings in this literature have, however, not been consistent, with failure to rep-
licate these attributional biases and observations that delusions are positively
correlated with low self-esteem, not negatively (see Freeman, 2007).
However, because self-esteem fluctuates significantly rather than remaining a
stable trait, particularly in psychosis (Thewissen et al., 2008), these cross-sectional
studies focusing on the presence vs. absence of delusions may have been less sen-
sitive to more dynamic relationships between threats to self and episodes of psy-
chotic preoccupation. The findings that variations in emotion and self-esteem
predict that variations in paranoid symptoms might be explained by a relation-
ship mediated by avoidance. In support of this, in a nonclinical population,
Udachina et al. (2009) found that experiential avoidance mediated the temporal
relationship between variations in self-esteem and paranoid ideation, particu-
larly when experiencing high levels of stress.
As well as potentially functioning to avoid threats to self, preoccupation may
also function to avoid other emotional experiences and associated cognitions,
including negative imagery. Anxiety and dysphoria are common in psychosis
and, as noted, often appear to precede episodes of delusional ideation or hal-
lucination. Although this association might be explained by a direct triggering
relationship, it is possible that avoidance may additionally have an effect. This
was suggested in a study by Goldstone, Farhall, and Ong (2011) which found that
experiential avoidance (i.e., attempts to avoid aversive thoughts, memories, feel-
ings, body sensations, etc.) mediated the association between current stress and
delusional ideation in both psychosis and nonclinical samples. This potentially
parallels models of worry in which prolonged engagement in verbal thinking
processes may suppress potentially more aversive emotional experiences and
imagery (Borkovec et al., 1998).
A further form of avoidance that may contribute to preoccupation with delu-
sions is to retreat into a psychotic world in order to avoid external reality. The
environments of people with psychosis may often be characterized by significant
social challenges such as unemployment, financial difficulties, and social isola-
tion. Additionally, people with psychosis appear particularly sensitive to expres-
sions of overinvolvement and criticism from family members, which can often
precipitate relapse (Butzlaff & Hooley, 1998). In this context, engagement in psy-
chotic experiences, particularly if with grandiose or laudatory content, may be a
source of positive reinforcement lacking in external reality and/or be negatively
reinforced as a means of escape from aversive environmental stimuli.
VO I C ES
Although hallucinations might be considered another form of anomalous expe-

rience that may fuel the processes described in the previous section, they require
additional consideration, as they are most often explicitly verbal phenomena
themselves, nearly always involving hearing voices (McCarthy-Jones et al., 2014).
This experience is found in approximately 70% of people with a diagnosis of
schizophrenia (Sartorius et al., 1986) as well as in a number of other diagnoses,
and in a small but significant proportion of people without a diagnosable psychi-
atric disorder in community samples (Larøi et al., 2012).
Although the experience of hearing human speech instead of other types of
sound is an almost universal feature of auditory hallucinations, the exact mani-
festation of this is variable, differing in frequency and duration, in vividness,
in loudness, in spatial location, and in number, from a single voice to multiple
different voices (McCarthy-Jones et al., 2014; Nayani & David, 1996). Mirroring
the distinction between preoccupation with and conviction in the reality of delu-
sions, a factor analysis of these basic characteristics suggested that frequency,
duration, and immersiveness of hallucinations are independent of their viv-
idness and sense of reality (Singh, Sharan, & Kulhara, 2003). In spite of this
variability, there are some commonalties in the ways in which auditory verbal
hallucinations manifest. First, voices usually sound different from the person’s
own speaking voice, often being a different age, gender, or accent from that of
the hearer (Nayani & David, 1996). Additionally, voice content typically refers
to the hearer in some way, usually either directly addressing (second person) or
talking about them (third person), sometimes in the form of a running com-
mentary (McCarthy-Jones et al., 2014). This voice content is usually meaning-
fully connected to the person’s ongoing activity or thoughts or to memories of
past events (Leudar, Thomas, McNally, & Glinksi, 1997). Although content of
voices is variable, it appears typical for most or at least some of voice experi-
ence to involve negative content, such as criticism, abuse, threats, warnings of
harm from others, and commands to do unwanted or harmful things (Nayani &
David, 1996). Positive content, such as encouraging or laudatory voices, may or
may not be present.
The presence of a higher degree of negative and emotive content, along with
increased frequency and duration of voices, is a key factor in distinguishing the
voices of people with psychotic disorders from those who hear voices but do not
have a diagnosable mental disorder (Daalman et al., 2011; Honig et al., 1998).
In fact, the experience among nonclinical voice-hearers appears to have similar
sensory qualities (loudness, location) to those of the experience of people with
psychotic disorders; if anything, the voices of nonclinical individuals are even

more likely to be attributed to external sources (Daalman et al., 2011). This sug-
gests that it is not the degree of reality distortion involved which accounts for
voices being clinically problematic, but the extent to which negative emotional
content dominates consciousness.
Preoccupation with Hearing Voices
As with the anomalous experiences described in the context of delusions, the

experience of hearing voices is likely to drive a search for meaning, which may
be associated with significant preoccupation in thinking about voice experi-
ence. However, given the specific characteristics of this experience, it seems par-
ticularly likely to draw attention. Thomas, Morris, Shawyer, and Farhall (2013)
described three layers of the experience of hearing voices that can lead to the per-
son’s attention and behavior becoming engaged with them. First, irrespective of
content, it is often a loud auditory experience that is difficult to control or escape
from, making it a particularly intrusive stimulus. Second, it comprises meaning-
ful verbal content, which itself is often emotive and personally significant, hence
is particularly likely to be experienced as a meaningful stimulus. Third, it has
the qualities of a human voice talking to or about the hearer, hence it represents
a stimulus that is also socially significant, particularly when negative content
conveys a sense of hostility. In line with this, the person very typically interprets
such voices not merely as heard speech but as another person (or other entity)
interacting with him or her in a human-like way (Benjamin, 1989; Chadwick &
Birchwood, 1994).
Each of these is a characteristic that may contribute to the salience of this
experience, capturing the hearer’s attention and making it difficult to focus
on the external world. Furthermore, the emotive and self-referential nature of
voice content, and the common experience of hearing voices as if coming from
a real sentient other, can draw the person to listen to voices actively as a source
of information about the self or the world or to predict its behavior. This is not
necessarily problematic; there have been proposals that paying attention to
voice content can be helpful in making sense of this experience, in particular
the origins of voice content in past aversive experience (Corstens, Longden &
May, 2011). However, habitually being drawn into listening to voices is likely to
be particularly disruptive to engagement and activity in the external world, and
appears to characterize those most disabled by the experience (Benjamin, 1989).
Furthermore, in addition to attentional engagement, it is typical for people to
go beyond merely listening to voices and to become drawn into verbally inter-
acting with them as they would a human in the external world. This may arise
in the form of people responding to their voices aloud, but more commonly
may involve covert verbalizations with voices through inner speech (Leudar
et al., 1997). When responding to voices, it appears that a two-way dialogue can
develop at least in some individuals (Leudar et al., 1997). Indeed, it is common
for voice hearers to agree that they have a “relationship” with their voices (Chin,
Hayward, & Drinnan, 2009) and to be able to give coherent accounts of this on
measures of interpersonal relationships (e.g., Benjamin, 1989).
Examining these responses in more detail, it has been observed that it is par-
ticularly common for people to be drawn into emotionally charged responses
to their voices, such as shouting at or arguing with them (Close & Garety, 1998;
Nayani & David, 1996). Chadwick and Birchwood (1995) identified this as part
of a fundamental response to hearing voices that they labeled “resistance.” It
appears that resistance is elicited by interpreting voices as hostile (Birchwood &
Chadwick, 1997). This corresponds to patterns observed in everyday interper-
sonal interactions in which perceived hostility tends to elicit reciprocal hostile
responses (Thomas, McLeod, & Brewin, 2009). Although appearing to be a com-
mon response, voice hearers report that this is less effective than other means of
coping (Carter, Mackinnon, & Copolov, 1996; Farhall & Gherke, 1997; Tsai & Ku,
2005) and that the presence of such hostile interactions with voices is predictive
of distress (Romme & Escher, 1989; Thomas et al., 2009). This response may be a
habitual but potentially counterproductive response.
The alternatives to resistance require some consideration. Chadwick and
Birchwood (1995) contrasted resistance and engagement as the two main
response styles to voices. Engagement may involve actively listening to, seek-
ing out, and accepting what voices say. However, engagement is strongly associ-
ated with experiencing voices as benevolent (Birchwood & Chadwick, 1997) and
may not provide a feasible response to the hostile voices that people tend to find
most problematic. Indeed, unqualified listening to negative content and harm-
ful commands is likely to increase negative impacts on mood and behavior. An
alternative response style that has been proposed is that of acceptance of voices.
Romme and Escher (1989) are often credited with highlighting the importance
of accepting voices, as a means of positive adaptation and of considering integra-
tion of voice experiences as part of one’s life, including a willingness to experi-
ence rather than eliminate them. In the coping literature, acceptance has also
emerged as a response style to voices. For example, in a principal components
analysis of coping responses, Farhall and Gherke (1997) differentiated active
acceptance of voice experience from passive coping (primarily looking to oth-
ers for support) and resistance of and verbalization to voices. Influenced by the
literature on acceptance and commitment therapy, Shawyer et al. (2007) pro-
posed that acceptance of voices, as distinct from engagement with voices, could
be conceptualized as a combination of a willingness to experience voices with
nonavoidant disengagement from them and maintenance of autonomous action.
Developing a measure of this—the Voices Acceptance and Action Scale—they
found that acceptance was orthogonal to resistance and engagement and predic-
tive of lower rates of depression and better quality of life (Shawyer et al., 2007).
In addition to overall response style, an important consideration is flexibility
in responding to voices, depending on the situation or content. For example,
flexibility could entail placing limits on when to interact with voices, disattend-
ing at some times and actively engaging with them at others; selectively engaging
with positive voices has also been proposed as an adaptive response (Romme &
Escher, 1989). In support of this, the balance of evidence suggests that a larger
repertoire of coping with voices appears to be predictive of better adaptation
(Farhall, Greenwood, & Jackson, 2007).
Responses to Voices and Voice Persistence
From this discussion it appears that becoming drawn into verbal engagement
with voices may have significant costs in terms of interference with functioning
and, potentially, when resisting and arguing with voices, in terms of distress. It
is further possible that verbal engagement with voices may maintain ongoing
hallucinatory activity. Although voices have often been regarded as uncontrol-
lable phenomena, detailed study of this issue has questioned this assumption,
with many voice hearers reporting that they can elicit hallucinatory experience
through focusing on them (attention) or talking to them (verbal engagement)
(Moritz & Larøi, 2008; Nayani & David, 1996). This suggests that by focusing
attention toward voices and responding back to them the voices will be experi-
enced. Indeed, voice hearers describe engaging in two-way conversations with
their voices, suggesting that responding to voices may lead to the formation of
meaningful replies (Leudar et al., 1997). Furthermore, literature on coping with
voices suggests that coping responses that involve talking back to voices are more
associated with the persistence of voices than are other responses (Farhall &
Gherke, 1997); constructive engagement in activity or interaction in the external
world may lead to voice activity reducing (Delespaul, deVries, & van Os, 2002).
PR EO C C U PAT I O N AS A T H ER A PEU T I C TA R G E T
The preceding survey of the literature suggests that preoccupation may become
established initially through a search for meaning of anomalous salient experi-
ences but potentially later maintained by repetitive thinking processes or verbal
engagement with voices. This activity may in turn reinforce psychotic experi-
ence through maintaining activation of cognitive networks that provide input
into psychotic symptoms. This immersion in psychotic experience may also be
further fueled by negative reinforcement arising from protection of self-esteem,
reduction of anxiety, or withdrawal from aversive environmental contingen-
cies. This situation may create a self-maintaining process that leads to psychotic
symptoms persisting and to their escalation at the time of relapse.
Current variants of CBTp primarily target change in the content of delusional
beliefs and beliefs about voices (Morrison & Barratt, 2010). Considering the
analysis just presented, the formulation-building process involved in CBTp is
likely to be helpful in promoting assimilation of anomalous experiences. CBTp
may also be helpful in modifying metacognitive-level beliefs that may maintain
engagement in psychotic experience, such as beliefs in paranoia as a survival
strategy (Morrison et al., 2005) or beliefs that voices may retaliate if not listened
to (Chadwick & Birchwood, 1994). It may also help in working with beliefs about
the self that drive immersion in psychosis as a form of avoidance. However, ulti-
mately, current formulations of CBTp have not been directed specifically at pre-
occupation with psychotic phenomena or the associated processes of attention,
internal verbalization, or avoidance. Although restructuring belief content can
lead to reductions in preoccupation (e.g., Chadwick & Lowe, 1994), cognitive
restructuring is limited by being a slow and tentative process and only appears
feasible when the person already holds some capacity to consider alternative
explanations for their experiences (Garety et al., 1997) so does not appear opti-
mal for this purpose.
Preoccupation could be more directly targeted by promoting alternate and
more flexible responses to psychotic experiences and ideation that provide an
alternative to the person becoming immersed in them. This more functional
focus indicates value in earlier, more behavioral incarnations of CBTp, such as
the coping strategy enhancement approach described by Tarrier (1992). Tarrier’s
approach involves conducting an individualized functional analysis of the ante-
cedents and maintaining patterns of episodes of hallucination and delusional
ideation, which is then used to inform the development and implementation
of alternate behavioral responses. This incorporates predominantly behavioral
methods including switching attention, focusing attention, increasing activity
levels, social engagement, modification of sensory input, and relaxation meth-
ods. There is evidence for the efficacy of this approach over both supportive
counseling and routine care in a thoroughly conducted trial (Tarrier et al., 1998).
While the effects of coping strategy enhancement specifically on preoccupation
have not been examined, it does offer a framework well suited to targeting preoc-
cupation with and immersion in psychosis.
Meanwhile, outside the psychosis literature, there have been developments of
further cognitive-behavioral methods for targeting ruminative thinking (e.g.,
Watkins et al., 2011), which may provide additional methods for extending CBTp
to address preoccupation more explicitly. A pilot study by Foster, Startup, Potts,
and Freeman (2010) found that use of a brief package of methods for targeting
worry was effective in reducing persecutory delusions relative to routine care,
indicating this as a promising direction for further development of CBTp.
Acceptance- and Mindfulness-Based Therapies
In the context of addressing preoccupation, third-generation cognitive-behavioral

interventions that promote acceptance and mindfulness as responses to inter-
nal experiences appear to offer particular promise as therapeutic approaches
suited to targeting preoccupation. These include acceptance and commit-
ment therapy (ACT; Hayes, Levin, Plumb-Vildarga, Boulanger, & Pistorello,
2013), mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982), and
mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002).
Following earlier work in applying mindfulness to chronic medical problems

(Kabat-Zinn, 1982), the use of mindfulness came to prominence as a treatment
for recurrent depression, influenced in particular by findings on the dominance
of ruminative thinking processes in depression as a risk for relapse (Teasdale,
Segal, & Williams, 1995). Mindfulness training involves regular practice in medi-
tation exercises that involve paying attention in a deliberate manner in the present
moment, typically with a focus such as the movements associated with breath-
ing. During mindfulness exercises, people practice recognizing when they have
become lost in thought and learn to redirect their attention to the present, skills
that promote regulation of attention and thinking. In addition, mindfulness pro-
motes a different relationship to experience characterized by openness, curiosity,
and acceptance of experience even when aversive (Bishop et al., 2004).
ACT also includes mindfulness, but it is a broader multicomponent interven-
tion. It is based on a theory of human experience in which the problems associated
with mental distress arise from entanglement with linguistically based cognitive
representations of experience (Hayes et al., 2013). A key concept within ACT is that
of cognitive fusion, when the person becomes caught up with responding to cog-
nitive representations of the world as if they were events in external reality, with
subjective experience and behavior becoming constricted by feared scenarios, con-
cepts of self, and rules of how to behave. Furthermore, as cognitive representations
and other private experiences cannot be escaped by moving away from them phys-
ically, fusion can give rise to attempts to escape discomfort through experiential
avoidance, which may include attempts to suppress thoughts and feelings or avoid
their environmental triggers, which can further restrict the person’s behavior.
In ACT, symptoms themselves are not targeted but instead their functional con-
sequences in terms of behavior. Hence, the aim of ACT is not to reduce symptoms
directly but to help people lead less restricted lives. The approach accomplishes
this by promoting greater psychological flexibility, usually described in terms of
the six processes of (1) fostering acceptance of uncontrollable aversive experi-
ences, (2) defusion from unhelpful cognitive representations, by putting them into
alternate contexts, (3) contact with the present moment, (4) adopting a perspective
of a stable self as observer of experiences, (5) clarification of personal values, and
(6) promoting deliberate committed action to these values. Mindfulness exercises
are usually incorporated to assist the person in getting in touch with the present
moment and to foster acceptance and the perspective of self as observer; a range
of other experiential exercises are also used. The overall aim of ACT is not to
reduce symptoms but to improve valued living irrespective of their presence.
Potential Applications of Acceptance and Mindfulness

to Psychosis
Self-Regulation
Acceptance- and mindfulness-based therapies have three key features that
may be important in providing ways to reduce preoccupation in psychosis (see
Figure 9.1). First, acceptance and mindfulness therapies promote conscious and
deliberate regulation of thought and behavior in place of habitual patterns. The
mindfulness exercises used in MBSR, MBCT, and ACT emphasize deliberate
control of attention, which is achieved by learning to recognize when one has
lost awareness of the present through mind-wandering, rumination, and inter-
nal preoccupation and to respond with redirection of attention, combined with
letting go of trains of thought that have arisen. This has clear potential applica-
tions in assisting people to let go of patterns of preoccupation with psychosis.
By engaging in mindful responses, individuals can focus their attention on the
present moment, helping to diminish the prominence of anomalous experiences
within consciousness and automatic responding to them. This practice, com-
bined with an active process of letting go of trains of thoughts in order to return
to the present moment, may help to interrupt patterns of verbal engagement with
psychotic experience—interaction with voices and delusion-related ruminations.
As an element of bringing people more closely in touch with awareness of the
present moment, these therapies also promote awareness over voluntary behav-
ior. Such awareness is further extended within ACT, which includes exercises
designed to develop awareness and clarity of personal values. These are har-
nessed as an alternate reference point to direct action in place of rumination and
behavioral repertoires arising habitually from experiential avoidance. This may
ANTECEDENTS
Fluctuations in
emotion, perceived salience
of events, and activation of
related cognitive networks
ACCEPTANCE AND
MINDFULNESS
PSYCHOTIC EXPERIENCES
Delusional ideation Deliberate self-regulation of
Hear voice attention and thinking
Decentering/defusion
PREOCCUPATION Acceptance: willingness to

Repetitive thinking experience psychotic
Verbal engagement with phenomena, their
voices antecedents, and other
avoided experiences
AVOIDANCE
Protection of self-esteem,
reduced anxiety, escape
from aversive environments
Figure 9.1. Potential role of acceptance- and mindfulness-based therapies in reducing

preoccupation with psychosis.
be helpful for further assisting people in disengaging from psychotic preoccupa-

tion, through emphasizing deliberate choice over behavior, thereby enabling the
person to exercise executive control over immersion in psychosis vs. engagement
in valued activity. Together, these self-regulation mechanisms may be helpful in
reducing the extent of activation of cognitive structures associated with delu-
sions and voice activity, which may in turn result in reduced persistence of psy-
chotic experiences.
Decentering and Defusion

Alongside strengthening intentional control over attention, mindfulness prac-
tice and ACT exercises enable the person to step back from the flow of internal
experience in order to see thoughts, emotions, and other private experiences as
mental events. Observing internal experience without becoming immersed in
the flow of thought potentially helps the person develop an awareness of both the
spontaneous and involuntary nature of ideation and recurrent themes in con-
tent. This practice is believed to cultivate a different relationship with thought,
in which the person is less identified with the content of thought as a literal rep-
resentation of reality.
The aim of cognitive defusion exercises used in ACT is to further support this
separation of thoughts from reality by undermining their salience and placing
them in different contexts. Defusion involves encouraging the person to experi-
ment with more detached or unconventional expressions of thought content,
including emotion-related thoughts, and observing the effects of this on their
subjective impact. For example, distress-related content might be verbalized on
its own and then prefixed by, “I’m having the thought that . . .”. From an ACT
perspective, the aim of this expression is to reduce the dominance of problematic
cognitive structures over behavior.
It seems likely that preoccupation can arise when the verbal structures of hal-
lucinations and delusions become a focus for cognitive fusion, resulting in their
dominance over thinking and behavior and a difficulty maintaining flexible
contact with the external world. Fusion with the content of psychotic experi-
ences may then be further associated with struggle and attempted avoidance of
these experiences and manifest, for example, in attempted resistance of voices or
attempted suppression of delusional ideas.
Acceptance
The third key feature of acceptance- and mindfulness-based interventions is
that they foster a different relationship to private experience, one that is char-
acterized by acceptance. During mindfulness practice, openness and curiosity
toward all experience is promoted, including that usually regarded as aversive,
in a spirit of being willing to accept without judgment whatever experiences
form part of the present moment. People are encouraged to turn their attention
toward usually avoided experiences in order to explore them, and to allow them
to be present in conscious awareness without attempting to suppress or escape
such experiences.
ACT tackles acceptance more explicitly through use of a range of exercises

designed to promote acceptance as an alternate response to experiences that are
struggled with or avoided. These exercises include those designed to highlight
the futility of attempting to avoid internal experiences and how such attempts to
avoid or suppress private experiences can be counterproductive or can be con-
suming at the expense of engagement in valued living. The concept of willing-
ness to experience aversive experiences is additionally used in conjunction with
acceptance and as part of promoting committed action in line with one’s values.
Use of these methods may be of utility in two particular ways in rela-
tion to psychotic phenomena. First, regarding voices as a specific symptom,
mindfulness-based approaches provide methods to promote acceptance as an
alternative response to the resistant responses that are typically elicited by nega-
tive voice content in the forms of both hostile verbal interaction and unproduc-
tive attempts to suppress voices. For example, ACT uses exercises to highlight
the unworkability of attempts to battle with voices in order to promote letting
go of struggle as an alternative; mindfulness exercises promote turning toward
voices to explore them as an element of experience rather than trying to suppress
them; and additional exercises are used to promote willingness to pursue valued
living irrespective of the presence of voices (Thomas, Morris, et al., 2013). These
methods might also be used with other aversive psychotic phenomena such as
thought insertion or passivity experiences.
Second, acceptance may be helpful in increasing tolerance of anxiety, dyspho-
ria, and feelings of low self-esteem that may precede episodes of delusional ide-
ation and/or provide an avoidant function for immersion in psychosis. Hence,
when experiencing aversive emotional states, acceptance may reduce the like-
lihood of this triggering delusional preoccupation. Here acceptance, mindful
turning toward emotions, and willingness would be directed at emotional expe-
riences instead of psychotic experiences.
Current Empirical Status of Acceptance- and

Mindfulness-Based Therapies for Psychosis
Mindfulness training has been tested primarily in a group format, including as

part of a broader protocol termed person-based cognitive therapy (Chadwick,
2006). Mindfulness appears to be feasible in this population and can bring about
improvements in ratings of mindfulness (Chadwick, Hughes, Russell, Russell,
& Dagnan, 2009; Langer, Cangas, Salcedo, & Fuentes, 2012). Although await-
ing a sufficiently powered controlled trial to examine effects on dimensions of
psychotic symptoms, there are promising results on overall outcomes from pre-
to post-treatment (Chadwick, Newman Taylor, & Abba, 2005; Chadwick et al.,
2009; Dannahy et al., 2011). The specific effects on preoccupation and mecha-
nisms involved have not yet been systematically examined. However, a qualita-
tive study of group member experiences has confirmed that group members are
able to learn to allow psychotic experiences to come and go without habitual
reactions to them (Abba, Chadwick, & Stevenson, 2008). Although the applica-
tion of mindfulness has been described primarily in working with voices, Ellett
(2013) has reported two cases of the effects of mindfulness on persecutory delu-
sions, finding steady reductions in preoccupation alongside reduced conviction,
distress, and impact of beliefs during the course of sessions.
ACT as treatment for individuals with psychotic symptoms has been directly
studied in three published randomized controlled trials—two targeting relapse
prevention during an acute phase (Bach & Hayes, 2002; Gaudiano & Herbert,
2006) and one targeting persisting command hallucinations (Shawyer et al.,
2012). A fourth trial has examined the use of ACT following clinical recovery,
focusing primarily on emotional adaptation (White et al., 2011). Evidence to date
suggests that ACT may have an effect on readmission rates (Bach, Gaudiano,
Hayes, & Herbert, 2012); it may help to reduce escalation of psychotic preoccupa-
tion when triggered, but its impact on persisting psychotic symptoms remains to
be demonstrated (Shawyer et al., 2013). Processes have so far focused on believ-
ability of psychotic symptoms (Bach et al., 2012), an index of cognitive fusion,
but impact on preoccupation has not yet been reported.
F U T U R E R ES E A R C H O N PR EO C C U PAT I O N AS A TA R G E T
O F AC C EP TA N C E A N D M I N D F U L N ES S
This survey of the literature suggests that preoccupation with psychosis

is a potentially important clinical target, and features of acceptance- and
mindfulness-based therapies may have specific utility in targeting it. The con-
cepts of delusional preoccupation and verbal engagement with voices repre-
sent measurable therapeutic targets, and those of self-regulation, decentering
and defusion, and acceptance represent potentially measurable therapeutic
processes.
Research on each of these processes remains preliminary, with many ideas
yet to be directly tested. A key issue is in operationalizing and measuring pre-
occupation. In delusions, preoccupation has been conceptualized in terms of
the frequency and duration (Haddock et al., 1999) or proportion of time (Peters
et al., 1999) during which thoughts relating to delusions are present. These have
been assessed with single scales within broader measures, which alone may lack
sensitivity to variability in preoccupation. A broader conceptualization may be
possible, incorporating aspects such as establishing the extent to which thoughts
dominate awareness to the point of being unable to think about other things, and
their degree of repetitiveness and unproductiveness. Assessment of delusional
preoccupation with a range of items may enable a more sensitive measure to be
developed. Additionally, verbal engagement with voices as a specific construct
seems important to examine in its own right, in order to determine the impact
of this construct as a specific behavioral response to voices.
Likewise, there is a need to develop ways of measuring processes involved in
acceptance- and mindfulness-based therapies. Self-report measures exist for
mindfulness (Chadwick, Barnbrook, & Newman-Taylor, 2008) and acceptance

of voices (Shawyer et al., 2007) as well as for experiential avoidance (Bond et al.,
2011), but the development of validated measures of broader ACT processes
such as cognitive defusion requires further work. Even so, ultimately, experi-
mental paradigms may be needed to study processes of delusional preoccupa-
tion and verbal engagement with voices. Given the reliance of this literature on
correlational studies between individual variation on constructs that are often
overlapping, the use of experimental paradigms may enable separation of dif-
ferent processes, and the testing of causal predictions about the nature of preoc-
cupation with psychotic experience. Research on rumination in depression and
worry in anxiety has benefited from methods of inducing specific mood states
(e.g., through listening to particular types of music) or particular styles of cog-
nitive processing. Parallel methods for assessing delusional preoccupation are
needed. Different responses to voices are possible to manipulate within experi-
mental designs, but a challenge in doing so is the unpredictability of voice activ-
ity and content itself, which by its very nature tends to be difficult to directly
control. Analogue research with recorded voice-like stimuli, experience sam-
pling methods, and temporal tracking of the impacts of different responses on
voices when they arise may prove to be useful methods for clarifying the rela-
tionships between different constructs.
A further key area for study is examining the potency of mindfulness and ACT
methods in the context of psychosis to effect changes in preoccupation. This is
particularly important, as therapeutic methods have been developed predomi-
nantly in the context of emotional disorders, where the targets are responses to
emotional disturbance rather than psychotic thinking processes, and generaliz-
ability requires testing. The literature to date has provided mostly supportive
data on the helpfulness of mindfulness in working with voices, but the extension
of mindfulness to delusions and the applicability of broader ACT methods are
less well understood. A particular issue to address is whether, as with CBTp, a
certain degree of metacognitive awareness of delusions as mental events may be
required for persons with psychosis to be able to make use of methods of disen-
gaging from psychotic symptoms.
In sum, preoccupation with psychotic experiences appears to be an important
target to explore in the development of psychological interventions and one that
may be particularly suited to acceptance- and mindfulness-based interventions.
Further investigation provides a valuable direction in developing psychological
therapies for individuals with psychosis.
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10
Disseminating and Implementing

Acceptance- and Mindfulness-
Based Approaches
to Psychosis
Challenges and Opportunities
HAMISH J. MCLEOD ■
A significant and long-standing challenge for psychotherapy skills training is the

effective translation of new theories and techniques into actual clinical practice.
Put simply, this is a question of disseminating key skills and knowledge, followed
by effective implementation. Unfortunately, there is evidence that completing
training in a therapy approach can lead therapists to judge their skills, compe-
tence, and knowledge as significantly improved even though independent assess-
ment of their actual clinical behavior indicates that they have not made changes
in practice of sufficient magnitude to produce better patient recovery (Miller &
Mount, 2001). This “illusion of knowledge” has many potential negative con-
sequences; for example, therapists may dismiss evidence-based techniques on
spurious grounds (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013) or may
idiosyncratically choose to adopt some evidence-based approaches but not oth-
ers (McHugh & Barlow, 2010). These challenges of implementation and dissemi-
nation affect not only psychiatry and psychology but also multiple domains of
healthcare provision (Gallo & Barlow, 2012; Powell et al., 2012). Fortunately, the
rise of implementation science has informed what should be done to improve
the reach and impact of new and emerging psychotherapy techniques (Beidas &
Kendall, 2010).
228 A cc e p t a n c e a n d M i n d ful n e s s i n t h e Tr e a t m e n t o f P s y ch o s i s
This chapter examines research addressing acceptance and mindfulness

approaches to psychosis, with the specific aim of determining how to promote
the development of this evidence base and enhance the dissemination and
implementation of effective techniques. We begin with a brief discussion of what
affects dissemination and implementation. These factors will then be used to
focus an examination of published randomized controlled trials (RCTs), uncon-
trolled trials, and case studies of acceptance and mindfulness approaches to the
treatment of psychosis. The final section identifies areas for further development
that will help advance the field.
FACTO R S A FFECT I N G D I S S EM I N AT I O N A N D
I M PL EM EN TAT I O N
Although there are now many sources of information about what constitutes
evidence-based practice and empirically supported psychological treatments
for various mental health problems (Chambless et al., 1998; Chambless &
Ollendick, 2001; National Institute for Clinical Excellence [NICE], 2009; Scottish
Intercollegiate Guidelines Network [SIGN], 2013), there is no guarantee that such
guidance will automatically diffuse into real-world clinical practice (Fairburn &
Wilson, 2013). This reflects the twin challenges of influencing how knowledge
and skills about a treatment are transferred (dissemination) and how the treat-
ment is actually applied in practice (implementation).
Post-qualification dissemination of new skills and knowledge into clinical
practice often happens serendipitously. For example, a clinician may identify a
need to update his or her skills and will decide to review a treatment manual
or attend a skills-based workshop. Until recently, it was unknown what level of
training experience was necessary to produce reliable implementation in prac-
tice and avoid promoting an artificially inflated sense of competence (Miller
& Mount, 2001). This question was empirically examined by Sholomskas et al.
(2005), who conducted an RCT comparing the effects of three different dissemi-
nation strategies on implementation outcomes. Participants were randomized to
either (1) review of a cognitive-behaviorial therapy (CBT) manual; (2) review of a
manual plus access to an Internet-based training site; or (3) review of the manual,
didactic seminar training, and case supervision. Therapeutic competence was
determined through a role-play assessment by assessors who were blind to train-
ing condition. The results were clear: Therapists who received the three-pronged
approach compared to those who only reviewed the manual were significantly
more competent (although many were still below the 80% level specified for
fidelity). Hence, the current gold standard for implementation of evidence-based
psychotherapy training is a multicomponent approach that includes provision of
a therapy manual, a skills workshop where the therapeutic skills can be acquired
and practiced, and clinical supervision that facilitates the generalization and
consolidation of skills (Beidas & Kendall, 2010; Herschell, Kolko, Baumann,
& Davis, 2010). Some of the other factors that affect the dissemination and
Disseminating and Implementing Acceptance- and Mindfulness-Based Approaches to Psychosis229
implementation of evidence-based practice include the quality of the training

(e.g., whether active or passive learning techniques are used), therapist variables
(e.g., extent of clinical experience), organizational support (e.g., access to suitable
clinical supervisors), and client variables (e.g., the fit between the therapy and
the specific presenting problem) (Beidas & Kendall, 2010).
A final critical issue to consider is that of treatment fidelity, in particular
the steps taken in trials to determine that participants received the treatment
as intended (Moncher & Prinz, 1991; Southam-Gerow & McLeod, 2013). This
information bears on two important issues: First, it tells us something about the
likelihood that any reported effects are actually due to the treatment approach,
and second, it provides information about how the implementation of the ther-
apy can be tested (Carroll et al., 2007; Hogue, Ozechowski, & Robbins, 2013).
Although multiple strategies can be used to test fidelity (Hogue et al., 2013), the
most common approach is to acquire structured ratings of therapist behavior
taken from therapy recordings or direct observation (Waltz, Addis, Koerner, &
Jacobson, 1993).
M I N D F U L N ES S - A N D AC C EP TA N C E- BAS ED
A PPR OAC H ES TO PSYC H O S I S: C U R R EN T E V I D EN C E
At present, mindfulness- and acceptance-based therapies for psychosis are not

endorsed as evidence-based treatments in UK guidelines (NICE 2009; SIGN,
2013), but Division 12 of the American Psychological Association (n.d.) has
graded acceptance and commitment therapy (ACT) for psychosis as a “prob-
ably efficacious treatment” (Chambless et al., 1998). This reflects the expansion
of “third-wave” approaches to psychotherapy that have developed over the past
decade (Khoury, Lecomte, Fortin, et al., 2013). During this period there has been
a marked increase in the number of psychosis-specific treatment studies explor-
ing the efficacy of approaches such as ACT (Hayes, Strosahl, & Wilson, 1999)
and person-based cognitive therapy (PBCT) (Chadwick, 2006). The therapeutic
potential of these approaches is reflected in the results of a recent meta-analysis
of mindfulness-, acceptance-, and compassion-focused approaches to psycho-
sis (Khoury, Lecomte, Gaudiano, et al., 2013). This study analyzed data from 13
distinct intervention trials that applied variants of mindfulness-, acceptance-,
or compassion-focused protocols to people presenting with psychotic symp-
toms and a variety of diagnoses. The overall results indicated moderate effect
sizes (Hedges g = .52, 95% CI.40–.64) for primary outcomes assessed within
subjects before and after treatment. The effect sizes were smaller for between-
group studies that used a comparator condition (treatment as usual, waitlist, or
active treatment). The pre-post within subject effects persisted following the end
of treatment in the studies that included a follow-up assessment (Hedges g = .62,
CI.36–.87). Interestingly, exploratory moderator analyses suggested a primary
effect of mindfulness on outcome that is complemented or optimized by accep-
tance and compassion processes. Analysis of specific primary outcomes suggests
that that the largest treatment effect was seen on negative symptoms compared
to other outcome measures. Although the considerable heterogeneity in many
of the studies points to the need for caution in generalizing the findings, it does
appear that these types of intervention have some robust effects for people pre-
senting with a wide variety of psychotic disorders (e.g., schizophrenia, major
depression with psychotic features, bipolar disorder). Furthermore, the modality
of delivery (group vs. individual treatment) does not appear to have an impact
on outcomes.
Following from these promising initial findings, the next challenge is to distill
out the key therapeutic ingredients. This includes identifying the essential skills
needed to deliver therapy, the nature of the therapist training, and the best meth-
ods for gauging therapist skill and competence.
Extracting the Evidence
MEDLINE and PsycINFO were searched covering the period 1996–May 2013
using a combination of “mindfulness,” “acceptance and commitment therapy,”
“psychosis,” and “schizophrenia” as search terms. This yielded 79 unique hits and
the titles and abstracts of these were screened for inclusion. Papers were excluded
if they were not focused on evaluating an acceptance- and mindfulness-based
therapy, did not report outcome data, were not written in English, or were an
opinion piece, review, dissertation, or conference abstract. The reference lists
of the remaining papers were screened to identify any studies not captured by
the database search terms. This resulted in a final set of 20 papers ranging from
single-n uncontrolled case studies through to RCTs.
General Characteristics of the Current Evidence Base
There have been four RCTs of individual therapy, eight group treatment studies
(including two RCTs), and eight case studies published in the past decade or so.
Out of the 369 people who participated in these studies, 253 were recipients of
the active treatment, with 97 being treated with either ACT or an ACT-based
intervention. The volume of studies is increasing over time, with four published
between 2002 and 2008 and 16 from 2009 to 2013. However, the evolution of
the evidence base differs from that seen in the CBT for psychosis (CBTp) litera-
ture, where individual case studies emerged first (Beck, 1952; Chadwick & Lowe,
1990) and were followed by increasingly sophisticated clinical trials (Garety
et al., 2008). In contrast, two of the more rigorous trials of ACT were conducted
in the 2002–2008 period, whereas more recently there has been an increase in the
proportion of single-n case studies.
When comparing ACT and mindfulness-focused intervention studies, a dif-
ference is evident in the mode of treatment delivery. The core mindfulness and
meditation approaches are more commonly delivered in a group format, whereas
ACT trials have typically involved individual therapy. In addition to the varia-
tions in delivery format, the number of sessions offered ranges from a minimum
of 3 (Gaudiano & Herbert, 2006) up to a maximum of 27 (Bloy, Oliver, & Morris,
2011). The intensity of contact also varied, from one session every 3 days (Bach
& Hayes, 2002) to eight sessions delivered over 4 months (van der Valk, van de
Waerdt, Meijer, van den Hout, & De Haan, 2012).
A final general observation about the existing evidence base relates to the
participant characteristics and treatment setting. By far the majority of study
participants had been ascribed a diagnosis of either schizophrenia or schizoaf-
fective disorder. The remainder were reported to have a variety of diagnoses,
including psychotic features in the context of bipolar disorder, major depression,
and depressive disorder not otherwise specified (NOS). On this basis, it seems
that the current evidence is primarily relevant to understanding people with
schizophrenia spectrum disorders, but there are strong indications that these
approaches address transdiagnostic processes.
The participants in the reviewed studies were treated in a variety of settings and
service contexts. Five of the 20 studies included participants who were inpatients
and 15 included outpatients. However, because two of the largest studies focused
on inpatients (Bach & Hayes, 2002; Gaudiano & Herbert, 2006), there is a pre-
dominance of hospitalized samples for the ACT trials. Finally, the implementation
context varies across studies and includes specialist early intervention services,
generic publically funded community mental health services, assertive commu-
nity treatment teams, research centers, and general psychiatric hospital settings.
In summary, anyone seeking evidence regarding the use of acceptance and
mindfulness approaches to treating psychosis is faced with a variety of tech-
niques and delivery formats (individual vs. group), tested in a range of treatment
settings, with patients ranging from the newly diagnosed through to people with
chronic psychoses. The next section of this chapter examines more closely the
study features that bear on issues of dissemination and implementation. The
studies are presented in a hierarchy reflecting the rigor and likely generalizabil-
ity of the findings based on the study design. RCTs are presented first, followed
by uncontrolled group treatment trials, with case studies presented last. In addi-
tion to examining the main findings of the studies, attention will also be devoted
to examining whether treatment fidelity, adherence to the protocol, or therapist
competence were determined and if so, how.
Main Findings—Randomized Controlled Trials
The literature search identified six RCTs that directly address the application
of acceptance and mindfulness-based interventions to the treatment of psy-
chosis (see Table 10.1). Four studies applied either an ACT treatment protocol
(Bach & Hayes, 2002; Gaudiano & Herbert, 2006) or a method that was explic-
itly adapted from the ACT approach (Shawyer et al., 2012; White et al., 2011).
Both of the remaining studies were group treatments with a primary emphasis
Table 10.1. Randomized Controlled Trials
Stated
Design and Primary Description of Fidelity
Study Sample Description Main Results
Treatment Setting Target of Treatment Protocol Procedures
Therapy
Bach & Hayes RCT—ACT plus TAU Total n = 40:40 Reduced Four 45- to 50- minute 50% reduction in The therapist was trained
(2002) vs. TAU delivered Schizophrenia (20:23) rehospitaliza- individual ACT rehospitalization. to competence by one
in an acute Schizoaffective (10:9) tion treatment sessions. ACT-treated group of the developers of
inpatient setting Mood disorder with Sessions 1–3 were spaced stayed out of the ACT. No explicit
psychotic features (6:6) by approximately 3 days. hospital an average measures of adherence
Delusional disorder (2:1) Final session was of 22 days longer to the manual were
Psychotic disorder NOS delivered within 3 days than controls over taken.
(2:1) of discharge 4 months.
Gaudiano & RCT— Total n = (19:21) Reduced Manualized “stand-alone” Self-reported Trial therapist was
Herbert ACT plus ETAU vs. Psychosis NOS (11) rehospitaliza- 1-hour ACT for hallucination- supervised by an
(2006) ETAU delivered in Major depression with tion and psychosis treatment related distress was expert in ACT.
an acute inpatient psychotic features (9) reduced sessions. Session content significantly lower
setting Schizophrenia (7) self-report included psychoeduca- post-treatment for
Depressive disorder and observer tion, mindfulness the ACT group.
with psychotic features reported exercises, and ACT Differences in
NOS (6) symptoms strategies. Average rehospitalization
Schizoaffective number treatment were not statisti-
disorder (5) contacts was 3 sessions cally significant.
Bipolar disorder with
psychotic features (2)
Chadwick RCT—mindfulness N = 9:9 Improve Twice weekly 30-minute No significant Therapist was super-
et al. groups vs. waitlist Schizophrenia (9:9) mindfulness mindfulness groups between-group vised by an expert in
(2009) control. skills and (guided meditation and effects but mindfulness-based
Community- clinical reflective discussion) secondary analyses therapy.
dwelling patients functioning plus home practice of showed pre-post Improvements on
(assessed with meditation for 5 weeks treatment improve- SMQ were cited as
the CORE) followed by 5 weeks of ments in function- evidence that the
home practice alone. ing (CORE) and intervention was
general mindfulness affecting
skills (SMQ) mindfulness.
White et al. Blinded RCT—ACT Total n = 14:13 Emotional 10 individual sessions ACT group had fewer Sessions were recorded
(2011) vs. TAU. Schizophrenia†= (7:6) dysfunction of ACT crisis contacts and and reviewed by an
Delivered to a Unspecified nonorganic following reduced negative expert in ACT.
mixture of psychosis (4:3) psychosis symptoms
inpatients and Schizoaffective disorder compared to TAU.
outpatients manic type (0:1)
Schizoaffective disorder
not specified (1:1)
Bipolar disorder mania
and psychosis (1:0)
Bipolar disorder depres-
sion and psychosis (1:1)
Langer et al. RCT — group MBCT N = 7:11 Increase mindful Eight weekly 1-hour Treated participants Not reported
(2012) vs. waitlist control No diagnostic details responding to sessions of MBCT plus showed greater
delivered in a reported stressful guided meditation post-treatment
community setting internal homework capacity for
experiences responding
mindfully to
stressful internal
experiences (SMQ).
(Continued)
Stated
Design and Primary Description of Fidelity
Study Sample Description Main Results
Treatment Setting Target of Treatment Protocol Procedures
Therapy
Shawyer et al. RCT — Bespoke Total n = 21:22 Compliance with Manualized protocol Compliance with Therapists recorded
(2012) treatment for Schizophrenia (17:14) harmful incorporating ACT and command in- session activities
command Schizoaffective (2:7) command mindfulness exercises. hallucinations was after each session.
hallucinations Mood disorder with hallucinations Three engagement and not viable as a Stratified random
(TORCH) vs. psychotic features (2:1) and self-rated assessment sessions primary outcome sample of therapy
befriending. confidence in followed by 12 treatment due to low base session tapes were
Delivered to resisting and sessions delivered over rate of the rated with a modified
community- coping with 4.7 months experience. version of the
dwelling patients commands Post-treatment CTS-Psy.
self-ratings of
confidence in
resisting and
coping with
commands were
equivalent for
treatment and
control
participants.
†
ICD-10 diagnoses.
Abbreviations: ACT, acceptance and commitment therapy; CORE, Clinical Outcomes in Routine Evaluation; CTS-Psy, Cognitive Therapy Scale for Psychosis; ETAU,
enhanced treatment as usual; MBT, mindfulness-based therapy; RCT, randomized controlled trial; SMQ, Southampton Mindfulness Questionnaire; TAU, treatment as
usual; TORCH, Treatment of Resistant Command Hallucinations.
on teaching mindfulness skills (Chadwick, Hughes, Russell, Russell, & Dagnan,

2009; Langer, Cangas, Salcedo, & Fuentes, 2012). An active control condition
(befriending) was used in only one study (Shawyer et al., 2012) with the remain-
der comparing the active treatment to variants of treatment as usual or waitlist
control conditions.
The primary outcome varied across the trials, but symptom reduction was
typically not stipulated as a primary goal. Instead, target outcomes included
indicators of improved functioning (e.g., reduced rehospitalization, improved
clinical functioning) or changes in secondary factors that should mediate bet-
ter outcomes (e.g., improved mindfulness skills, greater confidence in coping
with noxious command hallucinations). This is consistent with the general
approach of acceptance- and mindfulness-based therapies in that the presence
or absence of symptoms is not viewed as a problem, rather it is the functional
consequences of the person’s relationship to the symptom experience that is tar-
geted for treatment.
The results of these RCTs present a mixed picture regarding the impact of these
therapy approaches on outcome. Reduced rehospitalization for ACT-treated
patients was demonstrated in one study (Bach & Hayes, 2002), but only reached
trend levels in an attempted replication with a smaller sample (Gaudiano &
Herbert, 2006). To address the possible impact of low study power, the data from
both studies were pooled and the differences in rehospitalization rates were
subjected to survival analysis (Bach, Gaudiano, Hayes, & Herbert, 2013). This
demonstrated a significant effect on rehospitalization at 4-month follow-up,
with ACT-treated patients sustaining community placement for an average of
104 days vs. 88 days for patients receiving treatment as usual. This effect on com-
munity tenure has also been demonstrated over longer timescales. A follow-up
study examining rehospitalization at 12 months for 51 of the patients from Bach
and Hayes’ original sample suggests that the general pattern of effects on rehos-
pitalization for the ACT-treated patients was maintained (Bach, Hayes, & Gallop,
2012). Given that both studies used very brief treatment protocols (four and three
sessions, respectively), it is relevant to consider whether a higher dose of ACT
makes any difference to outcome. This can partly be addressed by scrutinizing
the other two ACT-based RCTs.
The “higher dose” RCTs of ACT entailed 10 (White et al., 2011) or 15 sessions
(including 3 assessment and engagement sessions; Shawyer et al., 2012). Therapy
was provided in an outpatient setting in both studies. These higher doses are
approaching the recommended minimum of 16 sessions of CBT stipulated in the
UK NICE treatment guidelines for schizophrenia (NICE, 2009). The treatment
targets of these two trials were quite different (see Table 10.1), but both had the
methodological advantage of using blinded assessment of outcome. However,
the samples were relatively small to detect the effect sizes typically seen in CBTp
trials (Wykes, Steel, Everitt, & Tarrier, 2007), and the impact of this is further
increased in the Shawyer et al. study, where the control treatment (befriending)
was found to have a positive effect on some outcomes. Overall, the data lead
to some tentative conclusions that ACT-based intervention can produce some

pre-post within-subject changes in clinically relevant domains, such as reduced
crisis calls and confidence about coping adaptively with unpleasant command
hallucinations.
A similar pattern is evident in the group treatment trials of mindfulness
approaches. Both of these studies compared small samples randomized to
group treatment or a waitlist control condition and both provide tentative
signals that mindfulness skills can improve following 8–10 treatment sessions
(see Table 10.1). In the case of Chadwick et al. (2009), secondary analyses
indicated that there was also a pre-post treatment improvement in general
functioning.
Although there are numerous caveats that limit the interpretation of these
preliminary results, it is possible to evaluate the extent to which these studies
provided clear evidence about the fidelity of the treatment provided. Five of
the six RCTs mention the procedures in place to address fidelity and thera-
pist competence issues (see Table 10.1). The most rigorous was the RCT by
Shawyer et al. (2012), which included blind ratings of therapy tapes using the
Cognitive Therapy Scale for Psychosis (CTS-Psy) and an independent rating
of trial quality using the Clinical Trials Assessment Measure (CTAM) (Tarrier
& Wykes, 2004). White et al. (2011) also took recordings of sessions and these
were reviewed by an expert in ACT, but no structured fidelity rating scale data
are reported. This general approach is evident in three of the other studies,
which explicitly mention that the trial therapists were trained to competence
and supervised by experts in ACT (Bach & Hayes, 2002; Gaudiano & Herbert,
2006) or mindfulness (Chadwick et al., 2009). All of the RCTs make reference
to the use of a manualized approach to the delivery of treatment with the
main ACT manual (Hayes et al., 1999) or Chadwick’s person based cogni-
tive therapy treatment manual (Chadwick, 2006) being the most commonly
cited source.
In summary, the currently available RCTs of acceptance and mindfulness
approaches provide feasibility and proof-of-concept data rather than compel-
ling evidence of clear efficacy and effectiveness. The scope for further imple-
mentation and dissemination work is helped by the availability of treatment
manuals, and it is evident that the therapy techniques can be taught to trial
therapists. However, the amount of training and supervision required to
attain competence still needs to be determined. There is also one example
showing that structured blinded fidelity checks can be conducted to deter-
mine adherence to the ACT treatment model (Shawyer et al., 2012). These
observations are all consistent with the literature being at an early stage of
development. This presents some challenges but it is also an opportunity to
derive fresh insights about potentially fruitful areas of innovation. With this
in mind, we move on to review studies that use less rigorous trial designs, but
with the same overall goal of identifying lessons that can be applied to the
development of the mindfulness- and acceptance-based approaches to treat-

ing psychosis.
Main Findings—Uncontrolled Group Trials
All of the six uncontrolled treatment trials identified in the literature search are
focused on mindfulness/meditation-based group treatments (see Table 10.2).
None of the uncontrolled trials used ACT. The protocols included a
mixture of mindfulness training, mindfulness-based stress reduction, and
loving-kindness meditation training. There were also some differences in the
stated treatment targets compared to those of the RCTs reviewed here. Negative
symptoms, anxiety, and symptom-related distress were explicitly identified
as primary targets in three studies. The reported primary outcome data were
mixed, and outcomes ranged from large effect sizes for the pre-post treat-
ment effects of loving-kindness meditation on negative symptoms (especially
anhedonia) (Johnson et al., 2011) to no effect of mindfulness-based therapy on
post-treatment Positive and Negative Syndrome Scale ratings (van der Valk
et al., 2012). The main theme evident across these studies is that the various
approaches were acceptable to participants and could be delivered successfully
in a group format.
Like the RCTs, these uncontrolled trials do not provide details relating to the
assessment of treatment fidelity, therapist competence, or adherence to the therapy
protocol. Two studies make no mention of the characteristics and training of the
trial therapists (Jacobsen, Jacobsen, Morris, Johns, & Hodkinson, 2011; van der Valk
et al., 2012), but all of the remaining four report on the level of meditation experi-
ence of the group facilitators and/or their supervisors. This meditation experience
was described as “extensive” (Johnson et al., 2011) or was expressed in years of per-
sonal practice, ranging from 1 to 8 years (Brown, Davis, LaRocco, & Strasburger,
2010; Chadwick, Newman Taylor, & Abba, 2005). The therapist for one study are
also reported to have completed a 7-day professional training in mindfulness-based
stress reduction (MBSR), in preparation for the trial (Brown et al., 2010).
This description of personal meditation practice in trial therapists raises a ques-
tion about the preparatory experiences that are necessary to effectively deliver
mindfulness-based interventions. Although there is insufficient data to indicate
whether personal meditation practice is necessary for providing mindfulness
interventions for psychosis, there is evidence from the non-psychosis therapy
literature indicating that trainee therapists who have direct experience of medi-
tative practice have better patient outcomes than therapists without this experi-
ence (Grepmair et al., 2007). Before examining the possible implications of this
for dissemination and implementation of mindfulness- and acceptance-based
approaches, we will complete the review of the current empirical evidence by
scrutinizing the pool of published case studies.
Table 10.2. Uncontrolled Trials
Sample Size
Design and (Intervention vs. Description
Target of Fidelity
Study Treatment Control Group of Treatment Main Results
Therapy Procedures
Setting Ratio) and Protocol
Diagnoses
Chadwick Uncontrolled open N = 11 Improved clinical Weekly 90-minute Pre-post comparisons Main therapists
et al. trial—mindfulness Schizophrenia (9) functioning groups (including a showed improvement in had 4–8 years of
(2005) group. Schizoaffective (assessed with the 15-minute break) general functioning as personal
10 community- disorder (2) CORE) delivered over 6 measured by the CORE. mindfulness
dwelling patients weeks. Group content practice
and 1 inpatient included mindfulness experience.
skills practice and
discussion about
application of
mindfulness in
everyday life.
Brown et al. Uncontrolled pilot N = 15 Eligible participants Two classes twice a week Program evaluation Facilitators had
(2010) trial of MBSR Schizophrenia (5) experienced for 8 weeks. Content interviews identified 1–4 years of
groups for Schizoaffective anxiety at least 1 included mindful mostly positive personal
outpatients with disorder (10) SD above the breathing and outcomes, including experience of
significant anxiety population mean walking, body scan, increased relaxation, mindfulness
on standardized and didactic compo- reduced symptoms, meditation
questionnaires. nents. CD-guided awareness of new ways practice and had
home practice of of thinking, and received 7 days of
meditation was expanded accredited
encouraged. self-reflection. training in MBSR.
Jacobsen Open uncontrolled N=8 Distressing symp- Up to six 1-hour group No statistical analysis of Not reported
et al. mindfulness group No diagnostic details toms of psychosis treatment sessions effects. Positive
(2011) therapy delivered reported incorporating two participant feedback
in an inpatient 10-minute guided indicated that the group
setting mindfulness exercises was acceptable.
Mean attendance was
2.9 sessions.
Johnson Open uncontrolled N = 18 Negative symptoms Six 1-hour group Post-treatment decreases Therapist had
et al. group treatment of Schizophrenia (8) of schizophrenia sessions delivered in total negative “extensive”
(2011) LKM delivered to Schizoaffective weekly for 6 weeks symptoms and meditation
outpatients disorder (6) followed by a single anhedonia showed large experience
Schizophreniform booster session 6 ESs. Post-treatment
disorder or psychosis weeks later. Guided increases in positive
NOS (4) home practice of emotions also showed
LKM was included. large ESs.
Dannahy Uncontrolled open N = 62 Distressing voices of 90-minute sessions 50 people (81%) were No formal rating of
et al. trial of PBCT Diagnoses were more than 2 years’ including 10 minutes considered treatment treatment fidelity
(2011) groups for not specified duration of guided meditation “completers” (>6 was taken but
community-based practice and a sessions attended). adherence to the
patients 10-minute break. Significant pre-post model was
Session content treatment improve- guided by a
included CBT-based ments in general written session
analysis of distressing well-being (medium by session
experiences, reflection ES) Treatment “dose” (9 treatment
on the effect of vs. 12 group sessions) protocol.
mindfully accepting did not alter the main
voices, and challeng- results.
ing of overgeneralised
negative self-schema.
(Continued)
Sample Size
Design and (Intervention vs. Description
Target of Fidelity
Study Treatment Control Group of Treatment Main Results
Therapy Procedures
Diagnoses
van der Open uncontrolled N = 17 (one subsequent Increase in mindful- Eight 1-hour sessions PANSS symptoms and Not reported
Valk et al. feasibility study of dropout) ness and general delivered over mindfulness (SMQ)
(2013) MBT group Schizophrenia (7) well-being and 4 months. Sessions were unchanged
therapy delivered Schizoaffective disorder decrease in included guided following treatment.
via community EIP (4) perceived mindfulness
service Schizophreniform symptoms meditation skills
disorder (3) training and identifi-
Depression with cation of barriers to
psychotic features (2) engaging in mindful-
Bipolar disorder (1) ness. Home practice
of meditation was
encouraged.
Abbreviations: CBT, cognitive-behavioral therapy; CORE, Clinical Outcomes in Routine Evaluation; EIP, early intervention for psychosis service; ES, effect size; LKM,
loving-kindness meditation; MBSR, mindfulness based stress reduction; MBT, mindfulness-based therapy; PBCT, person-based cognitive therapy; SD, standard
deviation; SMQ, Southampton Mindfulness Questionnaire.
Main Findings—Case Studies
Although case studies have limitations regarding bias, generalizability, and

reproducibility, they can be valuable for discovering new ways to understand
and treat psychopathology. Mindfulness- and acceptance-based approaches to
psychosis were the subject of eight case studies examined here. A broad range
of therapy approaches was reported, with ACT being used in three studies,
Chadwick’s person-centered approach in two, loving-kindness meditation and
CBTp incorporating detached mindfulness in one study each. The final study
used a multicomponent treatment package that included exercise, peer support,
and mindfulness-based CBT (see Table 10.3). The 12 participants treated across
these eight case studies were mostly diagnosed with schizophrenia or closely
related disorders.
The primary outcomes for these case studies involved negative symptoms,
hallucination-related distress, and paranoia. Most of the studies reported some
positive outcomes and the range of effects included affective changes (e.g.,
increased positive affect, decreased depressive symptoms), behavioral changes
(e.g., increased role engagement), and reduced symptom burden (e.g., changes
on the Brief Psychiatric Rating Scale, diminished delusional conviction). One
notable difference between these case studies and the treatment trials already
discussed is that two of these case studies were explicitly focused on the impact
of psychotherapy on medication use. Hutton, Morrison, & Taylor (2012) reported
successfully treating a medication-naïve patient with CBTp that incorporated a
detached mindfulness component. Schuman-Oliver, Noordsy, & Brunette (2013)
described a case in which treatment with mindfulness-based interventions was
associated with a dramatic reduction in the need for polypharmacy in a patient
with persistent functional problems attributed to schizoaffective disorder. Given
that psychosocial treatments for psychosis have commonly been provided as an
adjunct to pharmacological interventions, these two case studies may signal a
new direction in treatment, where psychological interventions may be explic-
itly examined as an alternative to drug treatments (see Hutton & Taylor, 2014;
Morrison, Hutton, Shiers, & Turkington, 2012).
Issues of fidelity and dissemination were addressed clearly in only two of the
eight case studies. In both cases the therapist’s level of personal meditation expe-
rience was reported (4 and 25 years, see Table 10.3), and in one case the therapist
had co-authored a book about loving-kindness meditation (Johnson et al., 2009).
None of the studies provided information about fidelity checks or structured rat-
ings of therapist competence or adherence to protocol.
K E Y T H EM ES A N D O B S ERVAT I O N S
These studies provide several insights into factors that will influence the success-
ful dissemination and implementation of mindfulness- and acceptance-based
approaches to psychosis. Before presenting some preliminary treatment guidelines
Table 10.3. Case Studies
Sample size
Design and (Intervention vs. Description of
Fidelity
Study Treatment Control Group Target of Therapy Treatment Main Results
Procedures
Diagnoses
Veiga-Martinez Case study—ACT N=1 Distress and behavioral 15 assessment and BPRS scores, work Not reported
et al. (2008) delivered in the Schizophrenia avoidance stemming treatment sessions attendance, and
community from auditory addressing key ACT social network all
hallucinations processes delivered improved
over 6 months post-treatment.
Newman-Taylor Case study— N=2 Reduced auditory 12 weekly sessions of 1 Self-reported ratings of Not reported
et al. (2009) mindfulness- Schizophrenia (2) hallucination- hour duration distress and belief
based intervention related distress incorporating guided conviction were
delivered to and reduced meditative practice reduced by week 12.
outpatients voice-related belief and Socratic
conviction discussion about
mindfulness practice
in everyday life
Johnson et al. Description of 3 N=3 Negative symptoms, Six hour-long weekly Two out of three The trial therapist
(2009) cases treated with Schizophrenia (1) particularly sessions involving participants showed had over
loving-kindness Schizoaffective anhedonia graded practice of increases in positive 25 years
meditation disorder (1) generating warm and affect and an meditation
Psychotic compassionate associated improve- experience
disorder NOS (1) feelings toward self ment in negative
and others. symptoms.
CD-guided daily
home practice of
meditation exercises
The remaining
participant showed
no change in
negative symptoms
but reported
improved coping
with hallucinations
following meditation
training.
Garcia-Montez Case study—ACT N=1 Paranoia and disturbed Weekly sessions of Behavioral changes are Not reported
& delivered on an Schizophrenia sense of self ACT delivered reported (e.g.,
Perez-Alvarez outpatient basis over 5 1/2 months restarting guitar
(2010) playing, visiting
shopping centers,
helping ill grand-
mother, return to
employment).
Bloy et al. (2011) Case study—ACT N=1 Paranoia, delusions, 27 hourly sessions Distress, delusional Not reported
delivered to an Unspecified psychosis emotional distur- delivered over thinking, engage-
outpatient in an marked by paranoia bance, rumination, 8 months. Targets ment in values
EIP setting plus depressive and and behavioral included values consistent behavior,
anxiety symptoms avoidance clarification, and HoNOS scores
mindfulness skills were all improved
training, defusion, post-therapy.
graded exposure,
and reduction of
avoidance.
(Continued)
Sample size
Design and (Intervention vs. Description of
Fidelity
Study Treatment Control Group Target of Therapy Treatment Main Results
Procedures
Diagnoses
Hutton et al. Case study—CBTp N=1 Distress arising from 11 sessions delivered in a Depressive symptoms Not reported
(2012) incorporating Unspecified psychosis auditory and visual tapering format over and dysfunctional
detached mindful- and low mood. hallucinations 9 months. Detached beliefs about voices
ness delivered in Participant was mindfulness was almost fully remitted
an outpatient medication naïve introduced at at the last session.
setting session 2.
Schuman-Oliver Case description— N=1 Rationalization of Polymodal BMI dropped from 27.6 Not reported
et al. (2013) Multicomponent Schizoaffective medication regime mindfulness-based to 24.7.
treatment package disorder without provoking interventions Polypharmacy was
delivered via clinical delivered over reduced from 9 to 3
community destabilization 6 months. This medications.
assertive outreach included MBCT,
service exercise coaching
with peer support,
and group mindful-
ness training (1 hour
weekly for 16 weeks).
Ellett (2013) Multiple baseline N=2 Reduce belief convic- Weekly individual All dimensions of Therapist had
case study of Delusional disorder (2) tion, distress, sessions incorporating persecutory beliefs 4 years of
mindfulness anxiety, and guided meditative (conviction, distress, mindfulness
training delivered depression in practice and reflective impact, preoccupa- practice
in an outpatient patients with discussion focusing tion) decreased along experience and
setting persecutory on promoting with self-rated had completed a
delusions in the metacognitive anxiety and 5-day MBCT
absence of insights. CD-guided depression. training course
hallucinations meditative home Participants reported
practice between behavioral improve-
sessions was ments (e.g. less
encouraged. checking behavior,
reduced avoidance).
SMQ scores also
improved.
Abbreviations: ACT, acceptance and commitment therapy; BMI, body mass index; BPRS, Brief Psychiatric Rating Scale; CBTp, cognitive-behavioral therapy for
psychosis; EIP, early intervention for psychosis service; HoNOS, Health of the Nation Outcome Scales; MBCT, mindfulness-based cognitive therapy; NOS, not otherwise
specified; RCT, randomized controlled trial; SMQ, Southampton Mindfulness Questionnaire.
and principles, it is worth summarizing the current state of the evidence base and
the key characteristics of the contributing studies. Overall, this literature is matur-
ing rapidly, as reflected in the fact that there are now sufficient treatment out-
come studies to permit meta-analysis of third-wave CBT approaches for psychosis
(Khoury, Lecomte, Gaudiano, et al., 2013). Although Khoury et al.’s meta-analysis
included a broader range of studies than discussed here,1 the results support the
conclusion that mindfulness-based techniques are an important contributor to
the moderate pre-post treatment effects seen on a variety of outcomes measures,
especially negative symptoms. The range of studies reviewed in this chapter also
provides clear proof of concept, feasibility, efficacy, and acceptability data to justify
continued work in this domain. What is currently lacking is compelling effective-
ness data that can inform the application of these techniques in clinical practice. As
is typical of the psychotherapy of psychosis literature (Wykes et al., 2007), the more
methodologically rigorous trials show less clear-cut treatment effects (Shawyer
et al., 2012; White et al., 2011) (although ratings of study quality were unrelated to
outcome in Khoury et al.’s meta-analysis). It is also apparent that there is consider-
able heterogeneity in the types of mindfulness- and acceptance-based techniques
being incorporated into trial protocols. For example, recent trials using medita-
tive practices such as metta (loving-kindness meditation) and compassion-focused
therapy (CFT) (Braehler et al., 2013; Johnson et al., 2011) reflect the diversification
of the techniques and theoretical models being tested. No doubt the coming years
will see a continuation of these developments as increasingly sophisticated studies
of third-wave approaches to psychosis are conducted.
In the meantime, it is relevant to consider how these new approaches can
be appropriately disseminated into practice. Given the relatively early stage of
the evidence base, the question of dissemination may be most relevant to new
research trials rather than routine care. However, the main gold-standard ele-
ments required for effective dissemination now exist (therapy manual, skills train-
ing, and supervision) (Sholomskas et al., 2005). The available treatment manuals
vary, from the generic (Hayes et al., 1999), through to more psychosis-specific
options (Chadwick, 2006; Morris, Johns, & Oliver, 2013). Also, many therapists
in the trials described here were able to access workshop training (e.g., in MBSR)
or idiosyncratic training developed specifically to fit the aims of the treatment
trial. It is possible that there may be some benefit in using the Delphi method,
to identify the core skills and attitudes that therapists applying acceptance and
mindfulness-based approaches to psychosis need to learn. The Delphi method
involves asking experts to provide their anonymized opinions on a topic, fol-
lowing which a facilitator summarizes the opinions and feeds them back to the
group for further comment. The process is repeated until a prespecified stop cri-
terion is met (e.g. 80% agreement is achieved). Applying this approach to CBTp
(Morrison & Barratt, 2009) led to the identification of 77 recommended treat-
ment elements grouped into seven domains (e.g., engagement principles, use
of change strategies). Given the diverse range of third-wave mindfulness- and
acceptance-based approaches to psychosis, it might be time to begin specifying
what elements are ubiquitous to all third-wave approaches and which are unique
to particular protocols.
One question that arises from the foregoing analysis of the outcome studies is
the extent to which therapists should be experienced in meditative practice before
conducting mindfulness-based treatments. The number of years of meditative
practice of the therapist was reported in five studies, but it is unclear whether
personal experience of meditation should be a mandatory aspect of therapist
training. Interestingly, there is some evidence from the wider psychotherapy lit-
erature that training learner psychotherapists in Zen meditative practice results
in improved patient outcomes (Grepmair et al., 2007). Future studies could deter-
mine whether this therapist factor affects third-wave therapy outcomes.
Another area critically in need of further work relates to the determination of
treatment fidelity. Only 1 of the 20 studies reviewed here provided fidelity data
derived from an established measure (Shawyer et al., 2012). For the most part,
the other trials inferred fidelity by using expert appraisal of the therapist perfor-
mance. This is a critical area for development; some of the advances made in CBT
protocols for nonpsychotic disorders (Simons, Rozek, & Serrano, 2013) may be
directly translatable to acceptance and mindfulness treatment protocols. There
is already an established method for assessing adherence to mindfulness-based
cognitive therapy for depression (Segal, Teasdale, Williams, & Gemar, 2002), and
preliminary work has begun on developing a coding scheme for determining
fidelity of ACT for psychosis (Plumb & Vilardaga, 2010).
W H ER E N E X T FO R AC C EP TA N C E- A N D
M I N D F U L N ES S - BAS ED T H ER A PI ES FO R PSYC H O S I S?
The psychological treatment of psychosis continues to evolve. Although the UK

NICE guidelines currently only endorse conventional CBTp and family inter-
vention as frontline psychological treatments for psychosis, the situation in the
United States is different, where ACT and mindfulness-based approaches are
endorsed treatments for schizophrenia by both Division 12 of the American
Psychological Association and the federal government’s Substance Abuse and
Mental Health Services Administration (SAMHSA). Recent meta-analytic find-
ings also suggest that acceptance-, mindfulness-, and compassion-based treat-
ments are on a trajectory to eventually have a strong enough evidence base to be
routinely offered therapies. Several of the effect sizes reported by Khoury et al.
(2013) are comparable to those seen in CBTp studies (Wykes et al., 2007), and in
the case of negative symptoms there is some evidence that mindfulness-based
approaches may have more of a therapeutic impact than conventional psycho-
logical treatments. The current evidence points to some initial conclusions about
who might benefit from these approaches, the most effective therapy techniques,
the dose required to achieve benefit, and the nature of the therapist skill set.
Like conventional CBTp, the third-wave approaches show some evidence of effi-
cacy for people who are at all stages of illness (from first episode through to chronic
conditions) and in a variety of treatment settings (e.g., acute inpatient settings to
community-based outpatient care). Also, because the range of diagnoses for par-
ticipants in treatment outcome studies covers a broad spectrum, there is no a priori
reason to constrain the application of acceptance and mindfulness approaches on

diagnostic grounds. However, the current data do highlight that distress or promi-
nent negative symptoms are possible key treatment targets. It also appears that the
learning of mindfulness skills is a critical mediator of treatment outcome (Khoury,
Lecomte, Gaudiano, et al., 2013). In the case of negative symptoms, practicing
loving-kindness meditation may be suitable as a discrete intervention (Johnson et
al., 2011). What is less clear is the dose required to ensure a therapeutic response.
Positive outcomes have been demonstrated with very brief treatment protocols
(Bach & Hayes, 2002), whereas other studies have reported a need to extend the
number of sessions offered in order to better meet patient needs (Dannahy et al.,
2011). So, under conditions where there is scope for flexibility, the pragmatic guid-
ance is that the dose should be titrated to the needs of the patient, based on the
speed of their therapeutic response. Similarly, there is currently no strong reason
to favor group or individual treatment approaches except that the studies which
have emphasized the teaching of meditation skills have typically been delivered in a
group format (Chadwick et al., 2009; Johnson et al., 2011; van der Valk et al., 2012).
The answer to the final question, regarding the core therapist skill set
required for the effective implementation of mindfulness- and acceptance-based
approaches, is less clear. There is currently no standardized way to conduct treat-
ment fidelity checks in trials, and the skills and competencies that are unique to
third-wave psychosis treatment approaches have yet to be fully specified. Much
like the work done on CBTp (Morrison & Barratt, 2009; Roth & Pilling, 2013), it
may be time for work to be done on mapping the competencies needed to effec-
tively deliver third-wave psychosis interventions.
In closing, it is worth considering how mindfulness- and acceptance-based
approaches can continue to mature alongside more established psychological
interventions for psychosis. There is a risk that going on to conduct head-to-head
trials of third-wave vs. conventional therapy approaches such as CBTp may ulti-
mately dilute the impact and scope of psychological interventions for psychosis.
The recent Treatment of Negative Symptoms (TONES) trial demonstrated that
equivalent improvements in negative symptoms can be achieved with seem-
ingly very different treatment approaches, such as CBT vs. cognitive remediation
therapy (CRT) (Klingberg et al., 2011). This points to the need for studies that
unpack mechanisms of therapeutic change, a relatively rare feature of current
mindfulness- and acceptance-based approaches (Khoury, Lecomte, Gaudiano,
et al., 2013). There is also an argument for making greater use of equivalence
or non-inferiority designs (D’Agostino, Massaro, & Sullivan, 2003; Piaggio,
Elbourne, Altman, Pocock, & Evans, 2006) in future therapy trials so that we
work toward a genuine expansion of the effective treatment options for the wide
range of sources of distress experienced by people with psychosis. The recent
application of mindfulness approaches to relatively neglected symptoms such
as anhedonia points to how the third wave can complement, rather than sup-
plant, existing therapies. The coming years present an important opportunity to
convert the current crop of feasibility and proof-of-concept studies into a mature
and robust body of scientific work that can make a meaningful contribution to
the lives of people experiencing psychosis.
N OT E
1. Khoury, Lecomte, Gaudiano, et al. (2013) used selection criteria that included trials
of compassion-focused therapy (CFT) (Braehler et al., 2013) and a combined behav-
ioral activation and ACT protocol (Gaudiano et al., 2013).
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11
Charting the Course Ahead

Future Clinical and Research Directions in Mindfulness
and Acceptance Therapies for Psychosis
BRANDON A. GAUDIANO ■
In Chapter 2 of this book, Turkington, Wright, and Courtley describe the

dramatic changes witnessed in cognitive-behavioral therapies for psychosis
(CBTp) over recent decades. Turkington pioneered the early application of
CBTp (Kingdon & Turkington, 1994), and his recent work integrating mind-
fulness and acceptance strategies for psychosis into CBTp demonstrates the
continued progress in this area. Approaches to CBTp have broadened greatly
over time, starting from a traditional cognitive perspective of psychosis by
employing Socratic questioning and behavioral experiments for testing spe-
cific hallucinations and delusions. More recently this approach has been
expanded for additionally fostering metacognitive processes related to accep-
tance and mindfulness without attempting to change specific symptoms.
Although the importance and role of cognitions in psychosis have always
been clear to both clinicians and researchers, strategies to help patients cope
with dysfunctional cognitions in a variety of ways have advanced as well. This
development appears to reflect a natural evolution in CBTp and parallels the
changes occurring in the field more broadly. Increasingly, mindfulness and
acceptance therapies are gaining empirical support and are becoming widely
disseminated to therapists around the world to treat mood and anxiety dis-
orders, substance abuse problems, and chronic medical conditions, as well
as to improve overall health and well-being (Grossman, Niemann, Schmidt,
& Walach, 2004; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hofmann,
254 A cc e p tanc e an d M in d f u ln e ss in th e T r e atm e nt o f Ps y ch o sis
Sawyer, Witt, & Oh, 2010; Veehof, Oskam, Schreurs, & Bohlmeijer, 2011;
Zgierska et al., 2009).
The preceding chapters in this book describe various types of mindful-
ness and acceptance therapies for psychosis (MATp). The reader will quickly
observe the great diversity of innovative ideas showcased in the treatment
protocols described in this book. Some of these MATp show promise in early
research studies, whereas others, such as acceptance and commitment therapy
(ACT) for psychosis (Hayes, Strosahl, & Wilson, 2012), have demonstrated
efficacy in independently conducted randomized controlled trials. However,
it is clear that MATp will continue to evolve as research and clinical work in
psychosis moves forward at a brisk pace, just as it did with early CBTp. The
question now becomes: Where do we go from here? In this chapter, I attempt
to chart a course ahead by considering the future research and clinical direc-
tions for MATp.
Where We Are Starting from
Before discussing the direction that research in MATp should take in the future,
it is first useful to consider our starting point. At the present moment, MATp
are just beginning to be discussed as part of evidence-based practices for psy-
chosis. For example, ACT for psychosis is currently listed as an empirically
supported therapy by the American Psychological Association (n.d.). This orga-
nization gave ACT for psychosis the designation of “probably efficacious treat-
ment,” based on three initial randomized controlled trials demonstrating safety
and efficacy in the treatment psychosis. In addition, the Substance Abuse and
Mental Health Services Administration (2010) has designated ACT in general
as an empirically supported treatment and notes that it is efficacious for psycho-
sis, among other conditions.
Recently, I collaborated with Bassam Khoury and colleagues (2013) to con-
duct the first published meta-analysis of MATp. We analyzed 13 studies that
included both open and randomized trials conducted in samples with psycho-
sis. The MATp we analyzed represented a diverse array of approaches such as
those included in this present book, including ACT, mindfulness-based cog-
nitive therapy, person-based cognitive therapy, loving-kindness meditation,
acceptance-based depression and psychosis therapy, mindfulness meditation
groups, and compassion-focused programs. The overall MATp pre-post treat-
ment effect size estimate was 0.52, which represents a moderately strong effect.
The effect size was 0.41 in studies comparing MATp with various control con-
ditions. Figure 11.1 shows the funnel plot of MATp effect sizes obtained in
these studies. There was significant heterogeneity in effect sizes found across
studies, so it is possible that some MATp are more efficacious than others.
Only future research will be able to provide more definitive answers to this
Charting the Course Ahead255
20
15
Precision (1/Std Err)
10
–2.0 –1.5 –1.0 –0.5 0.0 0.5 1.0 1.5 2.0

Hedges’s g
Figure 11.1. Pre-post effect size (Hedges’s g) estimates for mindfulness and acceptance
therapies for psychosis.
Reprinted from Schizophrenia Research, 150(1), B. Khoury, T. Lecomte, B. A. Gaudiano,
& K. Paquin, “Mindfulness interventions for psychosis: A meta-analysis,” 176–184,
Copyright (2013), with permission from Elsevier.
question. Furthermore, MATp outcomes appeared to be maintained in studies

that included post-treatment follow-up assessments (e.g., effect sizes of 0.62 for
open trials and 0.55 for randomized trials). It is important to note that these
effects obtained in early MATp studies appear to be similar to those reported
in previous meta-analyses of traditional CBTp (Wykes, Steel, Everitt, &
Tarrier, 2008).
Additional findings from the meta-analysis demonstrated that MATp
appeared to be more effective for negative than for positive symptoms of psy-
chosis (Khoury et al., 2013), which is not surprising, given the focus of mind-
fulness and acceptance treatments on changing the person’s relationship to his
or her symptoms instead of the psychotic symptoms themselves. Furthermore,
although not moderated by study quality or treatment length, pre- to
post-treatment outcomes were strongly related to corresponding changes in
“third-wave” constructs that included mindfulness, acceptance, and compas-
sion (β = .52). The relationship between these third-wave strategies and effect
size outcomes is depicted in Figure 11.2. Such findings suggest that MATp may
achieve their effects on outcomes at least partly by altering the hypothesized
mindfulness- and acceptance-based processes targeted in these treatments.
Although the preliminary findings of this meta-analysis were promising, con-
clusions are tempered by the relatively small number of clinical trials to date
and the heterogeneity of studies included in terms of their different clinical
samples, treatment lengths, comparison groups, outcome measures, and treat-
ment components. Next, I explore important issues in MATp that will require
further research to clarify.
1.00
0.90
0.80
0.70
Hedges’s g
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.09 0.23 0.37 0.51 0.65 0.79 0.93 1.07 1.21 1.34 1.48
Third-Wave Strategies
Figure 11.2. Relationship between “third-wave” mindfulness, acceptance, and
compassion strategies for psychosis and pre-post treatment outcome effect sizes
(Hedges’s g).
Reprinted from Schizophrenia Research, 150(1), B. Khoury, T. Lecomte, B. A. Gaudiano,
& K Paquin, “Mindfulness interventions for psychosis: A meta-analysis,” 176–184,
Copyright (2013), with permission from Elsevier.
Understanding the Underlying Psychopathology of Psychosis
One area that requires further study is our understanding of the clinical phe-
nomenon of psychosis from a mindfulness- and acceptance-based theoretical
perspective. Research on the phenomenology of psychosis is still in its early
stages related to MATp. However, relevant work has been conducted over
the years that may shed light on this topic and often focuses on the perni-
cious effects of avoidance. Early work by Falloon and Talbot (1981) indicated
that attempts to suppress auditory hallucinations were ineffective in patients
with chronic schizophrenia. In related work, Farhall and Gehrke (1997) inter-
viewed 81 patients with hallucinations and reported that “resistance” cop-
ing predicted increased psychological distress. Also, Escher and colleagues
(Escher, Delespaul, Romme, Buiks, & Van Os, 2003) showed that higher levels
of “defensive” coping predicted negative outcomes in a sample of adolescent
voice-hearers. Furthermore, Tait and colleagues (2003, 2004) followed patients
after an acute psychotic episode and found that a “sealing-over” recovery style,
characterized by avoidance of the psychotic experience, was associated with
negative self-evaluative beliefs and poor treatment engagement.
Experiential avoidance (EA), which represents attempts to escape unwanted
internal experiences (e.g., thoughts, feelings, memories) even when doing so
causes impairment, is theorized to be an important factor in the development
and maintenance of various forms of psychopathology, including psychosis
(Hayes et al., 2006). Recent work by Shawyer et al. (2007) demonstrated that EA
was associated with increased depression and hallucinations in a sample of 43
patients diagnosed with psychotic disorders. In a sample of 30 patients follow-

ing a psychotic episode, White et al. (2011) showed that EA predicted depres-
sion and anxiety severity even after controlling for levels of mindfulness. Recent
work also has shown that EA is positively associated with delusional experiences
such as paranoia (Goldstone, Farhall, & Ong, 2011; Udachina et al., 2009). Other
research indicates that EA may contribute to cognitive impairments in schizo-
phrenia (Villatte, Monestes, McHugh, Freixa i Baque, & Loas, 2010).
In Chapter 9 in this volume, Thomas proposes a mindfulness- and
acceptance-informed model of psychosis that brings together converging lines
of research on avoidance and rumination in individuals experiencing psychosis.
He cogently argues that preoccupation in psychosis suggests specific interac-
tions among ruminative thinking processes, attempts to engage or resist voices,
and negative reinforcement cycles related to anxiety reduction, maintenance of
self-esteem, and withdrawal from aversive environmental contingencies. Thus,
as in other areas of psychopathology research (Hayes et al., 2006), early research
emphasizes the critically important roles of avoidance behaviors and rumination
in the development and maintenance of both positive and negative symptoms
of psychosis. The model described by Thomas is a significant step in this direc-
tion. However, future research will be required to flesh out a comprehensive and
empirically supported theoretical model of psychosis informed by mindfulness
and acceptance processes. Such a model will be critical for identifying and refin-
ing targets for MATp to improve the future impact of these treatments. Future
MATp research should include measures that will help to clarify the theoretical
model, including EA, rumination, anxiety and mood symptoms, views of the
self, and other avoidance behaviors.
Comparisons with Other Therapies
One emerging question in MATp research is how specific the effects of these
interventions are for improving clinical outcomes. Most previous randomized
controlled trials have compared MATp to routine care or treatment as usual
including pharmacotherapy and sometimes other services (e.g., case manage-
ment or other nonstructured psychotherapy). In all the studies in this area to
date, MATp have been provided to patients receiving at least pharmacotherapy,
and so evidence suggests that these therapies produce benefits to patients beyond
medications alone, which is an important result to demonstrate. However,
there is little research to date comparing MATp with other psychotherapeutic
approaches that differ in their theoretical underpinning, techniques, and strate-
gies. Given the broad support for and extensive study of traditional CBTp, it will
be important for future research to examine what, if any, unique contributions
MATp produce in terms of clinical outcomes or mechanisms of action.
The recent study by Shawyer et al. (2012) provides some initial information
on this topic. These researchers conducted an ambitious clinical trial in which
patients with command hallucinations were randomized to a novel treatment
integrating cognitive-behavioral and mindfulness/acceptance strategies

(called “TORCH”) vs. a supportive intervention (called “befriending,” which
did not contain TORCH strategies) vs. a waitlist control condition (including
treatment as usual with medication management). Although the study admit-
tedly had low statistical power for examining effects between active treatments
due to its small sample size (n = 44), TORCH and befriending both produced
significant improvement on outcomes relative to the waitlist condition, but the
two treatments did not statistically differ from one another on most measures.
TORCH patients self-reported greater improvement in their command hallu-
cinations, but this effect was not detected in blinded interviewer-based assess-
ments. Unfortunately, because MATp and CBTp strategies were combined in
a novel experimental intervention that had not been previously tested, it is
unclear how generalizable the results are to other MATp approaches with dem-
onstrated efficacy.
However, the difficulty in finding significant differences in outcomes in the
Shawyer et al. (2012) study is similar to findings in the broader CBTp litera-
ture when these treatments are compared with supportive interventions (Penn
et al., 2004). It is true that such “horse race” or comparative efficacy trials only
answer some of the many important research questions requiring further study.
Nevertheless, it would be helpful for future research to examine the efficacy of
already established MATp interventions with that of similarly well-designed sup-
portive interventions, as well as comparisons with traditional CBTp, to examine
the relative benefits of various psychosocial approaches available to patients with
psychosis. Furthermore, when a variety of interventions appear to produce simi-
lar outcomes, it becomes important to study patients’ preferences and the relative
acceptability of the different therapies to guide treatment choices.
Mediators and Moderators of Treatment Effects
As future studies are conducted that compare MATp with other therapies, the
issue of the mediators and moderators of treatment effects will become increas-
ingly important to understand. Comparative efficacy studies (i.e., Treatment
A vs. Treatment B) answer the question of which treatment works best. In addi-
tion, investigations of mediators can answer the question of how treatments
work (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001). Even if two interven-
tions are found to both improve outcomes equally well, they might achieve these
effects through different mechanisms of action, which can be tested by examin-
ing the statistical mediation of treatment effects. It will be important to exam-
ine whether MATp and other psychosocial interventions work at least partially
through mindfulness and acceptance processes or through some other means.
Early research on ACT for psychosis appears to support mechanisms consis-
tent with mindfulness and acceptance. In ACT, cognitive defusion is defined as
the alteration of the relationship the individual has to his or her internal experi-
ences that diminishes their unhelpful functions (Hayes et al., 2006); it involves
the ability to recognize thoughts as thoughts (“I’m having the thought ‘I’m
depressed’ ”) instead of buying into specific thought content (“I’m depressed”).
In an ACT clinical trial for inpatients with psychosis, Gaudiano, Herbert, and
Hayes (2010) showed that changes in patients’ believability of hallucinations,
which was conceptualized a measure of cognitive defusion, statistically medi-
ated the benefits that ACT showed on patients’ distress related to their hallu-
cinations relative to those receiving treatment as usual alone. Another study
combining data from two previous ACT for psychosis studies (Bach & Hayes,
2002; Gaudiano & Herbert, 2006) conducted in inpatient settings showed that
changes in the believability of psychotic symptoms also statistically mediated
the effect that ACT produced on post-discharge rehospitalization rates relative
to treatment as usual alone (Bach, Gaudiano, Hayes, & Herbert, 2013). As men-
tioned earlier, the meta-analysis of MATp by Khoury et al. (2013) also indicated
that overall changes on mindfulness, acceptance, and compassion measures
strongly predicted treatment outcomes, suggesting that these treatments may
produce their effects by successfully altering these hypothesized mechanisms of
action. However, future research in this area is needed, including better mea-
sures of MATp mediators and comparisons of mediation effects for MATp with
those of other psychosocial treatments, to understand the specificity of these
results. It also will be important for future investigations to better specify the
timing of effects to test whether earlier changes in mindfulness and acceptance
lead to later improvements in symptoms and functioning, to better demonstrate
cause-and-effect relationships.
In addition to studying which treatments work (comparative efficacy trials)
and how they work (mediators), it also is important to understand under what
conditions treatments are most efficacious, which involves the examination of
treatment moderators (Kraemer et al., 2001). Moderators could include char-
acteristics such as sex, race, ethnicity, and diagnosis, or they could pertain to
features of psychopathology. For example, does the initial level of psychosis
severity affect patients’ responses to MATp? Do patients initially high in experi-
ential avoidance benefit more from MATp that specifically target this feature of
psychopathology? Currently, there is little information on moderators of MATp
that would help us to understand when these interventions may be more or less
effective for different subgroups of patients.
An example of researchers successfully using analyses of mediators and mod-
erators to elucidate the relative contributions of traditional cognitive-behavioral
vs. mindfulness/acceptance treatments was demonstrated in a randomized con-
trolled trial in a nonpsychotic clinical population. Arch, Eifert, et al. (2012) found
that patients with mixed anxiety disorders randomized to ACT vs. CBT showed
similar improvements at post-treatment, although there was evidence of greater
reductions in anxiety severity at later follow-up in the ACT condition. Additional
mediation analyses showed that both ACT and CBT appeared to produce their
effects by changing the ACT-consistent mediator of cognitive defusion (Arch,
Wolitzky-Taylor, Eifert, & Craske, 2012). Furthermore, a follow-up moderator
analysis conducted by the investigators indicated that certain baseline variables
affected later outcomes. More specifically, patients who exhibited greater anxiety
sensitivity at baseline responded better to CBT, whereas those with a comorbid
depressive disorder responded better to ACT (Wolitzky-Taylor, Arch, Rosenfield,
& Craske, 2012). A similar type of investigation is needed to identify potential
MATp-specific moderators and mediators. Therefore, it will be important for
future investigations of MATp to include measures of hypothesized mediators
and moderators and to assess them throughout treatment to help identify if
earlier changes in these proposed mechanisms or preexisting factors affect later
treatment outcomes. Ultimately, research on the mediators and moderators of
MATp could help us to distill what Rosen and Davison (2003) call empirically
supported principles of change, which are the active processes that may cut
across different efficacious therapies, enabling clinicians to focus on delivering
the most essential components in a more efficient manner.
Adapting Treatment for Different Phases of Illness
Another important issue that requires further study is the better adaptation of
MATp for patients during different stages of their illness. In frequently chronic
psychotic disorders such as schizophrenia, the prodromal, acute, and residual
periods of illness differ in terms of their clinical features and potential treatment
targets. There is emerging evidence that MATp are generally safe for patients over
different phases of illness. However, research on MATp for early or first-episode
psychosis specifically is still in its infancy. For example, van der Valk et al. (2013)
reported equivocal results in an open trial of a novel intervention combining
meditation exercises, acceptance, and cognitive strategies for patients experienc-
ing their first psychotic episode. Research is more consistent with patients during
acute episodes. Two previous randomized controlled trials (Bach & Hayes, 2002;
Gaudiano & Herbert, 2006) conducted in acutely ill inpatient samples demon-
strated the benefits of ACT specifically on various clinical outcomes during and
following patients’ hospital stays. In terms of longer term outpatient treatment,
the study by Shawyer et al. (2012) used a combined ACT and CBT intervention
to treat patients in the community with persistent hallucinations and showed
numerous positive effects on outcomes. Furthermore, a pilot randomized con-
trolled trial by White et al. (2011) in which an ACT-based approach was used for
treating the emotional dysfunction following a psychotic episode demonstrated
greater improvements in depression, negative symptoms, and mindfulness than
with treatment as usual alone.
Although these initial studies suggest that MATp are generally safe and poten-
tially effective, further research is needed to better understand how these inter-
ventions should be systematically adapted and delivered to patients throughout
psychosis. For example, patients in their first episode of psychosis are often more
focused on trying to change and control their symptoms, making it potentially
more difficult to engage them in MATp that emphasize nonjudgmental awareness
and acceptance of symptoms. Therefore, motivational strategies (e.g., focusing
on values) might be particularly important to include as part of MATp for treat-

ing patients earlier in their illness. In contrast, chronically ill patients who have a
longer history of psychosis might be easier to engage in acceptance-based strate-
gies, given their more extensive personal experience with the paradoxical effects
of symptom control strategies. Another consideration is that more intensive
meditation exercises typically are contraindicated for patients during acute or
severe psychotic episodes (Shonin, Van Gordon, & Griffiths, 2014). Modifications
often are necessary and can include using a mindful eating exercise instead of an
eyes-closed, intensive meditation practice. Even though the same mindfulness
and acceptance processes may ultimately prove applicable for patients during
different phases of illness, further work is needed to specify which strategies are
safe and effective for which patients, given the diverse array of clinical presenta-
tions and levels of acuity characteristic of psychotic disorders across the lifespan.
Dissemination and Implementation Efforts
Another important issue that requires attention from researchers relates to the
future dissemination and implementation of MATp. Dissemination and imple-
mentation pertain to efforts to distribute information on efficacious interven-
tions and to promote their adoption and use by real-world clinicians in typical
clinical settings (Weisz, Ng, & Bearman, 2014). Of course, it is important to
ensure that such efforts match the quality and strength of research evidence sup-
porting MATp so as not to promote their use prematurely or inappropriately. It
also is the case that, as research continues to document the benefits of mindful-
ness and acceptance in psychosis, it will be essential to responsibly transport
these interventions into the community. Most studies of MATp to date have
focused on investigating their safety and efficacy under well-controlled condi-
tions. Such efforts are crucial, but there is a relative paucity of research thus far
to inform the training of clinicians in MATp, so that these interventions can be
effectively implemented to reach patients in need. In contrast, study therapists
in MATp clinical trials often have had specialized training in mindfulness and
acceptance therapies, but these methods are newer and often not yet routinely
taught in therapist training programs. There are significant differences in both
theory and technique between traditional CBTp and MATp, so it is unclear how
easy it will be for clinicians to learn MATp skills and implement them correctly
if they were originally trained in other approaches.
McLeod (Chapter 10 in this volume) reviews the evidence to date that points
to the potential clinical benefits of MATp when applied to patients experiencing
schizophrenia and related disorders. However, he also emphasizes that additional
work is needed to develop feasible and effective therapist training programs and
reliably assess therapist fidelity and competence when delivering MATp. Fidelity
refers to the therapist’s ability to reliably deliver the intervention as intended,
and competence refers to the therapist’s level of clinical skill in doing so. For
example, one issue related to therapist training is how much personal meditation
practice on the part of the therapist is useful and needed for him or her to be
able to effectively teach these skills to patients. McLeod also notes that further
research is needed to clarify how MATp should be implemented in relation to
other frontline evidence-based psychosocial interventions, such as traditional
CBTp and family therapies. He concludes that, at present, research suggests that
MATp may be most effective for targeting emotional distress and negative symp-
toms and may be useful for clinicians to consider when these clinical problems
are particularly relevant to patients’ treatment plans and goals.
Utilizing New Technologies
Technology is changing the ways in which psychosocial interventions are being

delivered. For example, various bibliotherapy programs are increasingly being
translated so that they can be delivered via the Internet and on more porta-
ble electronic devices such as tablet computers (Newman, Szkodny, Llera, &
Przeworski, 2011). Videoconferencing technology now permits therapists to hold
virtual “in-person” sessions with their patients in different locations, provid-
ing greater convenience and outreach to those who are geographically isolated
(Backhaus et al., 2012). In addition, the increasing use of smartphones allows
people to stay connected via the Internet while outside their homes (Luxton,
McCann, Bush, Mishkind, & Reger, 2011). Such phones provide new opportu-
nities for patients to utilize a multitude of helpful apps to monitor their symp-
toms and implement various self-management techniques between traditional
appointments with their treatment providers. Although frequently applied to
more common clinical problems such as anxiety and depression, emerging
research suggests the feasibility and potential benefits of mobile devices when
used by individuals with psychosis.
Research suggests that over 85% of people with schizophrenia accept and
can be trained to use mobile devices (Granholm, Loh, & Swendsen, 2008),
which is comparable to rates found in nonclinical populations (Ben-Zeev,
McHugo, Xie, Dobbins, & Young, 2012). Assessments collected using mobile
devices have demonstrated incremental validity over traditional measures
used for assessing symptoms. For example, one study found that spikes in
daily paranoia were better captured via mobile devices among patients who
reported low paranoia in traditional, retrospective assessments (Oorschot,
Lataster, Thewissen, Wichers, & Myin-Germeys, 2012). Preliminary work has
also documented the potential use of mobile devices to not only better moni-
tor symptoms but also provide useful interventions that can be implemented
in a patient’s natural environment. For example, Granholm et al. (2012)
reported the results of an open trial in which patients with schizophrenia
participated in a phone text-messaging intervention that encouraged the use
of cognitive-behavioral techniques. Findings demonstrated that the texting
intervention had positive effects on medication adherence, social contacts,
and auditory hallucinations.
Vilardaga, McDonell, Leickly, and Ries (Chapter 3 in this volume) note that
assessment and intervention work using mobile devices fit well with a contextual
model of psychosis. Contextual models are consistent with MATp because they
collect in vivo information that enables a greater understanding of the relevant
environmental and internal factors occurring just before and immediately follow-
ing changes in symptoms and functioning. In a naturalistic longitudinal assess-
ment study, Vilardaga, Hayes, Atkins, Bresee, and Kambiz (2013) showed that, for
patients with psychosis, the use of acceptance-based coping was a better predictor
of improved functioning than was cognitive-reappraisal strategies. Such research
can help elucidate which strategies patients with psychosis may find most ben-
eficial and can support the implementation of these strategies at home. Various
mindfulness- and acceptance-based phone apps are already available on the mar-
ket, and some are being tested in ongoing research. However, caution is needed, to
ensure that these apps are safe and effective when used outside of research studies.
Nevertheless, research on mobile technology suggests many new possibilities for
expanding the reach of MATp to supplement more traditional in-person treat-
ment and is sure to be an important avenue for future study.
A summary of the recommendations discussed here for future MATp research
is provided in Table 11.1.
Table 11.1. Recommendations for Future Research in Mindfulness

and Acceptance Therapies for Psychosis (MATp)
Research Domain
Areas of Emphasis Recommendations
Clarify underlying • Develop a comprehensive model of psychosis rooted in
psychopathology mindfulness and acceptance processes.
• Include measures of these constructs in future clinical
trials to test and refine the theoretical model.
Strengthen • Better specify treatment as usual and routine care
comparison comparison conditions in clinical trials.
conditions used in • Compare with supportive/educational comparison
clinical trials conditions that account better for “nonspecific” treatment
effects.
• Compare with traditional CBTp to better understand the
similarities and differences between these approaches, as
well as their common features.
Test mediators and • Identify and test whether the hypothesized mechanisms
moderators of of action of MATp relate to mindfulness and acceptance
outcomes processes and account for the effects on clinical outcomes.
• Clarify the conditions under which MATp are more
or less effective, based on demographic (e.g., age) and
clinical characteristics of patients (e.g., baseline levels of
experiential avoidance).
(Continued)
Research Domain
Adapt for different • Examine the effectiveness of MATp at various stages of
phases of illness psychotic illness, including the prodromal, acute, and
residual phases.
• Modify and adapt strategies to more specifically address
the needs of patients with early vs. chronic psychosis.
Improve • Develop and test formal therapist training programs
dissemination and (especially for nonexperts in mindfulness therapies) to
implementation aid in implementation efforts in the community.
efforts • Refine and test measures of therapist adherence and
competence to verify therapists’ abilities implementing
these treatments.
• Research the appropriate use of MATp in relation to other
empirically supported psychosocial treatments such as
traditional CBTp and family approaches.
Utilize new • Adapt and test MATp for delivery via the Web and on
technologies mobile devices.
• Develop and test smartphone applications that can
be used by patients between treatment appointments
to monitor symptoms and support self-management
strategies.
Note: CBTp, cognitive-behavior therapies for psychosis.
F U T U R E C L I N I CA L D I R ECT I O N S
Where We Are Starting from
As previously discussed, the diversity of MATp currently available speaks

to the rich clinical history from which these interventions have emerged,
encompassing both traditional cognitive-behavioral and Buddhist or Eastern
philosophies. Although various MATp share certain features, meaning-
ful differences also exist in terms of their theoretical underpinnings and
strategies employed, as outlined in the earlier chapters of this book. For
example, some approaches emphasize traditional guided meditation prac-
tices (Chadwick, Hughes, Russell, Russell, & Dagnan, 2009), whereas others
utilize alternative techniques for fostering mindfulness, such as ACT (Bach,
Gaudiano, Pankey, Herbert, & Hayes, 2006). Furthermore, newer approaches
are increasingly emphasizing self-compassion and how fostering this pro-
cess can complement and extend acceptance and mindfulness approaches
(Braehler et al., 2013).
To date, the clinical practice of MATp has lagged behind the research, as one
might expect for treatments that are rooted in empirically supported principles and
thus emphasize the importance of clinical research prior to wide-scale implemen-
tation. In other words, it is important to first determine that MATp are safe and
effective before promoting their widespread use as frontline treatments. However,
the research in this area is maturing enough so that books are beginning to be pub-
lished that provide therapists with specific “how to” guidance for implementing
MATp in their clinical work. For example, a recent book edited by Morris, Johns,
and Oliver (2013) covers the application of ACT and related approaches to a variety
of clinical problems and settings for individuals experiencing psychosis. Another
book in this area, by Wright et al. (2014), provides a comprehensive treatment plan
to guide the integration of CBTp and MATp strategies. As MATp becomes more
widely implemented by clinicians in the community, a variety of clinical issues
will require greater attention to meet the needs of practitioners and support the
widespread use of these interventions in “real-world” practice settings.
Improving Strategies Specifically for Psychosis
Even though research indicates that MATp have a solid foundation in terms of
their basis for treating individuals experiencing psychosis, the actual “technol-
ogy,” or strategies and techniques used to apply these principles to successfully
change mindfulness and acceptance processes require further refinement and
improvement. As mentioned earlier, research suggests that traditional medita-
tion practices require adaptation when employed in clinical populations with
psychosis (Shonin et al., 2014). It is important to emphasize that even though
many clinicians equate the concept of “mindfulness” with “meditation,” they
are, in fact, different. Mindfulness refers to a psychological process related to
nonjudgmental awareness and acceptance of present moment experiences,
whereas meditation refers to a specific type of practice that is designed to fos-
ter this mindfulness process (Hayes, 2003). Case reports suggest that intensive,
internally focused meditation exercises should be used with caution in individu-
als experiencing certain types of psychopathology, such as trauma and psychosis
(Sethi & Bhargava, 2003). The internal focus of traditional meditation exercises
can sometimes lead to further psychotic preoccupation and detachment from
reality in such patients, producing iatrogenic effects that will not actually foster
mindfulness as intended. Adaptations are recommended in which patients are
instructed to keep their eyes open and to focus on doing a particular activity,
such as eating or washing dishes, but to do so in a mindful fashion to mitigate
any potential concerns.
It is important that we allow research to guide the implementation of mindful-
ness strategies instead of tradition alone, so that we can develop improved exer-
cises that are more acceptable and feasible for patients experiencing psychosis. For
example, ACT proposes a variety of exercises that foster mindfulness in addition to
employing traditional meditation techniques. In the “Take your Mind for a Walk”
exercise, the therapist follows the patient on a brief walk outside of the office while
acting as his or her “mind” (Bach et al., 2006). The therapist simply walks behind
the person and comments on the environment and the person’s hypothetical inter-
nal state of mind (e.g., “I wonder what that person is doing over there”). In this way,
the patient can practice walking while making values-based choices as to where
to go and what to do, regardless of whether the “mind” agrees or not with these
decisions. In the context of a strong therapeutic alliance, such activities can foster
mindfulness by helping patients learn to practice nonjudgmental awareness and
acceptance of their mental events without the use of traditional meditation prac-
tices. A variation of this technique can involve having patients record their nega-
tive thoughts and then listen to them through earbuds (for increased privacy) while
taking a walk outside the office with the therapist. Another innovative technique
is one described by Morris and Oliver (2009) that they use when working with
younger people with psychosis. They have developed a worksheet that resembles
an iPod-like music playlist in which patients record their values-consistent actions
to complete over the next 24 hours, similar to the way they would list their favorite
music tracks. Along these lines, it will be important to continue to develop tailored
strategies that are suited to the unique needs of patients experiencing psychosis.
Integrating with Other Psychosocial Treatments
Further clinical guidance is needed to develop better strategies for integrating

MATp with other psychosocial interventions that patients may be concurrently
receiving. Some research has begun to inform this process. For example, my col-
leagues and I reported the results of both open and pilot randomized controlled
trials in which we integrated ACT with behavioral activation therapy (Martell,
Addis, & Jacobson, 2001) to develop a novel intervention we call ADAPT
(acceptance-based depression and psychosis therapy), which is designed to
address co-occurring depression and psychosis (Gaudiano et al., 2014; Gaudiano,
Nowlan, Brown, Epstein-Lubow, & Miller, 2013). We chose ACT and behavioral
activation because both are behavior therapies that share a common philosophi-
cal foundation, emphasize the central role of avoidance in the development and
maintenance of psychopathology, and have developed empirically supported
techniques for addressing psychosis and depression in a complementary fashion.
Results of our pilot work indicated that ADAPT produced sustained and clini-
cally significant effects on depression, psychosis, and psychosocial functioning,
and also successfully changed theoretically consistent targets of the interven-
tion (e.g., behavioral activation and experiential avoidance). These promising
early results support the need to test ADAPT in a future large-scale, clinical
trial. Patients with psychosis, however, often have other comorbid problems in
addition to depression, such as anxiety and substance use disorders (Buckley,
Miller, Lehrer, & Castle, 2009). Additional approaches are needed that combine
evidence-based treatments for patients with psychosis and other commonly
co-occurring disorders.
Other researchers have also begun working toward the systematic integration
of traditional CBTp and MATp approaches. As discussed earlier, Shawyer et al.
(2012) developed and tested TORCH in an initial clinical trial, which is an inte-
grated treatment combining cognitive-behavioral and mindfulness and accep-
tance techniques for treating persistent auditory hallucinations. In addition,
Turkington et al. (see Chapter 2 in this volume) describe an innovative, but as yet
untested, new treatment for psychosis that integrates a wide range of currently
available psychological techniques, including cognitive, behavioral, acceptance,
mindfulness, and self-compassion strategies. To date, little formal work has been
conducted integrating MATp and empirically supported family approaches for
psychosis (Pharoah, Mari, Rathbone, & Wong, 2010); there is much untapped
potential here for future work.
One open question that remains is how well these various psychosocial
approaches can be employed so that they will work together, instead of against
one another, as part of a patient’s overall treatment plan. Simply providing
these different interventions to patients separately without any coordination of
care may lead to less effective outcomes. It is possible that different treatment
rationales, messages, and strategies could conflict with each other and confuse
patients and their family members. For example, messages by the therapist to
“accept” instead of “change” experiences can produce misunderstandings if
not carefully implemented. Ideally, therapists would be able to use a variety of
evidence-based techniques that address specific patient problem areas. However,
these strategies are likely to be most effective when guided by a coherent and
unified case conceptualization and when employed in ways that are careful to
complement each other based on empirically supported, underlying principles
of behavior change.
Combining with Pharmacotherapy
Related to the issue of combining MATp with other psychosocial interventions is

how to use these interventions in a synergistic way with ongoing pharmacother-
apy for psychosis. Pharmacotherapy with antipsychotic medications is still and
will likely remain the frontline treatment for psychotic disorders. Medications
primarily target symptom reduction in psychosis. In contrast, MATp focus less
on directly changing symptoms and more on fostering mindfulness and accep-
tance processes that may indirectly decrease psychotic symptoms. MATp may be
particularly useful when targeted to address additional clinical problem areas,
such as overall well-being and distress related to psychosis, which contribute
substantially to functional impairment. As with any form of combined treat-
ment, MATp will be most effective when the therapist has a close working rela-
tionship with the prescriber so that the patient’s care can be coordinated in an
ongoing manner.
Recent research has highlighted the limitations of current pharmaco-
therapy for psychosis, some of which may suggest further opportunities and
a specific role for MATp. Although antipsychotic medications may be effec-

tive for reducing positive symptoms, their impact on negative symptoms and
functioning is limited (Bobes, Arango, Garcia-Garcia, Rejas, & CLAMORS
Study Collaborative Group, 2010). Other research indicates that the benefit of
antipsychotic medications relative to pill placebo often is less than typically
assumed (Leucht et al., 2012); that newer atypical antipsychotics are not neces-
sarily more effective than older generation medications (Leucht et al., 2009);
that long-term antipsychotic treatment may produce brain abnormalities and
contribute to cognitive deficits (Ho, Andreasen, Ziebell, Pierson, & Magnotta,
2011; Takeuchi et al., 2013); and that at least a subset of patients with psychosis
achieve better functional outcomes and clinical stability when antipsychotics
are discontinued following an acute psychotic episode (Harrow, Jobe, & Faull,
2012; Wunderink, Nieboer, Wiersma, Sytema, & Nienhuis, 2013). Emerging
research suggests a clear role for psychosocial interventions. A recent ran-
domized controlled trial demonstrated that patients with schizophrenia who
refused to take antipsychotic medications achieved substantial clinical benefits
and showed no clinical worsening when provided with CBTp alone (Morrison
et al., 2014).
There is some indication that mindfulness-based treatments can produce
more benefits than can medications alone in nonpsychotic clinical populations,
which suggests intriguing possibilities if applied to the treatment of psychosis.
For example, Segal et al. (2010) reported the results of a randomized controlled
trial of mindfulness-based cognitive therapy (MBCT) for preventing relapse in
depression. Patients who remitted following 8 months of antidepressant treat-
ment were then randomized to continue antidepressant medication or dis-
continue and start MBCT or pill placebo. Results showed that MBCT without
further medication treatment achieved similar protection against depression
relapse and recurrence to that of maintenance pharmacotherapy over the next
18 months, and both of these treatments were superior to placebo. Therefore, it
will be useful to explore future clinical applications of MATp for reducing exces-
sive antipsychotic medication use following acute stabilization, when clinically
appropriate to consider. In addition, MATp could prove useful for augmenting
pharmacotherapy by targeting outcomes that may not be improved by medica-
tions alone, such as psychosocial functioning and quality of life.
It also is important that a clear rationale for MATp be adopted when dis-
cussing medication treatment that is consistent with the mindfulness- and
acceptance-based coping strategies being taught to patients. For example, con-
versation about medication in ACT for psychosis is typically framed in the
context of values and workability (Bach et al., 2006). The choice of taking med-
ications is related to patients’ personal values and how drugs can be used in
ways that assist individuals in achieving their valued goals. This can lead to a
discussion of the potential benefits (decreased hallucinations or delusions) and
costs (increased side effects such as sedation) of this choice. Instead of medica-
tions becoming the primary focus of the discussion as in some other treatment
models, the ACT therapist discusses medications as a tool that may allow the
person to engage more successfully in values-consistent actions while he or she

simultaneously uses other mindfulness and acceptance-based coping strate-
gies for dealing with continued psychotic experiences to minimize the exces-
sive role of medication, when desired. The potential benefit of a values-based
rationale for choosing to take medications for psychosis is that it is inherently
more respectful of the patient’s personal choices, provides a normalizing ratio-
nale for this treatment, and is less stigmatizing than other approaches that
stress the need for medication based on the rationale of having a “disease” that
requires such treatment.
Incorporating Service User Perspectives
To date, the dialogue about MATp has largely taken place among clinicians
and researchers and thus has mainly reflected their concerns. However, as the
research supporting MATp continues to grow, it becomes increasingly critical to
formally integrate the perspectives of service users as well. Early research con-
ducted in the context of clinical trials suggests that MATp typically are viewed
as acceptable and that patients are largely satisfied with these treatments (e.g.,
see Gaudiano et al., 2013). However, it will be important to solicit additional
feedback and input from services users and their family members in order to
inform future modifications of MATp. There is great potential for integrat-
ing service-user perspectives into MATp, because these interventions match
very naturally with the recovery-oriented mental health movement given their
emphasis on functioning and not just on symptoms (Lysaker, Glynn, Wilkniss, &
Silverstein, 2010).
Qualitative research points to several ways we can better match MATp with
the specific needs of service users. For example, Abba, Chadwick, and Stevenson
(2008) used qualitative methods to examine 16 patients’ experiences of relating
differently to their psychotic experiences following mindfulness-based treat-
ment. They were able to identify a three-stage process that patients reported was
helpful and involved bringing awareness to psychosis, watching the experience
without reacting to it, and fostering greater self-acceptance. May, Strauss, Coyle,
and Hayward (2014) collected qualitative data by interviewing 10 patients about
their experience after receiving person-based cognitive therapy for distressing
voices (Chadwick, 2006). Similar themes emerged to indicate that, following
treatment, patients viewed voices as less powerful, developed a sense of self that
was more positive and separate from their voices, and improved their interper-
sonal relationships. In a study related to ACT for psychosis, Bacon, Farhall, and
Fossey (2014) thematically analyzed interviews from nine patients treated with
this approach. All patients found the treatment to be acceptable and useful,
particularly with regard to the mindfulness, defusion, acceptance, and values
components. These researchers concluded that the treatment experience for ser-
vices users could be improved by better connecting ACT metaphors and con-
cepts to the person’s experiences, using caution when applying certain intensive
mindfulness and abstract defusion techniques to prevent confusion, and focus-

ing more on values work to improve functioning.
Future possibilities for integrating service-user perspectives in MATp could
include the use of targeted focus groups to solicit feedback, to improve strate-
gies and techniques. Another consumer-focused area of expansion would be to
train peer support persons (Davidson, Chinman, Sells, & Rowe, 2006) with lived
experience of psychosis, to help patients implement MATp strategies. It will be
important for future efforts that MATp clinicians team up with local consumer
mental health advocacy groups, such as the National Alliance for the Mentally Ill
(NAMI). Currently, the availability of MATp in the community is very limited.
Collaborations with consumer groups can help extend the reach of these inter-
ventions in the future and increase consumer demand for these services, thus
leading to greater patient choice in the types of psychosocial treatments offered
in community treatment programs.
A summary of recommendations for future clinical practice in MATp is given
in Table 11.2.
Table 11.2. Recommendations for Future Clinical Practice in Mindfulness

and Acceptance Therapies for Psychosis (MATp)
Clinical Domain
Continue to improve • Develop novel mindfulness exercises that do not rely on
techniques and intensive meditation practices, which are contraindicated
strategies in patients with severe psychosis.
• Develop additional techniques and strategies tailored
specifically for psychotic symptoms instead of relying
only on generic exercises developed for other clinical
populations.
Integrate with other • Continue to explore the combination of efficacious
commonly used traditional behavioral, cognitive, and family therapies to
therapies strengthen the effects of these interventions in practice.
• Develop methods for integrating MATp so that they
can be utilized in a complementary fashion as part of
comprehensive community treatment programs for
psychosis.
Combine with • Limitations in pharmacological treatments for psychosis
pharmacotherapy point to further opportunities for MATp to serve an
important role in improving negative symptoms, quality
of life, and functioning.
• Explore the use of MATp to help reduce excessive
medication use in psychosis and prevent relapse in the
longer term, based on studies showing similar effects in
nonpsychotic clinical populations.
Clinical Domain
Integrate • Solicit feedback to better incorporate service-user
perspectives from perspectives into MATp to improve acceptability and
service users MATp’s ability to meet the needs of consumers and their
families.
• Develop peer support programs and team up with mental
health consumer groups to advocate for expanded use of
MATp in the community when indicated.
Note: CBTp, cognitive-behavior therapies for psychosis.
After reviewing the current state of affairs for MATp in terms of research and
clinical practice, it appears safe to conclude that the future looks very bright
for these interventions and for their potential role as part of comprehensive
treatment for individuals with psychosis. Initial research demonstrates that
MATp can be used in safe and acceptable ways with patients. These mindful-
ness and acceptance interventions appear to be useful as hypothesized for
changing behavioral and mental processes processes to aid in improving out-
comes for patients with psychosis beyond symptom reduction alone. However,
there are a variety of different MATp currently being tested, and initial
research suggests that their effects on outcomes are variable. Therefore, much
more research will be needed to improve the techniques, strategies, and deliv-
ery packages related to these interventions so that they can be implemented in
ways that are maximally effective for patients. Now that MATp are gaining in
empirical support and popularity in the clinical realm, various issues are aris-
ing that will require expanded research to tackle important issues. In particu-
lar, researchers will need to focus more on how to disseminate and implement
these treatments in real-world clinical settings and how they can be better
adapted to the needs of service users. This problem-solving is to be expected at
this point in the development of MATp. As researchers continue to investigate
the benefits and limitations of these interventions, and as clinicians continue
to refine and adapt these treatments so that they work better in practice, it is
hoped that MATp may one day achieve the type of success already attained
by traditional CBTp. The ultimate goal of this clinical and research work is
to provide the evidence needed for MATp to become recommended frontline
interventions for psychosis that can work in concert with other treatments to
improve the full range of outcomes and promote recovery in individuals with
severe mental illness.
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INDEX
AAQ-II (Acceptance and Action cognitive defusion concept in, 117, 129,
Questionnaire), 88, 101 218, 221, 258
Abba, N., 17, 170, 195, 269 cognitive fusion concept in, 64, 82, 216,
ABC model, In PBCT, 157–158 218, 220
Acceptance common versus distinctive
in acceptance and mindfulness elements of, 75
therapies, 218–219 compassion-focused therapy (CFT)
clinical trial of coping by, 5 integrated with, 89–90,
of command hallucinations, 110, 99–100
113–117, 213 conclusions, 76–77
description of, 4 for depression in psychosis
ecological momentary assessments aims and phases of, 91–92
(EMA) and, 35–36 concerns about, 100
experiential, 36 intervention progress, 95–99
interventions for, 58–59 matrix approach, 93–94
mindful, 95 outcomes, 82–83
precise understanding of, 41–42 studies on, 260
psychological, 35 exercises to promote acceptance over
Acceptance and Action Questionnaire avoidance, 219
(AAQ-II), 88, 101 hallucination-related believability
Acceptance and commitment therapy mediated by, 5
(ACT), 57–80 mindfulness and, 120–122, 127–129,
ACT Companion mobile app for, 265–266
43, 45–47 mindfulness meditation in
adaptations for psychosis cognitive-behavioral therapy and,
treatment, 65–67 191–192
American Psychological Association psychosis model in, 62–65
support for, 254 research studies of, 72–76, 220,
approach of, 57–61 230–231, 235, 269–270
auditory hallucinations and, 117 strategies and techniques of, 61–62
befriending therapy versus, 140–141 Acceptance and mindfulness-based
case vignette, 67–72 therapies, development model for,
cognitive-behavioral therapy integrated 203–226
with, 18–20, 260, 267 delusions, 204–211
278 I n d e x
Acceptance and mindfulness-based factors affecting, 228–229

therapies (Cont.) future research and clinical directions,
anomalous experience and, 206–207 261–262
as multidimensional phenomena, overview, 227–228
204–206 themes and observations, 241–247
preoccupation with, 207–211 Acceptance-based coping, 263
overview, 203–204 Acceptance-based depression and
phenomenology of psychosis, 204 psychosis treatment (ADAPT),
preoccupation as therapeutic target, 75, 266
214–220 ACT (acceptance and commitment
research directions, 220–221 therapy). See Acceptance and
voices, 211–214 commitment therapy (ACT)
Acceptance and mindfulness-based ACT Companion mobile app, 43,
therapies, directions for, 253–276 45–47
clinical directions, 264 ACT for depression after psychosis trial
improving psychosis strategies, (ADAPT), 83, 91
265–266 Action, committed, 61, 65, 122–123
integrating with other psychosocial Activity scheduling with mastery and
treatments, 266–267 pleasure recording, 16, 18
pharmacotherapy combined with, ACT Made Simple (Harris), 62
267–269 AHs (auditory hallucinations). See
service user perspectives Auditory hallucinations (AHs)
incorporated with, 269–271 Al-Issa, I., 115
starting points, 264–265 Allen, T. E., 13
research directions, 253–264 American Psychological Association
dissemination and implementation (APA), 5, 57, 229, 247, 254
efforts, 261–262 Angus, B., 13
illness phases, adapting treatment to, Anticipatory pleasure, 31
260–261 Antipsychotic medications
introduction, 253–254 CBT sidelined because of, 13
mediators and moderators of as dominant psychosis treatment, 3
treatment effects, 258–260 mindfulness therapy along with,
other therapies versus, 257–258 267–268
psychosis psychopathology, 256–257 side effects of, 21
starting points, 254–256 Anxiety, 113, 260
technology use, 262–264 Anxiety and Depression subscales, 88
Acceptance and mindfulness-based Anxiety psychosis, 15
therapies, disseminating and APA (American Psychological
implementing, 227–252 Association), 5, 57, 229, 247, 254
directions for, 247–248 Apps
evidence for, 229–241 ACT Companion mobile app, 43,
case study findings, 241 45–47
characteristics of, 230–231 assessment use of, 41–44
extracting, 230 BeWell mobile app, 43
overview, 229–230 DBT Coach mobile app, 43
randomized controlled trial findings, as future direction for treatment,
231–237 262–263
uncontrolled group trial findings, Mobilyze! mobile app, 43
237–241 mood predicted by, 43, 45–46
Index279
SmartQuit mobile app (smoking Big data, from EMAs, 44–45

cessation), 43 Birchwood, M. J., 15–16, 81, 84,
T2 Mood Tracker mobile app, 43 110–111, 213
Arch, J. J., 259 Bleuler, E., 15
Assertiveness, TORCH techniques Branching, in EMA, 36
from, 125 Brenner, H. D., 15
Atkins, D. C., 263 Bresee, C., 263
Attachment system, reactivating, 87 Bricker, J., 42
Attentional deficits, cognitive remediation Brief Psychiatric Rating Scale, 73, 82
for, 13 Brown, L. A., 82
Attentional training technique, 193 Brunette, M. F., 241
Auditory hallucinations (AHs). See also Byrne, S., 16
Hallucinations
as acceptance and mindfulness-based Calgary Depression Scales for
therapy issue, 211–214 Schizophrenia, 88–89
medication resistant, 114 Cameron, R., 13
responses to, 108–111 Cannabis use, 31
suppression attempts for, 256 Cases
Auto-reports, mobile technologies acceptance and commitment therapy
for, 44 (ACT), 67–72
Avoidance cognitive-behavior therapy (CBT),
experiential, 35, 58, 63–64, 256–257 acceptance-based, 125–129
psychological flexibility depression in psychosis, 90–91
decreased by, 63 findings from, 241
psychosis preoccupation and, 209–211 person-based cognitive therapy,
Avoidance-based coping, 4–5 156–162
Castillo, R. J., 115
Bach, P. A., 5, 57, 59, 62, 66–67, 73, CBT (cognitive-behavioral therapy). See
117, 135 Cognitive-behavioral
Bacon, T., 74, 137, 269 therapy (CBT)
Barnes-Holmes, D., 17 CFT (compassion-focused therapy). See
BAVQ (Beliefs about Voices Compassion-focused
Questionnaire) (BAVQ), 15, therapy (CFT)
110–111, 131, 194 Chadwick, P. D. J., 5, 14–16, 110–111, 152,
Beck, A. T., 12–13 154–155, 165, 174–175, 180, 213,
Beck-Sander, A., 111–112, 116 236, 241, 269
Befriending therapy, 15, 130, 137, 140–141 Clinical Outcomes in Routine Evaluation
Behavior therapy, as first wave of (CORE), 193
treatment, 4 Clinical Trials Assessment Measure
Belief modification, in TORCH, 119–120, (CTAM), 133, 138, 236
126–127 Clozapine therapy, 13
Beliefs about Voices Questionnaire Cognitive-behavioral therapy (CBT),
(BAVQ), 15, 110–111, 131, 194 12–24. See also Mindfulness
Bentall, R., 14 meditation in cognitive-behavioral
Ben-Zeev, D., 208 therapy
Berk, L. A., 113 acceptance, commitment, compassion,
BeWell mobile app, 43 and mindfulness integrated
Bibliotherapy programs, 262 with, 18–20
280 I n d e x
Cognitive-behavioral therapy (Cont.) Cognitive therapy, 4, 268. See also

acceptance and mindfulness Person-based cognitive
promoted by, 4 therapy (PBCT)
ACT integrated with, 267 Cognitive Therapy for Voices, Delusions,
ACT versus, 58 and Paranoia (Chadwick,
anxiety sensitivity and, 260 Birchwood, and Trower), 15
cognitive models and techniques, 13–14 Cognitive Therapy Scale for Psychosis
cognitive remediation emergence, 13 (CTS-Psy), 236
cognitive remediation therapy (CRT) Cohen, C. I., 113
versus, 248 Collaborative empiricism, 12
compassion-focused and Command hallucinations, 15–16,
positive psychology-based 74–75, 257–258. See also
approaches, 15–18 Cognitive-behavior therapy
conclusions, 21 (CBT), acceptance-based;
delusion content as target of, 214–215 Hallucinations
for medication adherence, 66 Commitment therapy, acceptance
positive outcomes from, 26, 57 and. See Acceptance and
psychoanalysis to, 12–13 commitment therapy (ACT)
for psychosis, 14–15 Committed action, 61, 65, 122–123
self-regulation strategies targeted by, 35 Compassionate mode of mind, 96–98
Cognitive-behavior therapy (CBT), Compassion-focused therapy (CFT). See
acceptance-based, 108–149 also Social mentality theory
background and rationale, 108–110 ACT integrated with, 89–90, 99–100
clinical vignettes, 125–129 affiliative behavior promoted by, 85
cognitive models, 110–111 for depression in psychosis, 83, 86–89
command hallucinations development of, 15–20
acceptance and, 113–117 mindfulness meditation in CBT
engagement and, 111 and, 192
resistance and, 112–113 trials using, 246
treatment of resistant (TORCH), Computerized EMAs, 34
118–125 CONSORT criteria for randomized
research directions, 137–141 control trials, 138, 140
TORCH common and distinctive Construct theory of mind, 64
elements, 129–130 Consummatory pleasure, 31
TORCH evaluation, 130–137 Contact with present moment, in
discussion, 135–137 ACT, 58, 60
hypotheses, 130 Context, 25–27
method, 130–132 Contextual behavioral assessments
results, 132–134 EMAs in tradition of, 28–30
Cognitive deficits, 27–28, 66 EMAs used in, 30–33
Cognitive defusion concept in ACT, 117, Coping strategies, TORCH techniques
129, 218, 258–259 from, 124
Cognitive fusion concept in ACT, 64, 82, CORE (Clinical Outcomes in Routine
216, 218, 220 Evaluation), 193
Cognitive reappraisal, 35–36, 38 Corrigan, P., 15, 85
Cognitive remediation therapy Courtley, J., 12, 253
(CRT), 248 Coyle, A., 269
Index281
CRT (cognitive remediation treating, 82–83

therapy), 248 treatment protocol for, 91
CTAM (Clinical Trials Assessment overview, 91–92
Measure), 133, 138, 236 phase 1: socialization, assessment,
CTS-Psy (Cognitve Therapy Scale for and formulation, 93–95
Psychosis), 236 phase 2: ACT intervention, 95–99
phase 3: beyond ACT
Davison, G. C., 260 intervention, 99
DBT Coach mobile app, 43 Depue, R. A., 83
Decentering, in acceptance and deVries, M., 31, 36
mindfulness therapies, 218 Disengaged acceptance, of command
Defeatist beliefs, in negative hallucinations, 115–117
schizophrenia symptoms, 16 Dissociation, 35
Defusion Distressing psychosis. See Person-based
in acceptance and mindfulness cognitive therapy (PBCT)
therapies, 218 Drive system, for regulating emotions, 84
in ACT, 59, 64 Drug-induced psychosis, 15
cognitive, 117, 129, 218, 258–259 Drury, V., 207
mind check analogy, 95–96 Dubin, W., 66
Delespaul, P., 31, 36 Dysphoria, 208
Delusions. See also Schizophrenia
anomalous experience and, 206–207 Earleywine, M., 87
as multidimensional phenomena, Ecological momentary assessments
204–206 (EMA), 25–54
Peters Delusion Inventory (PDI), 63 acceptance and mindfulness-based
preoccupation with, 207–211 processes using, 35
Depression assessment strategy
ACT and, 260 inadequacies, 27–28
CBT change mechanisms for, 172–173 challenges in, 44–45
experiential avoidance and, 256–257 clinical practice insights, 45–47
ruminative thinking in maintaining, conclusions, 47–48
208–209 context in, 25–27
Depression in psychosis, 81–107 contextual behavioral assessments
acceptance-based depression and using, 30
psychosis treatment (ADAPT), in contextual behavioral
75, 266 tradition, 28–30
ACT treatment for, 74 opportunities in, 40–42
ACT for depression after psychosis trial technologies in, 42–44
(ADAPT), 83, 91 Eifert, G. H., 259
case vignette, 90–91 Ellett, L., 150, 194
compassion-focused therapy for, Ellington, K., 208
86–90, 99–100 EMA (ecological momentary
conclusions, 101–102 assessments). See Ecological
overlap, 16 momentary assessments (EMA)
overview, 81–82 Emotions, 84, 113
research directions, 100–101 Engagement, of command hallucinations,
social mentalities and, 83–85 110–111, 114–115, 213
282 I n d e x
Engagement and assessment, in Haddock, G., 15

TORCH, 118 Häfner, R. J., 13
Enhanced treatment as usual (ETAU), 73, Hallucinations. See also
82, 135 Cognitive-behavior therapy
Epstein-Lubow, G., 82 (CBT), acceptance-based;
Escher, S. D., 14, 109, 213, 256 Command hallucinations
Experiential acceptance, 36, 38 hallucination-related believability, 5
Experiential avoidance, 35, 58, 63–64, hyperventilation triggering, 13
256–257 prevalence of, 63
reality testing, 13–14
Falloon, I. R. H., 256 social rank mentality and, 84
Family-based psychosocial treatment of resistant command
interventions, 4 hallucinations (TORCH), 74–75
Faragher, E. B., 15 Harris, R., 62
Farhall, J., 63, 66, 74, 108, 113, 137, 210, Hated-Self subscale, Forms of
212–213, 269 Self-criticism/attacking
Fidelity and competence, in treatment Reassurance Scale, 89
administration, 140, 229, 231, Hayes, S. C., 5, 17, 62, 67, 73, 117,
232-234, 236-245, 247-248, 135, 263
261, 264 Hayward, M., 150, 269
Fixity, in PBCT, 153 Hektner, J., 30
Forms of Self-criticism/attacking Hemsley, D. R., 14
Reassurance Scale, 89 Herbert, J. D., 5, 73, 82
Forsyth, J. P., 87 Hodel, B., 15
Fossey, E., 74, 137, 269 Hole, R. W., 13
Foster, C., 215 Honig, A. M., 109
Fowler, D., 14, 115, 138 Hospital Anxiety and Depression
Fox, J. R. E., 111–112 Scale, 88
Fred Hutchinson Cancer Research Husby, R., 207
Center, 43 Hutton, P., 241
Freeman, D., 215
Frise-Smith, T., 109 Individual psychosocial interventions, 4
Insight acceptance, of command
Garety, P. A., 14, 138, 205 hallucinations, 115–116
Gaudiano, B. A., 3, 73, 75, 82, 253 Integrated treatment model, 18–19
Gherke, M., 213 Internal experience in PBCT, relationship
Gilbert, P., 16, 83–84, 87–88, 96, 112 with, 151, 153
Gillis, R., 109 Internet. See Apps
Goldstone, E., 63, 210 Interventions. See also Depression in
Goodliffe, L., 166–167 psychosis
Goodness of fit, in PBCT, 152–153 acceptance, 58–59
Graded activity scheduling, 16 EMA to improve, 42
Granholm, E., 36, 208, 262 need for simpler, 137–138
Grant, P. M., 16 psychosocial, 4, 57
Gray, N. S., 111–112 TORCH, 125
Guided discovery, 12
Guided imagery, 61 Jacobs, L. I., 13
Gumley, A., 88 Johns, L., 265
Index283
Jǿrgensen, P., 207 McLeod, H. J., 227, 261–262

Joseph, S., 205 Meaden, A., 16, 84
Medications
Kabat-Zinn, J., 17 adherence to, 66
Kambiz, A., 263 antipsychotic, 267–268
Kaney, S., 14 auditory hallucinations resistant
Khoury, B., 246–247, 254, 259 to, 114
Kimhy, D., 39 Meditation, 191–192, 265
Kingdon, D. G., 14–15 MEDLINE, 230
Kuipers, E., 138 Meichenbaum, D., 13
Kuyken, W., 89 Mental Health Unusual Perceptions Scale
(MUPS), 109
Labuschangne, I., 209 Metacognitive theory, 16
Lardinois, M., 31 Metta (loving-kindness meditation), 246
Laws, K. R., 163 Miller, A., 82
Learning ACT (Luoma, Walser, and Milton, F., 13
Hayes), 62 Mindful acceptance, of command
Leickly, E., 25, 263 hallucinations, 116–117
Lewis, H., 111–112 Mindfulness. See also Acceptance
Lifengage RCT of ACT vs. befriending, and mindfulness-based
140–141 therapies, development
Lowe, D., 14 model for; Acceptance and
Luoma, J. B., 62 mindfulness-based therapies,
Lynch, D., 163 directions for; Acceptance and
mindfulness-based therapies,
MAAS (Mindfulness Attention disseminating and implementing;
Awareness Scale), 90 Person-based cognitive
MacBeth, A., 88 therapy (PBCT)
Machine learning, for hypothesis in acceptance and commitment therapy
testing, 44 (ACT), 120–122, 127–129
Maher, B. A., 206 acceptance with, 95
MATp. See Acceptance and compassion-focused strategies related
mindfulness-based to, 89–90
therapies, development description of, 4–5
model for; Acceptance and ecological momentary assessments
mindfulness-based therapies, (EMA) and, 35–36
directions for; Acceptance and introduction to, 3–11
mindfulness-based therapies, book organization, 6–8
disseminating and implementing overview, 3–4
Matthews, G., 173 psychosis treatment with, 4–6
May, K., 166–167, 269 precise understanding of, 41–42
MBCT (Mindfulness-based cognitive in therapeutic practice, 17
therapy), 215–216, 268 Mindfulness Attention Awareness Scale
MBSR (mindfulness-based stress (MAAS), 90
reduction), 215–216 Mindfulness-based cognitive therapy
McCarron, J., 15 (MBCT), 215–216, 268
McDonell, M., 25, 263 Mindfulness-based stress reduction
McKenna, P. J., 163 (MBSR), 215–216
284 I n d e x
Mindfulness meditation in National Alliance for the Mentally Ill

cognitive-behavioral therapy, (NAMI), 270
170–200 National Center for Telehealth and
acceptance and commitment therapy Technology, 43
and, 191–192 National Registry of Evidence-Based
cautions, 174–175 Programs and Practices (Substance
change mechanisms in, 172–173 Abuse and Mental Health Services
in clinical practice, 175–180 Administration), 57
clinical vignette, 182–185 Neff, K., 86, 96
cognitive approach to psychosis, Negative self-schematic experience (NSS),
171–172 154–155, 163
common and distinctive elements of, Neurodevelopmental model of
185–191 psychosis, 13
compassion-focused therapy and, 192 Newman-Taylor, K., 17
conclusion, 195–196 Nolen-Hoeksema, S., 208
integrating, 180–182 Noordsy, D. L., 241
introduction, 170–171 Noorthoorn, E. O., 109
person-based cognitive therapy Novitsky, M. A., 66
and, 191 Nowlan, K., 82
rationale for, 174 NSS (negative self-schematic experience),
research evidence and direction, 154–155, 163
193–195
Mizrahi, R., 207 Oliver, J., 265–266
Mobile devices. See Apps Ong, B., 63, 210
Mobile technologies, use in assessment, Outcomes measurement, 139
41–44. See also Apps Oxytocin-based compassion system in
Mobilyze! mobile app, 43 brain, 16
Modes of mind, 173
Modified Global Assessment of Panksepp, J., 83
Functioning, 131 PANSS (Positive and Negative Syndrome
Møller, P., 207 Scale), 131, 139, 237
Momentary quality-of-life items, in Paranoia, 35, 63
EMA, 36 Patwa, V. K., 13
Moment-to-moment outcomes, 38 PDI (Peters Delusion Inventory), 63
Mood, mobile apps to predict, 43, 45–46 Perris, C., 14
Moran, D. J., 59 Personalized psychoeducation, TORCH
Morley, S., 14 techniques from, 124
Morris, E. M., 212, 265–266 Person-based cognitive therapy (PBCT),
Morrison, A. P., 16, 21, 241 150–169
Morrone-Strupinsky, J. V., 83 clinical vignette, 156–162
Motivational interviewing, 65–66, common versus distinctive elements of,
123–124 162–163
MUPS (Mental Health Unusual evidence for, 163–166
Perceptions Scale), 109 mindfulness meditation in
MyExperience software (University of cognitive-behavioral therapy
Washington), 36, 39 and, 191
Myin-Germeys, I., 31, 38 overview, 5
Index285
proximal development zones Acceptance and Action Questionnaire

overview, 150–151 (AAQ-II) measurement of, 101
relationship with internal ACT and, 58–59, 216
experience, 153–154 Self Compassion Scale correlates
schemata, 154–155 with, 88
symbolic self, 155–156 Psychometrics, secondary role in EMA
symptomatic meaning, 152–153 of, 29–30
radical collaboration, 151–152 Psychosis. See also Depression in
research directions, 166–167 psychosis; Ecological momentary
Perspective taking, deficits in, 64 assessments (EMA); Mindfulness
Peters, E., 205, 207 meditation in cognitive-behavioral
Peters Delusion Inventory (PDI), 63 therapy; Person-based cognitive
Pharmacotherapy, with acceptance and therapy (PBCT)
mindfulness-based therapies, acceptance-based depression and
267–269 psychosis treatment (ADAPT), 75
Plaistow, J., 84 ACT adaptations for treatment
Polk, K., 93 of, 65–67
Positive and Negative Syndrome Scale ACT model of, 62–65
(PANSS), 131, 139, 237 psychotherapy for, 3–4
Positive psychology-based reality distortion cluster of symptoms
approaches, 15–18 in, 204
Positive self-schematic experience (PSS), "sealing over" recovery style in, 256
155, 163 Psychosocial interventions, 57
Potts, L., 215 Psychotherapy, 3–4
Power of Self-Compassion, The Psychotic Symptoms Rating Scales,
(Welford), 91 15, 131
Preoccupation PsycINFO, 230
with delusions, 207–211
future research on, 220–221 Qualitative research, 166–167, 269
as therapeutic target, 214–220 Quality of Life Enjoyment and
Procter, S., 87 Satisfaction Questionnaire, 131
Progressive muscular relaxation, 13
Proximal development zones, in PBCT Radical collaboration, in PBCT, 151–152
overview, 150–151 Reality distortion cluster of symptoms in
relationship with internal experience, psychosis, 204
153–154 Reality testing, 12–14
schemata, 154–155 Rebound effects, 4
symbolic self, 155–156 Rehabilitation, cognitive remediation not
symptomatic meaning, 152–153 predictive of, 15
PSS (positive self-schematic experience), Relational frame theory, 17
155, 163 Relationship with internal experience, in
Psychiatric Symptom Rating Scale, 194 PBCT, 151, 153
Psychoanalysis, 12–13 Relaxation approaches, 13
Psychodynamic work, CBT Remediation, emergence of, 13, 15
with, 14 Resistance to command hallucinations,
Psychological acceptance, 35, 38 110, 112–113, 213
Psychological flexibility Ries, R., 25, 263
286 I n d e x
Roberts, G. W., 14 Self-compassion. See Depression in

Roche, B., 17 psychosis
Roder,V., 15 Self-Compassion Scale, 88
Rogerian principles, 150 Self-efficacy enhancement, TORCH
Rogers, R., 109 techniques from, 124
Role-play assessments, for therapeutic Self-esteem, 63, 87
competence, 228 Self-medication hypothesis, 31
Romme, M. A., 14, 109, 114–115, 213 Self-regulation, 35–40, 216–218
Rose, J. J., 66 Self-regulatory executive function model
Rosen, G. M., 260 (S-REF), 16, 173
Rossell, S., 209 Self-report measures, 27–28, 44
Ruminative thinking processes, in Sensitivity disorder, 15
emotional disorders, 208–209, 221 Sensky, T., 15
Rush, A. J., 13 Service user perspectives, in acceptance
and mindfulness-based therapies,
SAMHSA (Substance Abuse and Mental 269–271
Health Services Administration), Shapiro, S. L., 89–90
57, 247, 254 Shawyer, F., 108, 130, 212–213, 236,
Sample size, in trials, 139 256–258, 260
Schemata, in PBCT, 151, 154–155 Sheppard, S. C., 87
Schizophrenia. See also Hallucinations; SHER (Single Hallucination Episode
various therapies Record), 131
ACT treatment for, 74 Short Quality-of-Life Scale, 45
antipsychotic medication Single-case design approach, 45
treatment for, 3 Single Hallucination Episode Record
auditory hallucinations in, (SHER), 131
108–109, 256 Slade, P. D., 14
CBT manuals for treatment of, 14 Smoking cessation, mobile app for
cognitive-behavioral therapy for, 13 (SmartQuit), 43
cognitive deficits in, 66 Social mentality theory, 83–85. See
construct theory of mind deficits in, 64 also Compassion-focused
context factors in, 25–26 therapy (CFT)
depression correlates with, 88–89 Social rank mentality, 16, 82, 84, 96
phone-text messaging intervention for, Society of Clinical Psychology, American
262–263 Psychological Association, 57
positive affect and being alone Socratic exploration, 20
relationship, 31 Soothing/affiliative system, for regulating
psychosocial treatment for, 4 emotions, 84–85, 96
quality-of-life scale for, 38 Southhampton Mindfulness
study emphasis on, 231 Questionnaire, 194
UK NICE treatment guidelines for, S-REF (Self-regulatory executive function
235, 247 model), 16, 173
Schuman-Oliver, Z., 241 Stabilization, 20
"Sealing over" recovery style, in Startup, H., 215
psychosis, 256 Steel, C., 207
Segal, Z. V., 268 Stevenson, C., 269
Self-as-perspective, in ACT, 60 Stigma, 84–85
Index287
Strauss, C., 150, 269 See also Cognitive-behavior

Substance Abuse and Mental Health therapy (CBT), acceptance-based
Services Administration Trial quality, 138–139
(SAMHSA), 57, 247, 254 Trower, P. E., 15–16, 84
Supportive therapy, CBTp tested T2 Mood Tracker mobile app, 43, 45
against, 15 Turkington, D., 12, 14–15, 253
Swendsen, J., 208 Turner, E., 109
Symbolic self, in PBCT, 151, 155–156
Symptomatic meaning, in PBCT, 151–153 Udachina, A., 35, 210
UK Hearing Voices Network, 114
Tait, L., 256 UK NICE treatment guidelines for
Talbot, R. E., 256 schizophrenia, 235, 247
Tarrier, N., 15 University of Washington, 36
TAU (treatment as usual), 72–73, 82, 135
Taylor, H., 241 VAAS (Voices Acceptance and
Taylor, K. N., 170 Action Scale), 38, 131–132,
Teasdale, J. D., 172 139–140, 213
Technology. See Apps Value life direction, 98
Therapeutic alliance, 14 Values, 60–61, 65
Thewissen, V., 31 Van Dam, N. T., 87, 90
Thomas, N., 203, 209, 212, 257 van der Gaag, M., 18
Threat-focused appraisals, 98 van Os, J., 36
Threat system, for regulating emotions, 84 Varese, F., 35
TONES (Treatment of Negative Vaughan, S., 115
Symptoms) trial, 248 Verdoux, H., 31
TORCH (treatment of resistant command Videoconferencing, 262
hallucinations), 74–75. See also Vilardaga, R., 25, 263
Cognitive-behavior therapy Voice-hearing experiences, 14, 211–214.
(CBT), acceptance-based See also Hallucinations
Traumatic psychosis, 15–16 Voices Acceptance and Action
Treating Psychosis: A Clinician’s Guide Scale (VAAS), 38, 131–132,
to Integrating Acceptance 139–140, 213
and Commitment Therapy, Voudouris, N., 113
Compassion-Focused Therapy and Vygotsky, L. S., 191
Mindfulness Approaches within
the Cognitive Behavior Therapy Walser, R. D., 62
Tradition (Wright), 18 Waters, F., 73
Treatise on the Schizophrenias Welford, M., 91, 96, 98
(Bleuler), 15 Wells, A., 16, 173–174, 193
Treatment as usual (TAU), 72–73, 82, 135 White, N. P., 257, 260
Treatment fidelity, 228, 236 White, R. G., 81, 91, 98
Treatment of Negative Symptoms Williams, J. M. G., 172–173, 172–174
(TONES) trial, 248 Wixted, J. L., 16
Treatment of resistant command Wright, N. P., 12, 18, 253, 265
hallucinations (TORCH), 74–75. Wykes, T., 139, 163

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Incorporating Acceptance and Mindfulness

into the Treatment of Psychosis

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© Oxford University Press 2015

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Library of Congress Cataloging-in-Publication Data

Foreword by Kim T. Mueser ix

SECTION I: Introduction and Background

2. The Evolution of Cognitive-Behavioral Therapy for Psychosis: The Path

3. Ecological Momentary Assessments in Psychosis: A Contextual

SECTION II: Specific Treatment Models

5. Treating Depression in Psychosis: Self-Compassion as a Valued Life

6. Acceptance-Based CBT for Command Hallucinations: Rationale,

7. Person-Based Cognitive Therapy for Distressing Psychosis: Integrating a

8. Mindfulness Meditation in Cognitive-Behavioral Therapy

SECTION III: Synthesis and Analysis

10. Disseminating and Implementing Acceptance- and Mindfulness-Based

11. Charting the Course Ahead: Future Clinical and Research Directions in

The mind is a wondrous but terrible thing—capable of giving birth to astound-

in the emphasis in many CBT approaches on developing a shared formulation

continues to be refined and modified; it is informed by emerging research on

Kim T. Mueser, PhD

Beck, A. T. (1952). Successful outpatient psychotherapy with a schizophrenic with a

Brandon A. Gaudiano, PhD, is a clinical psychologist in the Psychosocial

Nicola Abba, DClinPsy Mark Hayward, DClinPsy, PhD

Katherine Newman Taylor, DClinPsy Douglas Turkington, MD

Introduction and Background

Antipsychotic medications currently dominate the treatment of psychotic dis-

In recent decades, a growing body of research has supported exciting new

mindfulness has been shown to produce numerous benefits to people’s psycholog-

work at least partly by changing the proposed mechanisms underlying psychosis

Although there are a variety of acceptance and mindfulness approaches being

including its essential techniques and strategies; (c) provides a clinical vignette

effective components of these treatments, and harness them to support recov-

American Psychological Association. (n.d.). Acceptance and commitment therapy from

T H E 19 50 S: B EC K—FR O M PSYC H OA N A LYS I S TO

It is fair to date the genesis of cognitive-behavioral therapy (CBT) for psychosis to

and avoidance behaviors, and eventually through sustained, gradual reality

The psychological elegance of Beck’s original casework was submerged by a wave

In 1973, Meichenbaum and Cameron demonstrated that cognitive remediation

T H E 19 8 0 S: E X PLO S I O N O F I N T ER EST I N C O G N I T I V E

In 1980, Jacobs described a cognitive approach to persistent delusions. By

In 1990, Lowe and Chadwick published an influential paper on verbal control

important book followed, by Chadwick, Birchwood, and Trower, entitled

Subgroups of schizophrenia/psychosis were described by Kingdon and

approach to command hallucinations based on social rank theory was described

• When a mini-formulation of maintenance is being collaboratively

Example of Integrating Acceptance and Commitment,

In their book, Treating Psychosis: A Clinician’s Guide to Integrating Acceptance

Figure 2.1. Integrated treatment model.

psychology principles woven throughout. Beckian CBT with its focus on an

It is also important to note some caveats and limitations regarding CBTp.

Allen, T. E., & Agus, B. (1968). Hyperventilation leading to hallucinations. American

ROGER VILARDAGA, MICHAEL MCDONELL,

Effective clinical behavior change begins with an assessment of an individual’s

Aren’t We Already Measuring Context?

outcomes. For example, the results of experimental research conducted in lab-

Current Assessment Strategies Are Not Adequate

Global self-report measures and interview data are particularly problematic

Affinity of EMAs to the Contextual Behavioral Tradition

From a contextual behavioral perspective, psychological events are under the