SummaryBackgroundEngaging, interactive, and automated virtual reality (VR) treatments might help solve the unmet needs of individuals with mental health disorders. We tested the efficacy of an automated cognitive intervention for fear of heights guided by an avatar virtual coach (animated using motion and voice capture of an actor) in VR and delivered with the latest consumer equipment.MethodsWe did a randomised trial of automated VR versus usual care. We recruited adults aged older than 18 years with a fear of heights by radio advertisements in Oxfordshire, UK. We diagnosed fear of heights if participants scored more than 29 on the Heights Interpretation Questionnaire (HIQ). We randomly allocated participants by computer in a 1:1 ratio to either automated VR delivered in roughly six 30-min sessions administered about two to three times a week over a 2-week period (intervention group) or to usual care (control group). Randomisation was stratified by severity of fear of heights. The research team, who were unaware of the random allocation, administered three fear-of-height assessments, at baseline (0 weeks), at the end of treatment (2 weeks), and at follow-up (4 weeks). The primary outcome measure was HIQ score (range 16–80, with higher scores indicating greater severity). This trial is registered with the ISRCTN registry, number ISRCTN11898283.FindingsBetween Nov 25, 2017, and Feb 27, 2018, 100 individuals were enrolled and underwent randomisation, of whom 49 were assigned to the VR treatment group and 51 to the control group. All participants completed the 4-week follow-up. The mean total treatment time in VR was 124·43 min (SD 34·23). Compared with participants in the control group, the VR treatment reduced fear of heights at the end of treatment (mean change score −24·5 [SD 13·1] in the VR group vs −1·2 [7·3] in the control group; adjusted difference −24·0, 95% CI −27·7 to −20·3; Cohen's d=2·0; p<0·0001). The benefit was maintained at follow-up (mean change score −25·1 [SD 13·9] in the VR group vs −1·5 [7·8] in the control group; adjusted difference −24·3, 95% CI −27·9 to −20·6; Cohen's d=2·0; p<0·0001). The number needed to treat to at least halve the fear of heights was 1·3. No adverse events were reported.InterpretationPsychological therapy delivered automatically by a VR coach can produce large clinical benefits. Evidence-based VR treatments have the potential to greatly increase treatment provision for mental health disorders.FundingOxford VR, and the National Institute of Health Research Oxford Health Biomedical Research Centre.

Background The Green et al., Paranoid Thoughts Scale (GPTS) – comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) – was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation. Methods In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted. Results The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09–3.67) and Persecution (a = 2.37–4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0–9; Persecution: 0–4); elevated (Reference: 10–15; Persecution: 5–10); moderately severe (Reference: 16–20; Persecution:11–17); severe (Reference: 21–24; Persecution: 18–27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion. Conclusions The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

Paranoia may build on negative beliefs held both about the self and others. Compassionate imagery may be one way of reducing such negative beliefs, and hence paranoia. Two studies tested this idea, one targeting compassion for the self and one targeting compassion for others. Two-hundred individuals from the general population scoring highly for paranoia were recruited. The studies used a randomised controlled experimental design, with embedded tests for mediation. Study one targeted self-compassion via creation of a compassionate coach (CC) image. Study two targeted compassion for others via loving kindness meditation (LKM). Individuals repeatedly entered neutral virtual reality social environments. Changes in compassion and paranoia were assessed. Compared to controls, the CC group increased in self-compassion (group difference = 2.12, C.I. = 1.57;2.67, p = <0.0001, d = 1.4) and decreased in paranoia (group difference = −1.73, C.I. = −2.48; −0.98, p = <0.0001, d = 0.8). Change in self-compassion explained 57% of change in paranoia. Compared to controls, the LKM group increased their compassion for others (group difference = 3.26, C.I. = 2.72;3.80, p = <0.0001, d = 1.7), and decreased in paranoia (group difference = −1.70, C.I. = −2.50; −0.89, p = <0.0001, d = 0.8). Change in compassion for others explained 67% of change in paranoia. Targeting negative beliefs about the self and others using compassionate imagery causes reductions in paranoia. Tests in clinical populations are indicated.

Background: Negative beliefs about the self, including low self-compassion, have been identified as a putative causal factor in the occurrence of paranoia. Therefore, improving self-compassion may be one route to reduce paranoia. Aims: To assess the feasibility, acceptability, and potential clinical effects of a brief compassionate imagery intervention for patients with persecutory delusions. Method: Twelve patients with persecutory delusions received an individual four-session compassionate imagery intervention. Assessments of self-concept and paranoia were completed before treatment, immediately after treatment, and at 1-month follow-up. A qualitative study exploring participants’ experiences of the treatment was also completed. Results: Twelve out of 14 eligible patients referred to the study agreed to take part. All participants completed all therapy sessions and assessments. Post-treatment, there were improvements in self-compassion (change score –0.64, 95% CI –1.04, –0.24, d = –1.78), negative beliefs about the self (change score 2.42, 95% CI –0.37, 5.20, d = 0.51), and paranoia (change score 10.08, 95% CI 3.47, 16.69, d = 0.61). There were no serious adverse events. Three themes emerged from the qualitative analysis: ‘effortful learning’, ‘seeing change’ and ‘taking it forward’. Participants described a process of active and effortful engagement in therapy which was rewarded with positive changes, including feeling calmer, gaining clarity, and developing acceptance. Conclusion: This uncontrolled feasibility study indicates that a brief compassionate imagery intervention for patients with persecutory delusions is feasible, acceptable, and may lead to clinical benefits.

Purpose The purpose of this paper is to test whether incorporating a 20-week Kundalini yoga programme into a residential home for children improves well-being outcomes. Design/methodology/approach This is a mixed methods feasibility study. Feasibility was assessed through recruitment and retention rates as well as participants’ self-report perceptions on social inclusion, mental health and well-being and through semi-structured interviews on the benefits of the study. Mutual recovery entailed that children in care (CIC), youth practitioners and management participated together in the Kundalini yoga sessions. Findings The study initially enrolled 100 per cent of CIC and 97 per cent (29/30) of eligible staff. Attendance was low with an average rate of four sessions per participant (SD=3.7, range 0-13). All the participants reported that the study was personally meaningful and experienced both individual (e.g. feeling more relaxed) and social benefits (e.g. feeling more open and positive). Pre- and post-yoga questionnaires did not show any significant effects. Low attendance was associated with the challenges faced by the children’s workforce (e.g. high levels of stress, low status, profile and pay) and insufficient consultation and early involvement of stakeholders on the study implementation process. Research limitations/implications Because of the chosen research approach (i.e. feasibility study) and low attendance rate, the research results may lack generalisability. Therefore, further research with larger samples including a control or comparison group to pilot similar research questions is mandatory. Practical implications This study has generated a number of valuable guiding principles and recommendations that might underpin the development of any future intervention for CIC and staff working in children’s homes. Social implications The concept of togetherness and mutuality within residential spaces is discussed in the paper. Originality/value The effects of Kundalini yoga have not been reported before in any peer-review publications. This paper fulfils an identified need (i.e. poor outcomes among CIC and residential staff) and shows how movement and creative practices can support the concept of mutual recovery.