Does Prospective Mental Imagery Predict Symptoms of Negative Affect and Anhedonia in Young People?

Adolescent depression is associated with unhelpful emotional mental imagery. Here, we investigated whether vividness of negative and positive prospective mental imagery predict negative affect and anhedonia in adolescents. 111 people from Israel completed measures of prospective mental imagery, negative affect, and anhedonia at two time-points approximately three months apart. Using three cross-lagged panel models, we showed once 'concurrent' (across-variable, within-time) and 'stability' paths (across-time, within-variable) were estimated, there were no significant cross-lag paths between: i) T1 prospective negative mental imagery and T8 negative affect (i.e. increased vividness of negative future imagery at Time 1 did not predict increased negative affect at Time 8); ii) T1 prospective positive mental imagery and T8 negative affect (i.e. reduced vividness of positive future imagery at Time 1 did not predict increased negative affect at Time 8); and iii) T1 prospective positive mental imagery and T8 anhedonia (i.e. reduced vividness of positive future imagery at Time 1 did not predict increased anhedonia at Time 8). Given high levels of attrition, future research should aim to explore these associations in a larger, more diverse population, as such data could inform on whether modifying earlier prospective mental imagery may influence later time/context-specific effects of prospective mental imagery on negative affect and anhedonia.

Is Future Mental Imagery Associated with Reduced Impact of the COVID-19 Pandemic on Negative Affect and Anhedonic Symptoms in Young People?

Background: Difficulties with prospective mental images are associated with adolescent depression. Current treatments mainly focus on verbal techniques to reduce negative affect (e.g. low mood) rather than enhancing positive affect, despite anhedonia being present in adolescents. We investigated the concurrent relationships between the vividness of negative and positive prospective mental imagery and negative affect and positive affect; and examined whether negative and positive prospective mental imagery moderated the impact of recent stress (COVID-19-linked stress) on negative and positive affect. Methods: 2602 young people (12-25 years) completed the Prospective Imagery Task and self-reported on symptoms of negative affect, anhedonia and COVID-19 linked stress. Results: Elevated vividness of negative future mental imagery and reduced vividness of positive future mental imagery were associated with increased negative affect, whereas only reduced vividness of positive future imagery was associated with increased symptoms of anhedonia. Elevated vividness of negative future images amplified the association between COVID-19 linked stress and negative affect, while elevated vividness of positive future images attenuated the association between COVID-19 linked stress and anhedonia. Conclusions: Future mental imagery may be differentially associated with negative and positive affect, but this needs to be replicated in clinical populations to support novel adolescent psychological treatments. Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-023-10352-1.

An early intervention for adolescent depression targeting emotional mental images and memory specificity: a process evaluation.

We have evaluated a novel early intervention for adolescent depression (age 16-18) in a feasibility randomised controlled trial. This nested process evaluation aimed to understand how this complex intervention worked. We sought to understand participants' views and experiences of receiving and interacting with the intervention to evaluate whether the underpinning theoretical basis of the intervention is justified and whether it contributes to valued outcomes for participants. Twelve participants were invited to take part in semi-structured interviews. Framework analysis was employed to identify important aspects of adolescents' experiences. The active ingredients identified by participants were consistent with and extended our understanding of the theoretical basis of the intervention. Four principle themes were identified: understanding how memory works and being able to remember memories in more detail; processing negative experiences and letting go; imagining positive future events; and understanding and being kinder to myself. The outcomes of the intervention were valued by participants. Six principle themes were identified: improving mood and well-being; reducing impact of negative memories; motivation and goal-directed behaviour; overcoming avoidance and rumination; relationships, communication and being open; and self-understanding and acceptance. A simplified logic model is also proposed to connect the intervention components, active ingredients, and valued outcomes. The findings provide an in-depth understanding of how participants interacted with the intervention and what they derived from it. For example, the findings establish processing negative experiences as a core intervention component, extend it to include letting go of these memories, and highlight that reducing the impact of negative memories is valued by participants. This richer understanding guides further intervention development and future implementation.

Using Imagery Rescripting as an Early Intervention for Depression in Young People.

Innovation is urgently needed for school-based early interventions for depression. Imagery rescripting for aversive memories has been shown to be a valuable therapeutic approach in adults. Yet it is rarely applied to young people or to depression. This is surprising given that intrusive images of aversive memories are implicated in the development and maintenance of depression. We review the literature and describe the co-development of an imagery rescripting protocol for young people (age 16-18) with high symptoms of depression. To contextualize and illustrate this approach, we identify three themes of negative images emerging from the 37 participants who completed imagery rescripting and provide a detailed case example for each theme. The identified themes are failure, interpersonal adversity, and family conflict or disruption. Given that there is some therapist concern about using imagery rescripting, we highlight any reported negative consequences of engaging in imagery rescripting. We propose that imagery rescripting is an acceptable and potentially effective tool for early intervention in depression, which is significantly underutilized in current practice.

Harnessing emotional mental imagery to reduce anxiety and depression in young people: an integrative review of progress and promise.

Emotional mental imagery is a powerful part of our mental landscape. Given its capacity to depict, process, and generate emotional events, mental imagery could have an important role in psychological therapies. This Series paper explores whether harnessing emotional mental imagery is meaningful to young people; ways in which interventions use emotional mental imagery; contextual and individual factors influencing intervention effectiveness; and mechanisms underpinning imagery techniques. We completed a systematic review of imagery interventions and consulted young people with lived experience (n=10) and leading international experts (n=7). The systematic search identified 86 papers covering a diverse range of imagery interventions. Across the seven categories of techniques reviewed, imagery rescripting for aversive memories, techniques targeting positive imagery, and imagery-enhanced protocols indicated the most potential. The report suggests that harnessing emotional mental imagery in psychological interventions could be a promising approach to reduce anxiety and depression and that mental health science could inform the development of new interventions and help to maximise intervention effectiveness.

Promoting helpful attention and interpretation patterns to reduce anxiety and depression in young people: weaving scientific data with young peoples' lived experiences.

BACKGROUND: Anxiety and depression are common, disabling and frequently start in youth, underscoring the need for effective, accessible early interventions. Empirical data and consultations with lived experience youth representatives suggest that maladaptive cognitive patterns contribute to and maintain anxiety and depression in daily life. Promoting adaptive cognitive patterns could therefore reflect "active ingredients" in the treatment and/or prevention of youth anxiety and depression. Here, we described and compared different therapeutic techniques that equipped young people with a more flexible capacity to use attention and/or promoted a tendency to positive/benign (over threatening/negative) interpretations of uncertain situations. METHODS: We searched electronic databases (PubMed, PsycINFO, EMBASE, and PsycARTICLES) for studies containing words relating to: intervention; youth; anxiety and/or depression and attention and/or interpretation, and selected studies which sought to reduce self-reported anxiety/depression in youth by explicitly altering attention and/or interpretation patterns. Ten young people with lived experiences of anxiety and depression and from diverse backgrounds were consulted on the relevance of these strategies in managing emotions in their daily lives and also whether there were additional strategies that could be targeted to promote adaptive thinking styles. RESULTS: Two sets of techniques, each targeting different levels of responding with different strengths and weaknesses were identified. Cognitive bias modification training (CBM) tasks were largely able to alter attention and interpretation biases but the effects of training on clinical symptoms was more mixed. In contrast, guided instructions that teach young people to regulate their attention or to evaluate alternative explanations of personally-salient events, reduced symptoms but there was little experimental data establishing the intervention mechanism. Lived experience representatives suggested that strategies such as deliberately recalling positive past experiences or positive aspects of oneself to counteract negative thinking. DISCUSSION: CBM techniques target clear hypothesised mechanisms but require further co-design with young people to make them more engaging and augment their clinical effects. Guided instructions benefit from being embedded in clinical interventions, but lack empirical data to support their intervention mechanism, underscoring the need for more experimental work. Feedback from young people suggest that combining complimentary techniques within multi-pronged "toolboxes" to develop resilient thinking patterns in youth is empowering.

Targeting image-based autobiographical memory in childhood to prevent emotional disorders: Intervention development and a feasibility randomised controlled trial.

Maladaptive cognitive styles confer vulnerability for emotional disorders and may emerge in childhood. In three phases, we developed and evaluated a novel parent-led intervention (My Memory Forest) to target overgeneral memory and avoidance of negative memories. In phase 1, the intervention was co-designed using two focus groups (n = 30 children) and consultation with teachers and parents. The acceptability, feasibility, and clinical potential of My Memory Forest was initially evaluated in phase two (n = 12 children aged 6 to 9) and then in a feasibility randomised controlled trial in phase three, against an active control (n = 56 aged 6 to 9). Acceptability and engagement were good, and no harm was reported by parents or participants. Phase 2 identified decreases in self-reported anxiety (d = 1.08), depression (d = 0.51) and vividness of negative events (d = 0.53). There was little change in parent-reported symptoms. In phase 3, recruitment was highly feasible and participant retention excellent (100%) but parent retention poor (55%). Descriptive statistics indicated similar changes in anxiety and depression for both groups. Changes between Phases 2 and 3 (e.g. methods of recruitment) could explain the discrepancy between results. Further development is necessary before proceeding to another trial. TRIAL REGISTRATION: ISRCTN13142918.

A feasibility randomised controlled trial of a brief early intervention for adolescent depression that targets emotional mental images and memory specificity (IMAGINE).

Brief, evidence-based interventions for adolescent depression are urgently required, particularly for school-settings. Cognitive mechanisms research suggests dysfunctional mental imagery and overgeneral memory could be promising targets to improve mood. This feasibility randomised controlled trial with parallel symptomatic groups (n = 56) compared a novel imagery-based cognitive behavioural intervention (ICBI) to non-directive supportive therapy (NDST) in school settings. Blind assessments (of clinical symptoms and cognitive mechanisms) took place pre-intervention, post-intervention and follow-up three months later. The trial aimed to evaluate the feasibility and acceptability of the methodology and interventions, and estimate the likely range of effects of the intervention on self-reported depression. The pre-defined criteria for proceeding to a definitive RCT were met: full recruitment occurred within eleven months; retention was 89%; ICBI acceptability was above satisfactory; and no harm was indicated. Intention-to-treat analysis found large effects in favour of ICBI (relative to NDST) at post-intervention in reducing depressive symptoms (d = -1.34, 95% CI [-1.87, -0.80]) and improving memory specificity (d = 0.79 [0.35, 1.23]), a key cognitive target. The findings suggest that ICBI may not only improve mood but also strengthen abilities associated with imagining and planning the future, critical skills at this life stage. A fully powered evaluation of ICBI is warranted. Trial Registration: https://www.isrctn.com/; ISRCTN85369879.

Assessment and treatment of depression in children and young people in the United Kingdom: Comparison of access to services and provision at two time points.

Depression in young people is common and impairing. There have been significant service changes in the United Kingdom in the last decade, aiming to improve access to evidence-based interventions for depression. However, it is unclear whether youth with depression, first, access services and, second, receive appropriate interventions. In the current study, anonymised data from child and adolescent mental health services were extracted from a 1-year period at two time points (time 1: n = 770; time 2: n = 733). First, these were compared with prevalence and population data. Second, a subsample (n = 45 at each time point) was evaluated against National Institute for Clinical Excellence (NICE) guidelines. Approximately, one-quarter of the expected number of cases (according to population and prevalence data) were seen in the 12 to 18-years age group, and only 2% of expected cases were seen in the 0 to 11-years age group. This was consistent across time points. Adherence to NICE guidance was mostly good at both time points, but there were concerns raised by this evaluation, in particular the use of medication in this population. From time 1 to 2, there was an increase in use of questionnaire measures, but a decrease in the correct completion of risk assessments.

Intrusive images of a distressing future: Links between prospective mental imagery, generalized anxiety and a tendency to suppress emotional experience in youth.

Distressing intrusive images commonly occur in anxiety. Worry may function to reduce the emotional power of intrusive imagery, but this also prevents emotional processing. As worry is a future-orientated process, suppression of intrusive future imagery could be particularly pertinent to generalized anxiety. Here, we investigate whether youth high in symptoms of generalized anxiety (compared to depression and social anxiety) experience greater impact of future imagery (more intrusions, hyperarousal and avoidance), and whether this relationship varies as a function of the tendency to suppress or reappraise emotional experience. These relationships are important in adolescence, when generalized anxiety commonly begins and emotional regulation strategies develop. Participants (n = 352, age 11-16) completed measures of symptomatology, the impact of prospective personally-relevant imagery (IFES) and emotional regulation strategies. IFES scores correlated with an established measure of prospective imagery. Higher IFES scores were uniquely associated with more symptoms of generalized anxiety and depression, but not with social anxiety. A tendency to supress emotion was related to higher IFES scores and moderated the relationship between generalized anxiety and IFES (but not between depression and IFES). This provides initial impetus to develop novel approaches to investigate and intervene cognitively with negative prospective imagery in adolescent generalized anxiety.

Attention bias for social threat in youth with tic disorders: Links with tic severity and social anxiety.

Many individuals with Tourette syndrome and chronic tic disorders (TS/CTDs) report poor social functioning and comorbid social anxiety. Yet limited research has investigated the role of cognitive factors that highlight social threats in youth with TS/CTD, and whether these biases underlie tic severity and co-occurring social anxiety. This study examined whether selective attention to social threat is enhanced young people with TS/CTDs compared to healthy controls, and whether attention biases are associated with tic severity and social anxiety. Twenty seven young people with TS/CTDs and 25 matched control participants completed an experimental measure of attention bias toward/away from threat stimuli. A clinician-rated interview measuring tic severity/impairment (YGTSS Total Score) and questionnaire measures of social anxiety were completed by participants and their parents. Young people with TS/CTD showed an attention bias to social threat words (relative to benign words) compared to controls but no such bias for social threat faces. Attention bias for social threat words was associated with increasing YGTSS Total Score and parent-reported social anxiety in the TS/CTDs group. Mediation analysis revealed a significant indirect path between YGTSS Total Score and social anxiety, via attention to social threat. Tentatively, these associations appeared to be driven by impairment rather than tic severity scores. Preliminary data suggests that youth with TS/CTD have enhanced attention to threat, compared to controls, and this is associated with impairment and social anxiety. Attention to threat could offer a cognitive mechanism connecting impairment and social anxiety, and so be a valuable trans-diagnostic treatment target.

Multisession Cognitive Bias Modification Targeting Multiple Biases in Adolescents with Elevated Social Anxiety.

Research studies applying cognitive bias modification of attention (CBM-A) and interpretations (CBM-I) training to reduce adolescent anxiety by targeting associated cognitive biases have found mixed results. This study presents a new multi-session, combined bias CBM package, which uses a mix of training techniques and stimuli to enhance user-engagement. We present preliminary data on its viability, acceptability and effectiveness on reducing symptoms and biases using an A-B case series design. 19 adolescents with elevated social anxiety reported on their social anxiety, real-life social behaviours, general anxiety, depression, and cognitive biases at pre/post time-points during a 2-week baseline phase and a 2-week intervention phase. Retention rate was high. Adolescents also reported finding the CBM training helpful, particularly CBM-I. Greater reductions in social anxiety, negative social behaviour, and general anxiety and depression, characterised the intervention but not baseline phase. There was a significant correlation between interpretation bias change and social anxiety symptom change. Our enhanced multi-session CBM programme delivered in a school-setting appeared viable and acceptable. Training-associated improvements in social anxiety will require further verification in a study with an active control condition/group.

A brief early intervention for adolescent depression that targets emotional mental images and memories: protocol for a feasibility randomised controlled trial (IMAGINE trial).

BACKGROUND: Adolescent depression is common and impairing. There is an urgent need to develop early interventions to prevent depression becoming entrenched. However, current psychological interventions are difficult to access and show limited evidence of effectiveness. Schools offer a promising setting to enhance access to interventions, including reducing common barriers such as time away from education. Distressing negative mental images and a deficit in positive future images, alongside overgeneral autobiographical memories, have been implicated in depression across the lifespan, and interventions targeting them in adults have shown promise. Here, we combine techniques targeting these cognitive processes into a novel, brief psychological intervention for adolescent depression. This feasibility randomised controlled trial will test the feasibility and acceptability of delivering this imagery-based cognitive behavioural intervention in schools. METHODS/DESIGN: Fifty-six adolescents (aged 16-18) with high symptoms of depression will be recruited from schools. Participants will be randomly allocated to the imagery-based cognitive behavioural intervention (ICBI) or the control intervention, non-directive supportive therapy (NDST). Data on feasibility and acceptability will be recorded throughout, including data on recruitment, retention and adherence rates as well as adverse events. In addition, symptom assessment will take place pre-intervention, post-intervention and at 3-month follow-up. Primarily, the trial aims to establish whether it is feasible and acceptable to carry out this project in a school setting. Secondary objectives include collecting data on clinical measures, including depression and anxiety, and measures of the mechanisms proposed to be targeted by the intervention. The acceptability of using technology in assessment and treatment will also be evaluated. DISCUSSION: Feasibility, acceptability and symptom data for this brief intervention will inform whether an efficacy randomised controlled trial is warranted and aid planning of this trial. If this intervention is shown in a subsequent definitive trial to be safe, clinically effective and cost-effective, it has potential to be rolled out as an intervention and so would significantly extend the range of therapies available for adolescent depression. This psychological intervention draws on cognitive mechanism research suggesting a powerful relationship between emotion and memory and uses imagery as a cognitive target in an attempt to improve interventions for adolescent depression. TRIAL REGISTRATION: ISRCTN85369879.

Looking forward to the future: Impoverished vividness for positive prospective events characterises low mood in adolescence.

BACKGROUND: Enhancing positive future imagery offers promise for treatment innovation in adult depression but has been neglected in adolescence. While negative life events are linked with depression-onset in adolescence, mechanisms underlying this association are poorly understood. We investigate whether difficulties in generating vivid positive future imagery characterise depression, compared to anxiety, and examine potential moderation of the relationship between negative life events and depressive symptoms in adolescence. METHOD: Three hundred and seventy-five young people (11-16 years) completed the Prospective Imagery Task, and self-reported on symptoms of anxiety and depression. They were also asked to describe a past negative life event they had been thinking about or imagining over the last seven days, which was subsequently coded by a clinician over whether it was no, low, moderate or high impact. RESULTS: Symptoms of depression were associated with less vivid positive imagery and more vivid negative imagery whether past or future, whilst symptoms of anxiety were associated with increased vividness for past negative events only. The relationship between life event severity and depression was increased for those with poorer vividness for positive future events. LIMITATIONS: These data were collected at a single time-point only, limiting conclusions on temporal relationships. All measures were also self-reported, increasing shared method variance. CONCLUSIONS: These findings suggest that the relationship between negative life events and prospective positive imagery are specific to depressive symptoms in adolescence and provide foundations for novel approaches to strengthen psychological interventions.

Interoceptive Accuracy in Youth with Tic Disorders: Exploring Links with Premonitory Urge, Anxiety and Quality of Life.

Aberrant interoceptive accuracy could contribute to the co-occurrence of anxiety and premonitory urge in chronic tic disorders (CTD). If it can be manipulated through intervention, it would offer a transdiagnostic treatment target for tics and anxiety. Interoceptive accuracy was first assessed consistent with previous protocols and then re-assessed following an instruction attempting to experimentally enhance awareness. The CTD group demonstrated lower interoceptive accuracy than controls but, importantly, this group difference was no longer significant following instruction. In the CTD group, better interoceptive accuracy was associated with higher anxiety and lower quality of life, but not with premonitory urge. Aberrant interoceptive accuracy may represent an underlying trait in CTD that can be manipulated, and relates to anxiety and quality of life.

Reduced specificity of autobiographical memories in young people with tic disorders.

OBJECTIVE: Depression is common in Tourette syndrome and Chronic Tic Disorders (TS/CTD) and contributes to significant impairment. The specificity of autobiographical memories is implicated in an individual's sense of self and their daily functioning but also in the onset and development of depression in the general population. Here, we examined whether memory specificity is reduced in young people with TS/CTD, relative to control participants, and whether memory specificity is associated with depression. METHOD: Thirty young people with TS/CTD (14 females; age: x̅ = 11.31; SD = 1.66; 87% White British) and twenty-six (12 females; age: x̅ = 11.23; SD = 2.43; 77% White British) control participants completed the study. Participants completed the Autobiographical Memory Task, which asks participants to respond with a specific memory to cue words, and a questionnaire measure of depressive symptoms. RESULTS: There was no significant difference between the two groups in terms of age, gender, ethnicity, IQ and depressive symptomatology. Young people with TS/CTD had less specific autobiographical memories than their peers (p < 0.001, r = 0.49). Across both groups, increased memory specificity for positive cue words was associated with reduced depressive symptomatology (p < 0.001, R2 = 0.51). CONCLUSIONS: Our findings indicate that autobiographical memory in young people with TS is characterised by a lack of specificity and, as with neurotypical peers, reduced memory specificity for positive words is associated with depressive symptoms. Autobiographical memory specificity could be an important factor in understanding mood symptoms that characterise young people with TS/CTD and may be an important cognitive target to reduce the development of depression in young people with TS/CTD.

Research Review: Cognitive bias modification of interpretations in youth and its effect on anxiety: a meta-analysis.

BACKGROUND: Emerging evidence suggests that cognitive bias modification of interpretations (CBM-I) is effective in altering interpretation biases and reducing anxiety in adults. Less is known about the impact of CBM-I in young people, but some recent findings, including a meta-analysis of combined cognitive bias modification of interpretation and attention techniques, have cast doubt on its clinical utility. Given the current debate, this meta-analysis sought to establish the independent effects of CBM-I on interpretations biases and anxiety in youth. METHODS: Studies were identified through a systematic literature search of PsycINFO, Ovid MEDLINE, PsycARTICLES, Web of Science and EMBASE between January 1992 and March 2017. Eligible studies aimed to target interpretation biases; did not combine CBM-I with another intervention; included a control condition; randomly allocated participants to conditions; assessed interpretation bias and/or anxiety as an outcome; included individuals up to age 18; and did not present previously reported data. Reference lists of included articles were checked for further eligible studies, and authors were contacted for unpublished data. RESULTS: We identified 26 studies meeting eligibility criteria that included in the meta-analysis. CBM-I had moderate effects on negative and positive interpretations (g = -0.70 and g = -0.52, respectively) and a small but significant effect on anxiety assessed after training (g = -0.17) and after a stressor (g = -0.34). No significant moderators were identified. CONCLUSIONS: In contrast to previous meta-analytic findings, our results indicate that CBM-I has potential but weak anxiolytic effects in youth. Our findings suggest that it may be premature to disregard the potential value of CBM-I research and further research in this field is warranted.

Young people with higher social anxiety are less likely to adopt the perspective of another: Data from the Director task.

BACKGROUND AND OBJECTIVES: Young people with social anxiety display poor social functioning but it is unclear whether this is underscored by difficulties in key social cognitive abilities, such as perspective taking. Here, we examined whether increased social anxiety is associated with reduced accuracy on a perspective taking task and whether this relationship is stronger at particular periods within adolescence. METHODS: Fifty-nine adolescents aged 11-19 years completed the computerised Director Task (DT) and the Social Anxiety Scale for Adolescence. In the DT, participants virtually move objects by following either instructions given by the 'Director' (who can see only some objects), or a simple rule to ignore certain objects. RESULTS: Participants who scored above the clinical cut-off for social anxiety (n = 17) were less accurate when they had to take the perspective of the Director into account than those scoring below cut-off, yet performed similarly on control trials. Preliminary analysis indicated that poorer performance was most strongly associated with social anxiety in mid-adolescence (14-16.5 years). LIMITATIONS: The DT has been used previously to measure online perspective taking but the underlying cognitive mechanisms have not been fully elucidated. Extending these findings using additional measures of perspective taking would be valuable. CONCLUSIONS: Adolescents with higher social anxiety were less accurate at taking the perspective of a computerised character, with some suggestion that this relationship is strongest during mid-adolescence. If replicated, these findings highlight the importance of addressing specific social cognitive abilities in the assessment and treatment of adolescent social anxiety.

The Feasibility and Acceptability to Service Users of CIRCuiTS, a Computerized Cognitive Remediation Therapy Programme for Schizophrenia.

BACKGROUND: Cognitive remediation (CR) is a psychological therapy, effective in improving cognitive performance and functioning in people with schizophrenia. As the therapy becomes more widely implemented within mental health services its longevity and uptake is likely to depend on its feasibility and acceptability to service users and clinicians. AIMS: To assess the feasibility and acceptability of a new strategy-based computerized CR programme (CIRCuiTS) for people with psychosis. METHOD: Four studies were conducted using mixed methods. Perceptions of attractiveness, comprehensibility, acceptability and usability were assessed using self-report questionnaires in 34 non-clinical participants (study 1), and five people with a schizophrenia diagnosis and three experienced CR therapists (studies 2 and 3). The ease with which pre-specified therapy programmes could be assembled was also assessed by three therapists (Study 2). Finally, the satisfaction of 20 service users with a diagnosis of schizophrenia regarding their experience of using CIRCuiTS in the context of a course of the CR therapy was assessed in a qualitative interview study (study 4). RESULTS: Ratings of perceived attractiveness, comprehensibility, acceptability and usability consistently exceeded pre-set high targets by non-clinical, clinical and therapist participants. Qualitative analysis of satisfaction with CIRCuiTS showed that receiving the therapy was generally seen to be a positive experience, leading to perceptions that cognitive functioning had improved and attempts to incorporate new strategy use into daily activities. CONCLUSIONS: CIRCuiTS demonstrates high acceptability and ease of use for both service users with a schizophrenia diagnosis and clinicians.