Abstract Recent evidence points to the high rates of traumatic events, particularly persistent ch... more Abstract Recent evidence points to the high rates of traumatic events, particularly persistent childhood victimisation, and posttraumatic stress reactions in people with psychosis. Psychological therapists therefore need to understand the relationships between trauma and psychotic experiences, to assist effective assessment, formulation, and intervention. This chapter provides an overview of current evidence and debates regarding trauma, posttraumatic stress, trauma-related psychosis, and their underlying psychological mechanisms. Irene will share her experiences to illustrate the impact that trauma can have on psychosis, and we will use the hypothetical case example of Janet to explore how we can make sense of this. A trauma-focused cognitive-behavioural model of psychosis will be described and used to understand Janet's difficulties, followed by a guide to assessment and formulation in clinical practice. The formulation model then provides the foundation for Chapter 19, which outlines how to approach therapy for people experiencing posttraumatic stress in psychosis.
Abstract This chapter discusses the evidence base concerning trauma-focused therapies (TFTs) in p... more Abstract This chapter discusses the evidence base concerning trauma-focused therapies (TFTs) in people with psychosis and PTSD, including Irene's account of her recovery, which indicates that several therapies can be safe and effective for people with this combination of problems. A phased approach to trauma-focused cognitive behaviour therapy in psychosis (tf-CBTp) is presented to help guide formulation and intervention for the broader range of posttraumatic stress in psychosis (PTSp) difficulties. Several controversies in this field (e.g. safety issues) are discussed and clinical guidance is given on how to use TFTs in psychosis. The delivery of tf-CBTp is illustrated with the case of Janet, who is a fictional person based on Amy and David's therapy experiences.
Introduction: Many people with psychotic disorders experience symptoms of post-traumatic stress d... more Introduction: Many people with psychotic disorders experience symptoms of post-traumatic stress disorder (PTSD). In recent years, several trauma-focused therapies (TFTs), including cognitive restructuring (CR), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) have been studied and found to be safe and effective in reducing PTSD symptoms in individuals with psychosis. However, studies were conducted in different countries, with varying inclusion criteria, therapy duration, control groups, and trial outcomes. RE.PROCESS will be the first study to compare the impact of CR, PE and EMDR with a waiting list control condition within the same context.Methods and analysis: This is the protocol of a pragmatic, single-blind, multicentre, superiority randomized controlled trial, in which CR, PE, and EMDR are compared to a waiting list control condition for TFT (WL) in a naturalistic treatment setting. Inclusion criteria are: Age ≥ 16 years; meeting full DSM-5 di...
Background People with psychosis have high rates of trauma, with a post-traumatic stress disorder... more Background People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists. Methods Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stre...
Background Marginalized groups are more likely to experience problems with technology-related acc... more Background Marginalized groups are more likely to experience problems with technology-related access, motivation, and skills. This is known as the “digital divide.” Technology-related exclusion is a potential barrier to the equitable implementation of digital health. SlowMo therapy was developed with an inclusive, human-centered design to optimize accessibility and bridge the “digital divide.” SlowMo is an effective, blended digital psychological therapy for paranoia in psychosis. Objective This study explores the “digital divide” and mobile app engagement in the SlowMo randomized controlled trial. Methods Digital literacy was assessed at baseline, and a multidimensional assessment of engagement (ie, adherence [via system analytics and self-report] and self-reported user experience) was conducted at 12 weeks after therapy. Engagement was investigated in relation to demographics (ie, gender, age, ethnicity, and paranoia severity). Results Digital literacy data demonstrated that techn...
Psychology and Psychotherapy: Theory, Research and Practice
Copies of full text items generally can be reproduced, displayed or performed and given to third ... more Copies of full text items generally can be reproduced, displayed or performed and given to third parties in any format or medium for personal research or study, educational, or not-for-profit purposes without prior permission or charge, provided that the authors, title and full bibliographic details are credited, a hyperlink and/or URL is given for the original metadata page and the content is not changed in any way. * The SlowMo PPI team comprised 9 peer researchers and service user consultants who were actively involved in the design, data collection, analysis and write up. Those who have given permission to use their names were Alice Hicks, Angie, Dan, Amy, Helen and Natalie (first names only), and Anthony (pseudonym) and Alex (pseudonym). One PPI team member sadly died during the study; they made an important early contribution but permission to name them in this paper was not granted before their death. We would like to acknowledge the intelligence and wisdom that they brought to the project. Title: The service user experience of SlowMo therapy: A coproduced thematic analysis of service users' subjective experience.
Background AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucina... more 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 f...
Background: Around one in five people may experience paranoid thoughts. An intervention of struct... more Background: Around one in five people may experience paranoid thoughts. An intervention of structured therapy developed by psychologists has been effective in improving such thought processes (Garety et al, 2014, Ross et al, 2009; Waller et al, 2011, 2015). However, engagement and persistence with the intervention remained difficult. This study explores how inclusive design methodologies transformed the intervention, and raises methodological questions as the practice moves further into the field of mental health. Method: An interdisciplinary team of psychologists and designers worked closely with service users in the research and development of an improved intervention, conducting in-depth interviews, observations of therapy, collaborative synthesis of findings, iterative prototyping and extensive user testing. Results: The revised intervention is a digital therapy platform (‘SlowMo’). This supports therapy sessions with interactive web-based media; this tailored content synchronis...
al. (2022) The impact of patient and public involvement in the SlowMo study: reflections on peer ... more al. (2022) The impact of patient and public involvement in the SlowMo study: reflections on peer innovation. Health Expectations, 25 (1). pp. 191-202.
Journal of Behavior Therapy and Experimental Psychiatry, 2020
Remembering the past to live better in the future: A feasibility randomised controlled trial of m... more Remembering the past to live better in the future: A feasibility randomised controlled trial of memory specificity training for motivation in psychosis.
Background Reasoning may play a causal role in paranoid delusions in psychosis. SlowMo, a new dig... more Background Reasoning may play a causal role in paranoid delusions in psychosis. SlowMo, a new digitally supported cognitive–behavioural therapy, targets reasoning to reduce paranoia. Objectives To examine the effectiveness of SlowMo therapy in reducing paranoia and in improving reasoning, quality of life and well-being, and to examine its mechanisms of action, moderators of effects and acceptability. Design A parallel-arm, assessor-blind, randomised controlled trial comparing SlowMo plus treatment as usual with treatment as usual alone. An online independent system randomised eligible participants (1 : 1) using randomly varying permuted blocks, stratified by site and paranoia severity. Setting Community mental health services in three NHS mental health trusts in England, plus patient identification centres. Participants A total of 362 participants with schizophrenia-spectrum psychosis. Eligibility criteria comprised distressing and persistent (≥ 3 months) paranoia. Interventions Eig...
Background: Remote therapy promises a cost-effective way of increasing delivery of psychologicalt... more Background: Remote therapy promises a cost-effective way of increasing delivery of psychologicaltherapy in underserved populations. However, research shows a "digital divide", with some groups experiencing digital exclusion. Aims: To assess whether technology, accessibility, and demographic factors influence remote therapy uptake among individuals with psychosis, and whether demographic factors are associated with digital exclusion. Methods: Remote therapy uptake and demographics were assessed in people (n ¼ 51) within a psychology-led service for psychosis, using a survey of access to digital hardware, data and private space. Results: The majority of individuals had access to digital devices, but 29% did not meet minimum requirements for remote therapy. Nineteen (37%) individuals declined remote therapy. Those who accepted were significantly younger and more likely to have access to technology than those who declined. The mean age of those with access to smartphones and large screen devices was younger than those without access. Conclusions: A subgroup of people with psychosis face barriers to remote therapy and a significant minority are digitally excluded. Older age is a key factor influencing remote therapy uptake, potentially related to less access to digital devices. Services must minimize exclusion through provision of training, hardware and data, whilst promoting individual choice.
Abstract Recent evidence points to the high rates of traumatic events, particularly persistent ch... more Abstract Recent evidence points to the high rates of traumatic events, particularly persistent childhood victimisation, and posttraumatic stress reactions in people with psychosis. Psychological therapists therefore need to understand the relationships between trauma and psychotic experiences, to assist effective assessment, formulation, and intervention. This chapter provides an overview of current evidence and debates regarding trauma, posttraumatic stress, trauma-related psychosis, and their underlying psychological mechanisms. Irene will share her experiences to illustrate the impact that trauma can have on psychosis, and we will use the hypothetical case example of Janet to explore how we can make sense of this. A trauma-focused cognitive-behavioural model of psychosis will be described and used to understand Janet's difficulties, followed by a guide to assessment and formulation in clinical practice. The formulation model then provides the foundation for Chapter 19, which outlines how to approach therapy for people experiencing posttraumatic stress in psychosis.
Abstract This chapter discusses the evidence base concerning trauma-focused therapies (TFTs) in p... more Abstract This chapter discusses the evidence base concerning trauma-focused therapies (TFTs) in people with psychosis and PTSD, including Irene's account of her recovery, which indicates that several therapies can be safe and effective for people with this combination of problems. A phased approach to trauma-focused cognitive behaviour therapy in psychosis (tf-CBTp) is presented to help guide formulation and intervention for the broader range of posttraumatic stress in psychosis (PTSp) difficulties. Several controversies in this field (e.g. safety issues) are discussed and clinical guidance is given on how to use TFTs in psychosis. The delivery of tf-CBTp is illustrated with the case of Janet, who is a fictional person based on Amy and David's therapy experiences.
Introduction: Many people with psychotic disorders experience symptoms of post-traumatic stress d... more Introduction: Many people with psychotic disorders experience symptoms of post-traumatic stress disorder (PTSD). In recent years, several trauma-focused therapies (TFTs), including cognitive restructuring (CR), prolonged exposure (PE), and eye movement desensitization and reprocessing (EMDR) have been studied and found to be safe and effective in reducing PTSD symptoms in individuals with psychosis. However, studies were conducted in different countries, with varying inclusion criteria, therapy duration, control groups, and trial outcomes. RE.PROCESS will be the first study to compare the impact of CR, PE and EMDR with a waiting list control condition within the same context.Methods and analysis: This is the protocol of a pragmatic, single-blind, multicentre, superiority randomized controlled trial, in which CR, PE, and EMDR are compared to a waiting list control condition for TFT (WL) in a naturalistic treatment setting. Inclusion criteria are: Age ≥ 16 years; meeting full DSM-5 di...
Background People with psychosis have high rates of trauma, with a post-traumatic stress disorder... more Background People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists. Methods Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stre...
Background Marginalized groups are more likely to experience problems with technology-related acc... more Background Marginalized groups are more likely to experience problems with technology-related access, motivation, and skills. This is known as the “digital divide.” Technology-related exclusion is a potential barrier to the equitable implementation of digital health. SlowMo therapy was developed with an inclusive, human-centered design to optimize accessibility and bridge the “digital divide.” SlowMo is an effective, blended digital psychological therapy for paranoia in psychosis. Objective This study explores the “digital divide” and mobile app engagement in the SlowMo randomized controlled trial. Methods Digital literacy was assessed at baseline, and a multidimensional assessment of engagement (ie, adherence [via system analytics and self-report] and self-reported user experience) was conducted at 12 weeks after therapy. Engagement was investigated in relation to demographics (ie, gender, age, ethnicity, and paranoia severity). Results Digital literacy data demonstrated that techn...
Psychology and Psychotherapy: Theory, Research and Practice
Copies of full text items generally can be reproduced, displayed or performed and given to third ... more Copies of full text items generally can be reproduced, displayed or performed and given to third parties in any format or medium for personal research or study, educational, or not-for-profit purposes without prior permission or charge, provided that the authors, title and full bibliographic details are credited, a hyperlink and/or URL is given for the original metadata page and the content is not changed in any way. * The SlowMo PPI team comprised 9 peer researchers and service user consultants who were actively involved in the design, data collection, analysis and write up. Those who have given permission to use their names were Alice Hicks, Angie, Dan, Amy, Helen and Natalie (first names only), and Anthony (pseudonym) and Alex (pseudonym). One PPI team member sadly died during the study; they made an important early contribution but permission to name them in this paper was not granted before their death. We would like to acknowledge the intelligence and wisdom that they brought to the project. Title: The service user experience of SlowMo therapy: A coproduced thematic analysis of service users' subjective experience.
Background AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucina... more 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 f...
Background: Around one in five people may experience paranoid thoughts. An intervention of struct... more Background: Around one in five people may experience paranoid thoughts. An intervention of structured therapy developed by psychologists has been effective in improving such thought processes (Garety et al, 2014, Ross et al, 2009; Waller et al, 2011, 2015). However, engagement and persistence with the intervention remained difficult. This study explores how inclusive design methodologies transformed the intervention, and raises methodological questions as the practice moves further into the field of mental health. Method: An interdisciplinary team of psychologists and designers worked closely with service users in the research and development of an improved intervention, conducting in-depth interviews, observations of therapy, collaborative synthesis of findings, iterative prototyping and extensive user testing. Results: The revised intervention is a digital therapy platform (‘SlowMo’). This supports therapy sessions with interactive web-based media; this tailored content synchronis...
al. (2022) The impact of patient and public involvement in the SlowMo study: reflections on peer ... more al. (2022) The impact of patient and public involvement in the SlowMo study: reflections on peer innovation. Health Expectations, 25 (1). pp. 191-202.
Journal of Behavior Therapy and Experimental Psychiatry, 2020
Remembering the past to live better in the future: A feasibility randomised controlled trial of m... more Remembering the past to live better in the future: A feasibility randomised controlled trial of memory specificity training for motivation in psychosis.
Background Reasoning may play a causal role in paranoid delusions in psychosis. SlowMo, a new dig... more Background Reasoning may play a causal role in paranoid delusions in psychosis. SlowMo, a new digitally supported cognitive–behavioural therapy, targets reasoning to reduce paranoia. Objectives To examine the effectiveness of SlowMo therapy in reducing paranoia and in improving reasoning, quality of life and well-being, and to examine its mechanisms of action, moderators of effects and acceptability. Design A parallel-arm, assessor-blind, randomised controlled trial comparing SlowMo plus treatment as usual with treatment as usual alone. An online independent system randomised eligible participants (1 : 1) using randomly varying permuted blocks, stratified by site and paranoia severity. Setting Community mental health services in three NHS mental health trusts in England, plus patient identification centres. Participants A total of 362 participants with schizophrenia-spectrum psychosis. Eligibility criteria comprised distressing and persistent (≥ 3 months) paranoia. Interventions Eig...
Background: Remote therapy promises a cost-effective way of increasing delivery of psychologicalt... more Background: Remote therapy promises a cost-effective way of increasing delivery of psychologicaltherapy in underserved populations. However, research shows a "digital divide", with some groups experiencing digital exclusion. Aims: To assess whether technology, accessibility, and demographic factors influence remote therapy uptake among individuals with psychosis, and whether demographic factors are associated with digital exclusion. Methods: Remote therapy uptake and demographics were assessed in people (n ¼ 51) within a psychology-led service for psychosis, using a survey of access to digital hardware, data and private space. Results: The majority of individuals had access to digital devices, but 29% did not meet minimum requirements for remote therapy. Nineteen (37%) individuals declined remote therapy. Those who accepted were significantly younger and more likely to have access to technology than those who declined. The mean age of those with access to smartphones and large screen devices was younger than those without access. Conclusions: A subgroup of people with psychosis face barriers to remote therapy and a significant minority are digitally excluded. Older age is a key factor influencing remote therapy uptake, potentially related to less access to digital devices. Services must minimize exclusion through provision of training, hardware and data, whilst promoting individual choice.
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