Patterns of Mental Health Service Utilisation: A Population-Based Linkage of Over 17 Years of Health Administrative Records.

A cross-sectoral partnership was formed in 2021 in support of the recommendations in an audit on access to state-funded mental health services. In this first paper, we aimed to describe the demographic and service utilisation of adults with a mental health diagnosis in the Western Australian state-funded health system from 2005 to 2021. Inpatient, emergency department, specialised (ambulatory) community mental health service, and death records were linked in individuals aged ≥ 18 years with a mental health diagnosis in Western Australia. Altogether, 392,238 individuals with at least one mental health service contact between 1st January 2005 and 31st December 2021 were included for analysis. Females, Aboriginal and/or Torres Strait Islander people, and those who lived outside major cities or in the most disadvantaged areas were more likely to access state-funded mental health services. While the number of individuals who accessed community mental health services increased over time (from 28,769 in 2005 to 50,690 in 2021), the percentage increase relative to 2005 was notably greater for emergency department attendances (127% for emergency department; 76% for community; and 63% for inpatient). Conditions that contributed to the increase for emergency department were mainly alcohol disorder, reaction to severe stress and adjustment disorders, and anxiety disorders. Sex differences were observed between conditions. The pattern of access increased for emergency department and the community plus emergency department combination. This study confirmed that the patterns of access of state-funded mental health services have changed markedly over time and the potential drivers underlying these changes warrant further investigation.

Farming, finance and family: factors associated with anxiety, depression and stress among Western Australian farmers.

Farming is a challenging, stressful and rewarding occupation involving many factors that are beyond farmers' control. The aim of this study was to investigate correlates associated with the anxiety, depression and stress of farmers in Western Australia. Farmers and farm residents (N = 124) completed an online survey assessing anxiety, depression, stress, farming stressors, social supports, coping strategies and sense of belonging. Higher financial/external trade and societal pressures, family/relationship tension, use of coping strategies such as self-blame, venting, disengagement and planning, lack of succession planning and considering selling the farm, and lower social support and sense of belonging, were associated with higher anxiety, depression and/or stress. The findings highlight the specific impacts of financial and family pressures on poorer mental health status among farmers. Clinical and community interventions that build on naturally occurring strengths, such as family support and community connectedness, are needed.

Opportunities lost? Rates and predictors of attrition in an eating disorders outpatient service.

OBJECTIVE: To examine rates and predictors of attrition from referral through to treatment completion in an outpatient public psychology service's eating disorder program in Perth, Western Australia. METHOD: The proportion (number) of clients (N = 671; mean age = 23.8 years) transitioning between stages of pre-treatment and treatment was identified. Associations between demographic, treatment and clinical variables and attrition were investigated using logistic regression. RESULTS: Only 34% (n = 230) of referred patients started treatment and 16% (n = 107) completed treatment. Referral acceptance was correlated with provisional diagnoses that meet the service's inclusion criteria, and attendance at an initial assessment was correlated with younger age. Treatment commencement was correlated with the presence of a co-occurring depressive or anxiety disorder, and no previous suicide attempts. Completing a full course of treatment was correlated with no previous hospitalisation for psychiatric issues, no previous suicide attempts, a history of psychiatric medication use, and treatment with family-based therapy. DISCUSSION: High rates of attrition were found from referral to treatment completion. A suggested framework for defining the different stages of attrition is proposed to allow for consistency of attrition reporting across the mental health field. Future studies are needed to identify why clients disengage following referral, assessment, and treatment commencement, to inform strategies to engage and sustain engagement and to optimise outcomes.

Improving Exposure Therapy: Rationale and Design of an International Consortium.

The Exposure Therapy Consortium (ETC) was established to advance the science and practice of exposure therapy. To encourage participation from researchers and clinicians, this article describes the organizational structure and activities of the ETC. Initial research working group experiences and a proof-of-principle study underscore the potential of team science and larger-scale collaborative research in this area. Clinical working groups have begun to identify opportunities to enhance access to helpful resources for implementing exposure therapy effectively. This article discusses directions for expanding the consortium's activities and its impact on a global scale.

The Emotion Beliefs Questionnaire: Psychometric properties, norms, and links to affective outcomes.

BACKGROUND: The Emotion Beliefs Questionnaire was recently developed to measure beliefs about the controllability and usefulness of negative and positive emotions. These are beliefs that have been theorised to be influential for emotion regulation and psychological outcomes. However, to date there are few studies utilising large, representative samples to examine the EBQ's psychometric properties and affective correlates. Our aim was to fill this gap by examining the EBQ's psychometric properties and exploring associations between emotion beliefs, emotion regulation, and affective disorder symptoms. METHODS: A sample of 1175 adults recruited from the general population in the United States completed measures of emotion beliefs, emotion regulation, and affective disorder symptoms. RESULTS: Confirmatory factor analyses supported the EBQ's intended subscale structure, where controllability and usefulness beliefs were separated by valence. This structure was invariant across gender, age, and education categories. The EBQ correlated in expected ways with other measures, demonstrating good validity, and had good to excellent levels of internal consistency reliability. LIMITATIONS: This study used a non-clinical sample that was predominantly White. Future work should utilise clinical and cross-cultural samples to maximise generalisability of findings. CONCLUSIONS: Our findings indicate that the EBQ is a psychometrically sound tool for measuring the multidimensional emotion belief construct. The EBQ may have clinical utility in the conceptualisation, assessment, and treatment of maladaptive emotion beliefs. Furthermore, our results highlight the importance of considering the potential influence of maladaptive emotion beliefs in emotion dysregulation and affective disorder symptoms.

Examining co-occurring social anxiety in cognitive behavioral therapy for eating disorders: Does it change and does it moderate eating disorder outcomes?

OBJECTIVE: Eating disorders (EDs) often co-occur with social anxiety disorder (SAD). However, little research has examined the influence of SAD symptoms on ED treatment outcomes in the context of individual outpatient cognitive-behavior therapy for eating disorders (CBT-ED). It is plausible that SAD symptom severity could improve as a result of ED treatment, given the high overlap between EDs and SAD. We sought to test whether baseline SAD symptoms moderate early response to CBT-ED or post-treatment outcomes in CBT-ED, and the degree to which SAD symptoms improve during therapy despite SAD not being an explicit treatment target. METHOD: ED clients (N = 226) aged ≥16 years were treated with CBT-ED. Outcomes were ED symptoms, clinical impairment, and SAD symptoms measured at baseline, session 5 and post-treatment. RESULTS: Baseline SAD was a weak moderator of early and post-treatment ED symptoms and impairment. SAD symptoms improved moderately over treatment among clients who started with elevated levels of SAD symptomology. DISCUSSION: Clients with EDs can experience good therapeutic outcomes regardless of their social anxiety severity at pre-treatment. SAD symptoms reduced over CBT-ED, but protocol enhancements such as exposure-based strategies that directly target co-occurring social-evaluative concerns may help achieve larger reductions in SAD symptoms. PUBLIC SIGNIFICANCE: Eating disorders often co-occur with anxiety disorders such as social anxiety. We found people who had both social anxiety and an eating disorder benefited as much from eating disorder treatment as people who did not have social anxiety. People who were socially anxious became less anxious as a by-product of receiving eating disorder treatment. It may be possible to reduce social anxiety further by enhancing eating disorder treatment protocols.

The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder.

OBJECTIVE: Few studies have investigated the role of generic relational factors, such as group cohesion and working alliance, in group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD). The aim of this study was to examine the temporal associations among working alliance, group cohesion, and an index of a CBT-specific factor, homework engagement, as correlates of fear of negative evaluation and symptoms of social anxiety in group CBT for SAD. METHOD: There were 105 participants with a diagnosis of social anxiety disorder who were randomly assigned to 12 sessions of group imagery-enhanced or standard CBT. Participants completed measures at various time points during the 12-session interventions, and the relationship among variables was examined through random-intercept cross-lagged panel models. RESULTS: Group cohesion was significantly associated with social anxiety symptoms at the end of treatment, however there was no significant relationship with working alliance. Greater homework engagement predicted lower social interaction anxiety, but only during mid-treatment. CONCLUSION: The results highlight the importance of supporting group cohesion and maximising homework engagement during core components of social anxiety treatment such as behavioural experiments.

Predictors of homework engagement in group CBT for social anxiety: client beliefs about homework, its consequences, group cohesion, and working alliance.

OBJECTIVE: Group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) is effective, but little data exist on generic relational components of the therapeutic process, such as group cohesion and therapy alliance, and central CBT-specific components such as homework engagement, beliefs, and perceived consequences. The aim of this study was to investigate the relationships between homework, group cohesion, and working alliance during group CBT for social anxiety disorder. METHOD: Participants (N = 105) with SAD engaged in 12 sessions of group CBT. Measures of homework, working alliance, and group cohesion were completed at multiple points throughout treatment. Random-intercept cross-lagged panel models were used to evaluate the prospective relationships between measures. RESULTS: Prospective relationships between the homework outcomes did not vary throughout the treatment period, with the only significant relationships seen between the random intercepts ("trait" levels). Homework beliefs were a significant negative predictor of future group cohesion, but only in mid- to late-treatment. Homework consequences and working alliance were significantly and positively predictive of each other throughout therapy. CONCLUSION: Early homework engagement is associated with higher engagement throughout therapy. Working alliance and homework engagement are important to bolster early in group CBT.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12616000579493..

Social anxiety, behavioural activation and depression risk in older men: protection through Men's Shed membership.

Reducing rates of depressive symptoms in older adults is a public health priority. Men's Sheds are a community organisation that may protect against depressive symptoms in older men. It is currently unclear how social anxiety and behavioural activation may relate to depressive symptoms for Men's Shed members. We employed a cross-sectional design to explore whether the relationships between social anxiety, behavioural activation and depressive symptoms were contingent upon Shed social network quality in a sample of 164 Men's Shed members. Conditional effects analysis found social anxiety (B = -0.08, p < 0.01) and behavioural activation's (B = 0.02, p < 0.001) relationships with depression to be contingent on Shed social network quality. Additionally, we found evidence for a conditional effect of social anxiety on the relationship between behavioural activation and depression (B = -0.03, p < 0.01) such that this relationship was stronger for those with higher levels of social anxiety. Our findings suggest that a strong social network within a Men's Shed weakens the association between social anxiety and depression, that the relationship between behavioural activation and depression is stronger in those with poorer Shed social networks, and that the relationship between behavioural activation and depression may be stronger for those with higher levels of social anxiety. We suggest that our findings contribute to increasing quantitative support for the mental health benefits of Men's Shed membership, highlight the potential importance of Shed social network quality and explore how social anxiety may affect the mental health outcomes for members.

Pathways from Men's Shed engagement to wellbeing, health-related quality of life, and lower loneliness.

Extensive qualitative evidence, but limited quantitative evidence, indicates that mutual aid organizations such as Men's Sheds have positive impacts on wellbeing, health-related quality of life, and loneliness. A recently developed theoretical model proposes that Men's Sheds may have these impacts via mediating factors such as broadening social networks, increasing behavioural activation and physical activity, reducing alcohol use, and providing meaning in life. The aim of this study was to quantitatively test a model whereby psychological safety (feeling safe, accepted, and valued) is associated with Men's Shed engagement (frequency of attendance, duration of membership, diversity of activities), which is associated with the hypothesized mediators, which, in turn, are associated with wellbeing, health-related quality of life, and loneliness. Men's Shed members (N = 333, Mage = 70.90 years, SD = 10.34, 98% male) completed a survey assessing the factors in the model. The hypothesized path model provided an excellent fit to the data. Findings indicated that higher psychological safety was associated with higher engagement, which, in turn, was associated with larger social networks and more meaning in life, which were associated with higher wellbeing and lower loneliness. Higher behavioural activation and less alcohol use were also associated with higher wellbeing. Higher Men's Shed engagement was not associated with higher behavioural activation and physical activity, or less alcohol use, but behavioural activation and alcohol use were directly associated with health-related quality of life. Implications for optimizing health outcomes within Men's Sheds are discussed.

Voice hearers' explanations of trauma-related voices and processes of change throughout imagery rescripting: A qualitative exploration.

OBJECTIVES: Post-traumatic stress is common among people who hear voices (auditory verbal hallucinations), many of whom hear trauma-related voices, whereby voice content is related to past trauma. Preliminary evidence suggests that imagery rescripting (ImRs) may more effectively reduce post-traumatic stress and voices compared to treatments that are based on existing models of PTSD or positive symptoms. No known studies have explored the potential maintaining factors of trauma-related voices in relation to ImRs. We aimed to uncover insights into the factors that maintain trauma-related voices and how ImRs may influence such factors by exploring voice hearers' explanations of voices and experiences of change throughout ImRs. DESIGN: Thematic analytical methodology was used due to the study's critical epistemological framework. METHODS: Semi-structured interviews explored relationships between trauma and voices, and experiences of change and stability throughout ImRs in a transdiagnostic sample (N = 10) who underwent 10-18 weekly ImRs sessions. Thematic analysis was used to develop themes. RESULTS: Two themes captured explanations of voices, which suggested voices may have counterproductive protective functions. Three themes captured psychological experiences during ImRs, which reflected concepts such as freedom to experience emotions, and experiences of justice, closure and grieving. Three themes described the outcomes of ImRs, reflecting concepts such as increased confidence, coping, perceived safety and voices becoming less powerful. CONCLUSIONS: Trauma-related voices may have underlying protective functions and ImRs may support emotional expression, adaptive trauma re-appraisals and improve self-worth and coping self-efficacy. These change processes may have clinical implications in ImRs and other treatments for trauma-affected voice hearers.

An Artificial Therapist (Manage Your Life Online) to Support the Mental Health of Youth: Co-Design and Case Series.

BACKGROUND: The prevalence of child and adolescent mental health issues is increasing faster than the number of services available, leading to a shortfall. Mental health chatbots are a highly scalable method to address this gap. Manage Your Life Online (MYLO) is an artificially intelligent chatbot that emulates the method of levels therapy. Method of levels is a therapy that uses curious questioning to support the sustained awareness and exploration of current problems. OBJECTIVE: This study aimed to assess the feasibility and acceptability of a co-designed interface for MYLO in young people aged 16 to 24 years with mental health problems. METHODS: An iterative co-design phase occurred over 4 months, in which feedback was elicited from a group of young people (n=7) with lived experiences of mental health issues. This resulted in the development of a progressive web application version of MYLO that could be used on mobile phones. We conducted a case series to assess the feasibility and acceptability of MYLO in 13 young people over 2 weeks. During this time, the participants tested MYLO and completed surveys including clinical outcomes and acceptability measures. We then conducted focus groups and interviews and used thematic analysis to obtain feedback on MYLO and identify recommendations for further improvements. RESULTS: Most participants were positive about their experience of using MYLO and would recommend MYLO to others. The participants enjoyed the simplicity of the interface, found it easy to use, and rated it as acceptable using the System Usability Scale. Inspection of the use data found evidence that MYLO can learn and adapt its questioning in response to user input. We found a large effect size for the decrease in participants' problem-related distress and a medium effect size for the increase in their self-reported tendency to resolve goal conflicts (the proposed mechanism of change) in the testing phase. Some patients also experienced a reliable change in their clinical outcome measures over the 2 weeks. CONCLUSIONS: We established the feasibility and acceptability of MYLO. The initial outcomes suggest that MYLO has the potential to support the mental health of young people and help them resolve their own problems. We aim to establish whether the use of MYLO leads to a meaningful reduction in participants' symptoms of depression and anxiety and whether these are maintained over time by conducting a randomized controlled evaluation trial.

Pathways from trauma to unusual perceptual experiences: Modelling the roles of insecure attachment, negative affect, emotion regulation and dissociation.

BACKGROUND: A range of traumas have been linked to voices (auditory verbal hallucinations) and unusual perceptual experiences (UPEs) in other perceptual-sensory domains. Models of PTSD and positive symptoms of psychosis are insufficient in explaining the relationship between trauma and voices. The trauma-related voices (TRV) model was developed to generate novel research in this area. AIMS: This study aimed to investigate pathways from trauma to the frequency of UPEs based on a subset of hypothesised relationships in the TRV model. MATERIALS: The PTSD Diagnostic Scale for DSM-5, State Adult Attachment Measure, Depression Anxiety and Stress Scales-21, Perth Emotion and Regulation Competency Inventory, Dissociative Experiences Measure Oxford, and Multi-modality Unusual Perceptual Experiences Questionnaire. METHODS: We used path analysis in a non-clinical sample (N = 528) to model indirect effects from diverse trauma experiences to the frequency of multi-sensory UPEs via a subset of mediators within the TRV model: insecure attachment, emotion regulation deficits, negative affect and dissociation. RESULTS: Our model was an excellent fit to the data and accounted for 37.1% of variance in UPE frequency, and all direct (ßs = .14-.61) and indirect pathways (ßs = .01-.08) were significant (ps < .001). DISCUSSION: Our findings suggest that insecure attachment may link diverse trauma experiences to emotion regulation deficits and negative affect, which are linked to UPE frequency via dissociation. CONCLUSION: Our findings provide preliminary evidence for a subset of relationships within the TRV model. Future studies are needed to gather stronger evidence of temporality and causation between these factors, and to test broader pathways within the TRV model.

The effect of positive and negative evaluation on state anxiety and repetitive negative thinking in social evaluative situations: An experimental study.

The Bivalent Fear of Evaluation (BFOE) Model suggests that fears of negative and positive evaluation are core cognitive vulnerability and maintenance factors for social anxiety disorder The aim of this study was to experimentally assess cognitive and emotional effects of positive and negative feedback in social anxiety. False positive or negative feedback (vs no feedback) was provided following a speech task to high and low socially anxious individuals to investigate impacts on state anxiety and repetitive negative thinking (N = 152, Mage = 22.13, 69 % female). Measures were completed prior to the speech and after the false feedback but prior to an anticipated discussion with the group about participants' feedback and performance. High socially anxious participants reporting higher state anxiety and repetitive negative thinking than low socially anxious participants. There were no feedback type by group interactions, indicating that high socially anxious individuals experienced heightened social anxiety and repetitive negative thinking regardless of feedback type (or the absence of feedback). Exploratory analyses revealed that state fear of negative evaluation but not state fear of positive evaluation uniquely predicted both outcomes. Implications for theory and clinical practice are discussed.

What explains the failure to identify replicable moderators of symptom change in social anxiety disorder?

Trials of cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) have struggled to identify replicable moderators of treatment outcome. This could be due to a genuine lack of effects, or a spurious finding caused by methodological factors such as inadequate testing of theory-driven moderators, use of small homogenous samples, failure to model non-linear relationships, and over-reliance on significance testing. We probed explanations for the field's failure to detect moderators by testing whether 15 theory-driven and atheoretical variables moderated treatment outcome in a large heterogeneous sample treated with group CBT for SAD. Moderation was not assessed by only using p-values for linear models, but also by considering effect sizes, plots, and non-linear relationships. Despite using a comprehensive approach to assess moderation, only two variables - the baseline severity of SAD symptoms and fear of negative evaluation (FNE) - were found to moderate social anxiety symptom trajectories. FNE had a non-linear relationship with symptom change that would have been missed using common research methods. Our findings suggest both a genuine lack of effects and limitations of research methods have contributed to the field's inability to identify moderators. We provide suggestions that may increase the likelihood of future researchers detecting genuine effects.

Concurrent and prospective associations between negative social-evaluative beliefs, safety behaviours, and symptoms during and following cognitive behavioural group therapy for social anxiety disorder.

BACKGROUND: Improving the delivery of cognitive-behavioural therapy (CBT) for social anxiety disorder (SAD) requires an in-depth understanding of which cognitive and behavioural mechanisms drive change in social anxiety symptoms (i.e., social interaction anxiety) during and after treatment. The current study explores the dynamic temporal associations between theory-driven cognitive and behavioural mechanisms of symptom change both during and following group CBT. METHODS: A randomized controlled trial of imagery-enhanced CBT (n = 51) versus traditional verbal CBT (n = 54) for social anxiety was completed in a community mental health clinic setting. This study included data collected from 12-weekly sessions and a 1-month follow-up session. Mixed models were used to assess magnitude of change over the course of treatment. Cross-lagged panel models were fit to the data to examine temporal relationships between mechanisms (social-evaluative beliefs, safety behaviours) and social interaction anxiety symptoms. RESULTS: Participants in both CBT groups experienced significant improvements across all cognitive, behavioural, and symptom measures, with no significant differences in the magnitude of changes between treatments. During treatment, greater social-evaluative beliefs (fear of negative evaluation, negative self-portrayals) at one time point (T) were predictive of more severe SAD symptoms and safety behaviours at T+1. Social-evaluative beliefs (fear of negative evaluation, probability and cost of social failure) and safety behaviours measured at post-treatment were positively associated with SAD symptoms at the 1-month follow-up. CONCLUSIONS: The current study identifies social-evaluative beliefs that may be important targets for symptom and avoidance reduction during and following CBT. Assessment of these social-evaluative beliefs throughout treatment may be useful for predicting future SAD symptoms and avoidance, and for adapting treatment to promote optimal change for patients.

Development of a research capacity and culture tool for people with lived experience of mental health challenges.

OBJECTIVE: This study investigated research capacity and culture in people with lived experience of mental health challenges by developing a quantitative tool that measures capacity to engage in research. METHOD: A cross-sectional, correlational methodology was employed, which comprised of three phases: lived experience consultations for item development (n = 15), item refinement (n = 20) and tool piloting. Items were adapted from, and extended, an existing research capacity and culture tool for healthcare workers. People (N = 112) with lived experience as mental health consumers, carers, peer workers and/or advocates aged 18-75 years took part in the tool piloting survey. RESULTS: Overall, participants rated their individual research capacity and culture skills as moderate (mean = 5.41, standard deviation = 2.04). The most commonly reported barriers to research engagement related to lack of knowledge, familiarity or experience with the research process. The most commonly reported enablers were altruistic, such as using their experiences to improve services and help others. Research capacity and culture significantly correlated with current research activities (rs = 0.25-0.41; ps < 0.05), but not with being a research participant (r = 0.09; p > 0.05), suggesting that building research capacity of people with lived experience requires them to be active members of research teams. CONCLUSION: The Lived Experience research capacity and culture tool developed in this study revealed that people with lived experience of mental health challenges are intrinsically motivated to engage in research to improve consumer outcomes. The tool may be useful to assess self, research team and organisational preparedness to conduct genuinely co-designed research, and to assess changes in lived experience research capacities and culture over time.

Impacts of imagery-enhanced versus verbally-based cognitive behavioral group therapy on psychophysiological parameters in social anxiety disorder: Results from a randomized-controlled trial.

Social anxiety disorder (SAD) is associated with marked physiological reactivity in social-evaluative situations. However, objective measurement of biomarkers is rarely evaluated in treatment trials, despite potential utility in clarifying disorder-specific physiological correlates. This randomized controlled trial sought to examine the differential impact of imagery-enhanced vs. verbal-based cognitive behavioral group therapy (IE-CBGT, n = 53; VB-CBGT, n = 54) on biomarkers of emotion regulation and arousal during social stress in people with SAD (pre- and post-treatment differences in heart rate variability (HRV) and skin conductance). We acquired psychophysiological data from randomized participants across four social stress test phases (baseline, speech preparation, speech, interaction) at pre-treatment, and 1- and 6-months post-treatment. Analyses revealed that IE-CBGT selectively attenuated heart rate as indexed by increases in median heart rate interval (median-RR) compared to VB-CBGT at post-treatment, whereas one HRV index showed a larger increase in the VB-CBGT condition before but not after controlling for median-RR. Other psychophysiological indices did not differ between conditions. Lower sympathetic arousal in the IE-CBGT condition may have obviated the need for parasympathetic downregulation, whereas the opposite was true for VB-CBGT. These findings provide preliminary insights into the impact of imagery-enhanced and verbally-based psychotherapy for SAD on emotion regulation biomarkers.

A narrative review of psychological theories of post-traumatic stress disorder, voice hearing, and other psychotic symptoms.

BACKGROUND: Most voice hearers report childhood trauma. Many voice hearers report comorbid post-traumatic stress symptoms and that the content of their voices (auditory verbal hallucinations) is directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma is thematically similar) related to their trauma. The factors that maintain trauma-related voices are unknown, and there is limited research in this area. This study aimed to identify potential maintaining factors of trauma-related voices by reviewing models of post-traumatic stress disorder (PTSD) and positive symptoms of psychosis. METHOD: Models of PTSD and positive symptoms were reviewed to identify potential factors that are unique and common to both sets of symptoms. RESULTS: We reviewed 10 models of PTSD, 4 models of positive symptoms, and 2 trauma-informed models of voice hearing. One model provided a theoretical explanation of different types of trauma-related voices. Twenty-one factors were extracted from 16 theoretical models. No existing model incorporated all these factors. DISCUSSION: Existing PTSD and positive symptom models present a range of common and unique factors. There may be value in extending existing integrative models to include a broader range of potential factors that could explain different pathways to, and expressions of, trauma-related voices. A future research agenda is presented to investigate how such an extension could lead to more complete individualized case formulations and targeted treatments.

The association between carer self-compassion, expressed emotion, quality of life, and paediatric eating disorder symptoms.

OBJECTIVE: The aim of this study was to investigate carer variables on paediatric eating disorders. We examined whether carer self-compassion, the tendency to treat oneself with kindness during distress and disappointments, was associated with lower carer expressed emotion, and, in turn, whether lower carer expressed emotion would be associated with both higher carer quality of life and lower eating disorder symptoms in young people. Further, we examined whether higher carer quality of life was associated with lower adolescent eating disorder symptoms. METHOD: Data were extracted from the Helping out Paediatric Eating Disorders (HOPE) project database. Participants included children and adolescents diagnosed with a DSM5 eating disorder and their primary carer (N of dyads = 359). Primary carers completed the Self-Compassion Scale-Short Form (SCS-SF), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF), and the Family Questionnaire-Expressed Emotion (FQ-EE). Children and adolescents completed an adapted version of the Eating Disorder Examination (EDE). RESULTS: As hypothesised, structural equation modelling (SEM) revealed a direct relationship between higher carer self-compassion and lower expressed emotion, and between lower expressed emotion and both higher carer quality of life and lower eating disorder symptoms. However, contrary to our hypothesis, carer quality of life was not significantly associated with paediatric eating disorder symptoms. Expressed emotion carried significant indirect effects between carer self-compassion and (a) paediatric eating disorder symptoms and (b) carer quality of life. DISCUSSION: The results highlight the importance of further research to determine whether targeting carer self-compassion is helpful in the treatment of eating disorders in young people.