Therapists' experience of the lifeline in narrative exposure therapy.

This study aimed to explore the therapist experience of delivering the lifeline component of narrative exposure therapy (NET), an intervention for individuals with posttraumatic stress disorder resulting from exposure to multiple traumatic events. The lifeline in NET involves constructing a chronological representation of the client's life using physical symbols to depict traumatic events as well as positive experiences. A semistructured interview was conducted with 16 therapists experienced in delivering the lifeline component of NET to adult clients. The data from these interviews were analyzed using thematic analysis. Five overarching domains were identified, each encapsulating three themes. The first domain pertains to the overlapping purposes of the lifeline, united by the vital function of developing the therapeutic relationship. The second domain describes the value and potential therapeutic mechanisms of the lifeline's "whole life" perspective. The third domain speaks to the intensely emotional nature of the lifeline process and some of the challenges this presents. The fourth domain relates to the physicality of the lifeline and the value this adds beyond a purely verbal method. The final domain encompasses several challenges described by therapists as well as potential areas for further development. This study provides a rich account of the novel lifeline component in NET. The findings provide direction for refinement of clinical practice and avenues for future research.

The role of characterisation in everyday voice engagement and AVATAR therapy dialogue.

BACKGROUND: Voices are commonly experienced as communication with a personified 'other' with ascribed attitudes, intentionality and personality (their own 'character'). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural engagement with voices or within psychological therapy for distressing voices. METHODS: Baseline characterisation (the degree to which the voice is an identifiable and characterful entity) of the dominant voice was rated (high, medium or low) using a newly developed coding framework, for n = 60 people prior to starting AVATAR therapy. Associations between degree of characterisation and (i) everyday behavioural engagement with voices (The Beliefs about Voices Questionnaire-Revised; n = 60); and (ii) interaction within avatar dialogue [Session 4 Time in Conversation (participant-avatar); n = 45 therapy completers] were explored. RESULTS: Thirty-three per cent reported high voice characterisation, 42% medium and 25% low. There was a significant association between characterisation and behavioural engagement [H(2) = 7.65, p = 0.022, ɛ2 = 0.130] and duration of participant-avatar conversation [F(2,42) = 6.483, p = 0.004, η2 = 0.236]. High characterisation was associated with increased behavioural engagement compared with medium (p = 0.004, r = 0.34; moderate effect) and low (p = 0.027, r = 0.25; small-moderate effect) with a similar pattern observed for the avatar dialogue [high v. medium: p = 0.008, Hedges' g = 1.02 (large effect); high v. low: p = 0.023, Hedges' g = 1.03 (large effect)]. No differences were observed between medium and low characterisation. DISCUSSION: Complex voice characterisation is associated with how individuals interact with their voice(s) in and out of therapy. Clinical implications and future directions for AVATAR therapy and other relational therapies are discussed.

Relating behaviours and therapeutic actions during AVATAR therapy dialogue: An observational study.

OBJECTIVES: AVATAR therapy is a novel relational approach to working with distressing voices by engaging individuals in direct dialogue with a digital representation of their persecutory voice (the avatar). Critical to this approach is the avatar transition from abusive to conciliatory during the course of therapy. To date, no observational study has examined the moment-to-moment dialogical exchanges of this innovative therapy. We aim to (1) map relating behaviours between participants and their created avatars and (2) examine therapeutic actions delivered within AVATAR dialogue. METHOD: Twenty-five of the fifty-three AVATAR therapy completers were randomly selected from a randomized controlled trial (Craig et al. The Lancet Psychiatry, 5, 2018 and 31). Seventy-five audio recordings of active dialogue from sessions 1 and 4 and the last session were transcribed and analysed using a newly developed coding frame. Inter-rater reliability was good to excellent. RESULTS: Fine-grained analysis of 4,642 observations revealed nuanced communication around relational power and therapeutic activity. Early assertiveness work, reinforced by the therapist, focussed on increasing power and distancing. Participants' submissive behaviours reduced during therapy, but the shift was gradual. Once the transition to a more conciliatory tone took place, the dialogue primarily involved direct communication between participant and avatar, focussing on sense of self and developmental and relational understanding of voices. CONCLUSIONS: AVATAR therapy supports voice-hearers in becoming more assertive towards a digital representation of their abusive voice. Direct dialogue with carefully characterized avatars aims to build the voice-hearers' positive sense of self, supporting the person to make sense of their experiences. PRACTITIONER POINTS: AVATAR therapy enables voice-hearers to engage in face-to-face dialogue with a digital representation ('avatar') of their persecutory voice. Fine-grained analyses showed how relating behaviours and therapeutic actions evolve during active AVATAR therapy dialogue. Carefully characterized avatars and direct therapist input help voice-hearers become more assertive over the avatar, enhance positive sense of self, and support individuals to make sense of their experiences.

Self-management interventions for people with severe mental illness: systematic review and meta-analysis.

BACKGROUND: Self-management is intended to empower individuals in their recovery by providing the skills and confidence they need to take active steps in recognising and managing their own health problems. Evidence supports such interventions in a range of long-term physical health conditions, but a recent systematic synthesis is not available for people with severe mental health problems.AimsTo evaluate the effectiveness of self-management interventions for adults with severe mental illness (SMI). METHOD: A systematic review of randomised controlled trials was conducted. A meta-analysis of symptomatic, relapse, recovery, functioning and quality of life outcomes was conducted, using RevMan. RESULTS: A total of 37 trials were included with 5790 participants. From the meta-analysis, self-management interventions conferred benefits in terms of reducing symptoms and length of admission, and improving functioning and quality of life both at the end of treatment and at follow-up. Overall the effect size was small to medium. The evidence for self-management interventions on readmissions was mixed. However, self-management did have a significant effect compared with control on subjective measures of recovery such as hope and empowerment at follow-up, and self-rated recovery and self-efficacy at both time points. CONCLUSION: There is evidence that the provision of self-management interventions alongside standard care improves outcomes for people with SMI. Self-management interventions should form part of the standard package of care provided to people with SMI and should be prioritised in guidelines: research on best methods of implementing such interventions in routine practice is needed.Declaration of interestsNone.

Experiences of outcome monitoring in service users with psychosis: Findings from an Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) demonstration site.

OBJECTIVES: Psychological therapy services are increasingly required to instate routine outcome monitoring (ROM), to demonstrate the clinical and economic impact of interventions. Professionals' views of ROM are an acknowledged barrier to implementation. Service user perspectives have rarely been examined, but acceptability and perceptions of ROM are critical to successful implementation. We investigated service users' experiences of ROM in an Improving Access to Psychological Therapies for people with Severe Mental Illness psychosis demonstration site. DESIGN: ROM comprised a periodic assessment battery completed at baseline, mid-therapy, and end-of-therapy and a single measure completed session-by-session. Qualitative and quantitative feedback were sought at each periodic ROM administration, and, for sessional ROM, at mid-therapy and end-of-therapy. Demographic and clinical correlates of satisfaction were examined cross-sectionally at baseline. Consistency of satisfaction over time and associations of satisfaction with engagement were examined longitudinally. METHODS: Service users rated baseline (n = 281/289), mid-therapy (n = 114/121), end-of-therapy (n = 124/154), and session-by-session (mid-therapy n = 63/87 and end-of-therapy n = 90/123) ROM from 0 ('extremely unhelpful') to 10 ('extremely helpful') and gave qualitative feedback. RESULTS: Service users predominantly found ROM helpful (score 6-10; 64-72%) or neutral (score 5; 19-29%). Finding ROM less helpful was associated with younger age and poorer general outcomes, but not with psychotic symptoms or therapy dropout. Emerging qualitative themes included feeling understood, valuing opportunities to reflect, expressing feelings, and tracking progress towards goals. Shorter batteries would be preferable, particularly for younger respondents, and those with poorer outcomes. CONCLUSIONS: ROM is acceptable for people with psychosis. Tailoring assessments to specific subgroups should be considered. PRACTITIONER POINTS: Routine outcome monitoring for psychological therapy is acceptable to people with psychosis. Most respondents experienced outcome monitoring as an opportunity to feel understood. Younger people and those with poorer functioning and well-being might be at higher risk of dissatisfaction. Short assessment batteries and less frequent outcome monitoring might be preferable for some service users. Limitations of the study Feedback about session-by-session outcome monitoring was not contemporaneous with completion and may be subject to memory or other biases. Only two-thirds of service users provided feedback about session-by-session ROM (compared to >94% for periodic ROM) so findings may not be fully representative. Feedback about measures was not provided anonymously, and it is possible that service users were reluctant to express criticism about ROM to the assessor.

Hypersensitivity to Contingent Behavior in Paranoia: A New Virtual Reality Paradigm.

Contingency in interpersonal relationships is associated with the development of secure attachment and trust, whereas paranoia arises from the overattribution of negative intentions. We used a new virtual reality paradigm to experimentally investigate the impact of contingent behavior on trust along the paranoia continuum. Sixty-one healthy participants were randomly allocated to have a social interaction with a pleasant virtual human (avatar) programmed to be highly responsive or not (high/low contingency). Perceived trustworthiness and trusting behavior were assessed alongside control variables attachment and anxiety. Higher paranoia and dismissive attachment were associated with larger interpersonal distances. Unexpectedly, extremely paranoid individuals experienced the highly contingent avatar as more trustworthy than their low contingency counterpart. Higher dismissive attachment was also associated with more subjective trust in both conditions. Extreme paranoia is associated with hypersensitivity to noncontingent behavior, which might explain experiences of mistrust when others are not highly responsive in everyday social situations.

The Phenomenology and Generation of Positive Mental Imagery in Early Psychosis.

BACKGROUND: Theoretical models of depression and bipolar disorder emphasise the importance of positive mental imagery in mood and behaviour. Distressing, intrusive images are common in psychosis; however, little is known about positive imagery experiences or their association with clinical symptoms. The aim of the current study was to examine the phenomenology of positive imagery in early psychosis and the relationship between the characteristics of positive, future-oriented imagery and symptom severity. METHOD: Characteristics, thematic content and appraisals of recent self-reported images were examined in 31 people with early psychosis. The vividness and perceived likelihood of deliberately generated, future-oriented images were investigated in relation to clinical symptoms. RESULTS: Eighty-four percent of participants reported experiencing a recent positive image. Themes included the achievement of personal goals, spending enjoyable time with peers and family, loving, intimate relationships and escape from current circumstances. The vividness and perceived likelihood of generated prospective imagery were negatively correlated with levels of depression and social anxiety. CONCLUSIONS: The relationship between emotional problems and the ability to imagine positive, future events may have implications for motivation, mood and goal-directed behaviour in psychosis. Everyday experiences of positive imagery may represent the simulation of future goals, attempts to cope or avoid aversive experiences or idealised fantasy. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The majority of participants experienced a recent positive image with themes related to goal attainment and social relationships. Depression and social anxiety levels were correlated with the vividness of intentionally generated positive future-oriented images and their perceived likelihood. The assessment of positive imagery in early psychosis appears warranted and may provide insights regarding individual coping strategies, values and goals.

Psychological interventions for housebound people with psychosis: service user and therapist perspectives in South East London.

BACKGROUND: People with psychosis often have difficulty leaving their homes to perform tasks of daily living, which also limits their access to clinic-based interventions to support recovery. Home-based psychological therapy may offer a solution. AIM: To examine service user and therapist perspectives on (i) houseboundness in psychosis and (ii) the value of home-based psychological interventions, as a first step towards a systematic evaluation. METHOD: Semistructured interviews with 10 service users and 12 therapists from a large inner city mental health NHS Foundation Trust were thematically analysed. RESULTS: Houseboundness most commonly resulted from anxiety, paranoia and amotivation, indicating the potential usefulness of targeted psychological therapies. Home-based therapy was offered unsystematically, with variable goals. Although beneficial for engagement and assessment, little gain was reported from undertaking a full course of therapy at home. CONCLUSION: Home visits could be offered by psychological therapists to engage and assess housebound service users, but home-based therapy may be best offered on a short-term basis, targeting paranoia, anxiety and amotivation to increase access to other resources. Given the increased cost associated with home-based psychological interventions, a systematic evaluation of their impact is warranted.

How do people with persecutory delusions evaluate threat in a controlled social environment? A qualitative study using virtual reality.

BACKGROUND: Environmental factors have been associated with psychosis but there is little qualitative research looking at how the ongoing interaction between individual and environment maintains psychotic symptoms. AIMS: The current study investigates how people with persecutory delusions interpret events in a virtual neutral social environment using qualitative methodology. METHOD: 20 participants with persecutory delusions and 20 controls entered a virtual underground train containing neutral characters. Under these circumstances, people with persecutory delusions reported similar levels of paranoia as non-clinical participants. The transcripts of a post-virtual reality interview of the first 10 participants in each group were analysed. RESULTS: Thematic analyses of interviews focusing on the decision making process associated with attributing intentions of computer-generated characters revealed 11 themes grouped in 3 main categories (evidence in favour of paranoid appraisals, evidence against paranoid appraisals, other behaviour). CONCLUSIONS: People with current persecutory delusions are able to use a range of similar strategies to healthy volunteers when making judgements about potential threat in a neutral environment that does not elicit anxiety, but they are less likely than controls to engage in active hypothesis-testing and instead favour experiencing "affect" as evidence of persecutory intention.

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.

Two people making sense of a story: narrative exposure therapy as a trauma intervention in early intervention in psychosis.

Background: Narrative exposure therapy (NET) is a recommended intervention for people with multiple trauma histories; however, research is lacking into its use with people experiencing psychosis, many of whom report multiple trauma histories.Objective: This study aimed to explore experiences of NET in early intervention in psychosis (EIP) services.Method: Eight clinicians and four experts with lived experience (experts by experience) of psychosis and multiple trauma were interviewed on a single occasion using two versions (clinician and expert by experience) of a semi-structured interview schedule. Data was analysed using thematic analysis.Results: Five overarching themes were generated, relating to fear and avoidance of memories, importance of trust, organizing memories and making new meaning, reconnecting with emotions, and considerations when delivering NET in EIP.Conclusions: Directly addressing the impact of multiple trauma in people experiencing first episode psychosis is frightening and emotive, but helps to address painful memories and organize them into a personal narrative. Increases in distress and anomalous experiences were carefully considered by clinicians, but typically outweighed by the benefits of NET. Challenges were comparable to those described in non-psychosis research. Implications for clinical practice and future research are outlined.

Many people experiencing psychosis report multiple trauma histories. Narrative exposure therapy (NET) is a recommended intervention for people with multiple trauma histories, but research into its use with people experiencing psychosis is limited.This qualitative study found that clinicians and experts by experience in early intervention in psychosis services valued NET for its effect on organizing memories, reducing their emotional impact, and making new meaning around experiences, and that challenges of NET were similar to those described in non-psychosis research.Some participants described experiencing distress and dysregulation during NET, including an increase in anomalous experiences. Although this was typically temporary and outweighed by NET's benefits, careful assessment before and flexibility during the intervention are considered important for building engagement and trust.

The voice characterisation checklist: psychometric properties of a brief clinical assessment of voices as social agents.

Aim: There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses degree of voice characterisation, identified as relevant to a new wave of relational approaches. Methods: The sample comprised participants experiencing distressing voices, recruited at baseline on the AVATAR2 trial between January 2021 and July 2022 (n = 170). Inter-rater reliability (IRR) and internal consistency analyses (Cronbach's alpha) were conducted. Results: The majority of participants reported some degree of voice personification (94%) with high endorsement of voices as distinct auditory experiences (87%) with basic attributes of gender and age (82%). While most identified a voice intention (75%) and personality (76%), attribution of mental states (35%) to the voice ('What are they thinking?') and a known historical relationship (36%) were less common. The internal consistency of the VoCC was acceptable (10 items, α = 0.71). IRR analysis indicated acceptable to excellent reliability at the item-level for 9/10 items and moderate agreement between raters' global (binary) classification of more vs. less highly characterised voices, κ = 0.549 (95% CI, 0.240-0.859), p < 0.05. Conclusion: The VoCC is a reliable and internally consistent tool for assessing voice characterisation and will be used to test whether voice characterisation moderates treatment outcome to AVATAR therapy. There is potential wider utility within clinical trials of other relational therapies as well as routine clinical practice.

Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis.

AIM: The moderate association between therapeutic alliance (TA) and psychological therapy outcome is well established. Historically, the field has not focused on people with a severe mental illness. This is the first review to conduct a meta-analysis of associations between TA and therapeutic engagement as well as outcome in psychological therapy for psychosis. ELIGIBILITY CRITERIA: Eligible studies conducted a quantitative investigation of the relationship between TA during a psychological therapy and outcome at a subsequent time-point. METHOD: A systematic review examined the relationship between TA and engagement as well as outcome measures within psychological therapy for psychosis. Correlational meta-analyses using an aggregate random effects model were conducted. RESULTS: Twenty-four studies were eligible for inclusion (n = 1,656) of which 13 were included in the meta-analyses. Client- and therapist-rated TA were associated with engagement in therapy (rclient (c)  = 0.36, p = .003; rtherapist (t)  = 0.40, p = .0053). TA was also associated with reduction in global (rc  = 0.29, p = .0005; rt  = 0.24, p = .0015) and psychotic symptoms (rc  = 0.17, p = .0115; rt  = 0.30, p = .0003). The systematic review identified no evidence or limited evidence for a relationship between TA during therapy and depression, substance use, physical health behaviours, global as well as social functioning, overall mental health recovery, and self-esteem at follow-up. Although number of studies was small, TA was related to a reduced risk of subsequent hospitalization in 40% of analyses (across two studies) and improved cognitive outcome in 50% of analyses (across three studies). CONCLUSIONS: The observed TA-therapy engagement and TA-outcome associations were broadly consistent with those identified across non-psychotic diagnostic groups. Well-powered studies are needed to investigate the relationship between TA and process as well as outcome in psychological therapy for psychosis specifically. PRACTITIONER POINTS: This is the first review to conduct a meta-analytic synthesis of the association between therapeutic alliance (TA) and both engagement and change in outcome in psychological therapies for psychosis. TA (as rated by therapist and client) was associated with the extent of therapeutic engagement as well as reduction in global mental health symptoms and psychotic symptoms. The significant associations between TA and engagement as well as change in outcome identified in the current review are broadly consistent with those observed across non-psychotic diagnostic groups. We consider factors that could impact upon the dynamic and potentially interdependent relationships between TA and therapeutic techniques, including attachment security and severity of paranoid ideation.

Optimising AVATAR therapy for people who hear distressing voices: study protocol for the AVATAR2 multi-centre randomised controlled trial.

BACKGROUND: AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucinations (henceforth 'voices'). A digital simulation (avatar) of the voice is created and used in a three-way dialogue between participant, avatar and therapist. To date, therapy has been delivered over 6 sessions, comprising an initial phase, focusing on standing up to a hostile avatar, and a second phase in which the avatar concedes and focus shifts to individualised treatment targets, including beliefs about voices. The first fully powered randomised trial found AVATAR therapy resulted in a rapid and substantial fall in voice frequency and associated distress that was superior to supportive counselling at 12 weeks. The main objective of this AVATAR2 trial is to test the efficacy of two forms of AVATAR therapy in reducing voice-related distress: AVATAR-brief (standardised focus on exposure, assertiveness and self-esteem) and AVATAR-extended (phase 1 mirroring AVATAR-brief augmented by a formulation-driven phase 2). Secondary objectives include the examination of additional voice, wellbeing and mood outcomes, the exploration of mediators and moderators of therapy response, and examining cost-effectiveness of both forms of therapy compared with usual treatment (TAU). METHODS: This multi-site parallel group randomised controlled trial will independently randomise 345 individuals to receive AVATAR-brief (6 sessions) plus TAU or AVATAR-extended (12 sessions) plus TAU or TAU alone (1:1:1 allocation). Participants will be people with a diagnosis of schizophrenia spectrum and other psychotic disorders who have heard distressing voices for more than 6 months. The primary outcome is the PSYRATS Auditory Hallucinations Distress dimension score at 16 and 28 weeks, conducted by blinded assessors. Statistical analysis will follow the intention-to-treat principle and data will be analysed using linear mixed models. Mediation and moderation analyses using contemporary causal inference methods will be conducted as secondary analyses. Service costs will be calculated, and cost-effectiveness assessed in terms of quality-adjusted life years accrued. DISCUSSION: This study will clarify optimal therapy delivery, test efficacy in a multi-site study and enable the testing of the AVATAR software platform, therapy training and provision in NHS settings. TRIAL REGISTRATION: ISRCTN registry ISRCTN55682735 . Registered on 22 January 2020. The trial is funded by the Wellcome Trust (WT).

AVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets.

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets along with information on acceptability and potential side effects. Interest in the approach is growing rapidly and this report acts as a necessary touchstone for future development.

Attributional biases in paranoia: the development and validation of the Achievement and Relationships Attributions Task (ARAT).

INTRODUCTION: Attributional biases, in particular a tendency to blame other people for negative events, have been reported among people with persecutory delusions and in people in the general population with subclinical paranoia. However, existing attribution measures have some shortcomings. The present study therefore describes the development and validation of a new attribution measure: the Achievement and Relationships Attributions Task (ARAT). The ARAT assesses attributional style in a range of everyday life situations related to achievement and interpersonal events, and provides a context for attributions. Each scenario has three possible causes embedded within it: internal, personal-external, and situational-external. METHODS: Three hundred and fifteen healthy volunteers completed the ARAT and measures of paranoia and depression. RESULTS: A tendency to blame other people rather than themselves was associated with high trait paranoia and multidimensional aspects of paranoid beliefs. Depression was associated with a decreased tendency to internalise success. CONCLUSIONS: The ARAT is a valid measure of attributional style in relation to paranoid ideation in a nonclinical population and has good interrater reliability.

Improving Access to psychological therapies for people with severe mental illness (IAPT-SMI): Lessons from the South London and Maudsley psychosis demonstration site.

Implementation of evidence-based cognitive behavioural therapy for psychosis (CBTp) remains low in routine services. The United Kingdom Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI) initiative aimed to address this issue. The project evaluated whether existing services could improve access to CBTp and demonstrate effectiveness using a systematic approach to therapy provision and outcome monitoring (in a similar way to the Improving Access to Psychological Therapies (IAPT) model for people with anxiety and depression). We report the clinical outcomes and key learning points from the South London and Maudsley NHS Foundation Trust IAPT-SMI demonstration site for psychosis. Additional funding enabled increased therapist capacity within existing secondary care community mental health services. Self-reported wellbeing and psychotic symptom outcomes were assessed, alongside service use and social/occupational functioning. Accepted referrals/year increased by 89% (2011/12: n = 106/year; 2012-2015: n = 200/year); 90% engaged (attended ≥5 sessions) irrespective of ethnicity, age and gender. The assessment protocol proved feasible, and pre-post outcomes (n = 280) showed clinical improvements and reduced service use, with medium effects. We conclude that, with appropriate service structure, investment allocated specifically for competent therapy provision leads to increased and effective delivery of CBTp. Our framework is replicable in other settings and can inform the wider implementation of psychological therapies for psychosis.

The Trauma and Life Events (TALE) checklist: development of a tool for improving routine screening in people with psychosis.

Background: Best practice guidelines recommend traumatic events should be assessed in psychosis to support the identification and, when indicated, treatment of post-traumatic stress reactions. However, routine assessment in frontline services is rare, and available tools are not tailored to psychosis. Assessment obstacles include lengthy measures, a focus on single, physically threatening events, and the exclusion of psychosis-related traumas. Objective: To develop and validate a brief trauma screening tool for the identification of clinically significant traumas in people with psychosis. Method: The Trauma and Life Events (TALE) checklist was developed in conjunction with people with lived experience of trauma and psychosis, and specialist clinicians and researchers. The psychometric properties (i.e. test-retest reliability, content validity, construct validity) of the TALE were evaluated in a sample of 39 people with psychosis diagnoses. Results: The TALE displayed moderate psychometric acceptability overall, with excellent reliability and convergent validity for sexual abuse. High rates of psychosis-related trauma and childhood adversity were reported, in particular bullying and emotional neglect. A dose-response relationship between cumulative trauma, post-traumatic stress and psychosis was found. Conclusions: The TALE is the first screening tool specifically designed to meet the needs of routine trauma screening in psychosis services. The psychometric limitations highlight the challenge of developing a measure that is both sufficiently brief to be useful in clinical settings and comprehensive enough to identify all relevant adverse events. Validation of the TALE is now required across the spectrum of psychosis.

Antecedentes: Las mejores guías clínicas recomiendan que los eventos traumáticos deben ser evaluados en psicosis para apoyar la identificación y, cuando se indique, el tratamiento de las reacciones de estrés postraumático. Sin embargo, la evaluación de rutina en los servicios de atención primaria es rara, y las herramientas disponibles no están adaptadas a la psicosis. Los obstáculos de evaluación incluyen mediciones prolongadas, un enfoque en eventos únicos que amenazan físicamente, y la exclusión de traumas relacionados con psicosis. Objetivo: Desarrollar y validar una herramienta breve de detección de trauma para la identificación de traumas clínicamente significativos en personas con psicosis. Método: La Lista de Verificación de Eventos Traumáticos y Vitales (TALE) se desarrolló en conjunto con personas que habían sufrido trauma y psicosis, y clínicos especialistas e investigadores. Las propiedades psicométricas (es decir, fiabilidad test-retest, validez de contenido y validez de constructo) del TALE se evaluaron en una muestra de 39 personas con diagnóstico de psicosis. Resultados: El TALE exhibió en general una aceptabilidad psicométrica moderada, con excelente confiabilidad y validez convergente para el abuso sexual. Se reportaron altas tasas de trauma relacionado con la psicosis y adversidad infantil, en particular el acoso escolar y la negligencia emocional. Se encontró una relación dosis-respuesta entre el trauma acumulativo, el estrés postraumático, y la psicosis. Conclusiones: TALE es la primera herramienta de detección específicamente diseñada para satisfacer las necesidades de la detección de trauma de rutina en los servicios de psicosis. Las limitaciones psicométricas resaltan el desafío de desarrollar una medida que sea lo suficientemente breve como para ser útil en contextos clínicos y lo suficientemente amplia como para identificar todos los eventos adversos relevantes. Actualmente se requiere la validación de TALE en todo el espectro de la psicosis.

Relationship between attachment style and symptom severity across the psychosis spectrum: A meta-analysis.

There is growing evidence for the role of attachment in psychosis, however, to date there has been no quantitative review of the prevalence of insecure attachment in psychosis. The current study sought to systematically appraise studies investigating the prevalence of insecure attachment and the association with psychosis-spectrum experiences using meta-analytic techniques. A systematic search of studies carried out between January 1980 and 30th November 2015 found 25 papers eligible for inclusion. The meta-analysis showed that the prevalence of insecure attachment style was significantly higher in individuals with psychosis (76%) than in non-clinical samples (38%), with fearful attachment being the most prevalent. Across the continuum, there was a small but significant relationship between positive symptom severity and insecure attachment and a significant relationship between negative symptom severity and insecure attachment in the non-clinical analysis. This relationship was not found in the clinical group. The prevalence of insecure attachment appears to be high in psychosis, however, the relationship between symptom severity and attachment is small. Attachment theory may provide greater understanding of the development of positive symptoms than previously thought, however, research needs to include more at-risk samples and longitudinal research to fully understand the dynamics of this relationship.

Psychological interventions on a specialist Early Intervention Inpatient Unit: An opportunity to engage?

BACKGROUND: This study explored engagement with psychology on a specialist early intervention psychosis inpatient unit, with a focus on whether demographics or admission factors impacted on engagement. METHOD: This was a retrospective cohort study using data extracted from patient notes for all service users who were admitted to an Early Intervention ward during a specified 6-month period. One hundred and one records were identified. RESULTS: Sixty-eight (67.3%) of the service users engaged in psychological therapy, 45.6% (n = 47) attended psychology groups and 58.4% (n = 59) engaged in individual psychology sessions. Service users admitted to the ward voluntarily were more likely to engage in individual psychology sessions in comparison to those admitted under section of the mental health act (ß = -0.270, P < .005). Length of admission predicted engagement with groups (ß = 0.38, P < .001) and individual psychology sessions (ß = 0.408, P < .001). Ethnicity, gender and number of admissions did not predict engagement in psychology. CONCLUSIONS: Psychological interventions are acceptable on a specialist early intervention psychosis inpatient ward and offer an opportunity to engage service users. Engagement was not predicted by demographic factors typically seen in community settings. Implications arising from these differences are discussed.