The role of attachment, coping style and reasons for substance use in substance users with psychosis.

Seventy substance users with psychosis who were participating in a clinical trial of a psychological therapy for psychosis were additionally assessed for attachment, coping styles and self-reported reasons for substance use in order to test a hypothesized sequential mediation model. In this model the relationship between insecure attachment and problematic substance use was assumed to be sequentially mediated by dysfunctional coping and the use of substances to cope with distress. Hypothesized associations between insecure-avoidant attachment and substance use were not supported, but the relationship between insecure-anxious attachment and problematic substance use was confirmed and found to be fully mediated by dysfunctional coping and coping reasons for use. Findings suggest that fostering secure attachments in people with psychosis might promote more successful coping and could prevent or reduce substance use related problems in this group.

Overcoming challenges in delivering integrated motivational interviewing and cognitive behavioural therapy for bipolar disorder with co-morbid alcohol use: therapist perspectives.

BACKGROUND: Alcohol misuse is common in bipolar disorder and is associated with worse outcomes. A recent study evaluated integrated motivational interviewing and cognitive behavioural therapy for bipolar disorder and alcohol misuse with promising results in terms of the feasibility of delivering the therapy and the acceptability to participants. AIMS: Here we present the experiences of the therapists and supervisors from the trial to identify the key challenges in working with this client group and how these might be overcome. METHOD: Four therapists and two supervisors participated in a focus group. Topic guides for the group were informed by a summary of challenges and obstacles that each therapist had completed at the end of therapy for each individual client. The audio recording of the focus group was transcribed and data were analysed using thematic analysis. RESULTS: We identified five themes: addressing alcohol use versus other problems; impact of bipolar disorder on therapy; importance of avoidance and overcoming it; fine balance in relation to shame and normalising use; and 'talking the talk' versus 'walking the walk'. CONCLUSIONS: Findings suggest that clients may be willing to explore motivations for using alcohol even if they are not ready to change their drinking, and they may want help with a range of mental health problems. Emotional and behavioural avoidance may be a key factor in maintaining alcohol use in this client group and therapists should be aware of a possible discrepancy between clients' intentions to reduce misuse and their actual behaviour.

A Theory-Informed Digital Health Intervention in People with Severe Mental Health Problems.

There is an important gap in scaling up psychosocial interventions for people with severe mental health problems so that these interventions are not only widely available but also delivered in a timely manner. We examined the feasability of adapting a psychological intervention traditionally delivered face-to-face onto a digital platform. We report both the clinical and technical processes used to adapt and develop the digital platform in a group of people in the early phase of psychosis. The digital platform prompts people to engage with the intervention multiple times a day over a 12-week period. Participants are also able to access a repository of multi-media content to support their mental health. The digital platform has been successfully validated by participants registered with early intervention for psychosis services in the Northwest of England, UK and is currently being tested in a powered efficacy trial.

Facilitators and Barriers to Participating in a Randomized Controlled Trial of a Psychological Therapy for Substance Use.

Research involving substance users with psychosis has high refusal and attrition rates. Understanding participants' experiences of research participation is therefore important. Twenty-two cannabis users with schizophrenia spectrum disorders were recruited. They were involved in a randomized controlled trial exploring the effectiveness of motivational interviewing plus cognitive behavioral therapy. Semistructured interviews were conducted, and their responses were analyzed using thematic analysis. Thematic analysis identified facilitators such as therapeutic benefit, knowledge about medical conditions, awareness of own drug habits, helping others, confidentiality, rapport with researchers, desiring social contact, and views of significant others. Barriers identified were cognitive challenge, amount of assessments, duration, and discussions about the past. Based on these insights, we recommend informing participants about clinical equipoise, confidentiality, and demands of the study; minimizing demands on participants; acknowledging participants' efforts; involving potential participants' significant others during recruitment; advertising research as an opportunity to help; and training researchers in building rapport.

Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial.

BACKGROUND: Alcohol use is a common problem in bipolar disorder (BD) and evidence indicates more promising outcomes for alcohol use than other substances. No trials have evaluated individual integrated motivational interviewing and cognitive behaviour therapy (MI-CBT) for problematic alcohol use in BD. We therefore assessed the feasibility and acceptability of a novel MI-CBT intervention for alcohol use in BD. METHODS: A single blind RCT was conducted to compare MI-CBT plus treatment as usual (TAU) with TAU only. MI-CBT was delivered over 20 sessions with participants followed up at 3, 6, 9 and 12 months post-randomisation. Primary outcomes were the feasibility and acceptability of MI-CBT (recruitment to target, retention to follow-up and therapy, acceptability of therapy and absence of adverse events). We also conducted preliminary analyses of alcohol and mood outcomes (frequency and severity of alcohol use and time to mood relapse). RESULTS: 44 participants were recruited with 75% retention to 6 and 12 months follow-up. Therapy participants attended a mean of 17.6 (SD 4.5) sessions. Therapy alliance and treatment fidelity were acceptable. Qualitative interviews indicated the intervention was experienced as collaborative, and helpful, in addressing mood and alcohol issues, although risk of overconfidence following therapy was also identified. Clinical outcomes did not differ between arms at 12 months follow-up. LIMITATIONS: As a feasibility and acceptability trial any secondary results should be treated with caution. CONCLUSIONS: Integrated MI-CBT is feasible and acceptable, but lack of clinical impact, albeit in a feasibility study, suggests need for further development. Potential adaptations are discussed.

Feasibility of using a smartphone app to assess early signs, basic symptoms and psychotic symptoms over six months: A preliminary report.

BACKGROUND: Psychosis relapses are common, have profound adverse consequences for patients, and are costly to health services. 'Early signs' have been used to predict relapse, in the hope of prevention or mitigation, with moderate sensitivity and specificity. We investigated the feasibility and validity of adding 'basic symptoms' to conventional early signs and monitoring these using a smartphone app. METHODS: Individuals (n = 18) experiencing a relapse within the past year were asked to use a smartphone app ('ExPRESS') weekly for six months to report early signs, basic symptoms and psychotic symptoms. Above-threshold increases in app-reported psychotic symptoms prompted a telephone interview (PANSS positive items) to assess relapse. RESULTS: Participants completed 65% app assessments and 58% telephone interviews. App items showed high concurrent validity with researcher-rated psychotic symptoms and basic symptoms over six months. There was excellent agreement between telephone call and face-to-face assessed psychotic symptoms. The primary relapse definition, based on telephone assessment and casenotes, compared well with a casenote-only definition but had better specificity. Mixed-effects models provided preliminary evidence of concurrent and predictive validity: early signs and basic symptoms were associated with most app-assessed psychotic symptom variables the same week and with a number of psychotic symptoms variables three weeks later; adding basic symptoms to early signs improved model fit in most of these cases. CONCLUSIONS: This is the first study to test a smartphone app for monitoring early signs and basic symptoms as putative relapse predictors. It demonstrates that weekly app-based monitoring is feasible, valid and acceptable over six months.

Development and Long-Term Acceptability of ExPRESS, a Mobile Phone App to Monitor Basic Symptoms and Early Signs of Psychosis Relapse.

BACKGROUND: Schizophrenia relapses are common, have profound, adverse consequences for patients and are costly to health services. Early signs interventions aim to use warning signs of deterioration to prevent full relapse. Such interventions show promise but could be further developed. This study addresses 2 developments: adding basic symptoms to checklists of conventional early signs and using a mobile phone app ExPRESS to aid early signs monitoring. OBJECTIVE: This study aimed to (1) design a pool of self-report items assessing basic symptoms (Basic Symptoms Checklist, BSC); (2) develop and beta test a mobile phone app (ExPRESS) for monitoring early signs, basic symptoms, and psychotic symptoms; and (3) evaluate the long-term acceptability of ExPRESS via qualitative feedback from participants in a 6-month feasibility study. METHODS: The BSC items and ExPRESS were developed and then adjusted following feedback from beta testers (n=5) with a schizophrenia diagnosis. Individuals (n=18) experiencing a relapse of schizophrenia within the past year were asked to use ExPRESS for 6 months to answer weekly questions about experiences of early signs, basic symptoms, and psychotic symptoms. At the end of follow-up, face-to-face qualitative interviews (n=16; 2 were uncontactable) explored experiences of using ExPRESS. The topic guide sought participants' views on the following a priori themes regarding app acceptability: item content, layout, and wording; app appearance; length and frequency of assessments; worries about app use; how app use fitted with participants' routines; and the app's extra features. Interview transcripts were analyzed using the framework method, which allows examination of both a priori and a posteriori themes, enabling unanticipated aspects of app use experiences to be explored. RESULTS: Participants' mean age was 38 years (range 22-57 years). Responses to a priori topics indicated that long-term use of ExPRESS was acceptable; small changes for future versions of ExPRESS were suggested. A posteriori themes gave further insight into individuals' experiences of using ExPRESS. Some reported finding it more accessible than visits from a clinician, as assessments were more frequent, more anonymous, and did not require the individual to explain their feelings in their own words. Nevertheless, barriers to app use (eg, unfamiliarity with smartphones) were also reported. Despite ExPRESS containing no overtly therapeutic components, some participants found that answering the weekly questions prompted self-reflection, which had therapeutic value for them. CONCLUSIONS: This study suggests that apps are acceptable for long-term symptom monitoring by individuals with a schizophrenia diagnosis across a wide age range. If the potential benefits are understood, patients are generally willing and motivated to use a weekly symptom-monitoring app; most participants in this study were prepared to do so for more than 6 months. TRIAL REGISTRATION: ClinicalTrials.gov NCT03558529; https://clinicaltrials.gov/ct2/show/NCT03558529 (Archived by WebCite at http://www.webcitation.org/70qvtRmZY).

Early Psychosis Service User Views on Digital Technology: Qualitative Analysis.

BACKGROUND: Digital technology has the potential to improve outcomes for people with psychosis. However, to date, research has largely ignored service user views on digital health interventions (DHIs). OBJECTIVE: The objective of our study was to explore early psychosis service users' subjective views on DHIs. METHODS: Framework analysis was undertaken with data obtained from 21 semistructured interviews with people registered with early intervention for psychosis services. Robust measures were used to develop a stable framework, including member checking, triangulation, independent verification of themes, and consensus meetings. RESULTS: The following 4 themes were established a priori: acceptability of technology in psychosis and mental health; technology increasing access to and augmenting mental health support; barriers to adopting DHIs; and concerns about management of data protection, privacy, risk, and security of information. The following 2 themes were generated a posteriori: blending DHIs with face-to-face treatment and empowerment, control, and choice. DHIs were also viewed as potentially destigmatizing, overcoming barriers faced in traditional service settings, facilitating communication, and empowering service users to take active control of their health care. CONCLUSIONS: In the first study of its kind, early psychosis service users' were largely positive about the potential use of DHIs supporting and managing mental health. Overall, service users felt that DHIs were a progressive, modern, and relevant platform for health care delivery. Concerns were expressed around privacy and data security and practical barriers inherent within DHIs, all of which require further attention. Future research should explore whether findings transfer to other service user groups, other technology delivery formats, and across a range of treatment modalities.

Integrated psychological therapy for people with bipolar disorder and co-morbid alcohol use: A feasibility and acceptability randomised controlled trial.

BACKGROUND: Co-morbid substance misuse, particularly alcohol, is common in bipolar disorder (BD) and associated with worse treatment outcomes. Research into psychological interventions for substance misuse in BD is at an early stage and no studies have specifically targeted problematic alcohol use. This paper describes the context and protocol for a feasibility and acceptability randomised controlled trial (RCT) evaluating a novel intervention combining motivational interviewing and cognitive behavioural therapy (MI-CBT) for participants with BD and problematic alcohol use, developed in collaboration with people with lived experience of both issues. METHODS AND DESIGN: An RCT will assess the feasibility and acceptability of MI-CBT in addition to treatment as usual (TAU) compared with TAU alone. Participants will be recruited from across the North West of England through NHS services and self-referral. The primary outcomes will be the feasibility and acceptability of the intervention assessed by recruitment to target, adherence to intervention, retention rate at follow-up, absence of adverse events and qualitative analysis of participants' reported experiences of intervention. The effect size of the impact of the intervention on alcohol use and mood outcomes will also be estimated. In addition, we will explore a number of potential process variables in therapy. DISCUSSION: This is the first RCT evaluating MI-CBT for BD and problematic alcohol use. Given the prevalence and impact of alcohol problems in BD this novel integrated intervention may have potential to offer important improvements in clinical and functional outcomes.

Actissist: Proof-of-Concept Trial of a Theory-Driven Digital Intervention for Psychosis.

Background: Timely access to intervention for psychosis is crucial yet problematic. As such, health care providers are forming digital strategies for addressing mental health challenges. A theory-driven digital intervention that monitors distressing experiences and provides real-time active management strategies could improve the speed and quality of recovery in psychosis, over and above conventional treatments. This study assesses the feasibility and acceptability of Actissist, a digital health intervention grounded in the cognitive model of psychosis that targets key early psychosis domains. Methods: A proof-of-concept, single, blind, randomized controlled trial of Actissist, compared to a symptom-monitoring control. Thirty-six early psychosis patients were randomized on a 2:1 ratio to each arm of the trial. Actissist was delivered via a smartphone app over 12-weeks; clinical and functional assessment time-points were baseline, post-treatment and 22-weeks. Assessors' blind to treatment condition conducted the assessments. Acceptability was examined using qualitative methods. Results: Actissist was feasible (75% participants used Actissist at least once/day; uptake was high, 97% participants remained in the trial; high follow-up rates), acceptable (90% participants recommend Actissist), and safe (0 serious adverse events), with high levels of user satisfaction. Treatment effects were large on negative symptoms, general psychotic symptoms and mood. The addition of Actissist conferred benefit at post-treatment assessment over routine symptom-monitoring and treatment as usual. Conclusions: This is the first controlled proof-of-concept trial of a theory-driven digital health intervention for early psychosis. Actissist is feasible and acceptable to early psychosis patients, with a strong signal for treatment efficacy. Trial Registration: ISRCTN: 34966555.

Attachment and therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis.

We examine associations between client attachment style and therapeutic alliance in a 3-arm randomized controlled trial of brief motivational interviewing and cognitive-behavioural therapy compared with longer term motivational interviewing and cognitive-behavioural therapy or standard care alone. Client self-report measures of attachment style were completed at baseline, and both clients and therapists in the treatment arms of the trial completed alliance measures 1 month into therapy. We found that insecure-anxious attachment was positively associated with therapist-rated alliance, whereas clients with insecure-avoidant attachment were more likely to report poorer bond with therapist. There was no evidence that client attachment significantly predicted clinical or substance misuse outcomes either directly or indirectly via alliance. Nor evidence that the length of therapy offered interacted with attachment to predict alliance.

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

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

Comparing early signs and basic symptoms as methods for predicting psychotic relapse in clinical practice.

BACKGROUND: Early signs interventions show promise but could be further developed. A recent review suggested that 'basic symptoms' should be added to conventional early signs to improve relapse prediction. This study builds on preliminary evidence that basic symptoms predict relapse and aimed to: 1. examine which phenomena participants report prior to relapse and how they describe them; 2. determine the best way of identifying pre-relapse basic symptoms; 3. assess current practice by comparing self- and casenote-reported pre-relapse experiences. METHODS: Participants with non-affective psychosis were recruited from UK mental health services. In-depth interviews (n=23), verbal checklists of basic symptoms (n=23) and casenote extracts (n=208) were analysed using directed content analysis and non-parametric statistical tests. RESULTS: Three-quarters of interviewees reported basic symptoms and all reported conventional early signs and 'other' pre-relapse experiences. Interviewees provided rich descriptions of basic symptoms. Verbal checklist interviews asking specifically about basic symptoms identified these experiences more readily than open questions during in-depth interviews. Only 5% of casenotes recorded basic symptoms; interviewees were 16 times more likely to report basic symptoms than their casenotes did. CONCLUSIONS: The majority of interviewees self-reported pre-relapse basic symptoms when asked specifically about these experiences but very few casenotes reported these symptoms. Basic symptoms may be potent predictors of relapse that clinicians miss. A self-report measure would aid monitoring of basic symptoms in routine clinical practice and would facilitate a prospective investigation comparing basic symptoms and conventional early signs as predictors of relapse.

Self-blame attributions in relatives of people with recent-onset psychosis: Associations with relatives' distress and behavioural control.

OBJECTIVES: There is evidence that self-blame is an important predictor of distress and depression in relatives of people with long-term psychosis, but there is limited research investigating the nature and correlates of self-blame in relatives of people with recent-onset psychosis. Self-blame motivates a tendency to engage with others and to repair wrongdoings; it might be that such cognitions also impact on relatives' behaviours towards the patient. This study examined the association between self-blame and psychological distress, and tested the prediction that greater self-blame would be associated with more behavioural control attempts to patients in a sample of relatives of people with recent-onset psychosis. METHODS: Statements pertaining to self-blame and behavioural control were extracted and rated from 80 interviews with relatives, who also completed the General Health Questionnaire-28. Content analysis was used to examine the nature of self-blame attributions. Regression analyses were used to explore the links between self-blame attributions and distress, and between self-blame and behavioural control in this recent-onset population. RESULTS: Higher levels of self-blame were associated with more behavioural control attempts, and self-blame predicted relatives' behavioural responses when adjusting for the contribution of control attributions. Self-blame was also linked with distress, but did not emerge as an independent predictor in multivariate analysis. Most relatives who blamed themselves did so for not overseeing their family member's mental health problems properly or for perceiving themselves generally as poor carers. CONCLUSIONS: This study extends findings related to self-blame to a population of relatives of people with recent-onset psychosis and highlights the possible role of blaming cognitions in promoting interpersonal engagement through behavioural control. PRACTITIONER POINTS: Self-blaming beliefs were linked with increased distress in relatives of people with recent-onset psychosis; Increased self-blame was associated with more behavioural control attempts; Most relatives blamed themselves for not overseeing their family member's mental health problems properly, and for perceiving themselves generally as poor carers. The cross-sectional study design limits inferences about causality.

Activity patterns in response to symptoms in patients being treated for chronic fatigue syndrome: An experience sampling methodology study.

OBJECTIVE: Cognitive-behavioral models of chronic fatigue syndrome (CFS) propose that patients respond to symptoms with 2 predominant activity patterns-activity limitation and all-or-nothing behaviors-both of which may contribute to illness persistence. The current study investigated whether activity patterns occurred at the same time as, or followed on from, patient symptom experience and affect. METHOD: Twenty-three adults with CFS were recruited from U.K. CFS services. Experience sampling methodology (ESM) was used to assess fluctuations in patient symptom experience, affect, and activity management patterns over 10 assessments per day for a total of 6 days. Assessments were conducted within patients' daily life and were delivered through an app on touchscreen Android mobile phones. Multilevel model analyses were conducted to examine the role of self-reported patient fatigue, pain, and affect as predictors of change in activity patterns at the same and subsequent assessment. RESULTS: Current experience of fatigue-related symptoms and pain predicted higher patient activity limitation at the current and subsequent assessments whereas subjective wellness predicted higher all-or-nothing behavior at both times. Current pain predicted less all-or-nothing behavior at the subsequent assessment. In contrast to hypotheses, current positive affect was predictive of current activity limitation whereas current negative affect was predictive of current all-or-nothing behavior. Both activity patterns varied at the momentary level. CONCLUSIONS: Patient symptom experiences appear to be driving patient activity management patterns in line with the cognitive-behavioral model of CFS. ESM offers a useful method for examining multiple interacting variables within the context of patients' daily life. (PsycINFO Database Record

Understanding Outcomes in a Randomized Controlled Trial of a Ward-based Intervention on Psychiatric Inpatient Wards: A Qualitative Analysis of Staff and Patient Experiences.

OBJECTIVE: Team formulation is advocated to improve quality of care in mental health care and evidence from a recent U.K.-based trial supports its use in inpatient settings. This study aimed to identify the effects of formulation on practice from the perspectives of staff and patient participating in the trial, including barriers and enhancers to implementing the intervention. METHOD: We carried out semistructured interviews with 57 staff and 20 patients. Data were analyzed using thematic analysis. RESULTS: Main outcomes were: improved staff understanding of patients, better team collaboration and increased staff awareness of their own feelings. Key contextual factors were as follows: overcoming both staff and patient anxiety, unwelcome expert versus collaborative stance, competing demands, and management support. CONCLUSION: Team formulation should be implemented to improve quality of care in inpatient settings and larger definitive trials should be carried out to assess the effect of this intervention on patient outcomes.

Culturally-adapted Family Intervention (CaFI) for African-Caribbeans diagnosed with schizophrenia and their families: a feasibility study protocol of implementation and acceptability.

BACKGROUND: African-Caribbeans in the UK have the highest schizophrenia incidence and greatest inequity in access to mental health services of all ethnic groups. The National Institute for Health and Care Excellence (NICE) highlights this crisis in care and urgent need to improve evidence-based mental healthcare, experiences of services and outcomes for this group. Family intervention (FI) is clinically and cost-effective for the management of schizophrenia but it is rarely offered. Evidence for FI with minority ethnic groups generally, and African-Caribbeans in particular, is lacking. This study aims to test the feasibility and acceptability of delivering Culturally-adapted Family Intervention (CaFI) to African-Caribbean service users diagnosed with schizophrenia. METHODS/DESIGN: This is a feasibility cohort design study. Over a 12-month intervention period, 30 service users and their families, recruited from hospital and community settings, will receive ten one-hourly sessions of CaFI. Where biological families are absent, access to the intervention will be optimised through 'family support members'; trusted individuals nominated by service users or study volunteers. We shall collect data on eligibility, uptake, retention and attrition and assess the utility and feasibility of collecting various outcome measures including readmission, service engagement, working alliance, clinical symptoms and functioning, perceived criticism, psychosis knowledge, familial stress and economic costs. Measures will be collected at baseline, post-intervention and at 3-month follow-up using validated questionnaires and standardised interviews. Admission rates and change in care management will be rated by independent case note examination. Variability in the measures will inform sample size estimates for a future trial. Independent raters will assess fidelity to the intervention in 10 % of sessions. Feedback at the end of each session along with thematically-analysed qualitative interviews will examine CaFI's acceptability to service users, families and healthcare professionals. DISCUSSION: This innovative response to inequalities in mental healthcare experienced by African-Caribbeans diagnosed with schizophrenia might improve engagement in services, access to evidence-based interventions and clinical outcomes. Successful implementation of CaFI in this group could pave the way for better engagement and provision across marginalised groups and therefore has potentially important implications for commissioning and service delivery in ethnically diverse populations. This study will demonstrate whether the approach is feasible and acceptable and can be implemented with fidelity in different settings.

Expressed Emotion and behaviourally controlling interactions in the daily life of dyads experiencing psychosis.

While research using Experience Sampling Methodology (ESM) suggests that, in general, contact with relatives or friends may be protective for psychotic experiences, contact with high-Expressed Emotion (high-EE) relatives can have adverse consequences for patients. This study investigated whether contact with high-EE relatives, and relatives' behaviourally controlling interactions (BCI) are related to patients' symptoms and to both patients' and relatives' affect when measured using structured diary assessments in the course of everyday life. Twenty-one patients experiencing psychosis and their closest relatives provided synchronized self-reports of symptoms (patients only), affect, dyadic contact and BCI over a 6-days period. Relatives' EE was obtained from Camberwell Family Interviews. Multi-level modeling showed that patients' reports of relatives taking control of them and helping them were associated with increased patient negative affect and symptoms. Relatives' self-reports of nagging, taking control and keeping an eye on the patient were related to fluctuations in relatives' affect. No evidence was found for the moderating effect of EE status on the association between dyadic contact and affect or, in the case of patients, symptoms. When measured using an ecologically valid methodology, momentary behaviourally controlling interactions within dyads experiencing psychosis can impact on patients' affect and symptoms.

Assessing the reliability of the five minute speech sample against the Camberwell family interview in a chronic fatigue syndrome sample.

PURPOSE: The current study aimed to examine the reliability of the Five Minute Speech Sample (FMSS) for assessing relative Expressed Emotion (EE) compared with the Camberwell Family Interview (CFI) in a sample of relatives of adult patients with Chronic Fatigue Syndrome (CFS). METHOD: 21 relatives were recruited and completed both assessments. The CFI was conducted first for all participants, with the FMSS conducted approximately one month later. Trained raters independently coded both EE measures; high levels of rating reliability were established for both measures. Comparisons were conducted for overall EE status, emotional over-involvement (EOI) and criticism. FINDINGS: The distribution of high and low-EE was equivalent across the two measures, with the FMSS correctly classifying EE is 71% of cases (n=15). The correspondence between the FMSS and CFI ratings was found to be non-significant for all categorical variables. However, the number of critical comments made by relatives during the FMSS significantly correlated with the number of critical comments made during the CFI. The poorest correspondence between the measures was observed for the EOI dimension. CONCLUSION: The findings suggest that the FMSS may be a useful screening tool for identifying high-EE, particularly criticism, within a sample of relatives of patients with CFS. However, the two measures should not be assumed equivalent, and the CFI should be used where possible, particularly with respect to understanding EOI.

Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis.

BACKGROUND: This paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis. METHODS: All clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5months, 9months and 18months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy. RESULTS: At baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point. CONCLUSIONS: Findings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.