Catching the threads: caregiving in Alzheimer's disease.

As someone who has researched the effects on carers living with people with severe psychiatric disorders, the author describes her own recent experience of being a carer. The article serves as a companion piece to her psychiatrist husband's account of his cognitive decline in Alzheimer's disease.

Sexual abuse and psychotic phenomena: a directed acyclic graph analysis of affective symptoms using English national psychiatric survey data.

BACKGROUND: Sexual abuse and bullying are associated with poor mental health in adulthood. We previously established a clear relationship between bullying and symptoms of psychosis. Similarly, we would expect sexual abuse to be linked to the emergence of psychotic symptoms, through effects on negative affect. METHOD: We analysed English data from the Adult Psychiatric Morbidity Surveys, carried out in 2007 (N = 5954) and 2014 (N = 5946), based on representative national samples living in private households. We used probabilistic graphical models represented by directed acyclic graphs (DAGs). We obtained measures of persecutory ideation and auditory hallucinosis from the Psychosis Screening Questionnaire, and identified affective symptoms using the Clinical Interview Schedule. We included cannabis consumption and sex as they may determine the relationship between symptoms. We constrained incoming edges to sexual abuse and bullying to respect temporality. RESULTS: In the DAG analyses, contrary to our expectations, paranoia appeared early in the cascade of relationships, close to the abuse variables, and generally lying upstream of affective symptoms. Paranoia was consistently directly antecedent to hallucinations, but also indirectly so, via non-psychotic symptoms. Hallucinosis was also the endpoint of pathways involving non-psychotic symptoms. CONCLUSIONS: Via worry, sexual abuse and bullying appear to drive a range of affective symptoms, and in some people, these may encourage the emergence of hallucinations. The link between adverse experiences and paranoia is much more direct. These findings have implications for managing distressing outcomes. In particular, worry may be a salient target for intervention in psychosis.

Longitudinal symptomatic interactions in long-standing schizophrenia: a novel five-point analysis based on directed acyclic graphs.

BACKGROUND: Recent network models propose that mutual interaction between symptoms has an important bearing on the onset of schizophrenic disorder. In particular, cross-sectional studies suggest that affective symptoms may influence the emergence of psychotic symptoms. However, longitudinal analysis offers a more compelling test for causation: the European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose. We predicted that the persistence of psychotic symptoms would be driven by the continuing presence of affective disturbance. METHODS: EuroSC included 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures of psychotic and affective symptoms were repeated four times at 6-month intervals, thereby furnishing five time-points. To examine interactions between symptoms both within and between time-slices, we adopted a novel technique for modelling longitudinal data in psychiatry. This was a form of Bayesian network analysis that involved learning dynamic directed acyclic graphs (DAGs). RESULTS: Our DAG analysis suggests that the main drivers of symptoms in this long-term sample were delusions and paranoid thinking. These led to affective disturbance, not vice versa as we initially predicted. The enduring relationship between symptoms was unaffected by whether patients were receiving first- or second-generation antipsychotic medication. CONCLUSIONS: In this cohort of people with chronic schizophrenia treated with medication, symptoms were essentially stable over long periods. However, affective symptoms appeared driven by the persistence of delusions and persecutory thinking, a finding not previously reported. Although our findings as ever remain hostage to unmeasured confounders, these enduring psychotic symptoms might nevertheless be appropriate candidates for directly targeted psychological interventions.

Prevalence of violence by people living with severe mental illness against their relatives and its associated impacts: A systematic review.

INTRODUCTION: Violence perpetration by adults with severe mental illness (SMI) specifically towards their relatives is a sensitive topic and a largely neglected area that has consequences and implications for different stakeholders, including healthcare providers. This paper sought to systematically review the relevant literature, to identify the types and rates of violence by people with SMI against their relatives, and to develop a detailed understanding of its reported impacts. METHODS: A systematic review, registered with PROSPERO (registration number CRD42019150784), was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review comprised searches of Medline, Embase, PsycInfo and CINAHL databases, supplemented by manual searches. Data from 38 papers using mixed methodologies were reviewed. RESULTS: Key findings highlighted that relatives experienced different types of violence, including physical, verbal, psychological, financial violence, and violence directed towards property. Different types often co-occurred. Mothers were the group most likely to report being victims, compared with other relatives. Reported impacts of violence on relatives included mental ill health (e.g., psychological distress, post-traumatic stress symptoms) and the deterioration, and in some cases the permanent breakdown, of family relationships and the family unit. However, relatives often continued to provide a framework of support for patients, despite risks to their own safety. CONCLUSION: Findings speak to the importance of future research extending the focus beyond the identified victimised relative or perpetrator, to also consider the impacts of violence at the family-wide level, and to improve the outcomes of families exposed to and dealing with violence by individuals living with SMI.

The Lived Experiences of Family Members and Carers of People with Psychosis: A Bottom-Up Review Co-Written by Experts by Experience and Academics.

Informal caregivers of individuals affected by psychotic disorder can play a key role in the recovery process. However, little research has been conducted on the lived experiences of carers and family members. We conducted a bottom-up (from lived experience to theory) review of first-person accounts, co-written between academics and experts by experience, to identify key experiential themes. First-person accounts of carers, relatives, and individuals with psychosis were screened and discussed in collaborative workshops involving individuals with lived experiences of psychosis, family members, and carers, representing various organizations. The lived experiences of family members and carers were characterized by experiential themes related to dealing with the unexpected news, the search for a reason behind the disorder, living with difficult and negative emotions, dealing with loss, feeling lost in fragmented healthcare systems, feeling invisible and wanting to be active partners in care, struggling to communicate with the affected person, fighting stigma and isolation, dealing with an uncertain future, and learning from one's mistakes and building resilience and hope. Our findings bring forth the voices of relatives and informal carers of people with psychosis, by highlighting some of the common themes of their lived experiences from the time of the initial diagnosis and throughout the different clinical stages of the disorder. Informal carers are key stakeholders who can play a strategic role, and their contributions in the recovery process merit recognition and active support by mental health professionals.

The impact of Patient and Public Involvement in the SlowMo study: Reflections on peer innovation.

BACKGROUND: The SlowMo study demonstrated the effects of SlowMo, an eight-session digitally supported reasoning intervention, on paranoia in a large-scale randomized-controlled trial with 362 participants with schizophrenia-spectrum psychosis. AIM: The current evaluation aimed to investigate the impact of Patient and Public Involvement (PPI) in the SlowMo study. METHOD: PPI members were six women and three men from Sussex, Oxford and London with experience of using mental health services for psychosis. They received training and met at least 3-monthly throughout the project. The impact of PPI was captured quantitatively and qualitatively through (i) a PPI log of recommendations and implementation; (ii) written subjective experiences of PPI members; (iii) meeting minutes; and (iv) outputs produced. RESULTS: The PPI log revealed 107 recommendations arising from PPI meetings, of which 87 (81%) were implemented. Implementation was greater for recruitment-, data collection- and organization-related actions than for dissemination and emergent innovations. Qualitative feedback revealed impacts on study recruitment, data collection, PPI participants' confidence, knowledge, career aspirations and society more widely. Outputs produced included a film about psychosis that aired on BBC primetime television, novel webpages and journal articles. Barriers to PPI impact included geography, travel, funding, co-ordination and well-being. DISCUSSION: A future challenge for PPI impact will be the extent to which peer innovation (innovative PPI-led ideas) can be supported within research study delivery. PATIENT AND PUBLIC CONTRIBUTION: Planned Patient and Public Contribution in SlowMo comprised consultation and collaboration in (i) design, (ii) recruitment, (iii) qualitative interviews and analysis of service users' experiences of SlowMo therapy and (iv) dissemination.

The Coping with Unusual Experiences for Children Study (CUES): A pilot randomized controlled evaluation of the acceptability and potential clinical utility of a cognitive behavioural intervention package for young people aged 8-14 years with unusual experiences and emotional symptoms.

OBJECTIVES: Health care guidelines recommend psychological interventions for childhood unusual experiences that are associated with distress or adverse functional impact (UEDs), based on adult, rather than child-specific, evidence. We report the first randomized controlled evaluation of the acceptability and potential clinical utility of cognitive behavioural therapy for childhood UEDs (CBT-UED). DESIGN: Pilot randomized controlled trial. METHODS: Participants aged 8-14 years were recruited from referrals to community services for children with emotional/behavioural problems and screened for self-reported UEDs. RESULTS: Of around 1,000 referrals over 36 months, 304 (30%) were identified to the research team, 174 (57%) were successfully contacted, 110 (63%) consented to screening, 96 (87%) attended a screening assessment, and 51 (53%) reported UEDs. Forty-nine (96%) consented to randomization to either CBT-UED (9-12 weekly sessions of 40-50 min, adjunctive to usual care, n = 24) or treatment-as-usual/waitlist control (TAU/WL, n = 25). Childhood internalizing emotional symptoms (e.g., feeling 'nervous'/'scared'/'tearful'/'worried'/'sick'; proposed primary outcome), UEDs, depression, anxiety, and childhood psychopathology (secondary outcomes) were measured at baseline, at 12 weeks, and, where therapy was ongoing but incomplete (<12 sessions) at 12 weeks, at end-of-treatment (EOT). Twenty-two CBT-UED participants (92%) attended ≥5 sessions. Forty-four participants (90%) completed 12-week assessments (CBT-UED, n = 21/24, 88%; TAU/WL, n = 23/25, 92%). Preliminary findings were encouraging for emotional symptoms and UEDs, but otherwise mixed. CONCLUSIONS: Retention, screening, and consent rates were as anticipated; recruitment took longer than planned. Trial procedures were acceptable to young people, their families, and clinicians. Therapy exceeded 12 weeks, but was well-received, with no serious adverse events attributed to participation. Further evaluation is needed. PRACTITIONER POINTS: Around half of 8- to 14-year-olds in Child and Adolescent Mental Health Services reported distressing unusual experiences. An age-adapted cognitive behavioural intervention appears feasible, and safe to deliver, with the potential to augment standard care. This is a pilot study, and further evaluation is needed. Longer term outcomes should be a focus of future evaluation.

Service user satisfaction with cognitive behavioural therapy for psychosis: Associations with therapy outcomes and perceptions of the therapist.

OBJECTIVES: Few studies have investigated service user satisfaction with cognitive behavioural therapy for psychosis (CBTp). This study explored its associations with clinical presentation and outcomes, retrospective expectations of progress, perceptions of the therapist, and demographic variables. DESIGN AND METHODS: One hundred and sixty-five service users completed self-report questionnaires pre- and post-CBTp in relation to the constructs of interest. Regression analyses explored associations with (1) overall satisfaction with therapy and (2) perceived progress, skills, and knowledge gained. RESULTS: Ninety-six per cent of service users reported satisfaction with therapy. Higher levels of overall satisfaction with, and perceived benefit from, therapy were associated with positive therapy expectations, positive ratings of therapist's personal qualities, competence and trustworthiness, lower pre-therapy depression, and improvements in quality of life. Symptom improvements were not related to overall satisfaction with therapy; however, with the exception of voices, better clinical outcomes were associated with subjective ratings of having made more progress and gained more CBT skills and knowledge. Demographic factors were not associated with satisfaction or perceived progress. In multiple regression analyses, expectations of progress showed the strongest associations with both satisfaction and perceived benefits. Other remaining significant associations consisted of perceptions of the therapist for satisfaction, and both pre-therapy levels of, and changes in, depression for perceived benefits. Qualitative feedback emphasized the importance of the therapeutic relationship and developing new coping strategies. CONCLUSIONS: The findings provide preliminary evidence that high levels of satisfaction with therapy are not contingent on good clinical outcomes and are instead associated with positive therapy expectations and perceptions of the therapist. PRACTITIONER POINTS: Therapy expectations represent a neglected area of research and may have implications for levels of satisfaction with therapy and perceived benefit. The findings reinforce the importance of cognitive behavioural therapy for psychosis (CBTp) therapists demonstrating that they are supportive, competent, and trustworthy. The findings suggest that positive experiences of therapy do not require changes in psychosis symptoms and are instead related to changes in quality of life. Depressive symptoms at the start of therapy may adversely influence the extent to which CBT skills and knowledge are gained and levels of perceived progress at the end of therapy. The present sample was restricted to service users who completed therapy. Satisfaction levels were high. Further research is needed to explore factors associated with dissatisfaction with therapy.

NICE v. SIGN on psychosis and schizophrenia: same roots, similar guidelines, different interpretations.

A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.

Variation in psychosocial influences according to the dimensions and content of children's unusual experiences: potential routes for the development of targeted interventions.

The psychosocial processes implicated in the development and maintenance of psychosis differ according to both the dimensional attributes (conviction, frequency, associated distress, adverse life impact) and the content or type (e.g. grandiosity, hallucinations, paranoia) of the psychotic symptoms experienced. This has informed the development of 'targeted' cognitive behavioural therapy for psychosis (CBTp): interventions focusing on specific psychological processes in the context of particular symptom presentations. In adults, larger effect sizes for change in primary outcomes are typically reported in trials of targeted interventions, compared to those for trials of generic CBTp approaches with multiple therapeutic foci. We set out to test the theoretical basis for developing targeted CBTp interventions for young people with distressing psychotic-like, or unusual, experiences (UEs). We investigated variations in the psychosocial processes previously associated with self-reported UE severity (reasoning, negative life events, emotional problems) according to UE dimensional attributes and content/type (using an established five-factor model) in a clinically referred sample of 72 young people aged 8-14 years. Regression analyses revealed associations of conviction and grandiosity with reasoning; of frequency, and hallucinations and paranoia, with negative life events; and of distress/adverse life impact, and paranoia and hallucinations, with emotional problems. We conclude that psychological targets for intervention differ according to particular characteristics of childhood UEs in much the same way as for psychotic symptoms in adults. The development of targeted interventions is therefore indicated, and tailoring therapy according to presentation should further improve clinical outcomes for these young people.

Moderators of noise-induced cognitive change in healthy adults.

Environmental noise causes cognitive impairment, particularly in executive function and episodic memory domains, in healthy populations. However, the possible moderating influences on this relationship are less clear. This study assessed 54 healthy participants (24 men) on a cognitive battery (measuring psychomotor speed, attention, executive function, working memory, and verbal learning and memory) under three (quiet, urban, and social) noise conditions. IQ, subjective noise sensitivity, sleep, personality, paranoia, depression, anxiety, stress, and schizotypy were assessed on a single occasion. We found significantly slower psychomotor speed (urban), reduced working memory and episodic memory (urban and social), and more cautious decision-making (executive function, urban) under noise conditions. There was no effect of sex. Variance in urban noise-induced changes in psychomotor speed, attention, Trail Making B-A (executive function), and immediate recall and social noise-induced changes in verbal fluency (executive function) and immediate recall were explained by a combination of baseline cognition and paranoia, noise sensitivity, sleep, or cognitive disorganization. Higher baseline cognition (but not IQ) predicted greater impairment under urban and social noise for most cognitive variables. Paranoia predicted psychomotor speed, attention, and executive function impairment. Subjective noise sensitivity predicted executive function and memory impairment. Poor sleep quality predicted less memory impairment. Finally, lower levels of cognitive disorganization predicted slower psychomotor speed and greater memory impairment. The identified moderators should be considered in studies aiming to reduce the detrimental effects of occupational and residential noise. These results highlight the importance of studying noise effects in clinical populations characterized by high levels of the paranoia, sleep disturbances, noise sensitivity, and cognitive disorganization.

Posttraumatic stress symptoms (PTSS) in caregivers of people with psychosis and associations with caregiving experiences.

OBJECTIVE: Posttraumatic stress symptoms (PTSS) have been identified in caregivers of people with psychosis, but their clinical correlates are less well known. This study aimed to assess PTSS in a sample of caregivers of people with psychosis and to examine the relationship between PTSS and caregiving experiences. METHOD: A total of 32 caregivers of people with psychosis completed self-report questionnaires and structured interviews assessing PTSS and caregiving processes, including expressed emotion, burden, and coping. RESULTS: In all, 44% of the sample reported PTSS, which were associated with caregiver reports of burden and less adaptive (avoidant) coping. No links were observed with expressed emotion in this sample. CONCLUSION: Almost half of caregivers of people with psychosis reported PTSS related to their caring role, which may have implications for their caregiving experiences and coping efforts. The findings highlight the importance of assessing need in caregivers and optimizing opportunities to offer needs-led therapeutic interventions to caregivers.

Interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis.

BACKGROUND: Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met. AIMS: To determine whether interventions provided to people caring for those with severe mental illness improve the experience of caring and reduce caregiver burden. METHOD: We conducted a systematic review and meta-analyses of randomised controlled trials (RCTs) of interventions delivered by health and social care services to informal carers (i.e. family or friends who provide support to someone with severe mental illness). RESULTS: Twenty-one RCTs with 1589 carers were included in the review. There was evidence suggesting that the carers' experience of care was improved at the end of the intervention by psychoeducation (standardised mean difference -1.03, 95% CI -1.69 to -0.36) and support groups (SMD = -1.16, 95% CI -1.96 to -0.36). Psychoeducation had a benefit on psychological distress more than 6 months later (SMD = -1.79, 95% CI -3.01 to -0.56) but not immediately post-intervention. Support interventions had a beneficial effect on psychological distress at the end of the intervention (SMD = -0.99, 95% CI -1.48 to -0.49) as did problem-solving bibliotherapy (SMD = -1.57, 95% CI -1.79 to -1.35); these effects were maintained at follow-up. The quality of the evidence was mainly low and very low. Evidence for combining these interventions and for self-help and self-management was inconclusive. CONCLUSIONS: Carer-focused interventions appear to improve the experience of caring and quality of life and reduce psychological distress of those caring for people with severe mental illness, and these benefits may be gained in first-episode psychosis. Interventions for carers should be considered as part of integrated services for people with severe mental health problems.

Nightmares in Patients With Psychosis: The Relation With Sleep, Psychotic, Affective, and Cognitive Symptoms.

OBJECTIVE: To examine the prevalence of nightmares in people with psychosis and to describe the link between nightmares and sleep quality, psychotic, affective, and cognitive symptoms. METHODS: Forty participants with psychotic symptoms completed an assessment of nightmares, sleep quality, positive symptoms of psychosis, affect, posttraumatic stress, social functioning, and working memory. RESULTS: Among the patients, 55% reported weekly distressing nightmares. Experience of more frequent nightmares was related to poorer sleep quality and sleep efficiency. More distressing nightmares were positively associated with greater delusional severity, depression, anxiety, stress, and difficulties with working memory. CONCLUSIONS: Nightmares might be common in those with psychosis and are associated with increased day- and nighttime impairment. Future research should investigate treatments for nightmares, for people presenting with psychotic symptoms.

Cognitive bias and unusual experiences in childhood.

Cognitive therapy is recommended for children with psychotic-like, or unusual, experiences associated with distress or impairment (UEDs; UK National Institute for Health and Care Excellence, 2013 [1]). Accurate models of the psychological underpinnings of childhood UEDs are required to effectively target therapies. Cognitive biases, such as the jumping to conclusions data-gathering bias (JTC), are implicated in the development and maintenance of psychosis in adults. In this study, we aimed to establish the suitability for children of a task developed to assess JTC in adults. Eighty-six participants (aged 5-14 years) were recruited from Child and Adolescent Mental Health Service (CAMHS) and community (school) settings, and completed the probabilistic reasoning ('Beads') task, alongside measures of intellectual functioning, general psychopathology, and UEDs. Self-reported reasoning strategy was coded as 'probabilistic' or 'other'. Younger children (5-10 years) were more likely than older children (11-14 years) to JTC (OR = 2.7, 95 % CI = 1.1-6.5, p = 0.03); and to use non-probabilistic reasoning strategies (OR = 9.4, 95 % CI = 1.7-48.8, p = 0.008). Both UED presence (OR = 5.1, 95 % CI = 1.2-21.9, p = 0.03) and lower IQ (OR = 0.9, 95 % CI = 0.9-1.0, p = 0.02) were significantly and independently associated with JTC, irrespective of age and task comprehension. Findings replicate research in adults, indicating that the 'Beads' task can be reliably employed in children to assess cognitive biases. Psychological treatments for children with distressing unusual experiences might usefully incorporate reasoning interventions.

A pilot evaluation of therapist training in cognitive therapy for psychosis: therapy quality and clinical outcomes.

BACKGROUND: Historically, it has been difficult to demonstrate an impact of training in psychological interventions for people with psychosis on routine practice and on patient outcomes. A recent pilot evaluation suggested that postgraduate training in Cognitive Behavioural Therapy for Psychosis (CBTp) increased the delivery of competent therapy in routine services. In this study, we evaluated clinical outcomes for patients receiving therapy from therapists who successfully completed training, and their association with ratings of therapist competence and therapy content. AIMS: To characterize the therapy delivered during training and to inform both a calculation of effect size for its clinical impact, and the development of competence benchmarks to ensure that training standards are sufficient to deliver clinical improvement. METHOD: Paired patient-reported outcome measures (PROMS) were extracted from anonymized therapy case reports, and were matched with therapy ratings for each therapist. RESULTS: Twenty clients received a course of competent therapy, including a high frequency of active therapy techniques, from nine therapists. Pre-post effect size for change in psychotic symptoms was large (d = 1.0) and for affect, medium (d = 0.6), but improved outcomes were not associated with therapist competence or therapy content. CONCLUSIONS: Therapists trained to research trial standards of competence achieved excellent clinical outcomes. Therapy effect sizes suggest that training costs may be offset by clinical benefit. Larger, methodologically stringent evaluations of training are now required. Future research should assess the necessary and sufficient training required to achieve real-world clinical effectiveness, and the cost-effectiveness of training.

Training frontline mental health staff to deliver "low intensity" psychological therapy for psychosis: a qualitative analysis of therapist and service user views on the therapy and its future implementation.

BACKGROUND: Increasing access to evidence-based talking therapies for people with psychosis is a national health priority. We have piloted a new, "low intensity" (LI) CBT intervention specifically designed to be delivered by frontline mental health staff, following brief training, and with ongoing supervision and support. A pilot feasibility study has demonstrated significant improvement in service user outcomes. This study is a qualitative analysis of the experiences of the staff and service users taking part in the evaluation. AIMS: To evaluate the acceptability of the training protocol and the therapy, and to examine the factors promoting and restraining implementation. METHOD: All trained staff and service users completed a semi-structured interview that was transcribed and subjected to thematic analysis. RESULTS: Service users spoke about learning new skills and achieving their goals. Staff spoke about being able to use a brief, structured intervention to achieve positive outcomes for their clients. Both groups felt that longer, more sophisticated interventions were required to address more complex problems. The positive clinical outcomes motivated therapists to continue using the approach, despite organizational barriers. CONCLUSIONS: For both trained staff and service users, taking part in the study was a positive experience. Staff members' perceived skill development and positive reaction to seeing their clients improve should help to promote implementation. Work is needed to clarify whether and how more complex difficulties should be addressed by frontline staff.

Urbanicity, persecutory delusions, and clinical intervention: the development of a brief CBT module for helping patients with persecutory delusions enter social urban environments.

BACKGROUND: Substantial epidemiological research has shown that psychotic experiences are more common in densely populated areas. Many patients with persecutory delusions find it difficult to enter busy social urban settings. The stress and anxiety caused by being outside lead many patients to remain in-doors. We therefore developed a brief CBT intervention, based upon a formulation of the way urban environments cause stress and anxiety, to help patients with paranoid thoughts to feel less distressed when outside in busy streets. AIMS: The aim was to pilot the new intervention for feasibility and acceptability and gather preliminary outcome data. METHOD: Fifteen patients with persecutory delusions in the context of a schizophrenia diagnosis took part. All patients first went outside to test their reactions, received the intervention, and then went outside again. RESULTS: The intervention was considered useful by the patients. There was evidence that going outside after the intervention led to less paranoid responses than the initial exposure, but this was only statistically significant for levels of distress. CONCLUSIONS: Initial evidence was obtained that a brief CBT module specifically focused on helping patients with paranoia go outside is feasible, acceptable, and may have clinical benefits. However, it could not be determined from this small feasibility study that any observed improvements were due to the CBT intervention. Challenges in this area and future work required are outlined.