Changes in Quality of Life in Treatment-Resistant Schizophrenia Patients Undergoing Avatar Therapy: A Content Analysis

Avatar Therapy has a significant impact on symptoms, beliefs, and quality of life of patients with treatment-resistant schizophrenia. However, little is known about how these changes are implemented into their lives and to which aspects of their lives these improvements relate. Ten consecutive patients enrolled in an ongoing clinical trial were assessed using semi-guided interviews before as well as three months after Avatar Therapy. These encounters have been recorded and transcribed so that the discourse could be thoroughly analyzed, leading to the generation of an extensive theme grid. As the cases were analyzed, the grid was adapted in a back-and-forth manner until data saturation occurred. The content analysis allowed the identification of nine main themes representing different aspects of the patients’ lives, each of which was subdivided into more specific codes. By analyzing the evolution of their frequency, it was observed that, following therapy, patients presented with fewer psychotic symptoms, better self-esteem, more hobbies and projects, and an overall improved lifestyle and mood. Finally, investigating the impact of Avatar Therapy on quality of life allows for a deeper understanding of how people with treatment-resistant schizophrenia can achieve meaningful changes and move towards a certain recovery process.

Remote group therapies for cognitive health in schizophrenia-spectrum disorders: Feasible, acceptable, engaging

Severe cognitive impairments and cognitive distortions are core to schizophrenia-spectrum disorders (SSDs) and are associated with deteriorated social functioning. Despite well-established efficacy of group psychosocial therapies targeting cognitive health in SSDs, dissemination of these programs remains limited. Remote delivery offers a promising strategy for increasing the programs' accessibility. Yet, little research has evaluated group therapies for cognitive health delivered in this way. Thus, we aimed to assess, from participants' and therapists' perspectives, the feasibility, acceptability, as well as levels and process of engagement in a videoconference delivery of group psychosocial therapies for SSD patients' cognitive health. Participants, outpatients, attended Action Based Cognitive Remediation or Metacognitive Training, both adapted for videoconference. Then, participants and therapists completed post-therapy questionnaires. Of the 28 participants attending at least one session, 75% completed more than half of sessions and seven dropped out. Technology did not appear to significantly hinder participation in the programs. All completing participants reported a positive experience with therapy, 67% were not bothered by the distance from the therapist, and 77% trusted that the information shared was kept confidential. Therapist-rated levels of attention M = 7.5/9 (SD = 1.04), participation M = 6.91/9 (SD = 1.32), and social interactions M = 5.31/9 (SD = 1.96) were satisfactory. Nonetheless, participants indicated that they would have appreciated more social interactions with group members. These positive results validate the earliest stage in the implementation process for remote group therapies targeting cognitive health in SSDs. Remote delivery promises to improve access to therapies targeting cognitive health and, ultimately, facilitate functional recovery for SSD patients.

Managing emotions in psychosis: Evaluation of a brief DBT-informed skill group for individuals with psychosis in routine community services

Objectives

Individuals with psychosis report that emotion regulation (ER) difficulties are treatment priorities, yet little is known about how targeted ER interventions may help. We evaluated a new eight‐session Dialectical Behavioural Therapy (DBT)–informed skills group specifically adapted for individuals with psychosis: the Managing Emotions Group (MEG) in diverse, inner‐city community services.

Method

A mixed‐method design was utilised to assess the feasibility (acceptability and potential clinical impact) of local delivery of MEG. Uptake, completion (≥50% of sessions), post‐session satisfaction ratings, and thematic analysis of qualitative feedback from 12 completers assessed acceptability. Pre–post‐intervention changes in psychological distress, self‐reported ER difficulties, and adaptive ER skill use assessed potential clinical impact.

Results

Forty‐eight individuals (81% of attenders) completed the intervention (M_age = 43, 54% female) of whom 39 completed pre‐ and post‐group measures. Participants reported high satisfaction and meaningful improvements in understanding and managing emotions, with positive impact on daily life. Self‐reported psychological distress, ER difficulties, and adaptive ER skill use significantly improved, with medium‐to‐large pre‐post effects (d = 0.5–0.7) except lack of emotional clarity (d = 0.3).

Conclusions

MEG was feasible and acceptable, and a future feasibility randomised controlled trial is warranted.

Practitioner points

Individuals with psychosis report that support with their emotions is a priority.

Brief interventions for emotion regulation difficulties are acceptable to individuals with psychosis and can be feasibly delivered in a local outpatient service.

Distress and emotion regulation difficulties and skills improved significantly from pre–post treatment for clients completing the managing emotions group.

Further implementation and evaluation are needed to support continued refinement to meet the needs and priorities of individuals with psychosis.

Feasibility and efficacy of an acceptance and mindfulness-based group intervention for young people with early psychosis (Feel-Good group)

BACKGROUND

Over the last decade, researchers have sought for alternative interventions that have better treatment effects than Cognitive Behavioral Therapy (CBT) when treating psychotic symptoms. Mindfulness-based interventions have been a proposed alternative to CBT, yet research regarding its feasibility, acceptance and effectiveness is lacking when treating individuals with early psychosis in inpatient settings.

OBJECTIVE

Before conducting a large-scale randomized-controlled trial (RCT), this pilot study evaluated the feasibility and the potential efficacy of a mindfulness-based inpatient group intervention that targets emotion regulation in patients with early psychosis, and thus indirectly improving psychotic symptoms.

METHODS

A pre-post study was performed. Thirty-six patients with early psychosis treated at the specialized inpatient treatment "Frühinterventions- und Therapiezentrum; FRITZ" (early intervention and therapy center) received eight group therapy sessions. Assessments were performed at baseline, after 8 weeks post treatment and at follow-up after 16 weeks.

RESULTS

Rates of patients who participated in the study suggests that a mindfulness-based group therapy is highly accepted and feasible for patients with early psychosis being treated in an inpatient ward. Friedman analyses revealed significant changes in the primary outcomes of emotional goal attainment (Goal 1: W = 0.79; Goal 2: W = 0.71) and psychotic symptoms (PANSS-T: W = 0.74). Significant, albeit small, effect sizes were found in patients' self-perception of emotion regulation skills (ERSQ: W = 0.23).

DISCUSSION

We found favorable findings regarding the feasibility and acceptance of the Feel-Good mindfulness-based intervention. Results of the study provide a basis for an estimation of an adequate sample size for a fully powered RCT that needs to be conducted to test whether Feel-Good is effective in the inpatient treatment of psychotic symptoms for individuals with early psychosis.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT04592042], identifier [NCT04592042].

Altering Dynamics of Autonomic Processing Therapy (ADAPT) trial: a novel, targeted treatment for reducing anxiety in joint hypermobility

Background

Hypermobility is a poorly recognised and understood musculoskeletal disorder thought to affect around 20% of the population. Hypermobility is associated with reduced physiological and psychological functioning and quality of life and is a known risk factor for the development of an anxiety disorder. To date, no evidence-based, targeted treatment for anxiety in the context of hypermobility exists. The present intervention (ADAPT—Altering Dynamics of Autonomic Processing Therapy) is a novel therapy combining bio-behavioural training with cognitive approaches from clinical health psychology targeting the catastrophisation of internal sensations, with aim to improve autonomic trait prediction error.

Method

Eighty individuals with diagnosed hypermobility will be recruited and the efficacy of ADAPT to treat anxiety will be compared to an Emotion-Focused Supportive Therapy (EFST) comparator therapy in a randomised controlled trial. The primary treatment target will be post therapy score on the Beck Anxiety Inventory, and secondary outcomes will also be considered in relation to interoception, depression, alexithymia, social and work adjustment, panic symptoms and dissociation. Due to COVID restrictions, the intervention will be moved to online delivery and qualitative assessment of treatment tolerance to online therapy will also be assessed.

Discussion

Online delivery of an intervention targeting anxiety would improve the quality of life for those experiencing anxiety disorder and help to reduce the £11.7 billion that anxiety disorders cost the UK economy annually.

Trial registration

World Health Organization ISRCTN17018615. Registered on 20th February 2019; trial protocol version 2

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 (r_{client (c)}  = 0.36, p = .003; r_{therapist (t)}  = 0.40, p = .0053). TA was also associated with reduction in global (r_c  = 0.29, p = .0005; r_t  = 0.24, p = .0015) and psychotic symptoms (r_c  = 0.17, p = .0115; r_t  = 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.

Self-reported emotion regulation difficulties in psychosis: Psychometric properties of the Difficulties in Emotion Regulation Scale (DERS-16)

OBJECTIVE

Individuals with psychosis self-report difficulties in understanding, relating, and responding to emotions as treatment priorities, yet we lack comprehensive, reliable, and valid assessments for routine clinical use.

METHODS

The psychometric properties of a brief version of the Difficulties in Emotion Regulation Scale-16 (DERS-16) were examined using anonymized data from a sample of 150 outpatients with psychosis.

RESULTS

Confirmatory factor analysis supported the five-factor structure of the DERS-16. The model fit was further improved by omitting two items. Measurement invariance was shown with respect to age and gender. The DERS-16 demonstrated good internal consistency, well comparable to the original DERS. Evidence toward convergent validity is also presented.

CONCLUSION

Findings suggest that the DERS-16 is a reliable and valid measure of self-reported emotion regulation difficulties in individuals with psychosis. Further research on the clinical utility of the DERS-16 is needed, including examination of its test-retest reliability and predictive validity in response to targeted interventions.

Self-concept and Engagement in LiFe (SELF): A waitlist-controlled pilot study of a novel psychological intervention to target illness engulfment in enduring schizophrenia and related psychoses

BACKGROUND

Illness engulfment, a process whereby one's self-concept becomes defined entirely by illness, is implicated in the association between insight and depressive symptomatology in schizophrenia. We examined the feasibility and acceptability of a brief intervention called Self-concept and Engagement in LiFe (SELF) that aims to reduce engulfment and enhance personal recovery.

METHODS

Forty individuals diagnosed with schizophrenia spectrum disorders were assigned to SELF intervention or waitlist-control (treatment-as-usual). Outcome measures included the Modified Engulfment Scale and measures of depressive symptomatology, self-esteem, recovery style, quality of life, and self-stigma.

RESULTS

Retention at post-therapy was 90% (18/20 completed SELF; 18/20 remained on waitlist). Eleven waitlist participants then completed SELF (73% overall retention). Participants reported high satisfaction with the intervention, and participation was associated with reduced engulfment (ES = 0.48), more adaptive recovery style (ES = 0.37), improved self-esteem (ES = 0.35), and reduced self-stigma (ES = 0.25). The treatment group had lower engulfment (adjusted mean = 91.9) compared to waitlist (adjusted mean = 100.0) post-therapy, F (1,32) = 5.78, p = .02, partial η² = 0.15.

CONCLUSIONS

The SELF intervention is highly acceptable to participants and can reduce engulfment and improve secondary outcomes. Future research should examine the efficacy of SELF in a larger randomized controlled trial.

Quantitative and Qualitative Strategies to Strengthen Internal Validity in Randomized Trials

Although the randomized controlled trial (RCT) is the most reliable design to infer causality, evidence suggests that it is vulnerable to biases that weaken internal validity. In this paper, we review factors that introduce biases in RCTs and we propose quantitative and qualitative strategies for colleting relevant data to strengthen internal validity. The factors are related to participants' reactions to randomization, attrition, treatment perceptions, and implementation of the intervention. The way in which these factors operate is explained and pertinent empirical evidence is synthesized. Quantitative and qualitative strategies are described. Researchers can plan to assess these factors and examine their influence, providing evidence of what actually contributed to the interventions' causal impact.

Do Attitudes Matter? Evaluating the Influence of Training in CBT-p-Informed Strategies on Attitudes About Working with People Who Experience Psychosis

Attitudes of mental health providers are an important consideration in training and delivering evidence-based practices. Treatment approaches for individuals who experience schizophrenia consistently endorse the importance of a recovery perspective. At the same time, a review of the literature suggests that the attitudes of many providers and many policies of community health care settings serving individuals who experience schizophrenia, may not align with the recovery perspective. This brief report provides a summary of the program evaluation outcomes of a wide range of mental health providers who participated in a 2-day intensive training to learn strategies informed by Cognitive Behavioral Therapy for Psychosis (CBT-p). This intensive training emphasizes engagement strategies and person-centered approaches inherent in the recovery perspective. Consistent with the aims of the training, participants' attitudes about working with people who experience psychosis appeared to be positively influenced by training.

Self-reported emotion regulation difficulties in people with psychosis compared with non-clinical controls: A systematic literature review

Emotions play a key role in the development and experience of psychosis, yet there are important gaps in our understanding of how individuals with psychosis understand and respond to their emotions. This systematic review investigated self-reported emotion regulation difficulties in individuals with psychosis compared with non-clinical controls. An electronic database search was conducted in Medline, PsychINFO, and Embase and supplemented by searches of reference lists and citations. Seventeen studies were included. A narrative synthesis was conducted because contextual diversity was present across the studies and outcomes. Individuals with psychosis reported greater difficulties in (i) emotional clarity (specifically with identifying, describing, and understanding their emotions), (ii) emotional acceptance, (iii) engaging in goal-directed behaviours when experiencing negative emotions, and (iv) willingness to experience emotional distress in the pursuit of meaningful activities in life. Evidence pertaining to other self-reported emotion regulation difficulties was less clear. Effect sizes were generally large in magnitude but there were few studies on some self-reported emotion regulation difficulties, and all studies were at moderate to high risk of bias. Further research is needed to clarify the nature of emotion regulation difficulties in individuals with psychosis to inform the provision of targeted clinical interventions.

Changes in care costs associated with cognitive behavioural therapy for psychosis delivered in routine clinical practice

Background: Schizophrenia spectrum disorders are long-term disabling conditions placing high economic demands on health services.Aim: To investigate whether cognitive behavioural therapy for psychosis (CBTp), delivered in a specialist psychological therapies service, was associated with a reduction in intensive care costs.Methods: Days using inpatient care and out of hours crisis support were recorded (N = 69). Costs associated with high intensity care use in the 12 months pre-referral were compared to during, and 12 months following cessation of therapy.Results: Despite the majority of participants incurring £0 at all time periods, costs of intensive mental health care more than halved with CBTp delivery, with a significant decrease during therapy, and at trend level after therapy (p = 0.07). Post hoc analysis revealed that offsetting the cost of therapy for those who utilised intensive care services at any time point (N = 18) resulted in therapy being cost neutral during therapy and cost effective (at trend level) 12 months following cessation of therapy.Conclusion: CBTp may reduce costs associated with intensive psychiatric care, even in a population where the minority use these services. Investment in therapy may lead to both clinical and financial benefits.

A stress management intervention for adults living with HIV in Nigerian community settings: An effects study

BACKGROUND

This study evaluated the effectiveness of a group-based cognitive-behavioral stress management intervention among community-dwelling adults living with HIV in Southeastern Nigeria.

METHOD

A total of 28 HIV-positive adults meeting the criteria for high perceived stress, anxiety, and depression were randomized into 1 of 2 groups: treatment group (n = 14); and no-treatment control group (n = 14). Stress level was measured using the 10-item Perceived Stress Scale (PSS-10). Depression and anxiety symptoms were assessed using Hospital Anxiety and Depression Scale (HADS). Secondary outcome measure was Satisfaction with Life Scale (SWLS). The intervention was delivered over the course of 10 weeks, using an evidence-based cognitive-behavioral stress management manual. We employed repeated-measures between and within-subjects analysis of variance (ANOVA) and Eta squared in the analyses and interpretation of data collected from the study participants at 3 time points.

RESULTS

Our results showed that, after benefitting from the cognitive behavioral stress management intervention, the PSS-10 and HADS scores were lowered significantly in the treatment group participants than those in the no-treatment control group during evaluations of post-treatment and 3 months follow-up outcomes. Significant improvements were also recorded in the treatment group participants' SWLS scores at post-treatment and follow-up compared with participants in the no-treatment group.

CONCLUSION

The present results suggest the need for further implementation of group-based cognitive-behavioral stress management interventions for people living with HIV. Cognitive-behavioral stress management clinicians should make efforts toward identifying HIV-positive adults experiencing psychological distress and design cognitive-behavioral stress management interventions in order to better assist them.

The contribution of participant, treatment, and outcome factors to treatment satisfaction

Treatment satisfaction, which refers to the positive appraisal of process and outcome attributes of a treatment, is a prominent indicator of quality care. Although it is known that participant, treatment, and outcome factors influence treatment satisfaction, it remains unclear which factors contribute to satisfaction with each process and outcome attribute. In this study, we examined the extent to which participant (age, gender, education, race, employment), treatment (type of therapy, method of assignment to therapy), and outcome (self-reported improvement in outcome) factors contribute to satisfaction with the process and outcome attributes of therapies for insomnia. This study consists of a secondary analysis of data obtained from a partially randomized preference trial in which persons with chronic insomnia (N = 517) were assigned to treatment randomly or by preference. Four types of behavioral therapies were included: sleep hygiene, stimulus control therapy, sleep restriction therapy, and multi-component therapy. Self-reported improvement in insomnia and satisfaction were assessed with validated measures at post-test. Multiple regression analysis was used to examine which factors influenced satisfaction with each treatment attribute. The findings showed that treatment and outcome, more so than participant, factors influenced satisfaction with the process and outcome attributes of the behavioral therapies for insomnia. Future research on satisfaction should explore the contribution of treatment (type and preference-matching) and outcome factors on satisfaction to build a better understanding of treatment attributes viewed favorably. Such understanding has the potential to inform modifying or tailoring treatments to improve their acceptance to participants and optimize their effectiveness.

Integrated Trauma-Focused Cognitive-Behavioural Therapy for Post-traumatic Stress and Psychotic Symptoms: A Case-Series Study Using Imaginal Reprocessing Strategies

Despite high rates of trauma in individuals with psychotic symptoms, post-traumatic stress symptoms are frequently overlooked in clinical practice. There is also reluctance to treat post-traumatic symptoms in case the therapeutic procedure of reprocessing the trauma exacerbates psychotic symptoms. Recent evidence demonstrates that it is safe to use reprocessing strategies in this population. However, most published studies have been based on treating post-traumatic symptoms in isolation from psychotic symptoms. The aims of the current case series were to assess the acceptability, feasibility, and preliminary effectiveness of integrating cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol. Nine participants reporting distressing psychotic and post-traumatic symptoms were recruited from a specialist psychological therapies service for psychosis. Clients were assessed at five time points (baseline, pre, mid, end of therapy, and at 6+ months of follow-up) by an independent assessor on measures of current symptoms of psychosis, post-traumatic stress, emotional problems, and well-being. Therapy was formulation based and individualised, depending on presenting symptoms and trauma type. It consisted of five broad, flexible phases, and included imaginal reprocessing strategies (reliving and/or rescripting). The intervention was well received, with positive post-therapy feedback and satisfaction ratings. Unusually for this population, no-one dropped out of therapy. Post therapy, all but one (88% of participants) achieved a reliable improvement compared to pre-therapy on at least one outcome measure: post-traumatic symptoms (63%), voices (25%), delusions (50%), depression (50%), anxiety (36%), and well-being (40%). Follow-up assessments were completed by 78% (n = 7) of whom 86% (n = 6) maintained at least one reliable improvement. Rates of improvements following therapy (average of 44% across measures post therapy; 32% at follow-up) were over twice those found during the waiting list period (19%). No participant indicated a reliable worsening of any symptoms during or after therapy. The study shows that an integrative therapy incorporating reprocessing strategies was an acceptable and feasible intervention for this small sample, with promising effectiveness. A randomised controlled trial is warranted to test the efficacy of the intervention for this population.