Using EMPOWER in daily life: a qualitative investigation of implementation experiences.

BACKGROUND: Digital self-management tools blended with clinical triage and peer support have the potential to improve access to early warning signs (EWS) based relapse prevention in schizophrenia care. However, the implementation of digital interventions in psychosis can be poor. Traditionally, research focused on understanding how people implement interventions has focused on the perspectives of mental health staff. Digital interventions are becoming more commonly used by patients within the context of daily life, which means there is a need to understand implementation from the perspectives of patients and carers. METHODS: Semi-structured one-on-one interviews with 16 patients who had access to the EMPOWER digital self-management intervention during their participation in a feasibility trial, six mental health staff members who supported the patients and were enrolled in the trial, and one carer participant. Interviews focused on understanding implementation, including barriers and facilitators. Data were coded using thematic analysis. RESULTS: The intervention was well implemented, and EMPOWER was typically perceived positively by patients, mental health staff and the carer we spoke to. However, some patients reported negative views and reported ideas for intervention improvement. Patients reported valuing that the app afforded them access to things like information or increased social contact from peer support workers that went above and beyond that offered in routine care. Patients seemed motivated to continue implementing EMPOWER in daily life when they perceived it was creating positive change to their wellbeing, but seemed less motivated if this did not occur. Mental health staff and carer views suggest they developed increased confidence patients could self-manage and valued using the fact that people they support were using the EMPOWER intervention to open up conversations about self-management and wellbeing. CONCLUSIONS: The findings from this study suggest peer worker supported digital self-management like EMPOWER has the potential to be implemented. Further evaluations of these interventions are warranted, and conducting qualitative research on the feasibility gives insight into implementation barriers and facilitators, improving the likelihood of interventions being usable. In particular, the views of patients who demonstrated low usage levels would be valuable.

An examination of the potential benefits of expert guided physical activity for supporting recovery from extreme social withdrawal: Two case reports focused on the treatment of Hikikomori.

Extreme and long-term social withdrawal, first described in Japan as Hikikomori, has now become a globally recognized mental health problem. Intervention studies severely lag behind epidemiological and phenomenological research. We present two descriptive case reports of Japanese university students with Hikikomori who participated in an early phase test of a structured intervention involving physical activities that was developed and facilitated by clinicians and physical education specialists-Human Movement Consultation (HMC). The two recipients (19- and 29-years old at the start of treatment) completed approximately 40 consultation sessions delivered over 3 years consisting of a combination of outdoor workouts (i.e., walking, running, and cycling) and interpersonal sports (e.g., table tennis, badminton, and tennis). Changes in social withdrawal behavior were independently rated from clinical health records using a structured scale (the Glasgow Hikikomori Scale; GHS). Behavioral observations and scale data for both cases indicated improvements from pre-treatment levels of social withdrawal. At the end of the intervention, both had returned to normative levels of functioning. Case A returned to university and Case B secured a new job upon the completion of HMC. To help advance our understanding of treatment options, these case descriptions analyze potential change mechanisms in order to understand how HMC can support recovery from extreme social withdrawal. One key observation is that both outdoor workouts and interpersonal sports offer a non-threatening method of enabling Hikikomori to engage in interpersonal interactions. Such connections via structured activities may allow the reinstatement of social skills in a graded manner. In addition, an initial focus on physical experiences may help promote psychological and social connectedness without triggering the social fears and challenges that underlie the Hikikomori state. The findings from these two cases offer a framework to guide further research and the development of exercise-based interventions for this hidden and often neglected group.

Splitting Things Apart to Put Them Back Together Again: A Targeted Review and Analysis of Psychological Therapy RCTs Addressing Recovery From Negative Symptoms.

Negative symptoms have attracted growing attention as a psychological treatment target and the past 10 years has seen an expansion of mechanistic studies and clinical trials aimed at improving treatment options for this frequently neglected sub-group of people diagnosed with schizophrenia. The recent publication of several randomized controlled trials of psychological treatments that pre-specified negative symptoms as a primary outcome warrants a carefully targeted review and analysis, not least because these treatments have generally returned disappointing therapeutic benefits. This mini-review dissects these trials and offers an account of why we continue to have significant gaps in our understanding of how to support recovery in people troubled by persistent negative symptoms. Possible explanations for mixed trial results include a failure to separate the negative symptom phenotype into the clinically relevant sub-types that will respond to mechanistically targeted treatments. For example, the distinction between experiential and expressive deficits as separate components of the wider negative symptom construct points to potentially different treatment needs and techniques. The 10 negative symptom-focused RCTs chosen for analysis in this mini-review present over 16 different categories of treatment techniques spanning a range of cognitive, emotional, behavioral, interpersonal, and metacognitive domains of functioning. The argument is made that treatment development will advance more rapidly with the use of more precisely targeted psychological treatments that match interventions to a focused range of negative symptom maintenance processes.

Candidate Factors Maintaining Social Anxiety in the Context of Psychotic Experiences: A Systematic Review.

Social anxiety is common in psychosis and associated with impaired functioning, poorer quality of life, and higher symptom severity. This study systematically reviewed factors maintaining social anxiety in people with attenuated, transient, or persistent psychotic experiences. Other correlates of social anxiety were also examined. MEDLINE, Embase, CENTRAL, and PsycINFO were searched for relevant literature up to October 19, 2020. Forty-eight articles were eligible for narrative synthesis: 38 cross-sectional studies, 8 prospective studies, 1 uncontrolled trial, and 1 qualitative study. From 12060 participants, the majority was general population (n = 8771), followed by psychosis samples (n = 2532) and those at high risk of psychosis (n = 757). The methodological quality and risk of bias were assessed using the Mixed Methods Appraisal Tool. Ninety percent of studies were rated as high to very-high quality. Poorer quality studies typically failed to adequately control for confounds and provided insufficient information on the measurement validity and reliability. Prominent psychological factors maintaining social anxiety included self-perceptions of stigma and shame. Common correlates of social anxiety included poorer functioning and lower quality of life. In conclusion, stigma and shame could be targeted as a causal mechanism in future interventional studies. The integration of findings from this review lead us to propose a new theoretical model to guide future intervention research.

Development and testing of a checklist to assess compliance with the faculty of pain medicine's core standards for pain management services: experience in a new national tertiary pain service.

INTRODUCTION: The Faculty of Pain Medicine recently published the first UK-focused Core Standards for Pain Management Services (CSPMS). We present an audit checklist tool developed to map compliance to the CSPMS, which offers a practical method of auditing any pain management service against the standards. METHODS: The checklist tool was developed and its utility was field-tested in the Scottish National Residential Pain Management Programme (SNRPMP), a newly established service offering residential service to people in Scotland. RESULTS: The checklist tool developed provides an easy and practical approach to evaluating any pain service against the national standards. Its application to evaluate the SNRPMP indicates that the service meets the majority of CSPMS standards and highlights aspects of the service requiring improvement. CONCLUSION: The layout of the developed checklist tool offers an alternative format for the structuring of the national standards in possible future revisions. The audit checklist tool enables evaluation of services with a numerical score, enabling monitoring of their compliance with national standards as well as comparisons between pain services.

Jamaican adolescents' receptiveness to digital mental health services: A cross-sectional survey from rural and urban communities.

BACKGROUND: Improving access to mental health resources for young people is an urgent healthcare challenge. As the majority of youth live in low and middle-income countries (LMICs) mental ill health can exert substantial adverse impacts on societies that can least afford it. Digital mental health technologies might help close the treatment gap but we need to understand barriers to implementing these strategies, especially in resource constrained contexts such as LMICs. METHODS: We surveyed adolescents (N = 107; aged 10-19 years) from Jamaican communities using questionnaires adopted from previous studies conducted in LMICs. The questions addressed mental health help-seeking preferences, expectations of help-seeking effectiveness, and practical and attitudinal barriers to using mobile-phone-based mental health resources. We present descriptive data alongside exploratory analyses of differences in attitudes and preferences expressed by subgroups of respondents. RESULTS: Adolescents reported very few practical or infrastructure barriers to accessing digital mental health resources. >90% of the sample had access to a smartphone, 78% expected that digital solutions could benefit adolescents with symptoms of mental distress, and 56% were interested in using mental health apps to monitor their own mental health. Stigma, shame, and embarrassment were major barriers to help-seeking and formal professional help was only preferred for more severe conditions such as psychosis and substance abuse. CONCLUSIONS: Practical barriers are unlikely to impede the uptake of digital mental health resources by Jamaican adolescents. Our data suggest that mental health literacy, stigma, and embarrassment pose more serious blocks to help-seeking.

Perspectives of patients, carers and mental health staff on early warning signs of relapse in psychosis: a qualitative investigation.

BACKGROUND: Relapse prevention strategies based on monitoring of early warning signs (EWS) are advocated for the management of psychosis. However, there has been a lack of research exploring how staff, carers and patients make sense of the utility of EWS, or how these are implemented in context. AIMS: To develop a multiperspective theory of how EWS are understood and used, which is grounded in the experiences of mental health staff, carers and patients. METHOD: Twenty-five focus groups were held across Glasgow and Melbourne (EMPOWER Trial, ISRCTN: 99559262). Participants comprised 88 mental health staff, 21 patients and 40 carers from UK and Australia (total n = 149). Data were analysed using constructivist grounded theory. RESULTS: All participants appeared to recognise EWS and acknowledged the importance of responding to EWS to support relapse prevention. However, recognition of and acting on EWS were constructed in a context of uncertainty, which appeared linked to risk appraisals that were dependent on distinct stakeholder roles and experiences. Within current relapse management, a process of weighted decision-making (where one factor was seen as more important than others) described how stakeholders weighed up the risks and consequences of relapse alongside the risks and consequences of intervention and help-seeking. CONCLUSIONS: Mental health staff, carers and patients speak about using EWS within a weighted decision-making process, which is acted out in the context of relationships that exist in current relapse management, rather than an objective response to specific signs and symptoms.

Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT.

BACKGROUND: Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome. DESIGN: The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU). SETTING: Secondary care mental health services in five cities in the UK. PARTICIPANTS: People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms. INTERVENTIONS: Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services. MAIN OUTCOME MEASURES: The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs. RESULTS: Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58). CONCLUSIONS: Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained. TRIAL REGISTRATION: Current Controlled Trials ISRCTN99672552. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.

A systematic review of recommended modifications of CBT for people with cognitive impairments following brain injury.

Due to diverse cognitive, emotional and interpersonal changes that can follow brain injury, psychological therapies often need to be adapted to suit the complex needs of this population. The aims of the study were to synthesise published recommendations for therapy modifications following brain injury from non-progressive traumatic, vascular, or metabolic causes and to determine how often such modifications have been applied to cognitive behavioural therapy (CBT) for post-injury emotional adjustment problems. A systematic review and narrative synthesis of therapy modifications recommended in review articles and reported in intervention studies was undertaken. Database and manual searches identified 688 unique papers of which eight review articles and 16 intervention studies met inclusion criteria. The review articles were thematically analysed and a checklist of commonly recommended modifications composed. The checklist items clustered under themes of: therapeutic education and formulation; attention; communication; memory; and executive functioning. When this checklist was applied to the intervention studies, memory aids and an emphasis on socialising patients to the CBT model were most frequently reported as adaptations. It was concluded that the inconsistent reporting of psychological therapy adaptations for people with brain injury is a barrier to developing effective and replicable therapies. We present a comprehensive account of potential modifications that should be used to guide future research and practice.

Brief compassion focused imagery for treatment of severe head injury.

OBJECTIVE: To determine whether participants with severe head injury (SHI) allocated to a brief compassion focused imagery (CFI) intervention show greater change in compassion than those exposed to relaxation imagery (RI). METHOD: Participants were exposed to a preparatory video to promote engagement and then randomly allocated to intervention. Pre- and post-preparatory measures were Motivation for Intervention and Fears of Compassion Scales, State-Trait Anxiety Inventory (STAI) and PANAS. Pre- and post-intervention self-report measures were the Empathy Quotient, Self-Compassion Scale, STAI and Relaxation Scale. Heart rate variability (HRV) was monitored throughout. RESULTS: Motivation for therapy increased after the preparatory video (z = 3.44, p = 0.001). Across the intervention, group differences were not found on self-report measures or HRV changes. When CFI and RI groups were pooled, improvement in relaxation (r = .41, p < 0.01) and state anxiety (r = .29, p < 0.05) were found across the intervention; these outcomes were not associated with changes in self-compassion or HRV. CONCLUSION: Brief CFI, a central aspect of compassion focused therapy, did not produce a reliable change in people with SHI. Enhanced motivation for psychological therapy after a brief preparatory video is relevant and underlines the need to understand mechanisms of action rather than the pursuing whole protocol approaches to therapy.

Using the primary process emotional-behavioural system to better meet patient needs in psychotherapy.

In order to increase therapeutic impact by enhancing awareness of clients' nonverbal communications, this article operationalizes the therapeutic alliance as a needs-satisfaction process. The client's competence as a needs seeker and the therapist assisting with the client's expression and satiation of basic social needs are proposed as being key mechanisms of change. Functional model of primary emotions derived from Panksepp's seven primary emotional systems (care seeking, caretaking, lust, fear and anxiety, anger, play, seeking, plus dominance and disgust) is integrated with Functional Analytic Psychotherapy's emphasis on in-session contingent natural reinforcement of clients' target behaviours. By identifying in-the-moment cues of underlying emotional-behavioural functions drawn from a categorization of clients' nonverbal communication can bridge the gap between client private events and therapist observables, in order to maximize therapist attunement and responsiveness to clients, and to increase the effectiveness of clinical interventions.

Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded, randomised controlled trial.

BACKGROUND: Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30-40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia. METHODS: We did a pragmatic, parallel group, assessor-blinded, randomised controlled trial in community-based and inpatient mental health services in five sites in the UK. Patients with schizophrenia who were unable to tolerate clozapine, or whose symptoms did not respond to the drug, were randomly assigned 1:1 by use of randomised-permuted blocks of size four or six, stratified by centre, to either CBT plus treatment as usual or treatment as usual alone. Research assistants were masked to allocation to protect against rater bias and allegiance bias. The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months, which provides a continuous measure of symptoms of schizophrenia; PANSS total was also assessed at the end of treatment (9 months). The primary analysis was by randomised treatment based on intention to treat, for all patients for whom data were available. This study was prospectively registered, number ISRCTN99672552. The trial is closed to accrual. FINDINGS: From Jan 1, 2013, to May 31, 2015, we randomly assigned 487 participants to either CBT and treatment as usual (n=242) or treatment as usual alone (n=245). Analysis included 209 in the CBT group and 216 in the treatment as usual group. No difference occurred in the primary outcome (PANSS total at 21 months, mean difference -0·89, 95% CI -3·32 to 1·55; p=0·48), although the CBT group improved at the end of treatment (PANSS total at 9 months, mean difference -2·40, -4·79 to -0·02; p=0·049). During the trial, 107 (44%) of 242 participants in the CBT arm and 104 (42%) of 245 in the treatment as usual arm had at least one adverse event (odds ratio 1·09, 95% CI 0·81 to 1·46; p=0·58). Only two (1%) of 242 participants in the CBT arm and one (<1%) of 245 in the treatment as usual arm had a trial-related serious adverse event. INTERPRETATION: At 21-month follow-up, CBT did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, CBT produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. There was no indication that the addition of CBT to treatment as usual caused adverse effects. The results of this trial do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some. FUNDING: National Institute for Health Research Technology Assessment programme.

Recovery and serious mental illness: a review of current clinical and research paradigms and future directions.

INTRODUCTION: Recovery from serious mental illness has historically not been considered a likely or even possible outcome. However, a range of evidence suggests the courses of SMI are heterogeneous with recovery being the most likely outcome. One barrier to studying recovery in SMI is that recovery has been operationalized in divergent and seemingly incompatible ways: as an objective outcome versus a subjective process. Areas covered: This paper offers a review of recovery as a subjective process and recovery as an objective outcome; contrasts methodologies utilized by each approach to assess recovery; reports rates and correlates of recovery; and explores the relationship between objective and subjective forms of recovery. Expert commentary: There are two commonalities of approaching recovery as a subjective process and an objective outcome: (i) the need to make meaning out of one's experiences to engage in either type of recovery and (ii) there exist many threats to engaging in meaning making that may impact the likelihood of moving toward recovery. We offer four clinical implications that stem from these two commonalities within a divided approach to the concept of recovery from SMI.

A carer burden and stigma in schizophrenia and affective disorders: Experiences from Sri Lanka.

OBJECTIVES: Stigma compounds the burden experienced by family members of those with a mental illness. This study aimed to examine burden experienced by carers of people with schizophrenia or affective disorders and to explore the relationship between carer burden and stigma. METHOD: A cross sectional descriptive study was conducted with patient-carer dyads involving 67 patients diagnosed with schizophrenia and 51 diagnosed with affective disorder. Carers completed the Zarit Burden Interview (short version) and stigma was measured using the Stigma Scale and the Internalised Stigma of Mental Illness Scale. RESULTS: Carer burden was significantly higher for schizophrenia than affective disorders. Female carers experienced significantly higher burden than male carers. Diagnosis, gender of carer and stigma predicted 22% of the variance in carer burden, with gender identified as a significant predictor. CONCLUSIONS: Reducing stigma related to disclosure of mental illness in carers has the potential to reduce carer burden.

The delaying effect of stigma on mental health help-seeking in Sri Lanka.

BACKGROUND: Mental health stigma has been associated with delays in seeking treatment. AIMS: To describe perceived stigma experienced by patients and carers in Sri Lanka and to determine the effects of stigma on help-seeking delay. METHODS: Survey of outpatients and family carers (n = 118 dyads) attending two psychiatric hospitals in Sri Lanka, using the Disclosure and Discrimination subscales of the Stigma Scale. RESULTS: Stigma was positively related to help-seeking delay for carers but not patients. Public stigma experienced by carers accounted for 23% of the variance in help-seeking delay. CONCLUSION: Reducing stigma may reduce help-seeking delays during the course of treatment.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review.

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

Design and protocol for the Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial: a randomised controlled trial.

BACKGROUND: For around a third of people with a diagnosis of schizophrenia, the condition proves to respond poorly to treatment with many typical and atypical antipsychotics. This is commonly referred to as treatment-resistant schizophrenia. Clozapine is the only antipsychotic with convincing efficacy for people whose symptoms are considered treatment-resistant to antipsychotic medication. However, 30-40 % of such conditions will have an insufficient response to the drug. Cognitive behavioural therapy has been shown to be an effective treatment for schizophrenia when delivered in combination with antipsychotic medication, with several meta-analyses showing robust support for this approach. However, the evidence for the effectiveness of cognitive behavioural therapy for people with a schizophrenia diagnosis whose symptoms are treatment-resistant to antipsychotic medication is limited. There is a clinical and economic need to evaluate treatments to improve outcomes for people with such conditions. METHODS/DESIGN: A parallel group, prospective randomised, open, blinded evaluation of outcomes design will be used to compare a standardised cognitive behavioural therapy intervention added to treatment as usual versus treatment as usual alone (the comparator group) for individuals with a diagnosis of schizophrenia for whom an adequate trial of clozapine has either not been possible due to tolerability problems or was not associated with a sufficient therapeutic response. The trial will be conducted across five sites in the United Kingdom. DISCUSSION: The recruitment target of 485 was achieved, with a final recruitment total of 487. This trial is the largest definitive, pragmatic clinical and cost-effectiveness trial of cognitive behavioural therapy for people with schizophrenia whose symptoms have failed to show an adequate response to clozapine treatment. Using a prognostic risk model, baseline information will be used to explore whether there are identifiable subgroups for which the treatment effect is greatest. TRIAL REGISTRATION: Current Controlled Trials ISRCTN99672552 . Registered 29(th) November 2012.

Metacognition in First Episode Psychosis: Item Level Analysis of Associations with Symptoms and Engagement.

Significant metacognitive impairments are observed in first episode psychosis (FEP) and chronic psychosis samples. There is evidence of associations between metacognition and presentation in FEP, but the relative contribution of metacognitive understanding of the self and the other is as yet unclear. The current study is a secondary analysis of date on metacognition, symptoms and engagement with treatment (help-seeking) in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology and help-seeking within treatment (clinician-rated service engagement) were also measured. An item level analysis of the MAS-R was conducted exploring associations between symptoms and cognitive, emotional, differentiation, integration and decentration aspects of metacognition. We report that associations between negative symptoms and deficits in the understanding of other's mental states extend across cognitive, emotional, integrative and decentration aspects of metacognition. We also report associations between negative symptoms and understanding one's own mind. We also note that cognitive and decentration aspects of metacognition were significantly associated with help-seeking once in treatment. Our findings suggest that an appreciation of metacognitive processes may inform treatment frameworks for FEP. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: Individual components of metacognition including the capacity to relate cognitive and emotional variables are important in first episode phychosis. Impaired metacognitive understanding of both one's own and others' mental states is associated with increased negative symptoms. Metacognitive variables may be important in understanding how different individuals seek help or engage with services after the initiation of treatment.

Validating measures of psychological flexibility in a population with acquired brain injury.

This study presents preliminary validation data on both the Acceptance and Action Questionnaire-Acquired Brain Injury (AAQ-ABI) and the Acceptance and Action Questionnaire-II (AAQ-II). Data from 150 participants with ABI was subject to exploratory factor analysis on the AAQ-ABI (15 items). A subset of 75 participants with ABI completed a larger battery of measures to test construct validity for the AAQ-ABI and to undertake a confirmatory factor analysis (CFA) on the AAQ-II (7 items). Three meaningful factors were identified on the AAQ-ABI: Reactive Avoidance, Denial, and Active Acceptance. Reactive Avoidance demonstrated good internal and test-retest consistency (α = .89) and correlated in expected directions with other related measures including the AAQ-II. CFA of the AAQ-II did not provide a good fit but did have similar correlations with measures of psychological distress as found in prior non-ABI samples. The results suggest both measures can be used with individuals following an ABI but they index different facets of psychological flexibility. The AAQ-ABI appears to measure psychological flexibility about the thoughts and feelings relating to the brain injury itself while the AAQ-II measures psychological flexibility around general psychological distress. Future research could explore the additional 2 factors of the AAQ-ABI and use these measures in outcome studies that promote psychological flexibility in individuals with an ABI.