The Relational Approach to Treating Self-Harm (RELATE): study protocol for a feasibility randomised controlled trial study of cognitive analytic therapy for adults who self-harm versus treatment at usual.

BACKGROUND: Self-harm is a prevalent behaviour that has a major detrimental impact on a person's life. Psychological therapies have the potential to help, but evidence of effective interventions remains limited. Access and acceptability of interventions can also be a significant challenge, with individuals either being unable to access help or having to endure long waiting lists. Cognitive analytic therapy (CAT) is a time-limited and relationally-focused psychotherapy that may provide a valuable treatment option for people who self-harm. This protocol outlines the methodology for the first feasibility randomised controlled trial (RCT) of CAT for adults that self-harm. The trial will aim to determine the feasibility, acceptability and safety of undertaking larger-scale evaluations of CAT for self-harm within an RCT context. METHOD: An RCT design with 1:1 allocation to CAT plus treatment as usual (TAU) or TAU alone. Participants will be adult outpatients with three or more instances of self-harm in the past year (target sample of n = 60). CAT will be 8 one-to-one weekly 60-min sessions plus a follow-up session up to 8 weeks after the last session. Assessments will occur at baseline, 12 weeks and 18 weeks after randomisation. Qualitative interviews with participants will gain insights into the feasibility and acceptability of CAT. Feasibility outcomes will be judged against progression criteria. DISCUSSION: CAT may be an effective and accessible treatment option for people who self-harm, providing a more relationally orientated alternative to more behavioural therapies. The proposed feasibility RCT is an important first step in evaluating CAT as a treatment for self-harm. TRIAL REGISTRATION: The trial was pre-registered (21/10/22) on ISR CTN (ISRCTN code: ISRCTN75661422).

Individual treatment selection for patients with post-traumatic stress disorder: External validation of a personalised advantage index.

OBJECTIVE: To test the predictive accuracy and generalisability of a personalised advantage index (PAI) model designed to support treatment selection for Post-Traumatic Stress Disorder (PTSD). METHOD: A PAI model developed by Deisenhofer et al. (2018) was used to predict treatment outcomes in a statistically independent dataset including archival records for N = 152 patients with PSTD who accessed either trauma-focussed cognitive behavioural therapy or eye movement desensitisation and reprocessing in routine care. Outcomes were compared between patients who received their PAI-indicated optimal treatment versus those who received their suboptimal treatment. RESULTS: The model did not yield treatment specific predictions and patients who had received their PAI-indicated optimal treatment did not have better treatment outcomes in this external validation sample. CONCLUSION: This PAI model did not generalise to an external validation sample.

Types and mechanisms of idiographic change during guided self-help for anxiety.

OBJECTIVES: To compare idiographic change during two formats of guided self-help (GSH); cognitive-behavioural therapy guided self-help (CBT-GSH) and cognitive analytic therapy guided self-help (CAT-GSH). DESIGN: Qualitative inductive thematic analysis. METHODS: Semi-structured interviews with N = 17 participants with a reliable change outcome on the GAD-7 after completing GSH for anxiety. Changes were categorised and themes extracted. RESULTS: No differences between CAT-GSH and CBT-GSH were found regarding types of change reported. The five overarching themes found were personal qualities of success, enlightenment through understanding, specific tools and techniques, changes to relationships and tailoring support. Four themes maximally differentiated between the two different types of GSH; CAT-GSH enabled relational insight and change whilst CBT-GSH enabled better understanding of anxiety, new coping techniques and supportive relationships. CONCLUSIONS: Both common and model-specific factors contribute to patient change during GSH. Whilst all forms of GSH are grounded in the psychoeducational approach, separate theoretical foundations and associated methods facilitate different types of ideographic change.

A meta-analytic evaluation of the effectiveness and durability of psychotherapy for adults presenting with functional dissociative seizures.

BACKGROUND: Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes. METHODS: This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes. RESULTS: Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis. CONCLUSIONS: The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Treating taboo thoughts on a psychiatric intensive care unit: a four-phase mixed methods single case experimental design.

BACKGROUND: Well-designed evaluations of psychological interventions on psychiatric intensive care units (PICUs) are a rarity. AIMS: To evaluate the effectiveness of cognitive behaviour therapy for intrusive taboo thoughts with a patient diagnosed with bipolar affective disorder admitted to a PICU due to significant ongoing risk of harm to self. METHOD: This was a four-phase ABC plus community follow-up (D) mixed methods n=1 single case experimental design. Four idiographic measures were collected daily across four phases; the baseline (A) was during PICU admission, the first treatment phase (B) was behavioural on the PICU, the second treatment phase (C) was cognitive on an acute ward and the follow-up phase (D) was conducted in the community. Four nomothetic measures were taken on admission, on discharge from the PICU, discharge from the acute ward and then at 4-week follow-up. The participant was also interviewed at follow-up using the Change Interview. RESULTS: Compared with baseline, the behavioural and the cognitive interventions appeared effective in terms of improving calmness, optimism and rumination, but the effects on sociability were poor. There was evidence across idiographic and nomothetic outcomes of a relapse during the follow-up phase in the community. Eleven idiographic changes were reported in the interview and these tended to be unexpected, related to the therapy and personally important. DISCUSSION: Single case methods can be responsive to tracking the progress of patients moving through in-patient pathways and differing modules of evidence-based interventions. There is a real need to implement robust outcome methodologies on PICUs to better evaluate the psychological aspects of care in this context.

Household factors and prevalence of squalor: meta-analysis and meta-regression.

BACKGROUND: Severe domestic squalor occurs when a person lives in a dwelling that is significantly unclean, disorganised and unhygienic. The limited previous research has primarily focused on the characteristics of those who live in squalor and the associated risk factors. Robust and reliable studies of squalor prevalence have not been conducted. This study sought to produce a reliable estimate of the point prevalence of squalor. METHODS: Using data from 13-years of the English Housing Survey, N = 85,681 households were included in a prevalence meta-analysis. Squalor prevalence over time, subgroup analysis and logistic regression investigated the role played by household and community characteristics. RESULTS: The point prevalence of squalor was estimated to be 0.85% and squalor was seen to decrease significantly over time. More significant community deprivation, a rented dwelling, lower income and high numbers of people in the home was associated with a greater risk of squalor. CONCLUSIONS: Squalor prevalence was higher than previous estimates and supports community care services in associated service planning. The results regarding household characteristics help to inform which households and individuals may be at a higher risk of living in squalid conditions.

Personal reformulation during the clinical associate psychologist apprenticeship: Exploratory mixed methods evaluation.

OBJECTIVES: Clinical associate psychologists (CAPs) train under the auspices of the apprenticeship programme and are a new addition to the psychological workforce. This project sought to evaluate whether a "personal reformulation" (PR) was helpful in terms of personal and professional development during the apprenticeship. METHODS: A mixed methods evaluation containing a longitudinal quantitative element and a "Big Q" qualitative element with a single cohort of N = 18 CAPs. A PR consists of a 2-hr one-to-one session and a follow-up session with a cognitive analytic psychotherapist. During a PR, a sequential diagrammatic reformulation is produced to aid recognition and revision of potentially problematic relationship patterns at work. Two outcome measures concerning reflective capacity and professional quality of life were completed at the start of the apprenticeship, pre-PR and at 3-month PR follow-up. The semi-structured interviews (n = 11) conducted at the follow-up were analysed using reflexive thematic analysis. RESULTS: Quantitative changes were limited to significant increases to general confidence and 8/12 apprentices had a reliable increase in confidence in communication. Qualitatively, five overarching themes were found: (1) gaining insight, (2) wellbeing, (3) nature of the space, (4) being an apprentice, and (5) moving forward. CONCLUSIONS: PRs were generally found to be emotionally challenging, but relatively large amounts of insight are possible from a very brief intervention that can contribute to personal and professional development during clinical training. More controlled research needs to be conducted and wider applications and evaluations of PRs in different professions would be welcome.

An investigation of treatment return after psychological therapy for depression and anxiety.

BACKGROUND: Some patients return for further psychological treatment in routine services, although it is unclear how common this is, as scarce research is available on this topic. AIMS: To estimate the treatment return rate and describe the clinical characteristics of patients who return for anxiety and depression treatment. METHOD: A large dataset (N=21,029) of routinely collected clinical data (2010-2015) from an English psychological therapy service was analysed using descriptive statistics. RESULTS: The return rate for at least one additional treatment episode within 1-5 years was 13.7%. Furthermore, 14.5% of the total sessions provided by the service were delivered to treatment-returning patients. Of those who returned, 58.0% continued to show clinically significant depression and/or anxiety symptoms at the end of their first treatment, while 32.0% had experienced a demonstrable relapse before their second treatment. CONCLUSIONS: This study estimates that approximately one in seven patients return to the same service for additional psychological treatment within 1-5 years. Multiple factors may influence the need for additional treatment, and this may have a major impact on service activity. Future research needs to further explore and better determine the characteristics of treatment returners, prioritise enhancement of first treatment recovery, and evaluate relapse prevention interventions.

A feasibility and pilot additive randomised control trial of attachment security priming during behavioural activation.

BACKGROUND: There is some initial evidence that attachment security priming may be useful for promoting engagement in therapy and improving clinical outcomes. AIMS: This study sought to assess whether outcomes for behavioural activation delivered in routine care could be enhanced via the addition of attachment security priming. METHOD: This was a pragmatic two-arm feasibility and pilot additive randomised control trial. Participants were recruited with depression deemed suitable for a behavioural activation intervention at Step 2 of a Talking Therapies for Anxiety and Depression service. Ten psychological wellbeing practitioners were trained in implementing attachment security priming. Study participants were randomised to either behavioural activation (BA) or BA plus an attachment prime. The diagrammatic prime was integrated into the depression workbook. Feasibility outcomes were training satisfaction, recruitment, willingness to participate and study attrition rates. Pilot outcomes were comparisons of clinical outcomes, attendance, drop-out and stepping-up rates. RESULTS: All practitioners recruited to the study, and training satisfaction was high. Of the 39 patients that were assessed for eligibility, 24 were randomised (61.53%) and there were no study drop-outs. No significant differences were found between the arms with regards to drop-out, attendance, stepping-up or clinical outcomes. CONCLUSIONS: Further controlled research regarding the utility of attachment security priming is warranted in larger studies that utilise manipulation checks and monitor intervention adherence.

Development and initial evaluation of a treatment integrity measure for low-intensity group psychoeducational interventions.

BACKGROUND: Despite the importance of assessing the quality with which low-intensity (LI) group psychoeducational interventions are delivered, no measure of treatment integrity (TI) has been developed. AIMS: To develop a psychometrically robust TI measure for LI psychoeducational group interventions. METHOD: This study had two phases. Firstly, the group psychoeducation treatment integrity measure-expert rater (GPTIM-ER) and a detailed scoring manual were developed. This was piloted by n=5 expert raters rating the same LI group session; n=6 expert raters then assessed content validity. Secondly, 10 group psychoeducational sessions drawn from routine practice were then rated by n=8 expert raters using the GPTIM-ER; n=9 patients also rated the quality of the group sessions using a sister version (i.e. GPTIM-P) and clinical and service outcome data were drawn from the LI groups assessed. RESULTS: The GPTIM-ER had excellent internal reliability, good test-retest reliability, but poor inter-rater reliability. The GPTIM-ER had excellent content validity, construct validity, formed a single factor scale and had reasonable predictive validity. CONCLUSIONS: The GPTIM-ER has promising, but not complete, psychometric properties. The low inter-rater reliability scores between expert raters are the main ongoing concern and so further development and testing is required in future well-constructed studies.

Testing a Low-Intensity Single-Session Self-Compassion Intervention for State Body Shame in Adult Women: A Dismantling Randomized Controlled Trial.

State body shame is a risk factor for eating disorders, and self-compassion is emerging as a potentially effective treatment option in such cases. This study tested the efficacy of a brief (15-minute) self-compassion intervention in reducing state body shame. Using dismantling trial methodology, participants were randomly allocated to an active compassion condition (n = 23), an inactive control compassion condition (n = 23), or an educational control condition (n = 23). Measures of state body image and state shame were collected pre-intervention, immediately after the intervention, and a day after the intervention. Subjective units of state body shame (SUBS) were intensively measured during each invention. Self-compassion interventions were equally efficacious at protecting against deterioration of state body shame and were effective at reducing state shame compared to the educational control condition, with medium effect sizes (respectively - np2 = .07 and np2 = .08). Reductions in state shame were retained at follow-up. None of the interventions had an effect on body image (np2 = .04). Findings demonstrate the clinical promise of brief self-compassion interventions, particularly as evidenced-based "homework" exercises.

Cognitive-behavioural versus cognitive-analytic guided self-help for mild-to-moderate anxiety: a pragmatic, randomised patient preference trial.

BACKGROUND: Guided self-help (GSH) for anxiety is widely implemented in primary care services because of service efficiency gains, but there is also evidence of poor acceptability, low effectiveness and relapse. AIMS: The aim was to compare preferences for, acceptability and efficacy of cognitive-behavioural guided self-help (CBT-GSH) versus cognitive-analytic guided self-help (CAT-GSH). METHOD: This was a pragmatic, randomised, patient preference trial (Clinical trials identifier: NCT03730532). The Beck Anxiety Inventory (BAI) was the primary outcome at 8- and 24-week follow-up. Interventions were delivered competently on the telephone via structured workbooks over 6-8 (30-35 min) sessions by trained practitioners. RESULTS: A total of 271 eligible participants were included, of whom 19 (7%) accepted being randomised and 252 (93%) chose their treatment. In the preference cohort, 181 (72%) chose CAT-GSH and 71 (28%) preferred CBT-GSH. BAI outcomes in the preference and randomised cohorts did not differ at 8 weeks (-0.80, 95% confidence interval (CI) -4.52 to 2.92) or 24 weeks (0.85, 95% CI -2.87 to 4.57). After controlling for allocation method and baseline covariates, there were no differences between CAT-GSH and CBT-GSH at 8 weeks (F(1, 263) = 0.22, P = 0.639) or at 24 weeks (F(1, 263) = 0.22, P = 0.639). Mean BAI change from baseline was a reduction of 9.28 for CAT-GSH and 9.78 for CBT-GSH at 8 weeks and 12.90 for CAT-GSH and 12.43 for CBT-GSH at 24 weeks. CONCLUSIONS: Patients accessing routine primary care talking treatments prefer to choose the intervention they receive. CAT-GSH expands the treatment offer in primary care for patients with anxiety seeking a brief but analytically informed GSH solution.

Implementation of a case formulation to reduce restrictive interventions on a psychiatric intensive care unit: quasi-experimental single case evaluation.

BACKGROUND: Despite the use of case formulation being encouraged for in-patient psychiatric care, there have been no previous examples and evaluations of this type of work on a psychiatric intensive care unit (PICU). AIMS: To evaluate whether a schema-informed formulation with a patient diagnosed with emotionally unstable personality disorder (EUPD), autism spectrum disorder (ASD) and mild learning difficulties was effective in reducing the use of restrictive interventions. METHOD: A biphasic n = 1 quasi-experimental design with an 8-week baseline versus an 8-week intervention phase. The restrictive outcomes measured were use of physical restraint, seclusion, and intramuscular rapid tranquilisation. The formulation was developed through eight one-to-one sessions during the baseline period, and was implemented via six one-to-one sessions during the intervention phase and discussion at the ward reflective practice group. The intervention encouraged better communication of schema modes from the patient and for staff to then respond with bespoke mode support. RESULTS: Incidents involving need for seclusion, restraint and rapid tranquilisation extinguished. DISCUSSION: The need for making access to psychological input a routine aspect of the care in PICUs and the necessity for developing a methodologically more robust evidence base for psychological interventions on these wards.

Is clinical decision making in stepped-care psychological services influenced by heuristics and biases?

BACKGROUND: The manner in which heuristics and biases influence clinical decision-making has not been fully investigated and the methods previously used have been rudimentary. AIMS: Two studies were conducted to design and test a trial-based methodology to assess the influence of heuristics and biases; specifically, with a focus on how practitioners make decisions about suitability for therapy, treatment fidelity and treatment continuation in psychological services. METHOD: Study 1 (N=12) used a qualitative design to develop two clinical vignette-based tasks that had the aim of triggering heuristics and biases during clinical decision making. Study 2 (N=133) then used a randomized crossover experimental design and involved psychological wellbeing practitioners (PWPs) working in the Improving Access to Psychological Therapies (IAPT) programme in England. Vignettes evoked heuristics (anchoring and halo effects) and biased responses away from normative decisions. Participants completed validated measures of decision-making style. The two decision-making tasks from the vignettes yielded a clinical decision score (CDS; higher scores being more consistent with normative/unbiased decisions). RESULTS: Experimental manipulations used to evoke heuristics did not significantly bias CDS. Decision-making style was not consistently associated with CDS. Clinical decisions were generally normative, although with some variability. CONCLUSIONS: Clinical decision-making can be 'noisy' (i.e. variable across practitioners and occasions), but there was little evidence that this variability was systematically influenced by anchoring and halo effects in a stepped-care context.

A meta-analytic review of the effectiveness of psychological treatment of functional/dissociative seizures on non-seizure outcomes in adults.

Psychological therapies are considered the treatment of choice for functional/dissociative seizures (FDSs). Although most previous studies have focused on seizure persistence or frequency, it has been argued that well-being or health-related quality of life outcomes may actually be more meaningful. This study contributes by summarizing and meta-analyzing non-seizure outcomes to quantify the effectiveness of psychological treatment in this patient group. A pre-registered systematic search identified treatment studies (e.g., cohort studies, controlled trials) in FDSs. Data from these studies were synthesized using multi-variate random-effects meta-analysis. Moderators of treatment effect were examined using treatment characteristics, sample characteristics, and risk of bias. A total of 171 non-seizure outcomes across 32 studies with a pooled sample size of N = 898 yielded a pooled effect-size of d = .51 (moderate effect size). The outcome domain assessed and the type of psychological treatment were significant moderators of reported outcomes. Greater rates of improvement were demonstrated for outcomes assessing general functioning. Behavioral treatments emerged as particularly effective interventions. Psychological interventions are associated with clinical improvements across a broad array of non-seizure outcomes, over and above seizure frequency, in adults with FDSs.

Dissonance-based prevention of eating pathology in non-Western cultures: A randomized controlled trial of the Body Project among young Saudi adult women.

The aims of this study were to determine the effectiveness of an adapted version of the Body Project for young Saudi women, and to determine the impact of compliance (i.e. adherence to homework and attendance) on outcomes. A randomized controlled trial was used, allocating Saudi undergraduate females (N = 92; mean age = 20.48 years; SD = 2.28) to either a culturally-adapted version of the Body Project or a health education control condition. Participants completed self-report measures of eating pathology, body image, depression and social anxiety before and following the interventions and at three-month follow-up. Interaction terms showed that, relative to the control group, the intervention group had significantly reduced levels of eating concerns, body dissatisfaction and depression, but social anxiety did not change significantly in either group. Levels of session attendance and homework completion did not influence outcomes. Thus, the Body Project was effective for Saudi women in reducing eating pathology, body image dissatisfaction, and depression, though not social anxiety. This outcome indicates the value of the Body Project as a prevention tool when adapted to non-Western cultures.

Long-term psychotherapy in tertiary care: A practice-based benchmarking study.

OBJECTIVES: The literature regarding the effectiveness of long-term psychological interventions delivered in tertiary care is scarce. This study sought to quantify and evaluate outcomes delivered in a UK tertiary care psychotherapy service against equivalent service benchmarks. DESIGN: A retrospective analysis of outcomes on the Outcome Questionnaire-45 (OQ-45) over a 10-year period in a tertiary care psychotherapy service. The modalities evaluated were cognitive-behavioural, cognitive-analytic, and psychoanalytic psychotherapies. METHODS: Effectiveness was calculated at the service level and for each modality using pre-post-effect sizes and recovery rates. Benchmarking included a random-effects meta-analysis. Trajectories of change for each modality were examined using growth curve models. RESULTS: Baseline distress on the OQ-45 was higher than comparative norms (M = 102.57, SD = 22.79, N = 364). The average number of sessions was 48.68 (SD = 42.14, range = 5-335). There was a moderate pre-post-treatment effect (d = .46, 95% CI = .37-.55) which was lower than available benchmarks. The modalities differed in duration but were largely equivalent in terms of outcome. The reliable improvement rate was 29.95%, and the recovery rate was 10.16%, and change over time was best explained using a nonlinear (cubic) time trend. CONCLUSIONS: The elevated distress at baseline appears to create the conditions for relatively lengthy interventions and attenuated clinical outcomes. Suggestions are made regarding the clinical role, function, and evaluation of tertiary care psychotherapy services.

The Effectiveness of Psychological Interventions Delivered in Routine Practice: Systematic Review and Meta-analysis.

This review presents a comprehensive evaluation of the effectiveness of routinely delivered psychological therapies across inpatient, outpatient and University-based clinics. This was a pre-registered systematic-review of studies meeting pre-specified inclusion criteria (CRD42020175235). Eligible studies were searched in three databases: MEDLINE, CINAHL and PsycInfo. Pre-post treatment (uncontrolled) effect sizes were calculated and pooled using random effects meta-analysis to generate effectiveness benchmarks. Moderator analyses were used to examine sources of heterogeneity in effect sizes. Overall, 252 studies (k = 298 samples) were identified, of which 223 (k = 263 samples) provided sufficient data for inclusion in meta-analysis. Results showed large pre-post treatment effects for depression [d = 0.96, (CI 0.88-1.04), p ≤ 0.001, k = 122], anxiety [d = 0.8 (CI 0.71-0.9), p ≤ 0.001, k = 69], and other outcomes [d = 1.01 (CI 0.93-1.09), p ≤ 0.001, k = 158]. This review provides support for the effectiveness of routinely delivered psychological therapy. Effectiveness benchmarks are supplied to support service evaluations across multiple settings.