Psychosocial treatments for psychosis and schizophrenia have evolved over the past 20 years to target cognitive biases associated with psychotic disorders. For many individuals, psychotic symptoms can be modified through specific cognitive and behaviour strategies. Recent research is suggesting that individuals with schizophrenia present high levels of emotional deregulation on the experiential, processing and expressive levels that could exacerbate their distress and their social impairments. Emotional distress seems to be at its highest level at the onset of the illness and at the first psychotic episode due to the adaptation to the illness and to social stigma.[2-4]
In a previous paper, we discussed the role of emotional experience in the aetiology and the development of the illness and we argued for the priority of integrating emotion regulation strategies in cognitive behaviour therapy for psychosis (CBTp). More specifically, emotional regulation strategies can help individuals experiencing psychotic symptoms for the first time to better manage their reactions following a psychotic episode. Among the emotional regulation strategies for individuals with psychosis are reappraisal, exposure, detachment, metacognition, acceptance, compassion and mindfulness. Some of these strategies, namely exposure, reappraisal and metacognition, have been used in CBTp, and have been demonstrated to be effective and valuable treatment strategies for positive and negative symptoms, as well as for anxiety and depression.[6-8] More recently applied strategies such as acceptance, detachment, compassion and mindfulness, often identified as part of what is known as the third wave of cognitive behaviour therapies, are now being considered as useful adjuncts to CBTp.
In a recent meta-analysis including 14 trials and enrolling a total of 468 participants, we investigated the feasibility and effectiveness of third-wave cognitive-behavioural interventions for individuals with psychosis. Results suggest that the effects on combined clinical outcomes were between small and moderate, were maintained at follow up and were higher for negative symptoms compared with positive ones. Third-wave strategies such as compassion, acceptance and mindfulness were strong moderators of the treatment's effectiveness. In addition, the practice of meditation did not present adverse effects on psychotic symptoms, and was well accepted and tolerated by participants. In fact, participants showed higher levels of mindfulness following the treatment and at follow up. In addition, two recent systematic reviews found that meditation and mindfulness techniques are useful adjuncts to usual care for psychotic disorders in reducing distress, hospitalization rates and increasing feelings of self-efficacy.[10, 11]
To date, a few studies have tested these treatment strategies in early psychosis, which is a period of intense distress, stigma and social isolation.[2, 4, 12, 13] Learning emotion regulation strategies might prove useful in diminishing distress associated with psychotic experience. As such, we developed an eight-session group-based treatment for individuals with early psychosis using third-wave strategies, namely compassion, acceptance, and mindfulness (we called it CAM).
The purpose of this pilot study was to determine the treatment's acceptability for participants, its feasibility and potential clinical utility for individuals with early psychosis. We hypothesized that CAM would be: (i) feasible and favourably received; and associated with improvements in (ii) emotional self-regulation; (iii) symptoms, particularly affective ones; (iv) insight; (v) distress; and (vi) maintained at 3-month follow up.
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Overall results support the feasibility of the new developed treatment, supporting our first hypothesis. The majority of the participants found the treatment positive and helpful. The aim of the treatment is to help individuals in early psychosis to regulate negative emotions associated with the illness and accompanying stigma. The treatment focused on mindfulness, acceptance and compassion as strategies to regulate negative emotions. Qualitative results indicate that the majority of participants were able to learn and integrate these strategies, especially mindfulness. We used a group format as it is recommended for individuals with early psychosis to increase peer-to-peer interactions, feelings of normalcy and modelling. Most of the participants expressed an interest in the group format and some of them complained about the lack of attendance of some participants.
As expected, participants reported large improvements in regulating negative emotions (specifically self-blaming, rumination and catastrophizing), and moderate to large improvements on affective symptoms (specifically depression, anxiety and somatic concerns). Results showed also a large improvement on self-care, which could be related to an increase in self-awareness. These results support our second and third hypotheses, and are consistent with the theoretical background of this study regarding the role of emotional self-regulation in treating psychosis. Results from previous studies that integrated third-wave interventions for psychosis suggested small to moderate effects on psychotic symptoms, a finding that was not supported in our study. Plausible reasons for the absence of such effects are the small number of participants and the low baseline levels of positive symptoms (M = 9.92, SD = 5.32) and negative symptoms (M = 6.83, SD = 2.08) among participants.
Most of the results were stronger at 3-month follow up than immediately following the 8-week CAM sessions, suggesting that the treatment might be more beneficial in the long run, as suggested by many CBT studies. More longitudinal results will be needed to reach conclusive results.
Participants did not show statistically significant improvements on the mindfulness measure, although an improvement at follow up was observed and mindfulness was mentioned qualitatively by most. Long-term improvements on mindfulness were also observed elsewhere. An explanation of the absence of measured improvements in mindfulness could be linked to the scale itself, as the FMI is designed to detect improvements among skilled meditators whereas the participants here had no previous experience in meditation. In addition, many of the strategies taught in the treatment pertained to general aspects of mindfulness (e.g. eating mindfully, loving-kindness/compassionate meditation) rather than direct mindfulness meditation practice. Furthermore, we did not measure the daily mindfulness practice of participants. In fact, some anecdotally mentioned weekly meditation practice whereas others appeared to have more difficulties grasping the idea of mindfulness, qualifying the group exercises as learning to ‘eat more slowly’ or ‘relaxation’. It is recommended that future studies measure the daily mindfulness practice of participants and perhaps use a more comprehensive measure of mindfulness (e.g. Mindfulness and Awareness Scale or Five-Facet Mindfulness Questionnaire).
Regarding the lack of improvements in social functioning, insight and distress, the former two were not directly addressed in the brief CAM treatment, whereas the latter might need further investigation, perhaps considering using another measure of distress.
The current study has several limitations. First, the uncontrolled study design precludes any causal inferences about the efficacy of the tested treatment (i.e. perhaps everyone in the first-episode program improved similarly, or the improvements here were linked to other mechanisms than the treatment, such as social interaction within a group setting or the regular follow up at the clinic). The study did not include measures of compassion or acceptance, or concrete behavioural measures of mindfulness practice which are essential components of the treatment. Finally, we did not record the reasons for irregular attendance among some participants.
In conclusion, the CAM group protocol for emotional regulation appears acceptable and feasible, and shows promise in terms of potential clinical treatment for early psychosis. Further studies are warranted in order to determine its efficacy in improving acceptance, compassion, and mindfulness practice, and in diminishing distress and symptoms.