SEARCH

SEARCH BY CITATION

Keywords:

  • acceptance;
  • compassion;
  • early psychosis;
  • mindfulness;
  • schizophrenia

Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. References

Aim

Emerging evidence supports the priority of integrating emotion regulation strategies in cognitive behaviour therapy for early psychosis, which is a period of intense distress. Therefore, we developed a new treatment for emotional regulation combining third-wave strategies, namely compassion, acceptance, and mindfulness (CAM) for individuals with early psychosis. The purpose of this study was to examine the acceptability, feasibility and potential clinical utility of CAM.

Method

A non-randomized, non-controlled prospective follow-up study was conducted. Outpatients from the First Psychotic Episode Clinic in Montreal were offered CAM, which consisted of 8-week 60–75 min weekly group sessions. Measures of adherence to medication, symptoms, emotional regulation, distress, insight, social functioning and mindfulness were administered at baseline, post-treatment and at 3-month follow up. A short feedback interview was also conducted after the treatment.

Results

Of the 17 individuals who started CAM, 12 (70.6%) completed the therapy. Average class attendance was 77%. Post-treatment feedback indicated that participants found the intervention acceptable and helpful. Quantitative results suggest the intervention was feasible and associated with a large increase in emotional self-regulation, a decrease in psychological symptoms, especially anxiety, depression, and somatic concerns, and improvements in self-care.

Conclusion

Overall results support the acceptability, feasibility and potential clinical utility of the new developed treatment. A significant increase in emotional self-regulation and a decrease in affective symptoms were found. No significant changes were observed on measures of mindfulness, insight, distress and social functioning. Controlled research is warranted to validate the effectiveness of the new treatment.

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.[1] 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).[5] 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.[8]

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.[9] 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.

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. References

Participants

Twenty-seven individuals from the first psychotic episode clinic at the Louis-H Lafontaine Hospital in Montreal (Canada) were approached to participate in this study. Inclusion criteria consisted of: a first psychotic episode, currently followed by the first episode clinic, fluent in French, no known organic disorder or mental retardation and capacity to offer informed consent.

Among the approached participants, 17 agreed to participate and provided data at pretreatment, among them only 12 completed the treatment (i.e. attended four sessions or more) and provided data after the treatment, and 10 provided data at follow up (i.e. 3 months later). Average therapy attendance among the participants was 6.17 sessions (SD = 1.34) out of 8. Among the non-completers, three attended one session and two attended two sessions. Among the reasons of quitting the group, one refused to sign the consent form, one was too ill and realized he could not follow the sessions, one was asked by his case manager to leave the group as he was disturbing other participants (had a comorbid diagnosis of attention deficit/hyperactivity disorder), one started working full-time and could no longer attend the group, and one did not provide any reason for quitting. Only one of the non-completers accepted to provide data at post-treatment; however, the data were discarded as the participant was overly confused and psychotic at the time of the assessment. Demographics of the participants are presented in Table 1.

Table 1. Social demographic data of participants completing the CAM intervention (N = 12)
Measure 
  1. CAM, compassion, acceptance, and mindfulness; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Age, years (mean (SD))29.08 (8.13)
Sex (male/female)8/4
Years of education (mean (SD))10.83 (1.47)
DSM-IV diagnosis, n 
Paranoid schizophrenia6
Schizophrenia, not otherwise specified2
Psychosis, not otherwise specified4
Age of first visit to a psychiatrist (mean (SD))21.88 (6.00)
Age of first hospitalization (mean (SD))21.92 (5.92)
Number of psychiatric hospitalizations (mean (SD))3.00 (2.98)
Marital status, n 
Single, never married10
Married/remarried1
Divorced1
Country of birth, n 
Canada11
Haiti1
Race, n 
Occidental7
First nation/Inuit1
Asian1
African/Caribbean2
Others1
Work status (employed/unemployed)3/9
Did jail time (yes/no)4/8
Had therapy in the last 6 months (yes/no)5/7
Alcohol/drug use, n 
Alcohol only1
Drugs only1
Both1
None9

Instruments

All of the measures were taken at baseline, post-treatment and 3-month follow up, except for the social demographic measure taken only at baseline, and the brief feedback interview conducted at the end of treatment.

Social demographic questionnaire

This questionnaire is based on the Canadian version of the PSR Toolkit[14] and includes information regarding the age, number of hospitalizations, occupation, schooling level and the age at the first psychiatric consultation. Further questions regarding diagnosis, alcohol and drug consumption, medication, and previous treatments were added.

Medication adherence questionnaire

Medication adherence was assessed with a combination of the Medication Adherence Scale/Medication Compliance Scale,[15] which asks the participants if they have been taking their medications as directed, and if not what are their intentions regarding taking their medications. Three questions also pertain to the frequency of forgetting, missing or modifying the dose intentionally.

Brief Psychiatric Rating Scale – expanded

The Brief Psychiatric Rating Scale (BPRS) is a semi-structured interview assessing the presence and the severity of psychiatric symptoms on a 7-point Likert scale. The expanded version includes 24 items,[16] and can be divided among the following factors: positive symptoms, negative symptoms, anxiety-depression and manic-excitement.[17] A total score of the 24 items can also be calculated.

Social Functioning Scale[18]

The Social Functioning Scale (SFS) is widely used to assess many dimensions of social functioning, namely social engagement/withdrawal, interpersonal behaviours, pro-social activities, recreation and hobbies, skills of independent living (independence/competence), and employment/occupation.

Emotional self-regulation

In evaluating the emotional self-regulation of participants, we used the Cognitive Emotion Regulation Questionnaire.[19] This measure is a self-report questionnaire consisting of nine distinct subscales (with four items in each subscale) covering cognitive and emotional dimensions (focus on thought/rumination, catastrophizing, self-blame, blaming others, positive refocusing, refocus on planning, positive reappraisal, putting into perspective). In addition, the scale incorporates an acceptance dimension, and it has been used with clinical populations,[19, 20] but not yet with psychotic-related disorders.

Psychological distress

The Psychological Distress Manifestation Measure Scale[21] is a short self-report questionnaire with 23 manifestations grouped in four factorial dimensions: self-depreciation (seven items), irritability (five items), anxiety/depression (five items) and social disengagement (six items).

Freiburg Mindfulness Inventory (FMI)-short version

To measure the level of mindfulness, we used the FMI-short version.[22] The short version (14 items) is a self-report questionnaire that was developed and validated by Walach and colleagues.[23] The items can be grouped in four factors: attention to the present moment; non-judgmental, non-evaluative attitude towards self and others; openness to one's own negative and positive sensations, perceptions, mood states, emotions and thoughts; and process-oriented, insightful understanding of experience at a more general level than immediate experience. The FMI-short version showed good reliability and construct validity.

Cognitive insight

In evaluating the participants' ability to understand their symptoms and behaviours, we used the Beck Cognitive Insight Scale (BCIS).[24] The BCIS comprises 15 items where respondents are asked to rate how much they agree with each statement by using a 4-point scale that ranges from 0 (do not agree at all) to 3 (agree completely). This self-report instrument contains two scales. The first scale measures objectivity, reflection and openness to feedback, whereas the second addresses decision-making such as: jumping to conclusions, certainty about being right and resistance to correction. The BCIS shows good psychometric properties.

Feedback interview

In the feedback interview, participants were asked open-ended questions regarding what they mostly liked in the therapy, what they mostly disliked, what skills they learned, what skills they aim to implement in their lives, in which areas of their lives they perceive amelioration, if any, and whether they recommend this therapy to a friend and why.

Procedure

The study was approved by the Hospital and University's research and ethics boards. Interested participants were contacted by a research assistant, who explained to them the consent form. The understanding of the consent form was assessed via a short questionnaire consisting of 10 true/false items about different aspects of the project. A well-informed consent was determined by getting the right answers for the 10 items after no more than three trials. After signing the consent form, each participant was interviewed separately by a trained research assistant for the BPRS. Participants then completed the remaining questionnaires with the help of a research assistant. Three groups were conducted over the course of 12 months.

Treatment protocol (CAM)

The treatment included eight sessions, each of 60–75 min. Two therapists conducted the sessions. One of the therapists (i.e. first author) had mindfulness experience and both therapists had clinical training with the target population, and were supervised by an experienced clinician in the field (i.e. second author). Participants had access to their usual treatment at the clinic, which included medication, regular follow ups with the psychiatrist (biweekly), and case management by a social worker, occupational therapist or psychiatric nurse (weekly). No other psychological treatment (individual or group) was offered to the participants of this study during the treatment or follow-up periods. Other groups (e.g. cognitive behaviour therapy and cognitive remediation) are also available at the clinic. CAM was based on the integration of strategies for emotion regulation in early psychosis. Mindfulness was introduced gradually and practiced using concrete exercises at the beginning (e.g. mindful eating and breathing). Later on, mindfulness meditation practice was introduced but exercises lasted less than 15 min in order to decrease the risk of experiencing intense psychotic symptoms while meditating. We provided meditation mats for the mindfulness exercises. Acceptance, detachment and compassion skills were taught through concrete strategies, such as acceptance of thoughts and emotions, defusion from own thoughts, and building compassion towards self and others. We chose to not use abstract or theoretical material (e.g. metaphors) given the cognitive difficulties of many individuals with psychotic disorders. The treatment also included exercises on individual values and personal objectives. Other strategies of emotion regulation were also discussed (e.g. narrative writing and social support). A treatment manual was developed and each participant was provided a copy. The manual included materials for each session and practice exercises. A summary for each session is presented in Table 2.

Table 2. Highlights of the protocol sessions
Session 1Presenting to the group
Explaining the module
Introduction to mindfulness
Mindfulness exercise: eating an apple mindfully
Session 2Values: define your own values, differences between values and goals
Group discussion about values
Mindfulness exercise: calming and self-soothing breathing
Session 3What prevents me from advancing in the direction of my own values?
Group discussion
Mindfulness exercise: imagine yourself in a peaceful and safe place
Session 4Acceptance: what is it? Difference between acceptance and resignation
Detachment: being an external observer
What you do when faced with threatening feelings or thoughts
Group discussion
Mindfulness exercise: exposure via imagery to a difficult memory or thought while practicing calming and self-soothing breathing (from session 2)
Session 5Compassion: what is it?
The role of compassion in the acceptance of threatening thoughts and emotions
Group discussion about how to generate compassion towards oneself
Mindfulness exercise: compassion towards oneself using loving-kindness meditation
Session 6The role of compassion towards others in one's own well-being
Group discussion about how to generate compassion towards others
Mindfulness exercise: compassion towards others using loving-kindness meditation
Session 7Other ways to increase wellness: narrative writing and social support
Group discussion about ways to feel good in short term versus long term
Mindfulness exercise: half-smile
Session 8Revision of the module
The role of positive emotions such as hope and optimism in well-being
Feedback from participants
Mindfulness exercise: Vipassana meditation

Statistical analyses

Considering the modest sample size, the preliminary nature of this study, and the importance of balancing type I and type II error, unadjusted P-values are reported. Furthermore, approaching significance results (P < 0.10) are noted accordingly. Independent sample t-tests and Wilcoxon–Mann–Whitney tests were conducted to examine potential pretreatment differences between completers and non-completers of treatment. Preliminary analyses also investigated differences in medication adherence at different time points. Differences between the three therapy groups were explored using one-way analysis of variance (ANOVA). Primary analyses using paired t-tests aimed to explore the differences in clinical measures between baseline (pretreatment) and both post-treatment and 3-month follow up. Effect sizes were also reported accordingly. Qualitative data from the treatment feedback interview were reviewed for themes related to perceived benefits and challenges of CAM.

Results

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. References

Completers versus non-completers

Preliminary analyses were conducted to examine the comparability between completers and non-completers of the treatment. No significant differences were found between the two groups on sociodemographic data or on any other baseline measure, except for social functioning. Indeed, non-completers had lower social functioning, namely on the interpersonal behaviour subscale of the SFS (t(15) = −2.14, P < 0.05). Social demographic data for completers are presented in Table 1.

Medication adherence

Most participants (11/12) reported taking their medication as prescribed at baseline, and one participant reported planning to take the medication as directed. No significant differences were observed between baseline and post-treatment (t(11) = 1.00, P = 0.34, ns), nor at the 3-month follow up. Given these results, medication adherence data were excluded from the main analyses.

Differences between therapy groups

One-way ANOVA tests were conducted at three time points (pre, post and follow up) to investigate the differences between the three CAM groups. No significant differences on clinical measures were found between the three groups at any of the three time points.

Potential intervention effects

Table 3 provides means and standard deviations for all the measures as well as within-group effect sizes for differences between baseline/post-treatment and baseline/3-month follow-up assessments. Analyses revealed large improvements (d = 1.00) in regulating negative emotions (i.e. self-blaming, rumination and catastrophizing) among participants at 3-month follow up. Participants also showed a moderate improvement (d = 0.61) in total regulation of emotions (i.e. positive and negative) at 3-month follow up, although results only approached significance (P = 0.06). For the BPRS total score, results showed a small effect (d = 0.25) at follow up, not statistically significant (P = 0.11). Positive symptoms showed a small improvement at post-treatment (d = 0.36), and depression-anxiety subscale showed a moderate to large improvement at follow up (d = 0.68), but results were a trend towards significance in both cases. The symptoms that mostly improved were: anxiety (d = 0.92), depression (d = 0.91), self-neglect (d = 0.71) and somatic concerns (d = 0.50). The values of effect sizes were calculated at 3-month follow up, and results were statistically significant for anxiety, self-neglect, and somatic concerns (P < 0.05), and approached significance for depression (P = 0.065). No significant improvements were found for social functioning, insight and distress measures.

Table 3. Means, standard deviations and effect sizes (Cohen's d) for all measures at pre-, post- and 3-month follow up
Outcome measureT0 (baseline)T1 (post-therapy)Effect size (d) T2 (3-month follow up)Effect size (d) 
Mean (SD)Mean (SD)Pre-postP-valueMean (SD)Pre-follow-upP-value
  1. ΔP < 0.10 (approaching significance). *P < 0.05; **P < 0.01.

  2. BCIS, Beck Cognitive Insight Scale; BPRS, Brief Psychiatric Rating Scale; CERQ, Cognitive Emotion Regulation Questionnaire; FMI, Freiburg Mindfulness Inventory; PDMMS, Psychological Distress Manifestation Measure Scale; SFS, Social Functioning Scale.

Symptoms       
BPRS total41.83 (13.59)37.83 (6.86)0.2790.15638.70 (9.75)0.2460.109
Positive9.92 (5.32)7.08 (3.60)0.3610.087Δ8.40 (3.97)0.2030.343
Negative6.83 (2.08)6.00 (2.04)0.4040.1666.70 (2.79)0.2000.575
Depression-anxiety10.50 (5.20)9.00 (3.84)0.3180.2508.10 (2.81)0.6760.082Δ
Manic-excitement7.92 (2.87)9.25 (5.03)−0.1980.3827.70 (2.36)0.1360.522
Mindfulness       
FMI total38.25 (7.36)38.92 (7.54)0.0890.50741.30 (9.20)0.4030.186
Emotional regulation       
CERQ total114.42 (17.14)115.75 (20.24)0.0700.775125.60 (19.29)0.6110.060Δ
Positive61.25 (12.76)62.17 (13.60)0.0700.77763.70 (14.12)0.1820.540
Negative53.17 (9.21)53.58 (11.84)0.0380.87761.90 (8.08)1.0030.007**
Insight       
BCIS total39.00 (8.19)36.92 (4.98)−0.2690.23036.40 (6.43)−0.3410.239
Psychological distress       
PDMMS total54.00 (20.81)54.17 (16.71)−0.0080.95851.80 (17.50)0.1140.905
Social functioning       
SFS total122.17 (18.21)124.83 (18.60)0.1440.548121.30 (23.66)−0.0400.985

Regarding who improved or not, six participants (50%) showed improvements on overall symptoms from baseline to post-treatment and follow up, whereas two showed deteriorations and four did not show any change. Participants who did not improve (n = 6) had significantly lower symptoms at baseline (t(10) = −5.01, P < 0.005), specifically lower positive psychotic symptoms (t(10) = −2.70, P < 0.05), a higher level of mindfulness (t(10) = 2.84, P < 0.05) and better social functioning (t(10) = 3.00, P < 0.05) compared with those who improved (n = 6). The two groups did not differ on measures of insight, emotional regulation, distress and sociodemographic measures.

In regard to mindfulness, eight participants (67%) showed improvements from baseline to post-treatment and follow up, whereas three showed a slight decline and one did not show any change. Even though the results are not statistically significant, the effect size at follow up for mindfulness was moderate (d = 0.40).

Qualitative results

The attendance rate was 77% for the treatment completers. The majority of participants (n = 8) reported that the treatment was a positive experience, describing it as ‘nice, wonderful, interesting and nourishing’, whereas one participant considered the experience as negative and ‘not enough nourishing’, and three were ambivalent, describing their experience as ‘ok, normal, ordinary, or convenient’. Regarding the components of the treatment, mindfulness was the most retained (n = 8), liked (n = 4) and practiced (n = 8), followed by interactions with the other group members and/or the therapists (n = 5), whereas compassion and acceptance were less reported by participants. The most common complaint was the lack of attendance among other participants. Nine of the 12 participants reported changes in their daily lives following the treatment and nine reported that they would recommend the therapy to a friend.

Discussion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. References

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.[25] 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,[9] 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.[6] 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.[9] 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[26] or Five-Facet Mindfulness Questionnaire[27]).

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.

References

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. References
  • 1
    Trémeau F. A review of emotion deficits in schizophrenia. Dialogues Clin Neurosci 2006; 8: 5970.
  • 2
    Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Br J Psychiatry 2000; 177: 47.
  • 3
    Birchwood M, Trower P, Brunet K, Gilbert P, Iqbal Z, Jackson C. Social anxiety and the shame of psychosis: a study in first episode psychosis. Behav Res Ther 2007; 45: 10251037.
  • 4
    Reed SI. First-episode psychosis: a literature review. Int J Ment Health Nurs 2008; 17: 8591.
  • 5
    Khoury B, Lecomte T. Emotional regulation and schizophrenia. Int J Cogn Ther 2012; 5: 6776.
  • 6
    Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull 2008; 34: 523537.
  • 7
    Beck AT, Rector NA, Stolar N, Grant P. Schizophrenia: Cognitive Theory, Research, and Therapy. New York: The Guilford Press, 2009.
  • 8
    Tai S, Turkington D. The evolution of cognitive behavior therapy for schizophrenia: current practice and recent developments. Schizophr Bull 2009; 35: 865873.
  • 9
    Khoury B, Lecomte T, Gaudiano BA, Paquin K. Mindfulness interventions for psychosis: a meta-analysis. Schizophr Res. doi: 10.1016/j.schres.2013.07.055
  • 10
    Helgason C, Sarris J. Mind-body medicine for schizophrenia and psychotic disorders. Clin Schizophr Relat Psychoses 2013. doi: 10.3371/CSRP.HESA.020813
  • 11
    Davis L, Kurzban S. Mindfulness-based treatment for people with severe mental illness: a literature review. Am J Psychiatr Rehabil 2012; 15: 202232.
  • 12
    Brunet K, Birchwood M, Upthegrove R, Michail M, Ross K. A prospective study of PTSD following recovery from first-episode psychosis: the threat from persecutors, voices, and patienthood. Br J Clin Psychol 2012; 51: 418433.
  • 13
    Lolich M, Leiderman E. Stigmatization towards schizophrenia and other mental illnesses. Vertex 2008; 19: 165173.
  • 14
    Arns P. Canadian Version of the PSR Toolkit. Ontario Federation of Community Mental Health and Addiction Programs; 1998.
  • 15
    Willey C, Redding C, Stafford J et al. Stages of change for adherence with medication regimens for chronic disease: development and validation of a measure. Clin Ther 2000; 22: 858871.
  • 16
    Lukoff D, Nuechterlein KH, Ventura J. Manual for the expanded brief psychiatric rating scale. Schizophr Bull 1986; 12: 594602.
  • 17
    Ventura J, Nuechterlein KH, Subotnik KL, Gutkind D, Gilbert EA. Symptom dimensions in recent-onset schizophrenia and mania: a principal components analysis of the 24-item Brief Psychiatric Rating Scale. Psychiatry Res 2000; 97: 129135.
  • 18
    Birchwood M, Smith J, Cochrane R, Wetton S. The Social Functioning Scale: the development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. Br J Psychiatry 1990; 157: 853859.
  • 19
    Garnefski N, Kraaij V. The Cognitive Emotion Regulation Questionnaire: psychometric features and prospective relationships with depression and anxiety in adults. Eur J Psychol Assess 2007; 23: 141149.
  • 20
    Garnefski N, Kraaij V. Relationships between cognitive emotion regulation strategies and depressive symptoms: a comparative study of five specific samples. Pers Individ Diff 2006; 40: 16591669.
  • 21
    Poulin C, Lemoine O, Poirier L-R, Lambert J. Validation study of a nonspecific psychological distress scale. Soc Psychiatry Psychiatr Epidemiol 2005; 40: 10191024.
  • 22
    Buchheld N, Grossman P, Walach H. Measuring mindfulness in insight meditation (vipassana) and meditation-based psychotherapy: the development of the Freiburg Mindfulness Inventory (FMI). J Medit Medit Res 2001; 1: 1134.
  • 23
    Walach H, Buchheld N, Buttenmuller V, Kleinknecht N, Schmidt S. Measuring mindfulness – the Freiburg Mindfulness Inventory (FMI). Pers Individ Diff 2006; 40: 15431555.
  • 24
    Beck AT, Baruch E, Balter JM, Steer RA, Warman DM. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 2004; 68: 319329.
  • 25
    Saksa J, Cohen S, Srihari V, Woods S. Cognitive behavior therapy for early psychosis: a comprehensive review of individual vs. group treatment studies. Int J Group Psychother 2009; 59: 357383.
  • 26
    Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol 2003; 84: 822848.
  • 27
    Baer RA, Smith GT, Lykins E et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment 2008; 15: 329342.