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Using ACT and Mindfulness in group therapy for individuals with early psychosis - adaptations and successes. Tania Lecomte, Ph.D., Université de Montréal Bassam Khoury, Ph.D.-candidate, Université de Montréal Alexandre Benoit, RN, M.Sc., Hôpital Louis-H. Lafontaine

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Using ACT and Mindfulness in group therapyfor individualswithearlypsychosis - adaptations and successes

Tania Lecomte, Ph.D., Université de Montréal

Bassam Khoury, Ph.D.-candidate, Université de Montréal

Alexandre Benoit, RN, M.Sc., Hôpital Louis-H. Lafontaine

Claude Leclerc, R.N., Ph.D., Université du Québec à Trois-Rivières

Relevance of act and mindfulness for early psychosis
Relevance of ACT and Mindfulness for earlypsychosis

  • Individualswithearlypsychosis are increasinglybeingofferedpsychologicaltherapies + medication in order to help improvecopingstrategies & stress management, and to prevent relapse.

  • Studieshave suggestedthat ACT (Bach & Hayes, 2004; Gaudiano & Herbert, 2006) could be useful for individuals with psychotic disorders, though few have specifically investigated it with individuals with early psychosis.

  • Individuals with early psychosis experience distress, anxiety and depression linked with their diagnosis and the overall experience of psychosis, difficulties which have been documented as responding well to ACT and Mindfulness.

Our interest for act and mindfulness for early psychosis
Our interest for ACT and Mindfulness for earlypsychosis

  • We recently conducted a large RCT using group CBT for psychosis (Lecomte et al., 2008, J Nerv and Ment Dis)and have obtained significant results in terms of decrease in symptoms and increase in self-esteem

    • in the intervention, there was a brief mindfulness/relaxation intervention that was rated as one of the preferred activities for many participants.

  • Recovery, as defined by the consumer-survivor movement, is about hope, redefining oneself according to one’s values, and includes spiritual as well as functional aspects – many of these same principles are present in ACT…


  • Determine the feasibility and overall acceptability of ACT/Mindfulness for early psychosis

Study 1
Study 1

  • Conducted by Alexandre Benoît, under the supervision of Claude Leclerc.

  • Procedure:

    • A manualized 4 session group ACT for individualswithearlypsychosiswasinitiallydevelopedcloselyfollowing the ACT principles, for recentlydischarged patients in a specialized first episodeclinic.

    • Each session includedactivitiesthatcovered one or more of the following six ACT clinicalsteps:

      • Creativedespair

      • Control as a problem

      • Cognitive defusion or distance fromthoughts

      • Self as an observer

      • Clarifying values

      • Engagement towards values and actions

Study 1 cont d

The sessions included various activities, e.g.

Study 1 (cont’d)

  • The bus driver (one participant is the driver and the others say things that make to make the person: anxious, sad, guilty, shameful, or feel good)

  • Bringing your thoughts for a walk (in pairs)

  • The polygraph (if anxious = get shocked… what will happen?)

  • Do not think of a pink elephant…

Study 1 cont d1


Study 1 (cont’d)

  • Participants couldonlybereferred by a psychiatrist (ethic’sboarddemand), if between 18-35 and at the First EpisodeClinic (lessthan 2 yearswithpsychoticsymptoms)

  • Over the course of 1 year, only 6 participants werereferred, of which 4 accepted and completed the intervention (X=30, 1 woman).

  • Reasons:

    • psychiatrists in the clinicwere not open to new psychological interventions, evenafterpresentations.

    • The intervention wasoffered by nurses… (perhaps more referrals if psychiatryresidentswereinvolved)

Study 1 cont d2
Study 1 (cont’d)



Overall the intervention was appreciated.

Participants enjoyed:

the group setting, learning relaxation strategies and socializing-sharing.

The small sample size did not allow to obtain statistical differences pre-post on any of the symptom measures, but on psychosocial constructs, there was a trend towards better social functioning and better self-esteem.

Concret thinking made metaphorsdifficult to understand.

Toomany concepts/activities per session.

Sessions lasted 2 hours (too long?)

Talk of suffering… toodifficult in too few sessions for participants to beatease (and attend each session).

Referral system inadequate.

Study 2
Study 2

  • Conducted by Bassam El-Khoury, under the supervision of Tania Lecomte.

  • Goal:

    • To ‘fix’ the problems found in the previous group approach by offering more sessions (8 sessions), adapting the content for individuals with cognitive deficits (limit metaphors, no more than one or two activities per session), positive concepts introduced first, and limit concepts to:

      • Compassion

      • Acceptance

      • Mindfulness

    • Also, the participants will be assessed at 3 months follow-up.

Study 21
Study 2

  • Each participant gets their own workbook, in which they can write their answers prior to sharing them.

  • The workbook is divided in two section:

    • Values

    • How to deal with difficulties in order to live our values

  • Each session ends with a mindfulness

    or meditation exercise (e.g.:

    mindfully eating an apple, breathing,

    visualizing a safe place, meditation with

    focus on compassion…)

Study 2 cont d


Study 2 (cont’d)

  • Participants are referred by members of the clinical staff to senior clinician (psychologist), if between 18-35 and at the First EpisodeClinic (lessthan 2 yearswithpsychoticsymptoms)

  • The pilot studywillinvolve 10 individuals in the intervention and 10 matched-controlsreceiving TAU. Qualitative and quantitative information isgathered on:

    • Emotionalregulation

    • Social functioning

    • Insight

    • Psychologicaldistress

    • Medicationadherence

    • Mindfulness

    • Symptoms (BPRS)

    • Theirexperience of the treatment

Study 2 cont d1

Preliminary results

Study 2 (cont’d)

  • So far only one group has been conducted.

  • 6 participants referred – 4 completed the intervention (one stopped after one session, the other too ill was rehospitalized)

  • Quantitatively:

    • Too soon to tell (small N) but Wilcoxon rank test suggest that 3/4 had fewer overall symptoms at post-therapy, higher scores on mindfulness (Freiburg), on overall emotional regulation.

    • N.B. : the fourth person had a comorbid cluster B axis II disorder and disliked the female therapist (who was more structuring).

Study 2 cont d2

Preliminary results

Study 2 (cont’d)

  • Qualitatively:

    • 3 out of 4 reallyenjoyed the intervention

    • Whattheyliked the most: distancingthemselves, meditation, hearingothers’ optinions and tips

    • Whattheydidn’tlike: nothing (2), having to break down situations (1), one of the therapists (1)

    • Whattheylearned: the importance to live in the moment; self-esteem and compassion; how to relax; how to eat more slowly.

    • Whatchanged for them: thinktwicebefore acting and more patient; more self-confidence, know my values; not sure; eatbetter, take time to eat.

    • N.B. 2/4 mentionedmeditatingeverydaysince the group ended


  • Individualswithearlypsychosisneedspecific adaptations in order to trulybenefitfrom ACT and mindfulnesstherapies in a group format.

  • Study 1 demonstrated the difficultiesthatcouldbeencountered (few references, comprehensiondifficulties, more sessions needed, etc) whereasStudy 2 (stillunderway) gives us more hope in the potentialfeasibility and impact of the approach (though one personapparentlydid not benefit as much).

  • Studieslookingintothirdwave cognitive therapies for individualswithearlypsychosisshouldmeasure and takeintoaccount cognitive deficits as well as Axis II disorders, sincethesemight influence the results.

  • To becontinued…

Thank you
Thank you!

Tania Lecomte, Ph.D.

Professeure Agrégée, chercheure au CRFS

Département de Psychologie

Université de Montréal,

Bur C-358, 90 rue Vincent d’Indy,

C.P. 6128, Succ. Centre-Ville,

Montréal, QC, H3C 3J7

Tel: 514-343-6274

Fax: 514-343-2285

Email: [email protected]