Acceptance and Commitment Therapy for individuals at risk for psychosis or with a first psychotic episode: A qualitative study on patients' perspectives

The aim of this qualitative study is to explore patients' perspectives on Acceptance and Commitment Therapy for early stages of psychosis. Therefore, we interviewed participants of the INTERACT study, that quantitatively investigated Acceptance and Commitment Therapy in Daily Life (ACT‐DL) in combination with treatment as usual, for early stages of psychosis, comparing it to treatment as usual.

(attenuated) positive symptoms, negative symptoms, cognitive disorders, psychiatric comorbidity, and present with functional impairments and lower quality of life (Fusar-Poli et al., 2017, 2020).3 years after UHR identification, 22% of people transition to psychotic disorder (Fusar-Poli et al., 2020).Only a quarter of individuals diagnosed with FEP achieve both symptomatic and social/vocational remission at 7-year follow-up (Henry et al., 2010).
A recent meta-analysis on treatment options for UHR (Mei et al., 2021) showed a pooled, small significant effect of all interventions on transition to psychosis and on attenuated positive symptoms, but no effect of any intervention on (attenuated) negative symptoms, psychiatric comorbidity, symptom-related distress, global functioning, or quality of life.For individuals with FEP, specialized first episode services can significantly improve outcomes but show no meta-analytic significant effect on prevention of relapse (Fusar-Poli et al., 2017).
Antipsychotic treatment is advised for this group and proven to be effective in reducing positive symptoms but is associated with inconvenient side-effects (NICE, 2014), and is suggested to delay, but not prevent relapse (Fusar-Poli et al., 2017).Therefore, new interventions to treat (attenuated) positive symptoms, and diminish the broad spectrum of associated problems and long-term risks, are needed.
Acceptance and Commitment Therapy (ACT) is a behavioural therapy, aiming to enhance psychological flexibility.Effects of ACT in the treatment of psychotic patients are promising although inconsistent (Jansen et al., 2020;Yıldız, 2020).Therefore, 'ACT in Daily Life' (ACT-DL) was developed, a blended care intervention combining ACT-sessions with an app to add Ecological Momentary Intervention (Myin-Germeys et al., 2016) to enhance therapeutic effects in real life conditions in early psychosis (Vaessen et al., 2019).The INTERACT study (Myin-Germeys et al., 2022) quantitatively investigated ACT-DL and showed that adding ACT-DL to treatment as usual (TAU) significantly improved momentary psychotic distress, global functioning, and negative symptomatology, compared to only TAU, for participants with UHR and FEP.
Qualitative information on ACT for psychosis is scarce.One qualitative study (Bacon et al., 2014) investigated ACT for individuals with schizophrenia or schizoaffective disorder with persistent positive symptoms.They found that all participants reported ACT as useful; a part reported positive changes related to ACT, some reported difficulty understanding certain exercises, and some were ambivalent about the usefulness of aspects of the therapy.Another study focusing on change processes in ACT groups for early psychosis (Bloy et al., 2021) reported that all participants described benefits from group ACT.Reported changes were related to group participation or to ACT itself.The current study will extend this work by focusing on participants' experiences with ACT-DL in the early stages of psychosis.This could help identify (un)helpful therapeutic factors (Elliott, 2010), leading to possibilities for improving effectiveness and compliance.We aimed to investigate: (1) what participants experienced when undergoing ACT-DL for (attenuated) psychotic symptoms, (2) how they engaged with ACT principles and (3) which elements they perceived as helpful or hindering.

| Design and participants
Semi-structured interviews were conducted with participants of the INTERACT study who were randomized in the ACT-DL condition.
Recruitment procedure and inclusion criteria for INTERACT have been described in detail elsewhere (Myin-Germeys et al., 2022).In  Interviews were performed after verbal and written explanation and after written informed consent of the participant.

| Intervention
ACT is a mindfulness-based behavioural therapy, aiming to improve psychological flexibility, through promoting detachment of ones' thoughts and judgements, accepting what cannot be changed, recognizing ones' personal values, and committing to them even when experiencing psychiatric symptoms.ACT uses six core principles to get here, each of them accompanied by specific methodology, metaphors, exercises, and homework (Harris, 2006;Larmar et al., 2014;Vaessen et al., 2019)

| Interviews
The interviews were conducted by a psychiatrist (JB) or a psychologist (AH).JB has worked several years in a specialized CHR-and FEP-team and has ever since felt engaged with (treating) these patients.A group that deals with complex experiences and symptoms, often starting in adolescencea both fragile and developmentally important period in their lives.AH is a clinical psychologist, working with admitted patients with schizophrenia.She has always been passionate about the psychotherapeutic treatment options for psychotic disorders.JB was not trained in ACT at the time of interviewing, trying to be as open-minded and unbiased as possible.This might have been a disadvantage in the recognition of potential meaningful information and further elaboration.However, she immersed herself in the theory and treatment protocols of ACT during the period of transcript analysis.AH was a trained ACT therapist when conducting the interviews, which could have helped her to recognize information worth elaborating but could also have biased her questioning.Interviews were audio-recorded and transcribed verbatim.

| Qualitative analysis
All interviews were transcribed by 2 authors (JB, AH).Interviews were transferred to NVivo, qualitative analysis software, for coding.We used a reflexive thematic analysis approach (Braun & Clarke, 2019, 2020, 2022)

| RESULTS
We interviewed 19 participants, 6 with UHR and 11 with FEP that had received ACT-DL, 2 audio-files were lost due to technical issues, resulting in a total of 17 interviews that were studied.Interviews lasted between 34 and 83 min (mean 48 min).Baseline characteristics of the participants are represented in Table 1.
From coding and interpretation of the 17 interviews, 9 themes were formulated as main findings and reflected either what participants said about the meaning of ACT -in general and for them personally-or what their doubts and struggles with ACT were.Therefore, we grouped these themes under 2 overarching themes, called 1.The purpose of ACT and 2. What to improve. the close link between these concepts (Table 3).

| Contact with the present moment
This ACT principle is embedded in therapy through mindfulness (exercises), as a tool to connect with the present moment.Six people mentioned mindfulness as an essential part of ACT therapy, one of them thought ACT was not much more then mindfulness (P16), see Table 4 for quotes.

| Values clarification and committed action
These ACT principles were mentioned as important by 13 participants.
Six recalled an exercise from session 5 (card sorting task) where they chose their most important personal values from a set of possibilities and reflect whether these got enough attention in their everyday life.
Four people specifically addressed that they committed more to their values since ACT; one had made an action plan to commit to her values.Another participant (P15) thought that ACT had not focussed enough on commitment.See Table 5 for characteristic quotes.6).
The participants of INTERACT shared their doubts, negative experiences and opinions on ACT with us in the interviews, and we consciously gave them space to do so.We generated 4 themes that include the most important findings here: 'symptom-specific approach', 'suitability for individuals with UHR/FEP', 'flexibility' and 'personal approach', summarized in an overarching theme called: What to improve.

| Symptom-specific approach
Three participants missed talking about their specific (pre)psychotic experiences or getting specific advice for them.

| Suitability for individuals with UHR/FEP
Two FEP participants felt that ACT might be suitable for other problems, but not for psychosis.Two different FEP participants found metaphors (figures of speech) are too hard to understand when being psychotic.One (UHR) participant described being incapable of connecting the metaphors to her emotions.Another (FEP) participant appeared to have been too psychotic to reach a certain level of cognitive understanding necessary to understand ACT principles and metaphors.

| Flexibility
Six participants thought sessions content was too structured or fixed.
They missed room for adjustment to their needs.Another participant mentioned the opposite: how much she had appreciated her therapist's flexibility about fitting ACT to her specific needs.

| Personal approach
Four participants suggested to create more room during ACT sessions to get to know the patient, talk about their complaints and history (Table 7).
T A B L E 2 Illustrative quotes on theme Acceptance.This study explored participants' experiences with ACT-DL for (attenuated) psychotic symptoms, aiming to understand how they engaged with ACT principles and which elements they perceived as (un)helpful.
Overall, participants described it as a feasible and helpful therapy.
Many of them learned to be more aware and accepting of their experiences, to focus more on the present moment and to commit to their personal values.
Participants generally showed good understanding of the concepts 'Acceptance', 'Cognitive Defusion' and 'the Observing Self', all promoting awareness and acceptance of ones' symptoms and experiences.Many reported being more aware of their (unwanted) thoughts and feelings and less preoccupied with wanting to change them.Other qualitative studies on ACT for psychosis also reported positive feedback on these concepts.In one study (Bacon et al., 2014), six (of nine) participants mentioned 'Defusion' as helpful, two reported 'Acceptance' as useful and six noticed changes in their beliefs and attitude towards symptoms.In another study (Bloy et al., 2021), a higher level of awareness was reported as one of the key processes related to change in experienced distress.Quantitative analyses of INTERACT (Myin-Germeys et al., 2022) showed a greater reduction in momentary distress associated with psychotic experiences in ACT-DL + TAU compared to TAU.This could be related to the described higher levels of awareness and acceptance.On the contrary, though, quantitative analyses found no differences on psychotic distress in the ACT-DL group compared to TAU only, mainly because TAU and TAU+ACT-DL were equally effective in reducing psychotic distress.This might be explained by the fact that UHR individuals experience a decline in mean distress after inclusion in an intervention trial, unrelated to the type of intervention (Wilson et al., 2020).
Mindfulness, closely related to the ACT concept 'Contact with the Present Moment', was mentioned as important by six of our participants.Five, all with FEP, felt mindfulness helped them to be more present, calmer, and less bothered by anxiety or fears.This is in line with a meta-analysis on mindfulness-based interventions for people with psychosis that demonstrated promising effects (Jansen et al., 2020).Mindfulness skills might help people with psychotic spectrum disorders to become more aware of unusual experiences and learn to cope with them differently (Chadwick, 2014).One participant in our study thought ACT was nothing more than mindfulness and therefore only suitable for milder problems then psychosis.In Bacons study (Bacon et al., 2014), mindfulness was also predominantly reported as helpful but for one person, who reported it only worked for 'less intense experiences'.Overall, mindfulness was positively reviewed by most people with (early stages of) psychosis.The minority with doubts about it, might benefit from more explanation about the relevance of mindfulness (exercises) for their symptoms, or from adjusted exercises to promote contact with the present moment.We conceptualized suggestions to further develop ACT for early stages of psychosis.Four FEP participants found components of ACT, mostly metaphors, too hard to understand or connect to when psychotic.Another FEP participant seemed to have misunderstood certain, more abstract, elements of ACT.In Bacons study (Bacon et al., 2014), something similar is described: two participants found therapy concepts and exercises difficult and another two reported misunderstandings about therapy and exercises.In qualitative studies on ACT for other psychiatric symptoms, for example, for eating disorders (Fogelkvist et al., 2021) and for depression or anxiety (Bahattab & AlHadi, 2021), we did not find similar comments.Possibly because (early) psychotic symptoms often present with cognitive and/or negative symptoms, compromising the capability to abstract and therefore to understand certain elements of ACT, like metaphors.
Seven participants suggested to include more psychosis specific content or spend more time to talk about their personal history and experiences with the ACT therapist.None of the other qualitative studies on ACT for psychiatric illnesses (Bacon et al., 2014;Bahattab & AlHadi, 2021;Bloy et al., 2021;Fogelkvist et al., 2021) short, participants had to meet UHR or FEP criteria (onset within last 3 years); a sufficient command of Dutch language; and the ability to provide written informed consent.They were recruited from secondary mental health services in the Netherlands and Belgium.148 participants were randomly assigned to either TAU or TAU + ACT-DL.Individuals assigned to the ACT-DL arm, received ACT-DL by a trained therapist, with ongoing treatment (TAU) at their mental health care facility.Recruitment for the qualitative study took place with convenience sampling between June 2018 and September 2019.Participants in the ACT-DL arm were asked to take part in the qualitative study, independent of treatment outcome, and were interviewed within 6 months post ACT-DL treatment.30 participants were approached and 19 participated.With the convenience sample we were able to obtain data from a rather heterogenous group of patients which provided sufficient information richness (demographic characteristics are shown in and all coding was done by JB.To enhance interpretative depth in the beginning stages of coding, SvGG, a psychologist with experience in qualitative research and ACT (not involved in INTER-ACT or it's participants) also coded the first 3 interviews, conceptualized potential patterns and discussed her codes and interpretations with JB.Hereafter, themes were further developed by JB, in a circular process of rereading transcripts, refining codes, searching for possible patterns of meaning, distancing from the data, reflection with other authors (FS, SvGG, MdK) on possible patterns, themes and our own subjectivity, and further development of patterns and themes.Regarding the first authors' (JB) role in the analysis; she was not part of the quantitative INTERACT investigators group and did not have specific hopes or expectancies for the results.She mainly wanted to understand if and how a person with (pre)psychotic experiences made sense of ACT therapy, without preference for good or bad experiences.
3.1.5| Psychological flexibility ACT theory describes psychological flexibility should grow by learning and combining the mentioned ACT principles.It means to be present, to be aware and accept unpleasant thoughts and feelings, whilst acting towards one's personal values.Four quotes aptly represented this (Table The concepts 'Values' and 'Committed Action' were positively evaluated in our study.Many participants had a clear memory about values related exercises and noticed positive changes by committing to their values.Other qualitative studies on ACT for psychotic spectrum disorders(Bacon et al., 2014;Bloy et al., 2021) mention the same.The INTERACT study (Myin-Germeys et al., 2022) showed significant improvement in global functioning and negative symptoms in the ACT-DL condition compared to TAU.It seems probable that when these individuals started to identify their personal values and started to act accordingly, this improved global functioning and negative symptoms.This gives reason to further investigate the potential effects of ACT on negative symptoms and global functioning.

Table 1 .
). Ethical approval for the qualitative amendment on the INTERACT study was granted by the Medical Ethical Committees of Maastricht and Leuven (NL46439.068.13;s59127).Participant demographic characteristics.
The aim of ACT was] that I must be a bit more aware of what my, I mean, what happens and the fact that this influences my behaviour, and this is what gives me nightmares and stress and that I should be aware of this and should be aware of the impact this has on me.6[An important goal of ACT] was gaining awareness, I think […], but yeah, I cannot make anything else of it then awareness, becoming aware of thinking.I hoped the thoughts would go because of meditation and accepting them, but I learned that the essence is that I accept I have these thoughts.First,I thought:'shit, there is that thought again', and now I think 'it is ok, this thought can be here'.[…]Mythoughtsarestillfrequent,butsinceACT,Ikeepthem close to me.5The metaphor with the Chinese Fingertrap, you try to detach yourself from the emotion, but is does not work by pulling.However, that by easily letting go… this really connected with me because I tend to hold on to these emotions so tight.15ACTaddedsomethingbecauseIhadnever[…] this way of looking at it, it felt good.To approach the thought instead of fighting it.[…][WhatIremembermostaboutACT] is that thoughts can run away with you, but that you do not have to control them, only acknowledge them.becalmerabout the fact that I was ill, which at first, I could not accept.How could I hear something that was not there?How is it possible I lost my job?[…]I felt ashamed and a failure because I was ill.But, when I saw I really was ill, I was more capable of letting go.[…]I accepted I could not do the same as before and that sometimes I had to take smaller steps then I was used to.[…]Ilearnednot be afraid of my thoughts [about a man in my house] anymore and to let them come, which made me much calmer.15[SinceACT] I try, because I hear voices, to not let them disappear, I experience them and ask them to stop talking.I do not want them to leave anymore […] which used to make them stronger.I feel that -it is a bit frightening to say-now that I am at peace with the fact that I have this thought, I gave more room to the original incident [bad trip] and now flashbacks to the incident are more frequent again.I wonder if this is a good development.
a Quotes were translated from Dutch/Flemish and slightly adjusted to enhance readability.
T A B L E 3 Illustrative quotes on theme Cognitive Defusion and The Observing Self.Illustrative quotes on theme Contact with the Present Moment.Illustrative quotes on theme Values Clarification and Committed Action.There were exercises, one that was very interesting was about values.We got to see a lot of words: which is important to you?So, I really started to work with that, cutting mine out of paper and looking at them a lot and working on the ones that were important to me.use or remember from ACT? Yes, well, it works when things are made visual or seen in words, it was about standards and values, no what was it, values and something else.[…] You could choose the values that were important to you, and I had never really thought about this.8 What stuck with me the most from ACT therapy, was this sheet with boxes on it, with different areas of focus, like family, relationship, social life, spirituality, health.You had to score how important an area of focus was for you and how much time and attention you gave to this area.This has really opened my eyes.I was spending a lot of time on things that are not that important to me, like my boyfriend, and little time on things that are important to me, like family and friendships.me concentrate on what is important to me, I used to live alongside these things.Family is very important, I used to see them once a week, also my friend.Now we walk in and out of each other's place every day, this is so much more pleasant.[…] So, this value really got much better.11 For example, autonomy, this is very important to me, but I kind of lost this during that relation [with my ex], and now I am reclaiming this.For example, at work I am bolder, because now I know: this is important to me, so I have to act on it.
a Quotes were translated from Dutch/Flemish and slightly adjusted to enhance readability.T A B L E 4 a Quotes were translated from Dutch/Flemish and slightly adjusted to enhance readability.T A B L E 5 a Quotes were translated from Dutch/Flemish and slightly adjusted to enhance readability.
Illustrative quotes on theme Psychological Flexibility.B, but there is someone, an obstacle, in the middle.It showed how you can take this obstacle on your back, you do not have to remove or avoid it, but carry it with you and still move on.[…] Everybody meets difficulties in life, but you do not have to erase or avoid them, you can just carry them along, and it does not have to be in your way to get where you want.Illustrative quotes on theme What to improve in ACT sessions?should talk more about (pre)psychotic experiences […] and not only about feelings and how to deal with them.12 I feel like ACT is developed for different people and applied now to people with psychosis, whereas the world of someone with psychosis is so far from the real world […] You are detached from the daily life, I missed a part on this experience in ACT.The metaphors were not for me, I mean, tug-of-war here, a dragon there, it makes me think: come on people, please, for someone with already such a full head, just tell me what you mean! 16 To be honest, ACT was not for me.It's mainly mindfulness, and a bit of pictures, metaphors.This is fine for people with milder, maybe prepsychotic symptoms.But for someone with psychosis, in my experience, this does not work at all, metaphors and all, so I was disappointed.Flexibility 2 The therapist told me, that the treatment has been designed like this for a reason and we were going to follow it exactly.But I was like, if this does not work for me, or I feel uncomfortable with it…then why cannot we search for a different way of doing it?16 Following the workbook literally, I really did not like it.Sometimes I was obliged to do a certain exercise, even when I said I really had no thoughts on it.7 Meditation and letting go, I think it's the essence of the treatment, to learn to let go.[…] But I, I think there are still a lot of things I need to work through.[…] I still feel this anger [towards a family member] and I want to reveal this.Explain why I feel this way, and to really do everything I can to resolve this conflict.If you just let go, without dealing with it first, I do not think it works.know this person in front of me yet, so I am not going to tell him: hey, this is what bothers me, […] because you do not have that relationship of trust yet.7 I do not understand the foundation: if you want to work through something, how can you skip that step, I mean, you need maybe three conversations, so the therapist knows: these are your problems.This makes it easier for you to let things go and you feel heard.
symptoms and to keep connecting those to the concepts of ACT.In addition, specifically for FEP patients, we are encouraged to add flexibility to ACT protocol: to adjust the level of abstraction, and to adjust or exclude metaphors or mindfulness exercises, depending on the patients' desires and abilities.T A B L E 6 a Quotes were translated from Dutch/Flemish and slightly adjusted to enhance readability.T A B L E 7 a Quotes were translated from Dutch/Flemish and slightly adjusted to enhance readability.