Acceptance and commitment therapy applied to early psychosis: Therapeutic foundations and a narrative systematic review

Table 1 Essential components of the therapeutic process of acceptance and commitment therapy for psychosis

Therapeutic elements	Main goals
Create a state of creative hopelessness	The goal is for patients to pay attention to their strategies for solving their problems and how these strategies ultimately failed
Raise the possibility that “the problem is control”	The patients should now understand that certain aspects of their experience (emotions, thoughts, memories) cannot be controlled. The use of central metaphors is recommended
Create a distance from the language (defusion)	Starting to doubt aspects other than hallucinations or delusions is one way to get patients to distance themselves from their experiences
Help create a transcendent sense of self (“self as context”)	Focus intervention on enhancing “self as context.” ACT techniques focus primarily on strengthening the sense of “self as context” instead of “self as content”
To clarify and strengthen the patient’s values	Look for conditions in which a person with psychosis can pursue these values despite their circumstances (e.g., symptoms). Materialize these values in actions aimed at achieving them
Develop willpower	The will presupposes a hierarchical organization of ends and places the person in front of the troubled and, therefore, the inevitably tragic character of existence. Therapy is placed in the context of the person's life, and relapses are included as an additional aspect

ACT: Acceptance and commitment therapy.

Table 2 Participants, interventions, comparators, outcomes, study design

Category	Description
P: Participants	People with psychotic disorders in their early stages. People with subthreshold psychotic symptoms
I: Intervention	Acceptance and commitment therapy or acceptance-based therapy for psychosis
C: Comparison	Comparison with other types of therapeutic intervention, TAU, or control groups
O: Outcomes	Changes in positive, negative, general, and mood symptoms; changes in psychosocial functionality; treatment adherence; feasibility; acceptability; rehospitalizations; improvement in coping with symptoms; changes in psychological flexibility
S: Study design	Randomized controlled trials, open trials, preliminary studies, or quasi-experimental studies. Secondary analysis from RCTs

TAU: Treatment as usual; RCT: Randomized controlled trial.

Table 3 Summary of reviewed studies on acceptance and commitment therapy in early psychosis

Ref.	Des.	Participants/samples	Population	Intervention	Conclusions	Results
Vaessen et al[65]	No RCT	n = 16. No control group	People with ultra-high risk (clinically established) or first-episode psychosis	ACT in Daily Life (ACT-DL): A new mobile health treatment protocol for people with early psychosis. The protocol was designed to facilitate the translation of therapeutic techniques learned during in-person ACT sessions into the patient’s daily life	ACT-DL may aid individuals in integrating skills they learn during therapy sessions into their everyday lives. ACT-DL may help early psychosis patients by applying ACT skills to different contexts of everyday life. Adherence to the protocol was relatively demanding	Participants evaluated the overall training (M = 5.63 ± 1.17), the ACT therapy sessions (M = 5.63 ± 1.36), and home exercises (M = 4.81 ± 1.63) as useful. Moreover, participants evaluated the app as useful (M = 4.56 ± 1.69) and reported that it helped them apply the exercises in daily life (M = 4.75 ± 1.71) and made them more aware of their feelings (M = 5.25 ± 1.56)
Van Aubel et al[66]	RCT	Total n = 55. ACT-DL (n = 27). Active control (n = 28)	Young people (16 to 25) with subthreshold depressive and/or psychotic symptoms	ACT-DL through an app	Depressive symptoms decreased more in ACT-DL than in active control. Self-reported symptoms decreased equally in ACT-DL and active control. ACT-DL did not modify PF	Depression scores (rated by the interviewer) decreased among participants in the ACT-DL group compared with controls (P = 0.027)
Myin-Germeys et al[67]	RCT	Total n = 148 ACT-DL + TAU (n = 71) TAU (n = 77)	People with ultra-high risk (clinically established) or first-episode psychosis	Multicenter INTERACT RCT. ACT-DL combines face-to-face therapy with an ecological momentary intervention (EMI)	The study did not support a significant effect of ACT-DL compared to TAU on primary outcomes However, global functioning and psychotic distress were improved in the ACT-DL group	Results showed that Global functioning (χ2 = 9.05; P = 0.033) and negative symptoms (χ2 = 19.91; P < 0.001) improved in ACT-DL compared to TAU, as did psychotic distress (χ2 = 21.56; P < 0.001) measured as EMI
van Aubel et al[68]	No RCT	n = 71. No control group	People with ultra-high risk (clinically established) or FEP	No intervention. Data on treatment engagement with and acceptability of ACT-DL during and after the intervention of ACT-DL. This study is a secondary analysis of the INTERACT trial	The study showed good treatment engagement with and acceptability of ACT-DL in early psychosis. Participants attended an encouraging number of face-to-face sessions and weekly interactions. Results suggested an effective real-world application of ACT techniques. Moreover, ACT-DL improved emotional awareness	The results demonstrated high levels of commitment and participation among the participants, with the majority (n = 42) completing all sessions. In addition, 86% to 96% of subjects rated the sessions and exercises as useful
Chien et al[69]	RCT	Total n = 126. AIM-AT (n = 42) Psychoeducation (n = 42) TAU (n = 42)	Outpatients with psychosis ≤ 3 years’ duration	Acceptance-based intervention plus motivational interviewing to improve medication adherence for people with early psychosis (AIM-AT)	Compared to the other two groups, participants in the AIM-AT experienced significant improvements in primary outcomes (medication adherence and knowledge of the disease). The AIM-AT group was also better in psychotic symptoms, psychosocial functioning, satisfaction with service, duration of hospitalization, and number of patients hospitalized during the follow-up	Compared with psychoeducation and/or TAU, the AIM-AT group had more significant improvements, with moderate to large effect sizes (η2 = 0.07–0.18). Adherence: η2 = 0.18. Insight: η2 = 0.10. Psychotic symptoms (PANSS): η2 = 0.12. Functioning (SLOF): η2 = 0.09. Length of hospitalization: η2 = 0.09
Özer and Dişsiz[7]	RCT	Total n = 53. ACT (n = 26) TAU (n = 27)	People with schizophrenia and other psychotic disorders with less than 3 years of duration	8-session ACT program as an online group therapy	Online group ACT applied to individuals with early psychosis was found to reduce psychotic symptoms and increase their levels of functioning. Hospitalizations were also found to be lower in the intervention group	Differences in post-test and follow-up on symptoms (total PANSS): χ2 = 42.66; P = 0.000. Effect size in between-group differences: Positive symptoms (W = 0.80); Negative symptoms (W = 0.65); General symptoms (W = 0.86). Differences in social functioning: χ2 = 42.67; P = 0.000. Effect size: W = 0.821
Li et al[54]	No RCT	n = 148. No control group	Individuals were at high clinical risk for psychosis or with first-episode psychosis	Data obtained from the INTERACT study baseline assessment, during which all participants completed 6 days of experience sampling assessment of momentary negative affect and assessments of emotion regulation strategy use	The study demonstrated that greater emotion regulation (ER) flexibility predicts more stable negative emotions and faster affective recovery. Findings further provide evidence for ER flexibility in early psychosis, emphasizing the adaptive nature of regulatory flexibility to reduced instability in negative affect (NA) and faster recovery from NA in everyday life	At the intrapersonal level, results show significant associations between lower NA instability and higher ER flexibility (P = 0.049). However, the opposite pattern is observed at the interpersonal level: Higher NA instability is associated with greater ER flexibility (P < 0.001)
Chong et al[70]	RCT	Total n = 72. ACT-LCP (n = 36). Active control (n = 37)	Early psychosis patients	Five-week group program focusing on ACT-based motivation for healthy lifestyles: ACT-based Lifestyle Counselling Program (ACT-LCP)	The ACT-LCP was feasible and acceptable, demonstrating initial efficacy in individuals with early psychosis. Improvements were observed in PF, autonomous motivation, psychotic symptoms, and quality of life at 12 weeks post-intervention	Significant improvements in ACT-LCP participants compared to controls at the 12-month follow-up in terms of physical activity (P < 0.001), autonomous motivation (aMD = 4.74; P < 0.001), psychological inflexibility (aMD = -7.69; P < 0.001), mental state (aMD = -6.83; P < 0.001), and quality of life (aMD = 0.46; P = 0.006)

The table includes only the measures that show a significant effect. SMD: Equivalent to Cohen's d; W: Kendall’s W; η²: Eta squared (effect size); M: mean ± SD; aMD: Adjusted mean difference; ACT: Acceptance and commitment therapy; TAU: Treatment as usual; RCT: Randomized controlled trial; FEP: First-episode psychosis; PANSS: Positive and negative syndrome scale; SLOF: Specific level of functioning scale.

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Table 4 Methodological quality appraisal of the randomized controlled trials

Domain/question	van Aubel et al[66]	Myin-Germeys et al[67]	Chien et al[69]	Özer and Dişsiz[7]	Chong et al[70]
Internal validity. Bias related to:
Selection and allocation
1. Was true randomization used for assignment of participants to treatment groups?	Y	Y	Y	Y	Y
2. Was allocation to treatment groups concealed?	U	Y	Y	Y	Y
3. Were treatment groups similar at the baseline?	Y	U	Y	Y	Y
Administration of intervention/exposure
4. Were participants blind to treatment assignment?	N	N	N	N	N
5. Were those delivering treatment blind to treatment assignment?	Y	Y	U	U	N
6. Were outcomes assessors blind to treatment assignment?	Y	Y	Y	N	U
Assessment, detection, and measurement of the outcome
7. Were treatment groups treated identically other than the intervention of interest?	Y	Y	Y	U	Y
8. Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?	Y	Y	Y	Y	Y
9. Were participants analyzed in the groups to which they were randomized?	Y	Y	Y	Y	Y
Participant retention
10. Were outcomes measured in the same way for treatment groups?	Y	Y	Y	Y	Y
Statistical conclusion validity
11. Were outcomes measured in a reliable way?	Y	Y	Y	Y	Y
12. Was appropriate statistical analysis used?	Y	Y	Y	Y	Y
13. Was the trial design appropriate, and any deviations from the standard RCT design accounted for in the conduct and analysis of the trial?	Y	Y	Y	Y	Y
Score	8	8	8	6	7

The classification follows the Joanna Briggs Institute checklist for methodological quality appraisal of randomized controlled trials[63]. Items 11 to 13 are not included in the overall score because they do not evaluate the internal validity. Y: Yes; U: Unclear; N: No.

Table 5 Description of the acceptance and commitment therapy in “Daily Life” key components

Module	Description
Creative hopelessness	Help patients understand that their previous attempts to solve their problems are failing and that they should consider other alternatives. The module contains two different ACT metaphors and four ACT exercises on “creative hopelessness.” The proposed exercises help patients to become more aware of their avoidant coping strategies
Acceptance	Acceptance is presented as an alternative to control and avoidance. Patients are provided with two ACT metaphors and seven ACT exercises focused on the “acceptance” component. These exercises are designed to help them put the theory into practice and experience their feelings and emotions without trying to change them
Cognitive defusion	Cognitive defusion is a chance to distance oneself from one's thoughts. Patients are guided through exercises focusing on observing and distancing from their thoughts. This week's mobile module includes two metaphors about the “cognitive defusion” component and 7 exercises for practicing cognitive defusion. Once patients can detach from their thoughts, they can transfer these strategies to thoughts about the self and let go of their self-image, which is the topic of the next module
Self as context	Distancing from unpleasant beliefs (learned during the cognitive defusion module) is generalized to include beliefs about the self. Once we understand that we are not what we think or feel, we can understand ourselves as observers of pleasant or unpleasant experiences. The self is resistant to change; on the contrary, its content can change. The daily life module for this week focuses on the “self as context” component and includes two metaphors and four “self as context” exercises (instead of “self as content”)
Contact with the present moment	This component helps patients focus less on the past and future and more on the “here and now.” Patients have practiced these skills throughout the other modules. The practice continues during the daily life module the week after this session, where two “contact with the present moment” metaphors remind patients to be aware of the present moment, and the same four exercises they have practiced during the session so far guide them in this process
Values	This module is designed to help people live a life guided by values rather than unpleasant experiences. During this session, patients are invited to think about their personal values, which serve as a guide in life and a pilot for their behavior. This module includes two metaphors from the “values” component. During the three days following the session, patients are supplied with 4 exercises to explore further which values are important to them. Exploring values is necessary to connect with the goal of the next module
Committed action	“Putting theory into practice” is a session dedicated to building meaningful, realistic, specific goals according to the personal values identified in the “values” session. The “committed action” daily life module includes two new metaphors and four new exercises to help patients set and achieve their objectives step by step
Psychological flexibility	The central theme of the last session is to understand how to apply ACT skills “in a flexible manner” to concrete situations, depending on the challenges of the present moment. Patients were given a module summarizing all previous components during this last week. The module contains one metaphor and one exercise related to each component (acceptance, cognitive defusion, values, and committed action)

ACT: Acceptance and commitment therapy.

Table 6 Description of the intervention protocol: Acceptance and commitment therapy-based intervention to improve medication adherence

Session/content	Session/content
Session 1: Commitment to the group program and understanding of psychosis, treatment, and care	Sessions 4-6: Goal review, mindfulness skill development, addressing medication ambivalence, and enhancing interpersonal and communication skills
Session 2: Introduction to ACT and beliefs about illness and medication	Sessions 7-9: Identifying obstacles to goal attainment, working on acceptance of unpleasant emotional experiences, and learning to break negative thought patterns
Session 3: Improved self-management of psychotic symptoms and negative thoughts, and medical history review	Session 10: Evaluation of changes and self-reflection, development of future plans and practices: “Maintaining effective coping strategies in high-risk life situations” and “behavioral rehearsal of relapse prevention”

AIM-AT: ACT-based intervention to improve medication adherence[69]. ACT: Acceptance and commitment therapy.

Table 7 Description of the intervention protocol: Acceptance and commitment therapy-based lifestyle counseling program

Session	Content
Session 1: Commitment, guidance, and psychoeducation in ACT	To provide an overview of ACT and establish goals for adopting healthy lifestyle habits
Session 2: Relationship between a healthy lifestyle and a sense of purpose	To guide participants in identifying their personal values and exploring how they can be aligned with healthy lifestyle choices
Session 3: Acceptance and shared humanity	Decrease fusion between self-criticism and self-concept and cultivate a personal perspective
Session 4: The inevitability of “that”	Implement strategies to manage negative cognitions associated with healthy behaviors
Session 5: Commitment to action	Develop behaviors related to a healthy lifestyle that align with personal values

ACT-LCP: ACT-based lifestyle counseling program[70]. “That” refers to the cognitions and feelings that usually hinder our attempts to engage with our desired healthy behaviors and other values. ACT: Acceptance and commitment therapy.