Strengthening Relationships Within Intensive Psychiatric Care: Staff Perceptions of an Attachment Training Intervention.

INTRODUCTION: Intensive psychiatric care units can be challenging environments in which to build strong staff-patient relationships. Attachment theory may provide a useful model for strengthening relationships in this setting. AIM: The aim of this study was to explore staff perceptions of the utility of attachment theory for understanding patient behaviour in the intensive psychiatric care setting. METHODS: Semi-structured interviews were conducted with 11 multi-disciplinary staff members. Interviews focused on the staff member's experience of learning about attachment theory and applying this perspective to their work on the ward. Transcripts were analysed using reflexive thematic analysis. RESULTS: The analysis led to the development of three themes: engaging the reflective self, new perspective on others and cohesive ward culture. CONCLUSION: Staff reported that learning about attachment theory supported them to better understand patient distress and associated behaviours. Notably, staff also used attachment theory to reflect on both their own internal states and the internal states of their colleagues. These reflections were suggested to bolster staff wellbeing and improve the ward milieu. IMPLICATIONS FOR PRACTICE: Integrating attachment theory into team formulation, ward rounds and reflective practice groups could have a benefit for clinical practice, staff wellbeing and team cohesion in this setting.

Screening for psychosis risk in primary mental health care services - Implementation, prevalence and recovery trajectories.

OBJECTIVES: Early interventions improve outcomes for people at high risk of psychosis and are likely to be cost saving. This group tends to seek help for emotional problems - depression and anxiety - via primary care services, where early detection methods are poor. We sought to determine prevalence rates of high risk for psychosis in UK primary care mental health services and clinical outcomes following routinely delivered psychological therapies. METHODS: We used a brief screen designed for settings with low base rates and significant time constraints to determine prevalence of high risk for psychosis in UK 'Talking Therapies' services. We examined socio-demographic characteristics, presenting problems and recovery trajectories for this group, compared with people not at risk of psychosis. RESULTS: A 2-item screen selected for specificity yielded a prevalence rate of 3% in primary care mental health services. People at elevated risk of psychosis were younger and more likely to report at least one long-term physical condition. This group presented with higher levels of depression, anxiety and trauma symptoms at assessment and were less likely to have recovered at the end of treatment, compared to people not at risk. CONCLUSIONS: Very brief screening tools can be implemented in busy health care settings. The 3% of referrals to UK primary care psychological therapies services at elevated risk of psychosis typically present with more severe symptoms and greater levels of comorbidity and may require augmented interventions to recover fully.

Psychosis and help-seeking behaviour-A systematic review of the literature.

PURPOSE: Many people with psychosis do not seek help which delays access to recommended treatments. Duration of untreated psychosis is associated with poor healthcare outcomes and increased risk of relapse. The reasons why people delay accessing treatment remain unclear. This is the first systematic review to synthesise the literature examining professional and non-professional help-seeking in psychosis across clinical and subclinical populations. METHODS: We searched four databases (APA PsycINFO, APA PsycArticles, Medline and British Library EThOS) to generate a comprehensive account of the quantitative literature. Heterogeneity of measures precluded a meta-analysis. RESULTS: We identified 19 articles (including 9686 participants) that met criteria for the review. Help-seeking in psychosis is associated with being female, having a higher level of education, and experiencing more than one symptom. People with psychosis report stigma, poor mental health literacy and lack of family support as key barriers. Clinicians report childhood physical abuse, insecure attachment and severity of psychosis as additional barriers. We also found differences in preferred sources of help across cultures. There is currently no consensus on reliable help-seeking measures. CONCLUSIONS: This is the first systematic review to examine help-seeking behaviour in psychosis. Assertive and culturally sensitive engagement efforts should be targeted towards people with a history of early adversity, poor mental health literacy, limited social support and more severe psychosis.

Secure attachment imagery facilitates help-seeking and help-acceptance in psychosis.

OBJECTIVES: People with psychosis delay accessing recommended treatments, resulting in poor healthcare outcomes and increased risk of relapse. Means of improving help-seeking and help-acceptance could reduce duration of untreated psychosis (DUP). This study examined the role of attachment style in help-seeking and help-acceptance in psychosis. DESIGN: We used an experimental design to test the effect of attachment imagery priming on help-seeking and help-acceptance intentions, in a sample with self-reported psychosis. The independent variables were attachment imagery condition (secure vs. avoidant) and time (pre- vs. post-prime). The dependent variables were state paranoia, help-seeking intentions and help-acceptance intentions. METHODS: We used an online research platform to recruit people with psychosis (n = 61). Participants were randomly allocated to the secure or avoidant attachment priming condition. All completed measures of state paranoia, help-seeking, and help-acceptance, before and after priming. RESULTS: In comparison with the avoidant condition, secure attachment imagery resulted in reduced paranoia and increased help-seeking and acceptance intentions, all with large effect sizes. CONCLUSIONS: This is the first study to use an experimental design to assess the role of attachment style in help-seeking and help-acceptance in a clinical sample. Attachment style is causally linked to behavioural intentions that contribute to DUP. Clinicians should assess attachment and help-seeking and acceptance, highlight these in formulation, and prioritise in treatment planning. Interventions that enhance help-seeking and acceptance could improve access to recommended treatments and reduce DUP.

Does insecure attachment lead to psychosis via dissociation? A systematic review of the literature.

PURPOSE: Insecure attachment may constitute a vulnerability factor for psychosis, and dissociation may be a key mechanism in the development of auditory hallucinations specifically. While there is good evidence for the role of these processes in isolation, it is unclear whether dissociation accounts for the association between insecure attachment and psychosis. This systematic review takes a theory-driven approach to examine proposed causal relationships across the clinical and nonclinical literature. METHODS: We searched five databases (PubMeD, Web of Science, PsycINFO, CINAHL and ETHOS) for published and unpublished research examining attachment, dissociation and psychosis. Two independent reviewers extracted the data and assessed the quality of all included studies. RESULTS: We identified 242 potential articles and included 13 in the final review (2096 participants). We found that (1) disorganised attachment was consistently associated with dissociation and inconsistently associated with voices and paranoia, (2) dissociation was associated with voices and paranoia, and these links were stronger in clinical samples, and (3) dissociation played a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups. CONCLUSIONS: This is the first review to synthesise the research examining attachment, dissociation, and psychosis. The evidence is consistent with proposed causal hypotheses and raises conceptual and measurement issues, for example, the need to clarify the relative contributions of different insecure attachment styles, and utilise behavioural/observational measures to strengthen study designs. Most importantly, we need experimental and longitudinal studies to confirm causal links and targets for treatment.

Cognitive behavioural therapy for psychosis: The end of the line or time for a new approach?

PURPOSE: Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta-analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes. METHOD: We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp. RESULTS: Modest effect sizes from meta-analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma). CONCLUSIONS: It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis.

Early intervention in psychosis services: A systematic review and narrative synthesis of barriers and facilitators to seeking access.

BACKGROUND: The duration of untreated psychosis (DUP) continues to be a global priority. Early intervention services were established to reduce treatment delays but have had limited impact. This systematic review examines barriers and facilitators to seeking access to these services, to identify targets for service level change. METHODS: We conducted a systematic review of relevant databases (PsychINFO, MEDLINE, CINAHL, and PsychARTICLES) using pre-defined search terms for psychosis, early intervention, and barriers and facilitators. Given the majority of qualitative studies, a thematic synthesis rather than meta-analysis was indicated. RESULTS: The search yielded 10 studies. Mental health stigma and discrimination predict DUP, compounded by structural barriers which limit the impact of early intervention services on timely access to recommended treatments. Synthesis of the qualitative studies generated three themes: knowledge, relationships, and stigma. Lack of knowledge, absence of supportive relationships (social and professional), and self-stigma constitute significant barriers to seeking access to early intervention services. CONCLUSIONS: This is the first review of the barriers and facilitators to seeking access to early intervention services. The findings highlight public health and secondary care service targets to expedite access to recommended treatments and thereby reduce the DUP.

Emotional and non-emotional mental imagery and auditory verbal hallucinations (hearing voices): A systematic review of imagery assessment tools.

It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non-emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non-emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full-text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non-emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non-emotional mental imagery.

Self-compassion as a mediator of the relationship between childhood sexual abuse and psychotic symptoms in clinical and non-clinical groups.

BACKGROUND: Previous research has shown a link between childhood sexual abuse (CSA) and more severe symptoms of psychosis. There is also evidence that self-compassion is a key mechanism linking adverse childhood experiences and mental health problems such as post-traumatic stress disorder and depression, but no research has examined these links in psychosis. METHODS: We analysed existing cross-sectional data, including 55 individuals with psychosis and 166 individuals from the general population. Participants completed standardized measures of CSA, self-compassion, paranoia, positive psychotic symptoms and distress linked to psychosis. RESULTS: The clinical group had higher scores on CSA and all psychosis measures, but we found no differences in self-compassion between the groups. Higher levels of CSA correlated with lower self-compassion and higher paranoia and positive symptoms in both groups. CSA also correlated with distress linked to psychosis in the non-clinical group. Lower self-compassion mediated the association between higher levels of CSA and more severe paranoia in both groups. In the non-clinical group, lower self-compassion also mediated the association between greater CSA and more positive psychotic symptoms and more severe distress. CONCLUSIONS: This is the first study to show that self-compassion mediates the link between CSA and both paranoia and psychotic symptoms in adulthood. Self-compassion may therefore be an important transdiagnostic candidate target in therapy to mitigate the impact of early adversity on paranoia in both clinical and non-clinical groups. Limitations include the small clinical sample and inclusion of a cannabis-using non-clinical sample, though recent cannabis use did not impact self-compassion levels.

Does disorganised attachment lead to auditory hallucinations via dissociation? An experimental study with an analogue sample.

OBJECTIVES: Auditory hallucinations (such as hearing voices) are common in clinical and non-clinical populations. Many people who hear voices also report early adversity and have an insecure attachment style. Current cognitive models suggest that dissociation mediates an association between disorganised attachment and auditory hallucinations, but this has not been tested experimentally. DESIGN: We recruited a non-clinical analogue sample highly predisposed to auditory hallucinations and utilised an experimental design to examine the impact of disorganised attachment imagery on hallucinatory experiences, and whether dissociation mediates an expected association. METHODS: Participants completed self-report measures of state auditory hallucinations and dissociation before and after random allocation to secure or disorganised attachment conditions. RESULTS: Attachment imagery did not affect auditory hallucinations. Both secure and disorganised attachment conditions increased state dissociation. Secure attachment imagery reduced paranoia, but state dissociation did not mediate this effect. An exploratory analysis found that trait dissociation fully accounted for the association between trait-disorganised attachment and hallucinatory experience while controlling for paranoia. CONCLUSIONS: Secure attachment imagery reduces paranoia but not auditory hallucinations and the impact on paranoia is not mediated by dissociation. Secure attachment imagery may be useful in reducing fears and distress associated with voices, rather than the frequency or severity of hallucinations. Disorganised attachment may increase hallucinatory experiences for people vulnerable to dissociation. Trait dissociation should be assessed in clinical settings and addressed where indicated as a means of targeting vulnerability to distressing voices.

Do emotion regulation strategies mediate the attachment-paranoia association? An experimental study of repeated attachment imagery priming and stress buffering.

OBJECTIVES: Paranoia describes unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but limited research examines mechanisms of change and no studies examine how secure imagery may be implemented most effectively in clinical practice. In this study, we tested: (a) the causal impact of secure, anxious, and avoidant attachment imagery on paranoia and anxiety, (b) whether emotion regulation strategies mediate these relationships, and (c) whether secure imagery buffers against social stress. DESIGN: We utilized a longitudinal, experimental design. METHOD: A general population sample with high non-clinical paranoia (N = 265) completed measures of paranoia, anxiety, and emotion regulation strategies. Participants were randomly allocated to secure, anxious, or avoidant conditions and repeated an imagery prime for four days prior to a social stress task. RESULTS: Relative to anxious and avoidant imagery, secure imagery decreased state paranoia and anxiety. These associations were not mediated by state emotion regulation strategies, and secure imagery did not buffer against stress. Exploratory analyses on trait variables revealed that: (a) hyperactivating strategies mediated the association between attachment anxiety and paranoia, and (b) suppression mediated the association between attachment avoidance and paranoia. CONCLUSIONS: Secure attachment imagery reduces state paranoia and anxiety and could be incorporated into psychotherapies to attenuate clinical paranoia. Measurement of state emotion regulation was problematic. Attachment imagery does not buffer stress; further research is required to test whether secure imagery facilitates recovery from stress. Attachment style is likely to account for trait paranoia via attachment-congruent emotion regulation strategies. Research is now needed to determine if these strategies can be targeted to alleviate paranoia in clinical populations.

How does insecure attachment lead to paranoia? A systematic critical review of cognitive, affective, and behavioural mechanisms.

BACKGROUND: The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis. METHOD: We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment-paranoia association. RESULTS: We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self- and other-beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment-secure people with psychosis are more likely to seek help and engage with services than attachment-insecure people. CONCLUSIONS: Attachment styles impact help-seeking behaviours in people with psychosis and are likely to influence paranoia via self- and other-beliefs, cognition fusion, and emotion regulation - these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia. PRACTITIONER POINTS: Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes. People with psychosis who are attachment-secure are more likely to seek help and engage with services than those who are attachment-insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help-seeking behaviours in people with psychosis. Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change.

Pathways from insecure attachment to paranoia: the mediating role of emotion regulation.

BACKGROUND: Paranoia is common across the clinical and non-clinical spectrum. Cognitive behavioural therapy for psychosis currently yields modest results, warranting research into symptom-specific maintenance factors to improve outcomes. There is strong evidence of a relationship between insecure attachment and increased paranoia, but little is known about the mediating mechanisms. Emotion dysregulation is associated with both insecure attachment and paranoia, and a candidate causal mechanism. AIMS: This study aimed to determine if emotion dysregulation mediates the association between attachment and paranoia. METHOD: Sixty-two individuals with elevated paranoia were recruited from NHS services and community settings across the South of England. Mediation analyses were conducted on trait attachment, emotion regulation and paranoia variables, which were collected at one time point. RESULTS: As predicted, emotion dysregulation mediated the relationship between attachment avoidance and paranoia, and between attachment anxiety and paranoia. Emotion suppression did not mediate the relationship between attachment avoidance and paranoia, possibly due to power. Attachment avoidance correlated with deactivating emotion regulation strategies (e.g. lack of emotional awareness) and attachment anxiety correlated with hyperactivating emotion regulation strategies (e.g. impulse control difficulties). Both deactivating and hyperactivating strategies correlated with paranoia. CONCLUSION: Emotion dysregulation is not routinely targeted in cognitive behavioural therapy for psychosis. This study suggests that incorporating emotion regulation strategies in therapy may improve clinical outcomes. Experimental studies are now required to support a causal argument, and pilot intervention studies should investigate if emotion regulation skills development (aligned with attachment style) is effective in reducing non-clinical and clinical paranoia.

How does attachment style affect psychosis? A systematic review of causal mechanisms and guide to future inquiry.

PURPOSE: The link between attachment and psychosis is now well established, but less is known about the causal mechanisms underlying this relationship. This systematic review synthesises the studies that examine mediating mechanisms in the attachment and psychosis relationship, in both clinical and non-clinical samples. METHOD: We conducted a database search (PsychINFO, MEDLINE, Web of Science) to identify all eligible studies irrespective of publication status, the language of article or article date. We assessed methodological quality and completed a narrative synthesis given the heterogeneity of studies to date. RESULTS: We identified 17 papers, comprising 3,672 participants. The relationship between attachment and psychosis is mediated by four variables or groups of variables. There is good evidence for the causal role of affective factors (affective dysregulation and affective disturbances) and cognitive factors (e.g., self-beliefs and self-esteem and beliefs about symptoms). Affective factors differed by attachment style. Tentative evidence was found for the role of duration of untreated psychosis and baseline negative symptoms. CONCLUSIONS: Cognitive and affective factors mediate the relationship between attachment style and psychosis. Whilst cognitive factors are routinely targeted in recommended psychological interventions for psychosis, affective factors and attachment style are less commonly considered. Psychological therapies may be improved by calibrating cognitive and affective interventions by attachment style, which should be subjected to experimental and then field studies to assess the impact on clinical and recovery outcomes. PRACTITIONER POINTS: The relationship between attachment and psychosis is now well established, and studies have started to examine mediating mechanisms. Affective and cognitive factors mediate the attachment-psychosis relationship. Affective factors differ by attachment style. There is limited evidence for the duration of untreated psychosis and negative psychotic symptoms as mediating mechanisms, and research replication is needed. Cognitive factors are routinely targeted in recommended psychological therapies for psychosis, but affective factors and attachment style are less commonly considered. Research should be conducted into the effectiveness of psychological therapies which calibrate cognitive and affective interventions, according to attachment style.

Lessons from an aborted controlled trial on the impact of befriending in an early intervention in psychosis population.

AIM: The current study aimed to explore the effects of organized befriending for an Early Intervention in Psychosis (EIP) population. METHODS: Participants were randomly assigned to control or intervention groups. Those in the befriending arm were paired based on a shared interests questionnaire. Qualitative and quantitative methods were planned to assess experience and impact of the intervention across clinical and recovery outcomes. We aimed to recruit 60 participants, however only 16 participants completed the trial. RESULTS: The study was unsuccessful due to issues with recruitment and retention of participants. We gathered feedback from those who withdrew, to understand this better. CONCLUSIONS: We offer our observations to other clinicians who may be considering similar research. A more assertive researcher-led approach over the first few meetings between matched pairs is likely to have been more effective in retaining participants' engagement in the study.

The Impact of Repeated Attachment Priming on Paranoia, Mood and Help-Seeking Intentions in an Analogue Sample.

Attachment security priming effects therapeutic change in people with depression and anxiety. Preliminary studies indicate that visualising secure attachment memories also reduces paranoia in non-clinical and clinical groups, probably due to a decrease in cognitive fusion. Benefits to clinical populations depend on the sustainability of these effects and the impact on help-seeking behaviours. The combination of paranoia and an insecure-avoidant attachment style is likely to be a particular barrier to help seeking. We used a longitudinal experimental design to test the impact of repeated attachment priming on paranoia, mood and help-seeking intentions and whether cognitive fusion mediates these effects. Seventy-nine people with high levels of non-clinical paranoia, aged 18-50 years (M = 20.53, SD = 4.57), were randomly assigned to a secure or insecure-avoidant priming condition. Participants rehearsed the visualisation prime on four consecutive days and were assessed on standardised measures of paranoia, positive and negative affect, help-seeking intentions and cognitive fusion. A series of mixed-model analyses of variance showed that security priming decreases paranoia, negative affect and cognitive fusion and increases positive affect and help seeking, compared to insecure-avoidant priming. Examining the impact of primed attachment (rather than measured attachment style) allows us to draw conclusions about the causal processes involved; mediation analyses showed indirect effects of the primes on paranoia and negative affect through cognitive fusion. With a growing understanding of (1) the impact of security priming on paranoia, affect and help-seeking behaviours, (2) causal mechanisms and (3) sustainability of effects, security priming may be developed into a viable intervention for clinical populations.

How does attachment imagery for paranoia work? Cognitive fusion and beliefs about self and others mediate the impact on paranoia and anxiety.

OBJECTIVES: Paranoia describes unfounded and distressing interpersonal threat beliefs. Secure attachment imagery has been shown to attenuate paranoia and anxiety in non-clinical and clinical groups, but little is known about the differential effects of anxious and avoidant imagery or mechanisms of change. In this study, we tested the impact of secure, anxious, and avoidant attachment imagery on paranoia, anxiety, and help-seeking intentions. We also examined hypothesized mechanisms of change, specifically whether cognitive fusion and negative self- and other-beliefs mediate these relationships. DESIGN: This study utilized an experimental, cross-sectional design. METHODS: A large (N = 303), international general population sample with high levels of non-clinical paranoia completed a series of measures before and after engaging in secure, anxious, or avoidant imagery. RESULTS: Relative to anxious and avoidant attachment imagery, secure attachment imagery reduced paranoia and anxiety and increased help-seeking intentions. Cognitive fusion and negative self- and other-beliefs mediated the impact of attachment imagery on paranoia and anxiety, but not help-seeking. CONCLUSIONS: In line with attachment and cognitive theory, secure attachment imagery is effective in reducing paranoia and anxiety and works by reducing cognitive fusion and negative self- and other-beliefs. These novel findings suggest that the secure imagery task could be incorporated into cognitive and behavioural therapies to reduce distressing interpersonal threat beliefs and associated negative affect, and increase help-seeking intentions. PRACTITIONER POINTS: When working with people experiencing paranoia, secure attachment imagery may be effective in reducing state paranoia and anxiety and improving help-seeking intentions. Attachment imagery works by influencing beliefs about self and others, and the degree to which people are fused with their beliefs. In clinical practice, the rationale for the imagery task fits well with psychological models of paranoia and the secure imagery task can be introduced as a way to cope when struggling with distressing beliefs about self and others, and feeling overwhelmed by these fears.

Targeting affect leads to reduced paranoia in people with psychosis: a single case series.

BACKGROUND: Current psychological interventions for psychosis focus primarily on cognitive and behavioural management of delusions and hallucinations, with modest outcomes. Emotions are not usually targeted directly, despite evidence that people with psychosis have difficulty identifying, accepting and modifying affective states. AIMS: This study assessed the impact of emotion regulation skills practice on affect and paranoia in seven people who met criteria for a diagnosis of schizophrenia or schizoaffective disorder. METHOD: The study utilised a single case ABA design and measured emotion regulation skills, affect and paranoia over baseline, intervention and withdrawal of intervention phases. We predicted that eight sessions of skills rehearsal would lead to improved emotion regulation, reduced negative affect, increased positive affect, and reduced paranoia. RESULTS: Most participants were able to learn to regulate their emotions, and reported reduced negative affect and paranoia. There was no clear pattern of change for positive affect. CONCLUSIONS: These findings suggest that emotion can be targeted in psychosis, and is associated with reduced paranoia. Emotion regulation may constitute a key treatment target in cognitive behavioural therapy for psychosis.

Impact of attachment imagery on paranoia and mood: evidence from two single case studies.

BACKGROUND: Cognitive behavioural therapy (CBT) for psychosis currently yields modest outcomes and must be improved. Attachment imagery may be an effective means of reducing severity of paranoid beliefs and associated affect. Experimental studies have demonstrated these effects in non-clinical groups. The impact in clinical populations remains untested. AIMS: This study assessed the impact of a brief attachment imagery task on paranoia and mood, in two people with a diagnosis of schizophrenia. METHOD: Two single case studies are presented. Both participants were working age adults with persecutory delusions. The study utilised an A-B-A design. Participants were recruited for a 6-week period, with a 2- and 3-week baseline respectively, 1-week intervention phase, and follow-up phase matched to duration of baseline. Trait paranoia and attachment were measured at the start of the baseline. State paranoia and affect were measured daily over the 6-week period. RESULTS: For both participants, the baseline phase was characterised by high and variable levels of paranoia, which reduced during the intervention phase, with a return to baseline scores at follow-up. We found a similar pattern for negative affect, and the reverse pattern for positive affect. CONCLUSIONS: Attachment imagery may function as an effective emotion regulation strategy for people with psychosis. Continued use is likely to be needed to maintain gains. This brief task could prove valuable to people needing skills to manage paranoia and mood, and give clinicians confidence that people can manage short-term distress in CBT for psychosis, for example when addressing past trauma.