Can virtual reality be used to understand persecutory delusions?

Persecutory delusions can be conceptualised as beliefs about the intentions of others. Contemporary models of persecutory delusions have different approaches to understanding interpersonal processes in paranoia. The current paper provides a critical review of the theoretical approaches and the empirical evidence on interpersonal processes across the continuum of paranoia. The three main models of persecutory delusions (Bentall and colleagues' Delusions-as-defence model, Freeman and Colleagues' Threat anticipation model and Trower and Chadwick Interpersonal theory of the self) propose that the social environment is involved in the development of persecutory delusions but they put forward different mechanisms to explain this. The evidence on interpersonal processes is organised in five main areas: interpersonal life events, attachment, schematic beliefs about relationships, social cognition and interpersonal behaviour. The review concludes with a summary of the evidence in relation to the three theoretical approaches, a discussion of methodological issues and the implications for future research

Psychological impact of identifying character strengths in people with psychosis

A one group pre-post test design investigated the impact of identifying character strengths using the Values In Action Inventory of Strengths (VIA-IS) with individuals with early psychosis (N = 29). Post-test improvements in positive affect and cognitive performance were observed. Neither self-esteem nor self-efficacy improved. The technique appears feasible for use within early intervention services. Adverse consequences should be monitored and additional components considered to enhance benefits

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

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

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

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

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

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

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

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

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

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

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

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

Understanding the Mind or Predicting Signal-Dependent Action? Performance of Children With and Without Autism on Analogues of the False-Belief Task

To evaluate the claim that correct performance on unexpected transfer false-belief tasks specifically involves mental-state understanding, two experiments were carried out with children with autism, intellectual disabilities, and typical development. In both experiments, children were given a standard unexpected transfer false-belief task and a mental-state-free, mechanical analogue task in which participants had to predict the destination of a train based on true or false signal information. In both experiments, performance on the mechanical task was found to correlate with that on the false-belief task for all groups of children. Logistic regression showed that performance on the mechanical analogue significantly predicted performance on the false-belief task even after accounting for the effects of verbal mental age. The findings are discussed in relation to possible common mechanisms underlying correct performance on the two tasks

Improving implementation of evidence based practice for people with psychosis through training the wider workforce: Results of the GOALS feasibility randomised controlled trial

BACKGROUND AND OBJECTIVES: There is a pressing need to improve access to evidence-based practice for people with psychosis. The primary aim of this study was to assess clinical feasibility of a manualised, evidence-based CBT intervention (GOALS) targeting a personalised recovery goal, delivered by the frontline workforce, following brief training. Secondly, we aimed to conduct preliminary statistical analyses of key outcomes and costs. METHODS:\ud The GOALS study is a feasibility randomised controlled trial (ISRCTN 73188383). 75 participants with current psychosis were recruited and randomly allocated to receive either treatment as usual alone or with GOALS therapy. RESULTS: Brief training enabled frontline staff to deliver the therapy according to protocol and 74% of therapy participants partially or fully achieved their goals. There were significant improvements with a moderate effect size of 0.56 on goal attainment. However, preliminary statistical analyses found no significant differences between groups on our primary outcome of activity levels or other secondary outcomes Health economic analysis found that point estimates of costs, controlling for baseline costs, implied savings (even including intervention costs), but the difference was not statistically significant. LIMITATIONS: The study was designed as a feasibility RCT, and therefore the results of secondary estimates of efficacy effects should be treated with caution. CONCLUSIONS: This approach holds promise in supporting people with psychosis to reach personal recovery goals, cost effectively