How can we measure psychological safety in mental healthcare staff? Developing questionnaire items using a nominal groups technique.

There have been growing concerns about the well-being of staff in inpatient mental health settings, with studies suggesting that they have higher burnout and greater work-related stress levels than staff in other healthcare sectors. When addressing staff well-being, psychological safety can be a useful concept. However, there is no measure of psychological safety that is suitable for use in inpatient mental health settings. Edmondson (1999) is the most commonly used measure of psychological safety, but it was designed for use in general physical healthcare settings. As inpatient mental health settings are unique environments, transferability of knowledge from physical to mental healthcare settings cannot be assumed. We sought to develop questionnaire items that capture psychological safety among healthcare staff working in acute inpatient mental healthcare settings. We used the nominal group technique, a consensus method involving rounds of discussion, idea generation, and item rating/ranking to identify priorities. Twenty-eight stakeholders participated, including 4 who had lived experience of mental health problems, 11 academics and 18 healthcare professionals (8 participants identified with more than 1 category). The study involved a workshop with three parts: (i) an overview of current research and limitations of the Edmondson (1999) measure as outlined above, (ii) discussion on what items should be retained from the Edmondson (1999) measure, and (iii) discussion on what items should be added to the Edmondson (1999) measure. Twenty-one items were generated and retained to capture psychological safety in inpatient mental health settings. These measure professionals' sense of being valued by their team and organization, feeling supported at work, feeling physically safe and protected from physical harm, and knowing they can raise concerns about risk and safety. This is the first study to generate questionnaire items suitable for measuring staff psychological safety in mental health settings. These have been generated via a consensus method to ensure stakeholders' views are reflected. Further research is needed to evaluate factor structure, internal reliability, and convergent validity.

The outcomes of imagery-focused interventions in relation to distress in people with delusions: a systematic literature review.

BACKGROUND: Imagery-focused therapies within cognitive behavioural therapy are growing in interest and use for people with delusions. AIMS: This review aimed to examine the outcomes of imagery-focused interventions in people with delusions. METHOD: PsycINFO, PubMed, MEDLINE, Web of Science, EMBASE and CINAHL were systematically searched for studies that included a clinical population with psychosis and delusions who experienced mental imagery. The review was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and quality appraisal of all included papers was completed using the Crowe Critical Appraisal Tool. Information from included texts was extracted and collated in Excel, which informed the narrative synthesis of results. RESULTS: Of 2,736 studies identified, eight were eligible for inclusion and rated for quality with an average score of 70.63%. These studies largely supported their aims in reducing levels of distress and intrusiveness of imagery. Four of the eight studies used case series designs, two were randomised controlled trials, and two reported single case studies. It appears that interventions targeting mental imagery were acceptable and well tolerated within a population of people experiencing psychosis and delusions. CONCLUSIONS: Some therapeutic improvement was reported, although the studies consisted of mainly small sample sizes. Clinical implications include that people with a diagnosis of psychosis can engage with imagery-focused therapeutic interventions with limited adverse events. Future research is needed to tackle existing weaknesses of design and explore the outcomes of imagery interventions within this population in larger samples, under more rigorous methodologies.

Imagery-Focused Therapy for Visual Hallucinations: A Case Series.

INTRODUCTION: Visual hallucinations (VH) are more common than previously thought and are linked to higher levels of distress and disability in people with a psychotic illness. Despite this, scant attention has been given to VHs in the clinical literature, and the few therapy case series of cognitive behavioural therapy (CBT) published to date have not demonstrated reliable change. In other areas of clinical research, problematic mental imagery has been found to be more strongly related to negative affect in psychological disorders than negative linguistic thinking, and imagery focused techniques have commonly been found to improve the outcomes in CBT trials. Given VHs have many similarities with visual mental imagery and many of the distressing beliefs associated with VHs targeted in CBT are maintained by accompanying mental imagery (i.e., imaging a hallucinated figure attacking them), it seems plausible that an imagery-focused approach to treating VHs may be most effective. METHODS: The current study is a multiple baseline case series (N = 11) of a 10-session imagery-focused therapy for VH in a transdiagnostic sample. RESULTS: The study had good attendance and feedback, no adverse events and only one [seemly unrelated] drop-out, suggesting good feasibility, safety and acceptability. The majority of clients reported reduction on both full-scale measures (administered at 3 baselines, midtherapy, posttherapy and 3-month follow-up) and weekly measures of VH severity and distress, ranging from medium to large effect sizes. CONCLUSIONS: The case series suggests that an imagery-focused approach to treating VHs may be beneficial, with a recommendation for more rigorous clinical trials to follow.

Attachment-focused iMAgery therapy for PSychosis (A-iMAPS): A case series targeting psychosis-related trauma.

OBJECTIVES: The experience of psychosis and its sequelae (including treatment experiences) can be traumatic and affect feelings of safety and security. Until relatively recently, trauma therapy has been avoided with psychosis populations due to concerns about additional harm. Intervention-based research is growing, but focus on psychosis-related trauma is limited. Engendering psychological safety may support engagement with trauma-focused therapy, for which attachment theory provides a strong foundation. Imagery can enhance felt security and is an effective modality for working with trauma. Therefore, this study aimed to examine feasibility and preliminary outcomes of a novel attachment-focused imagery therapy (A-iMAPS) addressing psychosis-related trauma. METHODS: A multiple baseline case series: Participants received between two and five baseline assessments then engaged in the six-session A-iMAPS intervention. Participants completed weekly measures of trauma symptoms and felt security. Further measures were completed pre- and post-intervention. RESULTS: Twelve clinical participants were recruited from NHS services in Northwest England and eight retained through baseline and intervention to the end-of-therapy assessment (attending all sessions). A significant improvement was seen for felt security between baseline and intervention phases. Other measures of trauma symptoms, core schemas, paranoia and attachment varied in change from baseline to end of therapy, but some promising preliminary results were seen. CONCLUSIONS: This study shows that a brief attachment-focused imagery therapy is a promising intervention for targeting psychosis-related trauma, for which there are currently no other specific intervention studies. Utilizing an attachment-informed framework when working with trauma in psychosis should be considered in future intervention studies.

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.

Commentary: Bringing together lived experience, clinical and research expertise - a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?).

BACKGROUND: There is a wealth of evidence to suggest that the Borderline Personality Disorder (BPD, or similar Emotionally Unstable Personality Disorder, EUPD) construct is harmful. We provide a commentary on the ideas expressed in the May Debate issue, highlighting both concerns and alternatives. METHOD: We bring together lived experience, clinical and research expertise. This commentary was written collaboratively drawing on all these sources of evidence. RESULTS: We outline evidence that the BPD construct is invalid, harmful, not necessary for effective treatment and a potential block to the development and evaluation of alternatives. CONCLUSIONS: We ask readers to consider these concerns, perspectives and ideas.

Characterizing core beliefs in psychosis: a qualitative study.

BACKGROUND: Cognitive behavioural treatments are recommended for people with psychosis. Core beliefs regarding the self and others are a key part of the models underpinning cognitive behavioural therapy but detailed understanding of these putative beliefs in people with psychosis are limited. A greater understanding of these mechanisms is necessary to improve and refine treatments. AIMS: This study utilized a qualitative approach to explore core schematic beliefs in psychosis (strongly held positive and negative beliefs about the self and others) and their relation to hallucinations and delusions. METHOD: Twenty individuals with psychosis participated in individual semi-structured interviews. Inductive thematic analysis was used to analyse the interviews. RESULTS: Four emergent themes were identified: (i) the solidity and permanency of core beliefs, (ii) the causes and development of core beliefs, (iii) a synergistic relationship between core beliefs and symptoms, and (iv) core beliefs associated with images and their influence on psychotic symptoms. CONCLUSIONS: This study provides new insights into the range and character of core beliefs in psychosis and provides important data to guide ongoing and future development of treatment approaches for psychosis.

iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS): a multiple baseline experimental case series.

BACKGROUND: Many people with psychosis experience persecutory delusions and report negative schematic beliefs and intrusive mental images which may be maintaining factors for psychotic symptoms. AIMS: This study examined the feasibility and acceptability of a new psychological therapy targeting schemas and images (iMAPS therapy). METHOD: The study used a randomised multiple baseline design. Participants with first episode psychosis were randomised using a multiple baseline design with 2-5 assessments. Six sessions of therapy, consisting of a combination of imagery techniques and imagery rescripting techniques, was used. In each session, participants completed a Mental Imagery in Psychosis Questionnaire (MIPQ) and imagery interview. Mood and delusional beliefs (PSYRATS) were also measured at each session. RESULTS: Five participants with first episode psychosis completed the baseline visits and attended all therapy sessions. One participant declined the final assessment. Results demonstrated significant reductions in negative schematic beliefs, delusions, imagery distress and other measures of schema (YSQ, SMI). Although multiple baseline randomisation strengthens the study, it lacked a control arm and blind assessments. CONCLUSIONS: iMAPS appears a feasible and acceptable treatment for psychosis, and further evaluation is indicated.

Delivery of cognitive-behaviour therapy for psychosis: a service user preference trial.

BACKGROUND: Clinical guidelines recommend cognitive behaviour therapy (CBT) for people with psychosis, however, implementation is poor and not everyone wishes to engage with therapy. Understanding service user (SU) preferences for receiving such treatments is a priority for services. AIMS: To explore SU preferences and outcomes of different methods of delivering CBT for psychosis. METHOD: SUs experiencing psychosis could choose between treatment as usual (TAU); TAU plus telephone-delivered CBT with self-help, CBT recovery manual (TS); high support CBT (HS - TAU plus TS plus group sessions) or randomisation. Participants received their option of choice and were followed-up on several outcomes over 9 and 15 months. RESULTS: Of 89 people recruited, three chose to be randomised and 86 expressed a treatment preference (32 chose TAU, 34 chose TS, 23 chose HS). There were few differences between those who chose therapy compared to those who chose TAU. Those who had more positive impacts from their symptoms were significantly more likely to choose TAU. CONCLUSIONS: Most people had strong preferences about treatment delivery and a substantial number did not wish to receive additional therapy. These findings have to be considered when planning and allocating resources for people with psychosis.

Assessing therapist adherence to recovery-focused cognitive behavioural therapy for psychosis delivered by telephone with support from a self-help guide: psychometric evaluations of a new fidelity scale.

BACKGROUND: Recent research has highlighted the importance of psychological interventions such as cognitive behavioural therapy (CBT) in improving outcomes and promoting recovery for people with experience of psychosis, although a lack of trained therapists means that availability of face-to-face CBT is low. Alternative modes of delivering CBT are being explored, such as telephone and self-help methods, although research to date on whether they can be implemented effectively is limited. AIMS: The aims of the present study were to describe and evaluate a new therapy fidelity scale (ROSTA; Recovery Oriented Self-help and Telephone therapy Adherence). This scale was developed to assess fidelity to cognitive behaviour therapy for psychosis (CBTp) focused on improving recovery, with optional subscales for delivery over the telephone and alongside a self-help guide. METHOD: Experienced CBT therapists rated recorded therapy sessions using the ROSTA scale. The scores were used to assess internal consistency and inter-rater reliability, before being compared to scores from an independent expert rater using an alternative fidelity scale for cognitive therapy in psychosis (the CTS-Psy), to investigate concurrent validity. RESULTS: The ROSTA scale demonstrated excellent internal consistency, inter-rater reliability and validity when evaluated as a whole, although findings were mixed in terms of the individual subscales and items. CONCLUSIONS: The ROSTA scale is, on the whole, a reliable and valid tool, which may be useful in training and supervision, a utility that would be further emphasized if the therapeutic intervention it assesses is deemed to be efficacious based on future work.

Assessing the delivering of iMAgery-focused therapy for PSychosis (iMAPS) via telehealth.

OBJECTIVES: To examine the feasibility and acceptability of a novel telehealth (video-conferencing software and telephone calls) imagery-based therapeutic intervention for people experiencing persecutory delusions. Utilising a multiple baseline case series design and exploring imagery-focused therapy for psychosis (iMAPS). DESIGN: A non-concurrent A-B multiple baseline design was used. METHODS: Participants experiencing persecutory delusions and self-reporting a psychosis or schizophrenia-spectrum diagnosis were recruited through online adverts. On completion of assessments, participants were randomly assigned to multiple baseline assessments, of between three and five sessions. Six therapy sessions followed, consisting of imagery formulation, safe-place imagery creation, compassionate imagery, imagery manipulation and rescripting. Participants completed pre- and post-measures and sessional measures via an online survey software or in semi-structured interviews. Two weeks post-intervention, a final measure was completed exploring any potential adverse effects of psychotherapy. RESULTS: Five female participants completed all baseline and therapeutic sessions, suggesting the therapy was and mode of delivery was feasible and acceptable. Results indicate strong effect sizes across PANSS positive subscale and mood, as well as participants reporting a clinically significant change in at least one measure, for example, PSYRATS. All participants reported a reduction in the realness and compelling nature of distressing imagery. CONCLUSIONS: Results suggest delivering a telehealth imagery-focused therapy is acceptable and feasibly delivered via telehealth. A control group and blinding of assessments would strengthen the methodological limitations present.

Trauma measures for use with psychosis populations: A systematic review of psychometric properties using COSMIN.

Traumatic events play a key role in the development and course of psychosis. Psychotic symptoms themselves and coercive treatment practices can be inherently traumatic. Hence, reliable and valid methods of assessing trauma and its impact (i.e., Post-Traumatic Stress Disorder (PTSD) symptomology) are essential for use with people with psychosis. Many measures are available to select from, but this is the first review to appraise the psychometric properties of trauma measures to guide decision making regarding instrument use. The review was prospectively registered on Prospero (CRD42022306100). Evaluation of methodological and psychometric quality followed Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidance. Twenty-four articles were eligible, with sixteen trauma measures evaluated. Childhood Trauma Questionnaire- Short Form demonstrated the most robust evidence for assessing experience of trauma. The Trauma and Life Experience (TALE) checklist was the only measure to include specific psychosis and iatrogenic harm items. For PTSD measures, the Symptoms of Trauma Scale and PTSD Symptom Scale- Self Report had the highest quality evidence. Psychometric strengths and weaknesses of various trauma measures are comprehensively evaluated, highlighting future research directions to strengthen the evidence base with emphasis on further evaluation of the TALE, which integrates trauma specific to psychosis.

Accelerating the development of a psychological intervention to restore treatment decision-making capacity in patients with schizophrenia-spectrum disorder: a study protocol for a multi-site, assessor-blinded, pilot Umbrella trial (the DEC:IDES trial).

BACKGROUND: A high proportion of patients diagnosed with schizophrenia-spectrum disorders will at some point in their lives be assessed as not having the capacity to make their own decisions about pharmacological treatment or inpatient care ('capacity'). Few will be helped to regain it before these interventions proceed. This is partly because effective and safe methods to do so are lacking. Our aim is to accelerate their development by testing, for the first time in mental healthcare, the feasibility, acceptability and safety of running an 'Umbrella' trial. This involves running, concurrently and under one multi-site infrastructure, multiple assessor-blind randomised controlled trials, each of which is designed to examine the effect on capacity of improving a single psychological mechanism ('mechanism'). Our primary objectives are to demonstrate feasibility of (i) recruitment and (ii) data retention on the MacArthur Competence Assessment Tool-Treatment (MacCAT-T; planned primary outcome for a future trial) at end-of-treatment. We selected three mechanisms to test: 'self-stigma', low self-esteem and the 'jumping to conclusions' bias. Each is highly prevalent in psychosis, responsive to psychological intervention, and hypothesised to contribute to impaired capacity. METHODS: Sixty participants with schizophrenia-spectrum diagnoses, impaired capacity and one or more mechanism(s) will be recruited from outpatient and inpatient mental health services in three UK sites (Lothian, Scotland; Lancashire and Pennine; North West England). Those lacking capacity to consent to research could take part if the key criteria were met, including either proxy consent (Scotland) or favourable Consultee advice (England). They will be allocated to one of three randomised controlled trials, depending on which mechanism(s) they have. They will then be randomised to receive, over an 8-week period and in addition to treatment as usual (TAU), 6 sessions of either a psychological intervention which targets the mechanism, or 6 sessions of assessment of the causes of their incapacity (control condition). Participants are assessed at 0 (baseline), 8 (end-of-treatment) and 24 (follow-up) weeks post-randomisation using measures of capacity (MacCAT-T), mechanism, adverse events, psychotic symptoms, subjective recovery, quality of life, service use, anxiety, core schemata and depression. Two nested qualitative studies will be conducted; one to understand participant and clinician experiences and one to investigate the validity of MacCAT-T appreciation ratings. DISCUSSION: This will be the first Umbrella trial in mental healthcare. It will produce the first 3 single-blind randomised controlled trials of psychological interventions to support treatment decision-making in schizophrenia-spectrum disorder. Demonstrating feasibility will have significant implications not only for those seeking to support capacity in psychosis, but also for those who wish to accelerate the development of psychological interventions for other conditions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04309435 . Pre-registered on 16 March 2020.

Developing Best Practice Guidance for Discharge Planning Using the RAND/UCLA Appropriateness Method.

Background: Discharge from acute mental health inpatient units is often a vulnerable period for patients. Multiple professionals and agencies are involved and processes and procedures are not standardized, often resulting in communication delays and co-ordination failures. Early and appropriate discharge planning and standardization of procedures could make inpatient care safer. Aim: To inform the development of a multi-component best practice guidance for discharge planning (including the 6 component SAFER patient flow bundle) to support safer patient transition from mental health hospitals to the community. Methods: Using the RAND/UCLA Appropriateness method, a panel of 10 professional stakeholders (psychiatrists, psychiatric nurses, clinical psychologists, pharmacists, academics, and policy makers) rated evidence-based statements. Six hundred and sixty-eight statements corresponding to 10 potential components of discharge planning best practice were rated on a 9-point integer scale for clarity, appropriateness and feasibility (median ≥ 7-9) using an online questionnaire then remote online face-to-face meetings. Results: Five of the six "SAFER" patient flow bundle components were appropriate and feasible for inpatient mental health. One component, "Early Flow," was rated inappropriate as mental health settings require more flexibility. Overall, 285 statements were rated as appropriate and feasible. Forty-four statements were considered appropriate but not feasible to implement. Discussion: This consensus study has identified components of a best practice guidance/intervention for discharge planning for UK mental health settings. Although some components describe processes that already happen in everyday clinical interactions (i.e., review by a senior clinician), standardizing such processes could have important safety benefits alongside a tailored and timely approach to post-discharge care.

'Care co-ordinator in my pocket': a feasibility study of mobile assessment and therapy for psychosis (TechCare).

OBJECTIVES: The aim of the project was to examine the acceptability and feasibility of a mobile phone application-based intervention 'TechCare', for individuals with psychosis in the North West of England. The main objectives were to determine whether appropriate individuals could be identified and recruited to the study and whether the TechCare App would be an acceptable intervention for individuals with psychosis. METHODS: This was a mixed methods feasibility study, consisting of a test-run and feasibility evaluation of the TechCare App intervention. SETTING: Early Intervention Services (EIS) for psychosis, within an NHS Trust in the North West of England. PARTICIPANTS: Sixteen participants (test-run n=4, feasibility study n=12) aged between 18 and 65 years recruited from the East, Central and North Lancashire EIS. INTERVENTION: A 6-week intervention, with the TechCare App assessing participants' symptoms and responses in real-time and providing a personalised-guided self-help-based psychological intervention based on the principles of Cognitive Behaviorual Therapy (CBT). RESULTS: A total of 83.33% (n=10) of participants completed the 6-week feasibility study, with 70% of completers achieving the set compliance threshold of ≥33% engagement with the TechCare App system. Analysis of the qualitative data suggested that participants held the view that the TechCare was both an acceptable and feasible means of delivering interventions in real-time. CONCLUSION: Innovative digital clinical technologies, such as the TechCare App, have the potential to increase access to psychological interventions, reduce health inequality and promote self-management with a real-time intervention, through enabling access to mental health resources in a stigma-free, evidence-based and time-independent manner. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02439619.

Does schema therapy change schemas and symptoms? A systematic review across mental health disorders.

PURPOSE: Schema therapy was first applied to individuals with borderline personality disorder (BPD) over 20 years ago, and more recent work has suggested efficacy across a range of disorders. The present review aimed to systematically synthesize evidence for the efficacy and effectiveness of schema therapy in reducing early maladaptive schema (EMS) and improving symptoms as applied to a range of mental health disorders in adults including BPD, other personality disorders, eating disorders, anxiety disorders, and post-traumatic stress disorder. METHODS: Studies were identified through electronic searches (EMBASE, PsycINFO, MEDLINE from 1990 to January 2016). RESULTS: The search produced 835 titles, of which 12 studies were found to meet inclusion criteria. A significant number of studies of schema therapy treatment were excluded as they failed to include a measure of schema change. The Clinical Trial Assessment Measure was used to rate the methodological quality of studies. Schema change and disorder-specific symptom change was found in 11 of the 12 studies. CONCLUSIONS: Schema therapy has demonstrated initial significant results in terms of reducing EMS and improving symptoms for personality disorders, but formal mediation analytical studies are lacking and rigorous evidence for other mental health disorders is currently sparse. PRACTITIONER POINTS: First review to investigate whether schema therapy leads to reduced maladaptive schemas and symptoms across mental health disorders. Limited evidence for schema change with schema therapy in borderline personality disorder (BPD), with only three studies conducting correlational analyses. Evidence for schema and symptom change in other mental health disorders is sparse, and so use of schema therapy for disorders other than BPD should be based on service user/patient preference and clinical expertise and/or that the theoretical underpinnings of schema therapy justify the use of it therapeutically. Further work is needed to develop the evidence base for schema therapy for other disorders.