The relationship between psychosis and psychological flexibility: A systematic review and meta-analysis

Executive summary

A systematic review and meta-analysis examined the relationship between psychosis (or psychosis-like symptoms) and the key processes of Acceptance and Commitment Therapy (ACT), including psychological flexibility, experiential avoidance, cognitive fusion, values clarity, and committed action. The review found:

– A large effect of psychological inflexibility on paranoia, a medium effect on delusions, and a small effect on auditory hallucinations.
– A medium effect of cognitive fusion on paranoia.
– A medium effect size when comparing psychological flexibility between psychosis and control groups.
– Additional mediation and moderation effects, suggesting these ACT processes play an important role in psychotic experiences.

These findings support the use of ACT-based interventions for treating psychosis, as they target the key processes underlying these experiences.

Psychosis and psychological flexibility: exploring the connection

Psychosis encompasses a range of experiences, including delusions, hallucinations, disorganised thinking and behaviour, and negative symptoms. While psychosis is often conceptualised as a categorical diagnosis, research increasingly supports viewing psychotic experiences on a continuum, with many individuals in the general population reporting psychosis-like symptoms.

A growing body of evidence suggests that the psychological inflexibility model, which underpins ACT, may be highly relevant to understanding and treating psychosis. This model proposes that psychological inflexibility – characterised by experiential avoidance, cognitive fusion, unclear values, and lack of committed action – is a transdiagnostic process that maintains psychological distress across disorders.

The current review, which synthesised findings from 35 studies, provides compelling evidence for the relationship between these key ACT processes and psychotic experiences. The meta-analyses revealed:

– A large effect of overall psychological inflexibility on paranoia, a medium effect on delusions, and a small effect on auditory hallucinations.
– A medium effect of cognitive fusion specifically on paranoia.
– A medium effect size difference in psychological flexibility between psychosis and control groups.

These findings suggest that targeting psychological flexibility and related ACT processes may be a promising avenue for psychological interventions for psychosis. By helping individuals become more psychologically flexible – allowing them to be in contact with distressing experiences without needless avoidance or struggle, clarify their personal values, and take committed action – ACT may alleviate the distress and impact of psychotic symptoms.

Recommendations for practice

Given the strong links between ACT processes and psychotic experiences, clinicians should consider incorporating ACT-based techniques into their work with individuals experiencing psychosis. Some key recommendations include:

1. Assessing psychological flexibility and related processes. Use validated measures to understand an individual’s level of experiential avoidance, cognitive fusion, values clarity, and committed action, as these can inform treatment planning.

2. Incorporating ACT strategies. ACT techniques such as mindfulness, cognitive defusion, values clarification, and behavioural activation can help clients become more psychologically flexible and manage psychotic symptoms more effectively.

3. Tailoring ACT to the needs of the individual. ACT should be adapted to the specific challenges faced by each client, whether that’s managing paranoia, reducing the distress of auditory hallucinations, or improving functioning in line with personal values.

4. Integrating ACT with other approaches. ACT can be effectively combined with other evidence-based treatments for psychosis, such as cognitive behavioural therapy, to provide a comprehensive, flexible, and person-centred approach.

By incorporating an ACT perspective into clinical practice, mental health professionals can empower individuals experiencing psychosis to lead more meaningful and valued lives, even in the presence of distressing symptoms. The research summarised in this review provides a strong foundation for the use of ACT-based interventions in this context.

Reference

Pittman, J., Richardson, T., & Palmer-Cooper, E. (2024). The relationship between psychosis and psychological flexibility and other acceptance and commitment therapy processes: a systematic review and meta-analysis. Journal of Contextual Behavioral Science. Advance online publication. https://doi.org/10.1016/j.jcbs.2024.100800

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