“Acceptance and Commitment Therapy for Schizophrenia and Psychosis Inpatients with Recovery and Experience Orientation (ASPIRE)”: A Pilot Study

Technical Summary: ASPIRE Pilot Study

Problem Statement
Psychotic disorders, particularly within the schizophrenia spectrum (SSPDs), are associated with severe impairments in quality of life, high rehospitalization rates (up to 44% within two years), and significant social challenges. While standard treatments include pharmacotherapy and Cognitive Behavioral Therapy (CBT), recent meta-analyses suggest CBT does not significantly outperform basic psychosocial interventions regarding efficacy or relapse prevention in psychotic disorders. Furthermore, the chronic nature of these conditions often necessitates a shift from pure symptom elimination to functional recovery. There is a need for therapeutic approaches that focus on symptom acceptance and psychological flexibility rather than control, yet evidence for Acceptance and Commitment Therapy (ACT) in inpatient settings remains mixed, with previous studies often limited to short durations (one week) or specific subpopulations (first-episode psychosis).

Methodology
This was a monocentric, noncontrolled pilot study conducted at the Department of Psychiatry, Psychotherapy, and Psychosomatics at Vivantes Klinikum Am Urban (Berlin, Germany) between October 2023 and October 2025. The study aimed to evaluate the feasibility, acceptability, safety, and preliminary effectiveness of a four-week ACT-based group intervention for inpatients.

• Participants: 38 inpatients aged 18–65 with DSM-5 diagnoses of SSPDs (including schizophrenia, schizoaffective disorder, and affective disorders with psychotic features) were enrolled. Notably, comorbid substance use disorders were not an exclusion criterion. The final analytic sample consisted of 28 participants who completed the intervention, with 20 assessed at the six-month follow-up.
• Intervention: The program was embedded within a ward (act23) where ACT principles were holistically integrated across the multidisciplinary team. The core intervention comprised two group formats:
  1. Compass Group: A weekly 50-minute open group led by ACT-trained clinicians, structured around four rotating modules (Life Orientation, Inner Obstacles, Personal Narratives/Self-Compassion, and Courageous Steps) addressing all six ACT core processes.
  2. Here-and-Now Group: Twice-weekly 25-minute mindfulness sessions led by trained physicians/psychotherapists to deepen nonjudgmental awareness.
• Measures: Assessments were conducted at baseline (T0), post-intervention (T1), and six-month follow-up (T2).
  • Clinical Outcomes: PANSS (symptom severity), GAF (global functioning), and QPR (recovery).
  • ACT/Mindfulness Outcomes: CHIME (mindfulness), FAH-II (psychological flexibility), and CFQ-D (cognitive fusion).
  • Feasibility/Safety: Patient satisfaction (ZUF-8), dropout rates, adverse events (AEs), and rehospitalization rates. Treatment fidelity was monitored via the ACT Fidelity Measure (ACT-FM).
• Analysis: Multivariate analyses of variance (MANOVA) and post hoc ANOVAs were used to assess changes over time. Effect sizes were calculated using partial eta squared ($\eta_p^2$).

Key Results

• Feasibility and Acceptability: The intervention demonstrated high feasibility and acceptability. The mean patient satisfaction score (ZUF-8) was 27.27, exceeding reference values. The dropout rate (26.32%) was comparable to standard psychotherapy adherence rates and lower than averages reported in broader ACT literature. No serious adverse events (SAEs) occurred, and no suicide attempts were recorded.
• Clinical Outcomes (T0–T1): Significant improvements were observed with large effect sizes:
  • Symptom severity (PANSS): $\eta_p^2 = 0.476$
  • Global functioning (GAF): $\eta_p^2 = 0.673$
  • Recovery (QPR): $\eta_p^2 = 0.366$
• ACT-Specific Outcomes (T0–T1):
  • Mindfulness (CHIME) showed a large, significant effect ($\eta_p^2 = 0.301, p = .002$).
  • Psychological flexibility (FAH-II) and cognitive fusion (CFQ-D) showed large effect sizes ($\eta_p^2 = 0.104$ and $0.131$, respectively) but did not reach statistical significance, likely due to sample size limitations.
• Follow-up (T2):
  • Improvements in PANSS and GAF scores were sustained and continued to improve at six months.
  • QPR gains plateaued after T1.
  • FAH-II and CFQ-D scores continued to improve slightly, whereas CHIME scores showed a slight decrease, suggesting a need for ongoing reinforcement of mindfulness skills.
  • The rehospitalization rate was 32.1% over six months, which is lower than rates reported in comparable studies.
• Fidelity: Treatment fidelity was high, with a mean ACT-consistent score of 32.5/36 on the ACT-FM.

Significance and Claims
The authors claim that this study provides the first evaluation of an interdisciplinary, ward-wide ACT-based group intervention for inpatients with SSPDs within the German healthcare system. The paper asserts that the intervention is feasible, safe, and well-accepted even among a heterogeneous population including those with comorbid substance use disorders and chronic conditions.

The findings suggest that ACT-based interventions can facilitate significant improvements in symptom severity, global functioning, and recovery processes in inpatient settings. The authors highlight that the approach's focus on acceptance and values-based living offers a valuable perspective for chronic conditions where symptom elimination is not always possible. However, the paper modestly concludes that while the results are promising, they require validation through future randomized controlled trials (RCTs). The authors note that the stagnation of some measures (QPR, CHIME) at follow-up indicates a need for structured aftercare and booster sessions to consolidate therapeutic gains. The study serves primarily as a foundation for power analyses in future controlled research rather than definitive proof of efficacy.