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The Active Therapeutic Processes of Acceptance and Commitment Therapy for Persistent Symptoms of Psychosis: Clients’ Perspectives

  • Tory Bacon (a1), John Farhall (a1) and Ellie Fossey (a1)


Background: There is limited research on the applicability and effectiveness of Acceptance and Commitment Therapy (ACT) for people experiencing psychotic disorders. Clinical trials suggest ACT may be efficacious in reducing distress and rehospitalization rates in psychosis. Mindfulness and reduced literal believability of thought content have been associated with reduced distress for this population. Aims: To better understand ACT for psychosis, this study investigated clients’ perspectives of the hypothesized active therapeutic processes of ACT. Method: Semi‑structured interviews, conducted with nine adults diagnosed with schizophrenia or schizoaffective disorder and persistent positive symptoms, were analysed thematically. Results: Four themes emerged: Usefulness of therapy; Changes attributed to ACT; Understanding of therapy; and Non-specific therapy factors. All participants found therapy useful and recommended ACT. Mindfulness, defusion, acceptance and values work were described as the most useful therapy components and contributing to positive changes. Self-rated frequency of symptoms did not change; however a reduction in the intensity and distress associated with symptoms was reported. Non-specific therapy factors were deemed useful by participants but not directly related to outcome. Conclusions: These findings are consistent with the theoretically defined underlying active processes of ACT and are relevant for this population. The findings also indicate important clinical implications for ACT for this client group: greater attention to the client connecting metaphors and concepts to the intended meaning may be valuable; caution should be used with some mindfulness and defusion techniques for intense experiences; and values work may be particularly useful for this population.


Corresponding author

Reprint requests to John Farhall, School of Psychological Science, La Trobe University, Bundoora, Victoria 3083, Australia. E-mail:


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Abba, N., Chadwick, P. and Stevenson, C. (2008). Responding mindfully to distressing psychosis: a grounded theory analysis. Psychotherapy Research, 18, 7787. doi: 10.1080/10503300701367992
Alain, C., Hargrave, R. and Woods, D. L. (1998). Processing of auditory stimuli during visual attention in patients with schizophrenia. Biological Psychiatry, 44, 11511159.
Allen, M., Bromley, A., Kuyken, W. and Sonnenberg, S. J. (2009). Participants’ experiences of mindfulness-based cognitive therapy. Behavioural and Cognitive Psychotherapy, 37, 413430. doi: 10.10117/S135246580999004X
Andresen, R., Oades, L. and Caputi, P. (2003). The experience of recovery from schizophrenia: towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry 37, 586594.
Bach, P. and 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, 11291139. doi: 10.1037//0022–006X.70.5.1129
Bach, P., Gaudiano, B. A., Hayes, S. C. and Herbert, J. D. (2012). Acceptance and Commitment Therapy for psychosis: intent to treat hospitalization outcome and mediation by believability. Psychosis, Social and Integrative Approaches, iFirst Article. doi:10.1080/17522439.2012.671349
Bellack, A. S. (2006). Scientific and consumer models of recovery in schizophrenia: concordance, contrast and implications. Schizophrenia Bulletin, 32, 432442. doi: 10.1093/schbul/sbj044
Bendall, S., Killackey, E., Jackson, H. J. and Gleeson, J. (2003). Befriending Manual. Melbourne: ORYGEN Research Centre, University of Melbourne.
Block, J. A. and Wulfert, E. (2000). Acceptance or change: treating socially anxious college students with ACT or CBGT. The Behavior Analyst Today, 1, 155.
Bloy, S., Oliver, J. E. and Morris, E. (2011). Using acceptance and commitment therapy with people with psychosis: a case study. Clinical Case Studies published online 1 December 2011. doi: 10.1177/1534650111420863. url:
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. C., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire – II: a revised measure of psychological flexibility and acceptance. Behavior Therapy, 42, 138.
Braun, V. and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77101.
Chadwick, P., Hughes, S., Russell, D., Russell, I. and Dagnan, D. (2009). Mindfulness groups for distressing voices and paranoia: a replication and randomized feasibility trial. Behavioural and Cognitive Psychotherapy, 37, 403412. doi:10.1017/S1352465809990166
Dahl, J., Wilson, K. G. and Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: a preliminary randomized trial. Behavior Therapy, 35, 785802.
Department of Health (2007). Framework for Recovery-orientated Practice. Melbourne: Victorian Government, Australia.
Dilks, S., Tasker, F. and Wren, B. (2008). Building bridges to observational perspectives: a grounded theory of therapy processes in psychosis. Psychology and Psychotherapy: Theory, Research and Practice, 81, 209229. doi: 10.1348/147608308X288780
Elliott, R. (2010). Psychotherapy change process research: realizing the promise. Psychotherapy Research, 20, 123135. doi: 10.1080/10503300903470743
Emmelkamp, P. M. G. (2004). Behavior therapy in adults. In Lambert, M. (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behaviour Change (5th ed.) (pp. 393446). New York: Wiley & Sons.
Farhall, J., Shawyer, F. and Thomas, N. (2010). Premature Excitement or Promising Direction? The application of Acceptance and Commitment Therapy to persisting psychotic symptoms. Proceedings of the 19th Annual Mental Health Services Conference of Australia and New Zealand, Perth, 2009. The MHS Conference Inc. Sydney Australia.
Farhall, J., Shawyer, F., Thomas, N. and Morris, E. (in press). Clinical assessment. In Johns, L., Morris, E. and Oliver, J. (Eds.), ACT and Mindfulness for Psychosis. London: Wiley.
Fletcher, L. and Hayes, S. C. (2005). Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23, 315336. doi: 10.1007/s10942-005-0017-7
Forbes, N. F., Carrick, L. A., McIntosh, A. M. and Lawrie, S. M. (2009). Working memory in schizophrenia: a meta-analysis. Psychological Medicine, 39, 889905.
Garety, P. A., Fowler, D. and Kuipers, E. (2000). Cognitive-behavioural therapy for medication-resistant symptoms. Schizophrenia Bulletin, 26, 7376.
Gaudiano, B. A. (2009). Öst's (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behaviour therapy: matching apples and oranges? Behaviour Research and therapy, 47, 10661070. doi: 10.1016/j.brat.2009.07.2010
Gaudiano, B. A. and Herbert, J. D. (2006a). Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. Behaviour Research and Therapy, 44, 415437. doi: 10.1016/j.brat.2005.02.007
Gaudiano, B. A. and Herbert, J. D. (2006b). Believability of hallucinations as a potential mediator of their frequency and associated distress in psychotic symptoms. Behavioural and Cognitive Psychotherapy, 34, 497502. doi: 10.1017/S1352465806003080
Gaudiano, B. A., Herbert, J. D. and Hayes, S. C. (2010). Is it the symptom or the relation to it? Investigating potential mediators of change in acceptance and commitment therapy for psychosis, Behavior Therapy, 41, 543554.
Gregg, J. A., Callaghan, G. M., Glenn, M., Hayes, S. C. and Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 75, 336343. doi: 10.1037/0022-006X.75.2.336
Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapy. Behavior Therapy, 35, 639665.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. and Lillis, J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behaviour Research and Therapy, 44, 125. doi: 10.1016/j.brat.2005.06.006
Hayes, S. C., Masuda, A. and De Mey, H. (2003). Acceptance and commitment therapy and the third wave of behavior therapy. Dutch Journal of Behavior Therapy, 2, 6996.
Hayes, S. A., Orsillo, S. M. and Roemer, L. (2009). Changes in proposed mechanisms of action during an acceptance-based behaviour therapy for generalized anxiety disorder. Behaviour Research and Therapy. doi: 10.1016/j.brat.2009.11.006
Hayes, S. C., Strosahl, K. D. and Wilson, K. G. (1999). Acceptance and Commitment Therapy: an experiential approach to behavioral change. New York: Guilford Press.
Hayes, S. C., Strosahl, K. D. and Wilson, K. G. (2012). Acceptance and Commitment therapy: the process and practice of mindful change (2nd ed.). New York: Guilford Press.
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., et al. (2004). Measuring experiential avoidance: a preliminary test of a working model. The Psychological Record, 54, 553578
Hayes, S. C., Villatte, M., Levin, M. and Hildebrandt, M. (2011). Open, aware and active: contextual approaches as an emerging trend in the behavioural and cognitive therapies. Annual Review of Clinical Psychology, 7, 141168. doi:10.1146/annurev-clinpsy-032210-104449
Hesser, H., Westin, V., Hayes, S. C. and Andersson, G. (2009). Clients’ in-session acceptance and cognitive defusion behaviours in acceptance-based treatment of tinnitus distress. Behaviour Research and Therapy, 47, 523528. doi: 10.1016/j.brat.2009.02.002
Hill, C. E. and Lambert, M. J. (2004). Methodological issues in studying psychotherapy processes and outcomes. In Lambert, M. (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (5th ed.) (pp. 84133). New York: John Wiley and Sons.
King, N. and Horrocks, C. (2010). Interviews in Qualitative Research. London: Sage Publications.
Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B. and Dixon, L. B. (2010). The schizophrenia patient outcomes research team (PORT): updated treatment recommendations 2009. Schizophrenia Bulletin, 36, 94103. doi: 10.1093/schbul/sbp130
Lundgren, T., Dahl, J. and Hayes, S. C. (2008). Evaluation of mediators of change in the treatment of epilepsy with acceptance and commitment therapy. Journal of Behavior Medicine, 31, 225235. doi:10.1007/s10865-008-9151-x
McCracken, L. M. and Gutérrez-Martínez, O. (2011). Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on acceptance and commitment therapy. Behaviour Research and Therapy, 49, 267274. doi:10.1016/j.brat.2011.02.004
McGowan, J. F., Lavender, T. and Garety, P. (2005). Factors in outcome of cognitive-behavioural therapy for psychosis: users’ and clinicians’ views. Psychology and Psychotherapy: Theory and Practice, 78, 513529. doi:10.1348/147608305X52559
McLeod, H. J. (2008). ACT and CBT for psychosis: comparisons and contrasts. In Blackledge, J. T., Ciarrochi, J. and Deane, F. (2009) (Eds.), Acceptance and Commitment Therapy: contemporary theory, research and practice. Bowen Hills: Australian Academic Press.
Messari, S. and Hallam, , , R. (2003). CBT for psychosis: a qualitative analysis of clients’ experiences. British Journal of Clinical Psychology, 42, 171188.
Milton, I. and Ma, H. (2011). Mindful paths to well-being and happiness: five programs compared. Psychotherapy Australia, 17, 6469.
National Institute for Clinical Excellence (2010). Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. London: NICE.
Öst, L. (2008). Efficacy of the third wave behavioral therapies: a systematic review and meta-analysis. Behavior Research and Therapy, 46, 296321. doi: 10.1016/j.brat.2007.12.005
Pankey, J. and Hayes, S. C. (2003). Acceptance and commitment therapy for psychosis. International Journal of Psychology and Psychological Therapy, 3, 311328.
Pitt, L., Kilbride, M., Nothard, S., Welford, M. and Morrison, A. (2007). Researching recovery from psychosis: a user-led project. Psychiatric Bulletin, 31, 5560. doi: 10.1192/ 105.008532
Powers, M. B., Zum Vörde Sive Vörding, M. B. and Emmelkamp, P. M. G. (2009). Acceptance and commitment therapy: a meta-analytic review. Psychotherapy and Psychosomatics, 78, 7380. doi: 10.1159/000190790
Ramon, S., Healy, B. and Renouf, N. (2007). Recovery from mental illness as an emergent concept and practice in Australia and the UK. International Journal of Social Psychiatry, 53, 108122. doi: 10.1177/0020764006075018
Shawyer, F., Farhall, J., Mackinnon, A., Trauer, T., Sims, E., Ratcliff, K., et al. (2012). A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders. Behaviour Research and Therapy, 50, 110121. doi: 10.1016/j.brat.2011.11.007
Tandon, R., Nasrallah, H. A. and Keshavan, M. S. (2009). Schizophrenia, “just the facts” 4: clinical features and conceptualization. Schizophrenia Research, 110, 123. doi: 10.1016/j.schres.2009.03.005
Tarrier, N., Kinney, C., McCarthy, E., Humphreys, L., Wittkowski, A. and Morris, J. (2000). Two year follow-up of cognitive-behaviour therapy and supportive counselling in the treatment of persistent positive symptoms in chronic schizophrenia. Journal of Consulting and Clinical Psychology, 68, 917922.
Thomas, , , N., Morris, E., Shawyer, F. and Farhall, J. (in press). Acceptance and commitment therapy for voices. In Johns, L., Morris, E. and Oliver, J. (Eds.), ACT and Mindfulness for Psychosis. London: Wiley.
Veiga-Martínez, C., Pérez-Álvarez, J. and García-Montes, M. (2008). Acceptance and commitment therapy applied to treatment of auditory hallucinations. Clinical Case Studies, 7, 118135. doi:101.1177/153465107306291
Vowles, K. E., McCracken, L. M., and Eccleston, C. (2008). Patient functioning and catastrophizing in chronic pain: the mediating effects of acceptance. Health Psychology, 27, S136143.
Vowles, K. E., McCracken, L. M. and Zhao-O'Brien, J. (2010). Acceptance and values-based action in chronic pain: an analysis of treatment outcomes and processes three years after treatment completion. The Journal of Pain, 11, S55.
White, R., Gumley, A., McTaggart, J., Rattrie, L., McConville, D., Cleare, S., et al. (2011). A feasibility study of acceptance and commitment therapy for emotional dysfunction following psychosis. Behaviour Research and Therapy, 49, 901907.
Weickert, T. W., Goldberg, T. E., Gold, J. M., Llewellen, B. B., Egan, M. F. and Weinberger, D. R. (2000). Cognitive impairments in patients with schizophrenia displaying preserved and compromised intellect. Archives of General Psychiatry, 57, 907913.
Wykes, T., Steel, C., Everitt, B. and Tarrier, N. (2008). Cognitive-behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523537. doi:10.1093/schbul/sbm114
Zettle, R. D. and Hayes, S. C. (1986). Dysfunctional control by client verbal behaviour: the context of reason-giving. The Analysis of Verbal Behavior, 4, 3038.
Zettle, R. D. and Raines, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438445.
Zettle, R. D., Rains, J. C. and Hayes, S. C. (2011). Process of change in acceptance and commitment therapy and cognitive therapy for depression: a mediation reanalysis of Zettle and Rains. Behaviour Modification, 35, 265283. doi: 10.1177/0145445511398344


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The Active Therapeutic Processes of Acceptance and Commitment Therapy for Persistent Symptoms of Psychosis: Clients’ Perspectives

  • Tory Bacon (a1), John Farhall (a1) and Ellie Fossey (a1)


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The Active Therapeutic Processes of Acceptance and Commitment Therapy for Persistent Symptoms of Psychosis: Clients’ Perspectives

  • Tory Bacon (a1), John Farhall (a1) and Ellie Fossey (a1)
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