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An acceptance and commitment therapy based protocol for the management of acute self-harm and violence in severe mental illness

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Abstract

Though only engaged in by a minority of sufferers, self-harm and violence can nevertheless occur within the context of a variety of mental illnesses, from personality disorder to affective disorders, to schizophrenia and other psychoses. Violence to the self (both with and without suicidal intent) and others are not uncommon occurrences on psychiatric wards. This paper explores the utilisation of a new mindfulness centred therapeutic protocol based on acceptance and commitment therapy for the management of self-harm and violence. The protocol was piloted on three patients with a history of high levels of violence to self or others on a psychiatric intensive care unit in London. An outline of acceptance and commitment therapy is provided, together with a detailed description of the protocol for the intervention itself, and some of the outcomes achieved. Recommendations for further adaptations, studies and clinical trials are considered.
Original Research Article
An acceptance and commitment therapy based protocol for
the management of acute self-harm and violence in severe
mental illness
Russell Razzaque
Consultant Psychiatrist, North East London NHS Foundation Trust, UK
Abstract
Though only engaged in by a minority of sufferers, self-harm and violence can nevertheless occur
within the context of a variety of mental illnesses, from personality disorder to affective disorders, to
schizophrenia and other psychoses. Violence to the self (both with and without suicidal intent) and
others are not uncommon occurrences on psychiatric wards. This paper explores the utilisation of a new
mindfulness centred therapeutic protocol based on acceptance and commitment therapy for the
management of self-harm and violence. The protocol was piloted on three patients with a history of high
levels of violence to self or others on a psychiatric intensive care unit in London. An outline of acceptance
and commitment therapy is provided, together with a detailed description of the protocol for the
intervention itself, and some of the outcomes achieved. Recommendations for further adaptations, studies
and clinical trials are considered.
Keywords
Self-harm; violence; acceptance and commitment therapy; severe mental illness; mindfulness
BACKGROUND
Self-harm among sufferers of severe mental
illness in the acute setting has consequences that
are both immediate and long term. According
to a recent report from the National Institute
for Clinical Excellence on self-harm, 1.8% of
those who commit self-harm manage to commit
suicide the same year and 8.5% will die by
suicide over a 22 year period (NICE, 2011).
Violence and aggression are also of significant
concern, particularly on psychiatric wards,
where 58% of violent attacks are found to be
serious and 78% are directed towards nursing
staff (Owen et al. 1998). Additional evidence
also points to a particular subset of individuals
perpetrating this violence. It tends to be young
males with a history of violence (El-Badri &
Mellsop, 2006) and it also tends to be the same
people (Lussier et al. 2009).
Third wave therapies
The so called ‘third wave’ of cognitive beha-
viour therapies is a relatively new area in the
field of mental health. They are said to include
dialectic behaviour therapy (DBT), mindfulness
based cognitive behaviour therapy (MCBT) and
acceptance and commitment therapy (ACT).
Correspondence to: Dr Russell Razzaque, Picasso Ward, Psychiatric
Intensive Care Unit, North East London NHS Foundation Trust, UK.
E-mail: russell.razzaque@nelft.nhs.uk
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Journal of Psychiatric
Intensive Care Journal of Psychiatric Intensive Care
Vol.00 No.0:1–5
doi:10.1017/S1742646412000258
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cNAPICU 2012
One of the common themes between them is
the utilisation of mindfulness based practises for
mental health problems (Baer, 2003). Such
interventions have started to show positive
results in the treatment of a variety of disorders
(Baer, 2005), and are now also incorporated into
NICE guidelines for treatments of these dis-
orders. DBT has already demonstrated consid-
erable success in dealing with both non suicidal
self-harm (Muehlenkamp, 2006), suicidal beha-
viours (Linehan et al. 2006) and violence
(Fruzzetti & Levensky, 2000).
One mechanism via which mindfulness based
techniques are postulated to have an impact
on such behaviours is through a reduction in
experiential avoidance (Chapman et al. 2006).
Experiential avoidance is a key construct in
ACT, and it is defined as the attempt to alter the
form, frequency, or situational sensitivity of
negative private events (e.g. thoughts, feelings,
and physiological sensations). An experiential
avoidance model of violence and self-harm
postulates that such acts are, in fact, attempts to
avoid experiences such as thoughts, feelings,
somatic sensations or other internal experiences
that are uncomfortable or distressing (Chapman
et al. 2006). A reduction in experiential avoidance
is therefore the fundamental goal of ACT.
An intervention, therefore, that focuses on a
reduction in such experiential avoidance, may
well have an impact on propensity towards self-
harm, violence and aggression in sufferers of
severe mental illness.
ACCEPTANCE AND COMMITMENT
THERAPY
According to the Association for Contextual
Behavioural Science (the professional organisa-
tion for acceptance and commitment therapy)
‘ACT illuminates the ways that language
entangles clients into futile attempts to wage
war against their own inner lives. Through
metaphor, paradox, and experiential exercises
clients learn how to make healthy contact with
thoughts, feelings, memories, and physical
sensations that have been feared and avoided.
(Hayes, 2005). The theoretical framework that
underpins ACT is known as relational frame
theory (RFT). RFT posits that humans possess
an ability that is unique to our species; namely
the deployment of sophisticated language. We
do so by forming what are known as bidirec-
tional associations between words and their
meanings so that, over time, both a word and its
meaning will start to fuse. We also develop
complex and deep associations between differ-
ent words and concepts, ultimately forming
whole networks of such associations within our
minds, which we may trigger at any time, in
response to interactions with the environment,
so taking us out of the present moment. As a
result, we are particularly creative as a species,
but this also makes us vulnerable to emotional
distress due to the constant inner chatter that
such a continual process involves. In addition,
our tendency to then attempt to ‘fix’ this
distress, as we would any external problem,
leads us to devise methods of avoidance of that
emotional distress (experiential avoidance)
which, in the emotional terrain, only serves to
exacerbate the problem. This ultimately makes
us vulnerable to psychopathology (Fledderus
et al. 2010).
ACT’s techniques involve intentionally bring-
ing one’s attention to the internal and external
experiences occurring in the present moment.
Such interventions have been shown to be of
considerable value in a number of disorders,
including for psychosis in an acute ward setting
(Bach & Hayes, 2002).
A core technique within the ACT treatment
approach is cognitive defusion. Cognitive defu-
sion is defined in the ACT Skills Training Manual
for Therapists (Luoma et al. 2007) as follows:
‘ACT argues that the problem with human
suffering as it relates to thoughts, is not that we
have the wrong thoughts, but rather that we
spend too much time ‘in’ them or ‘looking
from’ them rather than simply looking at them
or observing them. Cognitive defusion attempts
to circumvent this problem by drawing the
client’s attention to thinking as an ongoing
behavioural process and helping clients to see
thoughts as thoughts, so those thoughts can be
responded to in terms of their workability,
rather than their literal truth.
Razzaque R
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PROTOCOL
The intervention was delivered to three patients
on Picasso Ward (the psychiatric intensive care
unit of Goodmayes Hospital in East London)
all of whom had a lengthy history of regular
bouts of violence towards themselves or others.
One had a primary diagnosis of schizoaffective
disorder, with frequent admissions (an average of
two to three per year) for psychotic relapses
involving significant self-harm including suicidal
intent. The other two had bipolar affective
disorder, with presentations including frequent
bouts of violence toward family members, carers
and ward staff.
The intervention was commenced with the
schizoaffective patient once his risk of imminent
self-harm had reduced. He was no longer
actively responding to auditory hallucinations
but continued to report them regularly with
consequent thoughts of self-harm. Similarly, in
the case of the two patients diagnosed with
bipolar affective disorder, their imminent risks
of violence had reduced before commencing the
therapy, but they continued to display aggressive
and abusive behaviour toward staff and/or
family members.
The treatment consisted of daily 20 minute
one to one sessions, provided over a period of
two to three weeks.
Phase one
Each session starts with a specific defusion
exercise in which the patient is asked to bring
a difficult (particularly emotive) thought or
feeling to mind and, instead of ruminating on
or turning them over, just to hold them and
notice how their bodies react to this for a few
moments. This is followed by a wider cognitive
defusion exercise, in the form of metaphor
based guided meditation. The script for this
rotates each day between 20 available scripts;
each script is based on the idea of watching
thoughts and feelings as the observer and
container of them, rather than going into their
content. The different metaphors used included
concepts such as fish in the sea; where each
thought or feeling is like a fish swimming in the
sea and the person is the sea itself. Other
metaphors included people in a busy office block
where, again, the thoughts and feelings are the
different people doing different jobs in the
building and the person experiencing them is
the building (the context) itself.
‘Self as context’ is an important concept in
ACT treatment (Luoma et al. 2007). It is seen as
a dimension of the self (the observer self) that is
an alternative to the self that is embroiled in and
fused to the world of thinking and doing,
known as ‘self as content’. Practicing experien-
cing one’s self from this perspective is a key
objective of each cognitive defusion exercise.
Phase two
The next phase is an exercise in the contempla-
tion of values (another core process in the ACT
schema; Luoma et al. 2007) via visual cues. Here,
the patient is asked to read to themselves a values
statement they prepared earlier in an introduc-
tory session, which lists their key life values in
terms of what kind of person they would like to
be in the areas of life most important to them
(e.g. a loving partner, a dedicated student). The
list is normally written within an outline drawing
of a person. They are asked to read through the
list, and then look upon the figure in soft focus as
if it were a mirror or photo in which they could
see themselves.
Phase three
Each session then finishes with a few minutes
of discussion around the patient’s experience of
the exercises. The clinician always guides the
discussion towards a highlighting of the experi-
ence of the thoughts and feelings within the
body during the exercise, rather than the
content of the thoughts themselves. This way,
through sharing of multiple examples, they will
learn to mindfully notice their thoughts and
feelings more, and become entangled in their
content less.
At every stage, the clinician engages in each
of the exercises together with the patient,
making it a collaborative exercise in personal
growth for them both.
An ACT-based protocol for the management of self-harm and violence
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Outcomes
Levels of aggressive and abusive behaviour
were determined for each patient based on
regular nursing shift reports, describing their
behaviour over the course of the day. Changes
in the levels of such behaviours were noted,
as were changes in expression of self-harm
or suicidal ideation as noted after interviews or
ward reviews.
In the patients with a diagnosis of bipolar
disorder, a clear reduction in aggressive and
abusive behaviour was observed during the
treatment period, and each developed an
increasing confidence in their ability to manage
such impulses in future. The Clinical Global
Index (CGI) is a rating scale that is routinely
used to determine clinical progress of patients
on the ward and, in each case, a consistent
reduction in severity of illness scores was
observed during the period of treatment.
Behaviours of an abusive and aggressive nature
towards staff were regularly reported for one
patient prior to commencement of therapy
and, during treatment, such outbursts consis-
tently reduced. At the end of the treatment,
reports of aggressive and abusive outbursts had
ceased entirely.
The patient with a diagnosis of schizoaffective
disorder experienced a mark reduction in self-
harm and suicidal ideation as well as a reduction
in derogatory auditory hallucinations. He too
showed a consistent reduction in severity of
illness CGI scores during the period of treat-
ment, and he also reported a more positive
mood and self esteem during formal ward
reviews.
The patient feedback regarding the interven-
tion was universally positive, with each feeling
that the ACT sessions contributed significantly
to a reduction in their impulsive and violent
behaviours. At the end of each course of
treatment, the patient asked for information
about the exercises so that continued mindfulness
practice might be facilitated in the community
after discharge. This was then provided in the
form of a print out describing self directing
exercises along the same lines.
DISCUSSION
Thereisaclearevidencebasefortheefcacy
of mindfulness based treatments across various
psychopathologies and there is some indication
that this may also translate to the use of treatments
such as ACT for the management of acute self-
harm or violence. This initial experience of
utilising ACT based treatments on a psychiatric
intensive care unit has produced some positive
results. The study, however, was not a controlled
one and each patient undergoing the intervention
was also subject to treatment as usual (i.e. standard
pharmacological therapies as appropriate to their
condition) which would also have an effect on
levels of aggressive and abusive behaviours and
self-harm ideation. More study is, therefore,
required to further verify the effect of such
interventions with controlled trials across wider
samples using validated outcome measures.
Currently under development is a group-based
intervention, based on this protocol, which is
designed to facilitate daily mindfulness practice for
both staff and patients together on psychiatric
wards, entitled Integrated Mutual Participation
Acceptance & Commitment Therapy (IMPACT)
groups. A study to examine more global change,
with outcome measures including use of PRN
medication, use of restraint, Clinical Global Index
(CGI)scoresandlengthsofstayiscurrently
underway. This is a historically controlled trial
and was launched in late 2011.
As data accumulates on the efficacy of such
measures, implementation of similar protocols,
in either a one to one or group setting, may
become a viable treatment option across PICUs
and forensic units for the management of self-
harm or violent behaviour. It will require
engagement and cooperation from the patient
and so will not have universal applicability, but
where patients are amenable, such interventions
may serve as a useful additional medium term
tool at the disposal of clinicians.
References
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Commitment Therapy to prevent the rehospitalization of
psychotic patients: a randomized controlled trial. Journal of
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Chapman, A., Gratz, K. and Broan, M. (2006) Solving the
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... Harvey, Henrickson, Bimler, and Dickson (2017) Overall, these studies suggested that ACT interventions offer a promising approach to addressing aggressive behavior (Donahue et al., 2017;Harvey et al., 2017;Razzaque, 2012) and its occurrence in intimate partner relationships (Berta & Zarling, In Press ;Zarling et al., 2015;Zarling et al., 2017a;Zarling & Berta, 2017b). ...
... Scholars have examined the impact of ACT on anger and aggression. ACT appears to decrease engagement in aggressive behavior (Donahue et al., 2017;Harvey et al., 2017;Razzaque, 2012) and intimate partner violence (Zarling et al., 2015;Zarling et al., 2017a;Zarling & Berta, 2017b;Berta & Zarling, In Press). ...
... easure compared to TAU at posttreatment (η2=0.54, p=0.02) and at three month follow up (η2=0.73, p=0.02). No other differences were obtained. Scholars suggested that changes in values consistency, rather than psychological inflexibility, may have been reflective of greater focus on values over the course of the intervention(Eisenbeck et al., 2017).Razzaque (2012) studied the effectiveness of an ACT intervention on three patients in a British psychiatric intensive care unit using a case study design. The intervention included defusion, self as context, values, and mindfulness delivered via 20-minute daily sessions over the course of two to three weeks. Participants had lengthy histories of self-h ...
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... Five distinct interventions were delivered by professionals that had specific qualifications to treat patients. Three of these were different forms of psychotherapy: animal assisted psychotherapy [30], acceptance and commitment therapy [31] and narrative group therapy [32]. Two interventions were similar to the psychotherapies in that the people delivering them had specific training, but they were not forms of psychotherapy. ...
... The designs varied greatly, ranging from RCTs [30,34], to a cluster-level controlled pre-post study [31] and case series [32,33]. ...
... The design of the study assessing the group narrative therapy intervention [32] makes drawing conclusions difficult, as only aggregate ward-level data that was routinely collected at admission and discharge is available from all patients, and it is not known whether they attended the group or not. However the wards on which narrative group therapy was offered showed a significant improvement in symptom scores compared to the control wards, suggesting the intervention may have provided some benefits. ...
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... The authors of this trial concluded that ACT may help reduce the intensity and frequency of SI due to increases in acceptance, valued action and a reduction in risk factors such as hopelessness and psychological pain [36]. The two casestudies measured and reported a reduction in both SI and DSH [44,45]. ...
... Walser et al [32] reported a 32% reduction in depression scores for the cohort of veterans that recorded SI at baseline. This study also reported a 40% [44,45]. Both studies report impressive reductions in SI for all five individuals studied; however the studies had many limitations, including lack of specificity around how SI and self-harm reports were measured (apart from hospital ward reports). ...
... Tighe et al's [27] trial showed significant reductions for depression and distress on standardised measures and a 30% reduction in SI scores (although this was non-significant between groups). All five participants whose case studies were presented improved significantly with marked reductions in SI/DSH [44,45]. In addition to the significant results for SI in the two pre-post studies, both of these studies showed improvements on the AAQ, a measure of psychological flexibility [32,36]. ...
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Objectives ACT for Life was developed to guide the application of Acceptance and Commitment Therapy (ACT) to maximize recovery from suicidal crises. The current study tested the acceptability of ACT for Life and evaluated the feasibility of the research design for a future efficacy trial. Method Seventy veterans were randomized to treatment as usual (TAU) or ACT for Life plus TAU. Participants were assessed at baseline, post-treatment, and one- and three-months post enrollment. Results The mean Client Satisfaction Questionnaire-8 score was 29.1 (SD = 4.2; 95% CI: 27.6, 30.8). Qualitative data further supported acceptability. Feasibility was demonstrated by 74.3% of participants completing the treatment per protocol and clinicians delivering the treatment with 95% fidelity. Preliminary data suggest that ACT for Life may improve recovery following suicidal crises. Conclusions ACT for Life was highly acceptable and feasible. Future research is warranted to establish the efficacy of ACT for Life.
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