Mary Welford

The questionnaire about the process of recovery (QPR): A measurement tool developed in collaboration with service users

Aims: To develop and validate a short recovery questionnaire in collaboration with service users. Method: 126 people with experience of psychosis were recruited via the National Health Service (NHS) Trust and self‐help organisations nationwide. Items were generated from in‐depth interviews into recovery and developed into a 25‐item self‐report questionnaire. Data were factor analysed, and a final 22‐item measure (the QPR) was tested for reliability and validity. To assess validity the QPR was administered together with measures of: psychological distress (the General Health Questionnaire – GHQ); empowerment (the Making Decisions and Empowerment Scale – MDES), and quality of life (the Schizophrenia Quality of Life Scale – SQLS). The QPR was administered again at two weeks to assess reliability. Results: The QPR is comprised of two subscales (intrapersonal and interpersonal). Internal consistency and reliability of the scale was satisfactory. There was a high level of association with MDES, GHQ and SQLS scores, and between QPR scores at time one and time two. Conclusions: The QPR possesses internal consistency, construct validity and reliability, and promises to be a useful tool for assisting clients to set goals, evaluation of these goals and promoting recovery from psychosis in routine service evaluation and research trials.

Intelligent real-time therapy: Harnessing the power of machine learning to optimise the delivery of momentary cognitive–behavioural interventions

Background Experience sampling methodology (ESM) [Csikszentmihalyi, M. & Larson, R. (1987). Validity and reliability of the experience-sampling method. Journal of Nervous and Mental Disease, 175(9), 526–536] has been used to elucidate the cognitive–behavioural mechanisms underlying the development and maintenance of complex mental disorders as well as mechanisms involved in resilience from such states. We present an argument for the development of intelligent real-time therapy (iRTT). Machine learning and reinforcement learning specifically may be used to optimise the delivery of interventions by observing and altering the timing of real-time therapies based on ongoing ESM measures. Aims The aims of the present article are to outline the principles of iRTT and to consider how it would be applied to complex problems such as suicide prevention. Methods Relevant literature was identified through use of PychInfo. Results iRTT may provide an important and ecologically valid adjunct to traditional CBT, providing a means of balancing population-based data with individual data, thus addressing the “knowledge–practice gap” [Tarrier, N. (2010b). The cognitive and behavioral treatment of PTSD, what is known and what is known to be unknown: How not to fall into the practice gap. Clinical Psychology: Science and Practice, 17(2), 134–143] and facilitating the delivery of interventions in situ, thereby addressing the “therapy–real-world gap”. Conclusions iRTT may provide a platform for the development of individualised and multifaceted momentary intervention strategies that are ecologically valid and aimed at attenuating pathological pathways to complex mental health problems and amplifying pathways associated with resilience.

Recovery-focused cognitive–behavioural therapy for recent-onset bipolar disorder: randomised controlled pilot trial

BACKGROUND Despite evidence for the effectiveness of structured psychological therapies for bipolar disorder no psychological interventions have been specifically designed to enhance personal recovery for individuals with recent-onset bipolar disorder. AIMS A pilot study to assess the feasibility and effectiveness of a new intervention, recovery-focused cognitive-behavioural therapy (CBT), designed in collaboration with individuals with recent-onset bipolar disorder intended to improve clinical and personal recovery outcomes. METHOD A single, blind randomised controlled trial compared treatment as usual (TAU) with recovery-focused CBT plus TAU (n = 67). RESULTS Recruitment and follow-up rates within 10% of pre-planned targets to 12-month follow-up were achieved. An average of 14.15 h (s.d. = 4.21) of recovery-focused CBT were attended out of a potential maximum of 18 h. Compared with TAU, recovery-focused CBT significantly improved personal recovery up to 12-month follow-up (Bipolar Recovery Questionnaire mean score 310.87, 95% CI 75.00-546.74 (s.e. = 120.34), P = 0.010, d = 0.62) and increased time to any mood relapse during up to 15 months follow-up (χ2 = 7.64, P<0.006, estimated hazard ratio (HR) = 0.38, 95% CI 0.18-0.78). Groups did not differ with respect to medication adherence. CONCLUSIONS Recovery-focused CBT seems promising with respect to feasibility and potential clinical effectiveness. Clinical- and cost-effectiveness now need to be reliably estimated in a definitive trial.

Cognitive therapy for internalised stigma in people experiencing psychosis: A pilot randomised controlled trial

We aimed to evaluate the feasibility of Cognitive Therapy (CT) as an intervention for internalised stigma in people with psychosis. We conducted a single-blind randomised controlled pilot trial comparing CT plus treatment as usual (TAU) with TAU only. Participants were assessed at end of treatment (4 months) and follow-up (7 months). Twenty-nine participants with schizophrenia spectrum disorders were randomised. CT incorporated up to 12 sessions over 4 months (mean sessions=9.3). Primary outcome was the Internalised Stigma of Mental Illness Scale - Revised (ISMI-R) total score, which provides a continuous measure of internalised stigma associated with mental health problems. Secondary outcomes included self-rated recovery, internalised shame, emotional problems, hopelessness and self-esteem. Recruitment rates and retention for this trial were good. Changes in outcomes were analysed following the intention-to-treat principle, using ANCOVAs adjusted for baseline symptoms. There was no effect on our primary outcome, with a sizable reduction observed in both groups, but several secondary outcomes were significantly improved in the group assigned to CT, in comparison with TAU, including internalised shame, hopelessness and self-rated recovery. Stigma-focused CT appears feasible and acceptable in people with psychosis who have high levels of internalised stigma. A larger, definitive trial is required.

A randomised controlled trial of recovery focused CBT for individuals with early bipolar disorder

BackgroundThere is increasing evidence for the effectiveness of structured psychological therapies for bipolar disorder. To date however there have been no psychological interventions specifically designed for individuals with early bipolar disorder. The primary objective of this trial is to establish the acceptability and feasibility of a new CBT based intervention (Recovery focused CBT; RfCBT) designed in collaboration with individuals with early bipolar disorder intended to improve clinical and personal recovery outcomes.Methods and designThis article describes a single blind randomised controlled trial to assess the feasibility and acceptability of RfCBT compared with treatment as usual. Participants will be recruited from across the North West of England from specialist mental health services and through primary care and self referral. The primary outcome of the study is the feasibility and acceptability of RfCBT as indicated by recruitment to target and retention to follow-up as well as absence of untoward incidents associated with RfCBT. We also intend to estimate the effect size of the impact of the intervention on recovery and mood outcomes and explore potential process measures (self appraisal, stigma, hope and self esteem).DiscussionThis is the first trial of recovery informed CBT for early bipolar disorder and will therefore be of interest to researchers in this area as well as indicating the wider potential for evaluating approaches to the recovery informed treatment of recent onset severe mental illness in general.Trial registration numberISRCTN43062149

A randomised controlled trial of home based rehabilitation versus outpatient based rehabilitation for patients suffering from chronic schizophrenia

Background: Outpatient-based treatments for patients suffering from chronic schizophrenia inadvertently exclude a significant proportion of subjects because they are often too poorly motivated to attend for treatment. In addition there are also concerns about whether the skills that are learnt in a hospital setting will generalise to situations when the individuals are at home. This study attempted to redress some of these potential deficiencies and followed on from an earlier local study which found that a community-based team met more of the needs of patients suffering from chronic schizophrenia. Method: Seventy-five patients suffering from chronic schizophrenia were allocated randomly to receive traditional outpatient-based or home-based rehabilitation from a clinical psychologist and an occupational therapist. They were assessed before and after 9 months of treatment on a range of clinical, social and quality of life outcomes. Distress to carers was also assessed. Readmission to hospital was recorded for each subject. Results: There were significant reductions in socially embarrassing behaviour (SBS), increases in interpersonal functioning and recreational activities and a trend for quality of life to improve in the home-based group. There were fewer admissions in the home-based group but the differences, although financially substantial, were not statistically significant. Conclusions: The home-based rehabilitation service was well received by the majority of patients suffering from chronic schizophrenia and led to some improvement in social behaviour, interpersonal functioning, recreational activities and quality of life.

Working together: Service Users and researchers in Psychosis research

This paper describes how Service Users and researchers worked together to develop a measure of recovery from psychosis “the Questionnaire about the Process of Recovery from psychosis” (QPR, Neil et al., 2009), and illustrates this experience from both perspectives. The obstacles faced and how these were overcome are described. It was found that it was possible for Service Users and non-Service Users to work collaboratively, that there were unique contributions from each and a sharing of areas of expertise, for example, research knowledge and expertise by experience. This paper highlights advantages of working collaboratively. It is hoped that sharing these experiences will encourage other researchers and Service Users to embrace this way of working.

An exploration of the therapeutic alliance within a telephone-based cognitive behaviour therapy for individuals with experience of psychosis

OBJECTIVES This study investigated the therapeutic alliance (TA) between clients and therapists involved in a telephone-based cognitive behaviour therapy (CBT) oriented psychological intervention for individuals experiencing psychosis. DESIGN The telephone intervention involved recovery-focused CBT with use of a self-help guide and group intervention co-facilitated by colleagues with personal experience of psychosis. It was delivered as part of a Participant Preference Trial. METHODS Twenty-one client/therapist dyads were examined within this study. In addition to a measure of TA, clients completed measures of depression, social functioning, symptom severity, and strength of treatment preference, while therapists completed measures related to the level of shared formulation, therapist confidence, and therapeutic change estimates. RESULTS Therapeutic alliance levels were comparable to previously reported face-to-face psychosis intervention studies. Clients consistently reported significantly higher TA ratings compared to therapists. Depression scores and the strength of preference for treatment were significantly associated with client TA. Greater therapist perceived change was associated with higher therapist rated TA, while higher numbers of missed therapy sessions associated with lower therapist ratings. CONCLUSIONS Telephone-based psychosis interventions may support the formation of positive relationships that are comparable to the quality of relationships developed between therapists and clients during face-to-face CBT therapy. Methodological limitations including low participant numbers and heightened risk of a Type I error necessitate caution when interpreting findings. Further research into therapist and client variables associated with TA is required. PRACTITIONER POINTS Telephone delivered interventions to support people with psychosis-related difficulties can result in the development of a good quality TA between therapists and clients. There is a significant difference between therapist and client ratings of TA. Clients tend to score the quality of the TA significantly more highly than therapists. Providing clients with choice when participating in therapeutic interventions could potentially contribute towards improved TA reporting by clients.

Assessing Therapist Adherence to Recovery-Focused Cognitive Behavioural Therapy for Psychosis Delivered by Telephone with Support from a Self-Help Guide: Psychometric Evaluations of a New Fidelity Scale

BACKGROUND Recent research has highlighted the importance of psychological interventions such as cognitive behavioural therapy (CBT) in improving outcomes and promoting recovery for people with experience of psychosis, although a lack of trained therapists means that availability of face-to-face CBT is low. Alternative modes of delivering CBT are being explored, such as telephone and self-help methods, although research to date on whether they can be implemented effectively is limited. AIMS The aims of the present study were to describe and evaluate a new therapy fidelity scale (ROSTA; Recovery Oriented Self-help and Telephone therapy Adherence). This scale was developed to assess fidelity to cognitive behaviour therapy for psychosis (CBTp) focused on improving recovery, with optional subscales for delivery over the telephone and alongside a self-help guide. METHOD Experienced CBT therapists rated recorded therapy sessions using the ROSTA scale. The scores were used to assess internal consistency and inter-rater reliability, before being compared to scores from an independent expert rater using an alternative fidelity scale for cognitive therapy in psychosis (the CTS-Psy), to investigate concurrent validity. RESULTS The ROSTA scale demonstrated excellent internal consistency, inter-rater reliability and validity when evaluated as a whole, although findings were mixed in terms of the individual subscales and items. CONCLUSIONS The ROSTA scale is, on the whole, a reliable and valid tool, which may be useful in training and supervision, a utility that would be further emphasized if the therapeutic intervention it assesses is deemed to be efficacious based on future work.

Delivery of cognitive-behaviour therapy for psychosis: a service user preference trial

Abstract Background: Clinical guidelines recommend cognitive behaviour therapy (CBT) for people with psychosis, however, implementation is poor and not everyone wishes to engage with therapy. Understanding service user (SU) preferences for receiving such treatments is a priority for services. Aims: To explore SU preferences and outcomes of different methods of delivering CBT for psychosis. Method: SUs experiencing psychosis could choose between treatment as usual (TAU); TAU plus telephone-delivered CBT with self-help, CBT recovery manual (TS); high support CBT (HS – TAU plus TS plus group sessions) or randomisation. Participants received their option of choice and were followed-up on several outcomes over 9 and 15 months. Results: Of 89 people recruited, three chose to be randomised and 86 expressed a treatment preference (32 chose TAU, 34 chose TS, 23 chose HS). There were few differences between those who chose therapy compared to those who chose TAU. Those who had more positive impacts from their symptoms were significantly more likely to choose TAU. Conclusions: Most people had strong preferences about treatment delivery and a substantial number did not wish to receive additional therapy. These findings have to be considered when planning and allocating resources for people with psychosis.