Participants' experiences of AVATAR therapy for distressing voices: a thematic qualitative evaluation.

BACKGROUND: AVATAR therapy is an innovative therapy designed to support people with distressing voices. Voice hearers co-create a digital representation of their voice and engage in dialogue with it. Although it has been successfully tested in a powered randomised controlled trial (ISRCTN65314790), the participants' experience of this therapy has not been yet evaluated. We aimed to explore enablers and barriers to engagement with the therapy and potential for real-world impact on distressing voices. METHODS: Thirty per cent of those who completed AVATAR therapy (15 people in total) and 5 who dropped out from therapy within the main AVATAR RCT were invited to participate in a semi-structured interview, which was audio-recorded and subsequently transcribed. RESULTS: Fourteen therapy completers (28% of the full sample) and one person who dropped out of therapy after 1 active session, were interviewed. Thematic analysis was used to explore the interviews. A total of 1276 references were coded, and five overarching themes identified: AVATAR therapy set-up; voice embodiment and associated emotions; working in a safe space (supported by the therapist); learning new ways of relating to the voices; impact of therapy on everyday life. Overall, the therapy set-up, with its digital components and its distinctive features as compared with common face-to-face talking therapies, was satisfactory. The inclusion of technology was well accepted as both a means to deliver the therapy and a tool to create a digital representation of the person's distressing voice. The co-creation of the avatar and the enactment of the relationship between the person and the voice were perceived as a very helpful process to promote the therapeutical dialogue. Participants reported engaging well with the therapist and feeling supported and identified specific learnt strategies to deal with the voices and how they have had an impact on everyday life. CONCLUSIONS: AVATAR therapy is acceptable and provides benefit for participants with psychosis. Our results highlighted the enablers and challenges of working dialogically with distressing voices using a digital representation and dealing with highly demanding emotional, cognitive, and relational processes linked to the experience. Our analysis also identified the core strategies learnt by participants and how these were generalised to their daily life resulting into a positive change in different domains, and in particular broader social relationships.

Added value or added burden? A qualitative investigation of blending internet self-help with face-to-face cognitive behaviour therapy for depression.

Objectives: Numerous studies and reviews have explored the value of adding therapist support to internet self-help for improving client adherence and outcomes. This study is different as it explores the value of adding internet self-help to face-to-face therapy, from the perspective of practitioners who used both. This study explores practitioners' experiences of whether-and how-internet self-help blended with face-to-face therapy may confer an added value or become an added burden to their routine practice. Methods: Using a structured topic guide, we collected narrative data via 3 focus groups and 1 telephone interview from 11 practitioners across two sites in England. We carried out a thematic analysis within two domains, "value vs. burden". Results: Practitioners reported that internet self-help can confer added value to face-to-face therapy by: fostering client engagement with face-to-face sessions; making therapy ubiquitous beyond sessions; and preventing therapeutic drift between sessions. Conversely, internet self-help can add burden to face-to-face therapy when it is experienced as disruptive, overwhelming and time-consuming. Conclusions: Recognizing and mitigating factors that can turn internet self-help from an added value to an added burden will help practitioners adopt and make the most out of blended therapy.

Service users' and carers' views on research towards stratified medicine in psychiatry: a qualitative study.

BACKGROUND: Approximately 30% of people with a diagnosis of schizophrenia receive little to no benefit from current medications. There is therefore an urgent need to develop more precisely targeted and effective treatments. Identifying biomarkers to predict response to treatment and stratify patients into groups may be a way forward. However, we know little about service users' and carers' attitudes regarding such a 'stratified medicine' approach for psychiatry-nor how this might impact on their willingness to participate in stratified medicine research. This paper presents psychiatric service user and carer views on research to develop stratified medicine for treatment resistant schizophrenia, and explores the conditions under which people would be prepared to participate in a trial and their willingness to undergo various research procedures. METHODS: Participatory methods were used throughout. A consultation was undertaken with an existing Service User Advisory Group (SUAG) in order to establish a topic guide. Service user focus groups were then conducted by service user researchers in Manchester, London and Edinburgh (totalling 18 people) and one carer focus group in London, attended by eight participants. Focus groups were digitally recorded, the transcripts analysed in NVivo 10 using a simple thematic analysis, and quotations de-identified to protect participants. RESULTS: The data reflected enthusiasm for the potential of stratified medicine and both service users and carers demonstrated a strong desire to help others. However, some service users and carers feared poor performance on neuropsychological assessments, and reported that certain medication side effects might discourage them from undergoing procedures demanding immobility and concentration. Concerns were voiced that stratified medicine could encourage an overemphasis on biological symptoms, at the expense of psychosocial factors and subjective experience. CONCLUSIONS: People with experience of treatment resistant schizophrenia would welcome stratified medicine research; however researchers should take into account how such experience might inflect service users' willingness to undergo various procedures in the context of this research. These results reinforce the value of service user perspectives in the development and evaluation of novel treatment approaches.