Study protocol for an adaptive, multi-arm, multi-stage (MAMS) randomised controlled trial of brief remotely delivered psychosocial interventions for people with serious mental health problems who have experienced a recent suicidal crisis: Remote Approaches to Psychosocial Intervention Delivery (RAPID).

BACKGROUND: People with serious mental health problems (SMHP) are more likely to be admitted to psychiatric hospital following contact with crisis services. Admissions can have significant personal costs, be traumatic and are the most expensive form of mental health care. There is an urgent need for treatments to reduce suicidal thoughts and behaviours and reduce avoidable psychiatric admissions. METHODS: A multi-stage, multi-arm (MAMS) randomised controlled trial (RCT) with four arms conducted over two stages to determine the clinical and cost effectiveness of three psychosocial treatments, compared to treatment as usual (TAU), for people with SMHP who have had recent suicidal crisis. Primary outcome is any psychiatric hospital admissions over a 6-month period. We will assess the impact on suicidal thoughts and behaviour, hope, recovery, anxiety and depression. The remote treatments delivered over 3 months are structured peer support (PREVAIL); a safety planning approach (SAFETEL) delivered by assistant psychologists; and a CBT-based suicide prevention app accessed via a smartphone (BrighterSide). Recruitment is at five UK sites. Stage 1 includes an internal pilot with a priori progression criteria. In stage 1, the randomisation ratio was 1:1:1:2 in favour of TAU. This has been amended to 2:2:3 in favour of TAU following an unplanned change to remove the BrighterSide arm following the release of efficacy data from an independent RCT. Randomisation is via an independent remote web-based randomisation system using randomly permuted blocks, stratified by site. An interim analysis will be performed using data from the first 385 participants from PREVAIL, SAFETEL and TAU with outcome data at 6 months. If one arm is dropped for lack of benefit in stage 2, the allocation ratio of future participants will be 1:1. The expected total sample size is 1064 participants (1118 inclusive of BrighterSide participants). DISCUSSION: There is a need for evidence-based interventions to reduce psychiatric admissions, via reduction of suicidality. Our focus on remote delivery of established brief psychosocial interventions, utilisation of different modalities of delivery that can provide sustainable and scalable solutions, which are also suitable for a pandemic or national crisis context, will significantly advance treatment options. TRIAL REGISTRATION: ISRCTN33079589. Registered on June 20, 2022.

Group Cohesion and Necessary Adaptations in Online Hearing Voices Peer Support Groups: Qualitative Study With Group Facilitators.

BACKGROUND: Face-to-face hearing voices peer support groups (HVGs), a survivor-led initiative that enables individuals who hear voices to engage with the support of peers, have a long-standing history in community settings. HVGs are premised on the notion that forming authentic, mutual relationships enables the exploration of one's voice hearing experiences and, in turn, reduces subjective distress. As such, group cohesion is assumed to be a central mechanism of change in HVGs. The rise of digital mental health support, coupled with the COVID-19 pandemic, has resulted in many HVGs adapting to online delivery. However, to date no studies have examined the implementation of these online groups and the adaptations necessary to foster cohesion. OBJECTIVE: This study aims to understand the experience of group cohesion among HVG facilitators in online groups compared with face-to-face groups. Specifically, we examined the ways in which the medium through which groups run (online or face-to-face) impacts group cohesion and how facilitators adapted HVGs to foster group cohesion online. METHODS: Semistructured qualitative interviews were conducted with 11 facilitators with varied experience of facilitating online and face-to-face HVGs. Data were analyzed using reflexive thematic analysis. RESULTS: The findings are organized into 3 themes and associated subthemes: nonverbal challenges to cohesion (lack of differentiation, transitional space, inability to see the whole picture, and expressions of empathy); discursive challenges to cohesion (topic-based conversation and depth of disclosure); and necessary adaptations for online groups (fostering shared experience and using the unique context to demonstrate investment in others). Despite challenges in both the setting and content of online groups, facilitators felt that group cohesion was still possible to achieve online but that it had to be facilitated intentionally. CONCLUSIONS: This study is the first to specifically investigate group cohesion in online HVGs. Participants noted numerous challenges to group cohesion when adapting groups to run online, including the unnaturally linear narrative flow of dialogue in online settings; lack of transitional spaces, and associated small talk before and after the session; ease of disengagement online; inhibited sharing; and absence of shared physical presence online. Although these challenges were significant, facilitators nevertheless emphasized that the benefits provided by the accessibility of online groups outweighed these challenges. Necessary adaptations for cultivating group cohesion online are outlined and include capitalizing on moments of humor and spontaneity, using group activities, encouraging information sharing between participants using the chat and screen-sharing features, and using objects from participants' environments to gain deeper insight into their subjective worlds.

Trauma therapies for psychosis: A state-of-the-art review.

BACKGROUND: Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis. METHOD: This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis. RESULTS: We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies. CONCLUSION: We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.

A case series study of compassion-focused therapy for distressing experiences in psychosis.

OBJECTIVES: Compassion-focused therapy (CFT) is an evolution-informed biopsychosocial approach that seeks to cultivate attachment and care motivational systems and their psychophysiological regulators. These can counteract some of the harmful effects of social threat, inferiority, shame, self-criticism and depression, which are common in people with psychosis and undermine their well-being, social trust and ability to feel safe. This study aimed to test the acceptability of a novel manualized individual CFT intervention for psychosis (CFTp). DESIGN: A non-concurrent, multiple-baseline, case series design, with three phases: baseline, intervention and follow-up. METHODS: The 26-session CFTp intervention was provided for a sample of eight people with distressing psychotic experiences and a psychosis-related diagnosis. The study aimed to assess acceptability of CFTp and to test clinically reliable improvements while receiving the intervention, compared to a baseline period. RESULTS: Seven of eight participants completed the therapy, and clinically reliable improvements were found at both the single-case and group level of analysis. At the single-case level, over half the participants showed improvements in depression (5/7), stress (5/7), distress (5/7), anxiety (4/7) and voices (3/5). One participant showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level (n = 7), there were significant improvements in depression, stress, distress, voices and delusions. The improvements in voices, delusions and distress were sustained at 6- to 8-week follow-up, but depression and stress dropped slightly to trend-level improvements. CONCLUSIONS: CFTp is a feasible and acceptable intervention for psychosis, and further investigation is warranted with a randomized controlled trial.

When therapists talk to voices: Perspectives from service-users who experience auditory hallucinations.

PURPOSE: The purpose of the study was to investigate service-users' experiences of a therapist engaging with their voices (auditory hallucinations) using psychological formulation and direct dialogue. METHOD: A nested qualitative study was conducted within a randomised controlled trial of a novel intervention for supporting voice hearers with a diagnosis of psychosis (Talking With Voices: TwV). Of 24 participants allocated to therapy, 13 (54%) consented to a semi-structured, in-depth interview which was audio-recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: Participants described their experiences of using the intervention to improve the relationship between themselves and their voice(s). The findings are organised within three themes and associated subthemes: (1) A desire for suitable help (Motivation to reduce voice-related distress, Limitation of other treatment options); (2) Engaging with voices (Challenges, Support and safety, Exploration and revelation); and (3) Contemplating the future (The aftermath of adversity, Living well with voices, Resources for moving forward). CONCLUSION: Despite the emotional challenges of the work, many participants experienced tangible gains in the ways they related to their voices post-intervention. For those who responded well, the development of safety strategies, including a strong therapeutic alliance, could facilitate a basis for developing new insights about the origin/nature of the voices which could then be applied in constructive ways. Further research is needed to understand which client characteristics indicate suitability for TwV as opposed to relational therapies that require less direct engagement with voices and/or the psychosocial conflicts with which they may be associated.

Top 10 priorities for Sexual Violence and Abuse Research: indings of the James Lind Alliance Sexual Violence Priority Setting Partnership.

OBJECTIVES: To establish a James Lind Alliance (JLA) Priority Setting Partnership (PSP) to identify research priorities relevant to the health and social care needs of adults with lived experience of recent and/or historical sexual violence/abuse. PARTICIPANTS: Adults (aged 18+ years) with lived experience of sexual violence/abuse (ie, 'survivors') were consulted for this PSP, alongside healthcare and social care professionals who support survivors across the public, voluntary, community, independent practice and social enterprise sectors. METHODS: In line with standard JLA PSP methodology, participants completed an initial online survey to propose research questions relevant to the health and social care needs of survivors. Research questions unanswered by current evidence were identified, and a second online survey was deployed to identify respondents' priorities from this list. Questions prioritised through the second survey were presented at a consensus meeting with key stakeholders to agree the top 10 research priorities using a modified nominal group technique approach. RESULTS: 223 participants (54% survivors) provided 484 suggested questions. Seventy-five unique questions unanswered by research were identified and subsequently ranked by 343 participants (60% survivors). A consensus meeting with 31 stakeholders (42% survivors) examined the top-ranking priorities from the second survey and agreed the top 10 research priorities. These included research into forms of support and recovery outcomes valued by survivors, how to best support people of colour/black, Asian and minority ethnic and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) survivors, improving access to high-quality psychological therapies, reducing public misconceptions/stigma, the impact of involvement in the criminal justice system on well-being, and how physical and mental health services can become more 'trauma informed'. CONCLUSIONS: These research priorities identify crucial gaps in the existing evidence to better support adult survivors of sexual violence and abuse. Researchers and funders should prioritise further work in these priority areas identified by survivors and the professionals who support them.

Corrigendum: "It hurt but it helped": A mixed methods audit of the implementation of trauma-focused cognitive-behavioral therapy for psychosis.

[This corrects the article DOI: 10.3389/fpsyt.2022.946615.].

Multiplicity in the experience of voice-hearing: A phenomenological inquiry.

Although it is recognized that voice-hearers often report a large number and variety of voices there have been few investigations of this multiplicity. Understanding the phenomenology of voice-hearing can provide a firm foundation for theorizing about its causes. In this international online survey of voice-hearers, details were elicited of the content of up to five utterances associated with up to five voices from each respondent. The contents were independently rated and associated with characteristics of each voice such as its perceived age, whether it had changed over time, and whether it was of a familiar person. We investigated predictors (e.g., diagnoses, voice gender, age first heard) of utterance negativity, length, and whether voices referred to themselves. The average number of voices reported was approximately four. The majority were perceived as male and had negative content. Child-aged voices were significantly less negative than all other voices except those perceived as being elderly. Multi-level analyses indicated that there was significant variability at the level of different utterances within voices but variability was more prominent at the level of different voices within an individual. The data were inconsistent with general cognitive models for hearing voices such as the misattribution of inner speech and were more congruent with a dissociation model of voice-hearing. Our findings support approaches based on subtype or dimensional methods of classifying voices, and additionally indicate that research and clinical assessment may benefit from more systematic assessment of multiplicity.

A psychological intervention for engaging dialogically with auditory hallucinations (Talking With Voices): A single-site, randomised controlled feasibility trial.

There is growing clinical interest in addressing relationship dynamics between service-users and their voices. The Talking With Voices (TwV) trial aimed to establish feasibility and acceptability of a novel dialogical intervention to reduce distress associated with voices amongst adults diagnosed with schizophrenia spectrum disorders. The single-site, single-blind (rater) randomised controlled trial recruited 50 participants who were allocated 1:1 to treatment as usual (TAU), or TAU plus up to 26 sessions of TwV therapy. Participants were assessed at baseline and again at end of treatment (six-months). The primary outcomes were quantitative and qualitative assessments of feasibility and acceptability. Secondary outcomes involved clinical measures, including targeted instruments for voice-hearing, dissociation, and emotional distress. The trial achieved 100 % of the target sample, 24 of whom were allocated to therapy and 26 to TAU. The trial had high retention (40/50 [80 %] participants at six-months) and high intervention adherence (21/24 [87.5 %] receiving ≥8 sessions). Signals of efficacy were shown in targeted measures of voice-hearing, dissociation, and perceptions of recovery. Analysis on the Positive and Negative Syndrome Scale indicated that there were no differences in means of general psychosis symptom scores in TwV compared to the control group. There were four serious adverse events in the therapy group and eight in TAU, none of which were related to study proceedings. The trial demonstrates the acceptability of the intervention and the feasibility of delivering it under controlled, randomised conditions. An adequately powered definitive trial is necessary to provide robust evidence regarding efficacy evaluation and cost-effectiveness. Trial registration: ISRCTN 45308981.

"It hurt but it helped": A mixed methods audit of the implementation of trauma- focused cognitive-behavioral therapy for psychosis.

Background: Emerging evidence supports the safety, acceptability, and efficacy of trauma therapies for people experiencing post-traumatic stress and psychosis, despite common concerns about iatrogenic harm when processing trauma memories for this population. However, to date there have been no mixed-method studies examining whether trauma-focused therapy can be implemented in routine care. This study reports an audit of a post-traumatic stress in psychosis clinic based in an inner-city trust in the U.K. National Health Service. Materials and methods: People under the care of psychosis community mental health teams with a significant history of past trauma were referred to the clinic by their multidisciplinary clinicians. Referral outcomes were recorded, including the proportion of people for whom trauma-focused cognitive-behavior therapy for psychosis was indicated. Post-traumatic stress symptoms were assessed pre- and post-therapy for clinically significant change on the Post-traumatic Stress Checklist (version 4) and Post-traumatic Stress Checklist (version 5). A subgroup of service users was also interviewed about their experience of therapy, with transcripts analyzed using inductive thematic analysis. Results: Seventy one service-users were referred to the clinic between 2014 and 2018, of which 51 (71.8%) attended an assessment. Of these, 20 (39.2%) were identified as having clinically significant PTSD symptoms with re-experiencing and were offered trauma-focused cognitive-behavior therapy for psychosis. Sixteen (80%) accepted and completed therapy, with no dropouts, and received a mean of 17.54 sessions (SD = 17.60, range = 12-91). There were no serious adverse events related to therapy. Clinically significant change was observed in 68.8% (n = 11) of the therapy group and post-therapy six people (37.5%) no longer met the threshold for clinically significant PTSD. Six service users completed an interview about their therapy experiences with findings organized within four main themes and associated subthemes: (1) Perseverance, (2) Establishing safety, (3) The challenges of therapy, and (4) Rebuilding one's life after trauma. Conclusion: Trauma-focused cognitive-behavior therapy for psychosis can be safe, acceptable, and effective when implemented in routine care. Lived experience perspectives highlight the emotional demands of therapy and long-term impact of trauma, thus underscoring the necessity of sufficient support and continuity of care both during and after therapy.

Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial.

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 stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5-10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement. DISCUSSION: The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use. TRIAL REGISTRATION: ISRCTN93382525 (03/08/20).

'It's like having a core belief that's able to speak back to you': Therapist accounts of dialoguing with auditory hallucinations.

PURPOSE: To investigate the clinical perspectives and experiences of therapists when engaging in direct dialogue with auditory hallucinations. METHOD: Therapist accounts were explored via a qualitative study nested within a pilot randomized controlled trial of a novel intervention for supporting distressed voice-hearers (Talking with Voices). Five therapists were involved, none of whom had substantive previous experience of the technique. All agreed to take part in two semi-structured, in-depth interviews which were arranged prior to delivering therapy and again after therapists had experience of conducting dialogues. Data were analysed using inductive thematic analysis. RESULTS: Participants described their impressions of seeking to improve the relationship between voice(s) and voice-hearer using dialogue. The findings are organized within three main themes and associated subthemes: (1) Commitment to delivery (professional values, mentorship, professional growth); (2) Communication and collaboration (therapeutic alliance, relationships with voices, managing clinical perceptions); and (3) Challenges of delivery (client/voice engagement, impact of trauma, systemic issues). A series of recommendations are derived from the findings to support implementation and guide the practice of therapists undertaking dialogue work with clients who hear voices. CONCLUSION: Despite clinical challenges, therapists also identified professional gains from conducting their work. Their accounts demonstrate that it is possible for practitioners with no previous formal experience to engage in direct communication with voices within a context of appropriate training and supervision. PRACTITIONER POINTS: Therapists with no previous experience of dialogue work can be trained and supported to verbally engage with the voices heard by people experiencing psychosis. Therapeutic alliance and therapist values are important components of successful therapy. Confidence for dialoguing with voices can be increased through drawing on therapist's existing transferable clinical skills. The emotional and practical needs of therapists undertaking such work should be addressed through training and regular group supervision.

Protocol for individual participant data meta-analysis of randomised controlled trials of patients with psychosis to investigate treatment effect modifiers for CBT versus treatment as usual or other psychosocial interventions.

INTRODUCTION: Aggregate data meta-analyses have shown heterogeneous treatment effects for cognitive-behavioural therapy (CBT) for patients with schizophrenia spectrum diagnoses. This heterogeneity could stem from specific intervention or patient characteristics that could influence the clinical effectiveness of CBT, termed treatment effect modifiers. This individual participant data meta-analysis will investigate a range of potential treatment effect modifiers of the efficacy of CBT. METHODS AND ANALYSIS: We will perform a systematic review and meta-analysis of studies investigating CBT versus treatment as usual, or CBT versus other psychosocial interventions, for patients with schizophrenia spectrum diagnoses. The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE and the online clinical trials registers of the US government, European Union, WHO and Current Controlled Trials will be searched. Two researchers will screen titles and abstracts identified by the search. Individual participant data will be requested for any eligible study, for the primary outcome (overall psychotic symptoms), secondary outcomes and treatment effect modifiers. Data will be checked and recoded according to an established statistical analysis plan. One-stage and two-stage random effects meta-analyses investigating potential treatment effect modifiers will be conducted. A list of potential treatment effect modifiers for CBT will be produced, motivating future research into particular modifiers. ETHICS AND DISSEMINATION: This study does not require ethical approval as it is based on data from existing studies, although best ethical practice for secondary analysis of clinical data will be followed. The findings will be submitted for publication in peer-reviewed journals, and promoted to relevant stakeholders. PROSPERO REGISTRATION NUMBER: CRD42017060068.

A treatment protocol to guide the delivery of dialogical engagement with auditory hallucinations: Experience from the Talking With Voices pilot trial.

PURPOSE: To present a treatment protocol for delivering Talking With Voices, a novel intervention for people with psychosis that involves dialogical engagement with auditory hallucinations. METHOD: This paper presents a manualized approach to therapy employed in the Talking With Voices trial, a feasibility and acceptability randomized control trial of 50 adult participants. A rationale for following a treatment manual is provided, followed by the theoretical underpinnings of the intervention and its principles and values, including the main tenet that voices can often be understood as dissociated parts of the self which serve a protective function by indicating social-emotional vulnerabilities. The four therapy phases for improving the relationship between the voice-hearer and their voices are outlined: (1) engagement and psychoeducation, (2) creating a formulation, (3) dialoguing with voices, and (4) consolidating outcomes, including key milestones at each phase. Implementation issues are discussed, as well as recommendations for best practice and future research. RESULTS: The Talking With Voices treatment protocol indicates that it is feasible to manualize a dissociation-based approach to support service users who are distressed by hearing voices. CONCLUSION: For some individuals, it is possible to engage in productive dialogue with even extremely hostile or distressing voices. Developing coping strategies, creating a formulation, and ultimately establishing a dialogue with voices has the potential to improve the relationship between voice(s) and voice-hearer. Further research is now required to evaluate feasibility, acceptability, and efficacy. PRACTITIONER POINTS: It is feasible to integrate a dissociation model of voice-hearing within a psychological intervention for people with psychosis. Combining psychosocial education, formulation and direct dialogue can be used to facilitate a more peaceful relationship between clients and their voices. Practitioners trained in other therapeutic modalities can draw on existing transferrable skills to dialogue with their clients' voices. The input of those with lived experience of mental health difficulties has an important role in guiding treatment design and delivery.

Development and initial evaluation of a measure of positive beliefs about dissociative experiences.

Theoretical models and qualitative research suggest that dissociation can be functional in some circumstances, despite being a cause of concern for many. This is the first study that evaluates a novel questionnaire on positive appraisals of dissociation (the Positive Beliefs about Dissociation Questionnaire; PBD-Q), and its link with dissociation frequency and related distress. Development of items was based on lived experience expertise within the research team and qualitative findings. Items were refined through cognitive interviewing with people with lived experience of dissociation prior to deployment using an online survey. A sample of 228 participants scoring >10 on the Dissociative Experiences Scale (DES-II) completed a battery of measures comprising the PBD-Q and a previously developed measure of negative beliefs of dissociation. Exploratory factor analysis revealed three factors: positive beliefs about emotion management, positive beliefs about self-expression, and positive beliefs about maintaining social image. Within this particular sample the PBD-Q showed excellent internal consistency, face validity, convergent validity, and test-retest reliability. Higher scores on the PBD-Q were significantly related to higher frequencies of dissociative experiences as well as dissociation-related distress. The factor structure remained stable when the analyses were restricted to individuals scoring >30 on the DES-II. In conclusion, our findings indicate that positive beliefs about dissociation can be reliably and validly measured in adults who experience levels of dissociation that are higher than the general population. These beliefs could be involved in the maintenance of dissociation and represent promising targets for future research, clinical assessment, and treatment.

The VOICES Typology of Curatorial Decisions in Narrative Collections of the Lived Experiences of Mental Health Service Use, Recovery, or Madness: Qualitative Study.

BACKGROUND: Collections of lived experience narratives are increasingly used in health research and medical practice. However, there is limited research with respect to the decision-making processes involved in curating narrative collections and the work that curators do as they build and publish collections. OBJECTIVE: This study aims to develop a typology of curatorial decisions involved in curating narrative collections presenting lived experiences of mental health service use, recovery, or madness and to document approaches selected by curators in relation to identified curatorial decisions. METHODS: A preliminary typology was developed by synthesizing the results of a systematic review with insights gained through an iterative consultation with an experienced curator of multiple recovery narrative collections. The preliminary typology informed the topic guide for semistructured interviews with a maximum variation sample of 30 curators from 7 different countries. All participants had the experience of curating narrative collections of the lived experiences of mental health service use, recovery, or madness. A multidisciplinary team conducted thematic analysis through constant comparison. RESULTS: The final typology identified 6 themes, collectively referred to as VOICES, which stands for values and motivations, organization, inclusion and exclusion, control and collaboration, ethics and legal, and safety and well-being. A total of 26 subthemes related to curation decisions were identified. CONCLUSIONS: The VOICES typology identifies the key decisions to consider when curating narrative collections about the lived experiences of mental health service use, recovery, or madness. It might be used as a theoretical basis for a good practice resource to support curators in their efforts to balance the challenges and sometimes conflicting imperatives involved in collecting, organizing, and sharing narratives. Future research might seek to document the use of such a tool by curators and hence examine how best to use VOICES to support decision making.

The Relationship Between Dissociation and Symptoms of Psychosis: A Meta-analysis.

Evidence suggests that dissociation is associated with psychotic experiences, particularly hallucinations, but also other symptoms. However, until now, symptom-specific relationships with dissociation have not been comprehensively synthesized. This is the first prospectively registered (CRD42017058214) meta-analysis to quantify the magnitude of association between dissociative experiences and all symptoms of psychosis. MEDLINE, PsycINFO, PubMed, and Scopus databases were searched using exhaustive terms denoting dissociation and psychotic symptoms. We included both nonclinical (58 studies; 16 557 participants) and clinical (46 studies; 3879 patient participants) samples and evaluated study quality. Ninety-three eligible articles considering 20 436 participants were retained for analysis. There was a robust association between dissociation and clinical and nonclinical positive psychotic symptoms (r = .437; 95%CI: .386 -.486), with the observed effect larger in nonclinical studies. Symptom-specific associations were also evident across clinical and nonclinical studies, and included significant summary effects for hallucinations (r = .461; 95%CI: .386 -.531), delusions (r = .418; 95%CI: .370 -.464), paranoia (r = .447; 95%CI: .393 -.499), and disorganization (r = .346; 95%CI: .249 -.436). Associations with negative symptoms were small and, in some cases, not significant. Overall, these findings confirm that dissociative phenomena are not only robustly related to hallucinations but also to multiple positive symptoms, and less robustly related to negative symptoms. Our findings are consistent with proposals that suggest certain psychotic symptoms might be better conceptualized as dissociative in nature and support the development of interventions targeting dissociation in formulating and treating psychotic experiences.

Study protocol for a randomised controlled trial of CBT vs antipsychotics vs both in 14-18-year-olds: Managing Adolescent first episode Psychosis: a feasibility study (MAPS).

BACKGROUND: Adolescent-onset psychosis is associated with more severe symptoms and poorer outcomes than adult-onset psychosis. The National Institute for Clinical Excellence (NICE) recommend that adolescents with first episode psychosis (FEP) should be offered a combination of antipsychotic medication (APs), cognitive behavioural therapy (CBT) and family intervention (FI). The evidence for APs in treating psychosis is limited in adolescents compared to adults. Nevertheless, it indicates that APs can reduce overall symptoms in adolescents but may cause more severe side effects, including cardiovascular and metabolic effects, than in adults. CBT and FI can improve outcomes in adults, but there are no studies of psychological interventions (PI) in patients under 18 years old. Given this limited evidence base, NICE made a specific research recommendation for determining the clinical and cost effectiveness of APs versus PI versus both treatments for adolescent FEP. METHODS/DESIGN: The current study aimed to establish the feasibility and acceptability of conducting such a trial by recruiting 14-18-year-olds with a first episode of psychosis into a feasibility prospective randomised open blinded evaluation (PROBE) design, three-arm, randomised controlled trial of APs alone versus PI alone versus a combination of both treatments. We aimed to recruit 90 participants from Early Intervention and Child and Adolescent Mental Health Teams in seven UK sites. APs were prescribed by participants' usual psychiatrists. PI comprised standardised cognitive behavioural therapy and family intervention sessions. DISCUSSION: This is the first study to compare APs to PI in an adolescent population with FEP. Recruitment finished on 31 October 2018. The study faced difficulties with recruitment across most sites due to factors including clinician and service-user treatment preferences. TRIAL REGISTRATION: Current controlled trial with ISRCTN, ISRCTN80567433 . Registered on 27 February 2017.

Compassion Focused Approaches to Working With Distressing Voices.

This paper presents an outline of voice-hearing phenomenology in the context of evolutionary mechanisms for self- and social- monitoring. Special attention is given to evolved systems for monitoring dominant-subordinate social roles and relationships. These provide information relating to the interpersonal motivation of others, such as neutral, friendly or hostile, and thus the interpersonal threat, versus safe, social location. Individuals who perceive themselves as subordinate and dominants as hostile are highly vigilant to down-rank threat and use submissive displays and social spacing as basic defenses. We suggest these defense mechanisms are especially attuned in some individuals with voices, in which this fearful-subordinate - hostile-dominant relationship is played out. Given the evolved motivational system in which voice-hearers can be trapped, one therapeutic solution is to help them switch into different motivational systems, particularly those linked to social caring and support, rather than hostile competition. Compassion focused therapy (CFT) seeks to produce such motivational shifts. Compassion focused therapy aims to help voice-hearers, (i) notice their threat-based (dominant-subordinate) motivational systems when they arise, (ii) understand their function in the context of their lives, and (iii) shift into different motivational patterns that are orientated around safeness and compassion. Voice-hearers are supported to engage with biopsychosocial components of compassionate mind training, which are briefly summarized, and to cultivate an embodied sense of a compassionate self-identity. They are invited to consider, and practice, how they might wish to relate to themselves, their voices, and other people, from the position of their compassionate self. This paper proposes, in line with the broader science of compassion and CFT, that repeated practice of creating internal patterns of safeness and compassion can provide an optimum biopsychosocial environment for affect-regulation, emotional conflict-resolution, and therapeutic change. Examples of specific therapeutic techniques, such as chair-work and talking with voices, are described to illustrate how these might be incorporated in one-to-one sessions of CFT.