Bryan Stiles

Objective: Caregivers play an important role in the recovery of young people experiencing early psychosis, though they often experience high distress and have limited access to support for their own wellbeing and mental health needs. Digital mental health interventions (DMHIs) such as Altitudes offer scalable and flexible support through the provision of psychoeducation, therapy content, and opportunities for social connection in a secure online platform. The objective of this study was to explore caregivers’ subjective experiences using Altitudes, a digital mental health intervention designed to support the wellbeing of caregivers of young people experiencing early psychosis. Methods: Semi-structured interviews were conducted with 21 caregivers who participated in a 6-month open trial of Altitudes in the United States. A reflexive thematic analysis was used to examine perceived benefits, challenges, and recommendations for improvement. Results: Four themes were identified: (1) Altitudes as a trusted resource in a confusing journey , reflecting caregivers’ appreciation for clear, credible information and normalization through peer connection; (2) The importance of human support , emphasizing the role of Clinical Moderators and Family Peer Workers as sources of empathy, accountability, and hope in the digital space; (3) Striking a balance and overcoming barriers to engagement , highlighting how caregiving demands and illness phase shaped participation and preferences for support; and (4) Recommendations for future development , including requests for more interactive features, notifications and reminders, and opportunities for live or in-person connection. Conclusions: Participants viewed Altitudes as a caregiver-focused resource that reduced isolation and stigma, and improved access to credible psychosis-specific information and therapy strategies. Embedding human-supported DMHIs within coordinated specialty care may strengthen continuity of care and improve outcomes for both caregivers and young people early in the course of psychotic illness.

Purpose: Family involvement in Coordinated Specialty Care (CSC) can enhance engagement and improve outcomes for young people with First Episode Psychosis (FEP). Digital interventions can circumvent many of the access and resource barriers that prevent families from engaging. The purpose of the current study was to better understand the experiences and challenges faced by caregivers who support a young person with FEP in the United States, and to use this information to guide the adaptation and further development of a digital intervention to support caregiver health and well-being. Methods: Participants engaged in interviews and focus groups centered on their experiences supporting an adult child with FEP, connecting their relative to CSC, and their preferences for a digital intervention to support caregivers. This study used content analysis to develop themes and subthemes across interview and focus group data. Results: Eight participants participated in the interviews and focus groups. Our findings support prior research indicating caregivers of young people with psychosis need evidence-based information about psychosis and assistance in managing systemic, social, and intrapersonal challenges. Participants advocated for a program with multimedia that could be accessed anywhere and anytime, facilitated connections with other caregivers, and emphasized messages of hope and recovery. Conclusion: Interventions aiming to promote mental health and well-being for FEP caregivers in the United States should incorporate evidence-based information about psychosis specific to caregivers and their relative's recovery stage, guidance for navigating the healthcare system and privacy laws, and actionable skills related to illness management, effective communication, and self-care.

Objective: Using daily life methods, the present study investigated the impact of Integrated Coping Awareness Therapy (I‐CAT), which includes mindfulness and positive psychological interventions, versus treatment‐as‐usual (TAU) on improving daily affective well‐being. Among I‐CAT participants only, we also examined the time‐varying effect of daily I‐CAT skill practice on daily affective well‐being.Methods: Data are drawn from a randomized controlled treatment trial involving 38 young adults with a schizophrenia spectrum disorder. Participants completed daily reports of positive (happiness, relaxation) and negative (stress, sadness) affect across 9 months of treatment. I‐CAT recipients completed daily practice of mindfulness and positive coping skills.Results: I‐CAT and TAU did not differentially impact daily affect across treatment. However, daily skill practice was associated with better daily affective outcomes in certain phases of I‐CAT. We also found that increased daily practice of positive coping skills was associated with better daily affective outcomes, whereas mindfulness practice was associated with poorer affective outcomes during certain periods of the I‐CAT intervention.Conclusions: In general, I‐CAT did not improve daily affective outcomes compared with TAU. However, components of I‐CAT, specifically the daily practice of positive coping skills, were associated with improved daily emotional well‐being in young adults with psychosis. Implications of these findings are discussed.

Objective: Early intervention in psychosis is associated with favourable outcomes. We investigated whether loved ones' illness duration moderated caregiver outcomes following a Cognitive Behavioural Therapy‐informed Family Intervention for psychosis (FIp).Methods: We conducted a secondary analysis of measures of FIp participants' depression and anxiety symptoms, caregiver appraisals, expressed emotion and foundational psychotherapeutic competencies at pre‐, post‐ and 4‐month follow‐up. Our primary aim was to evaluate whether duration of illness moderated participant outcomes.Results: Relative to pre‐intervention, all caregivers reported lower depression, anxiety and expressed emotion, as well as higher positive attitudes and mastery of cognitive behavioural skills, at post‐intervention and 4‐month follow‐up. Outcomes were not moderated by their loved one's illness duration.Conclusion: Families may benefit equally from FIp regardless of illness duration. Although we recommend that FIp are offered as early as possible, modifications for families with lengthier illness courses are not implicated by our findings.

Background: Understanding variables that influence therapy outcomes can improve the results of interventions and reduce socio-health costs. The current study examined possible predictors and moderators of outcome (age, gender, duration of panic disorder, motivation to change, conscientiousness, and experiential avoidance) in Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT). Method: Eighty participants with a diagnosis of panic disorder, 56 women and 24 men, with an average age of 38 years, received 12 group sessions of CBT or ACT. They were assessed with several measures at pre-treatment, post-treatment, and 3-month follow-up. Results: CBT outperformed ACT among older subjects, men, and those with a shorter duration of panic disorder. ACT outperformed CBT among younger subjects, women, and those with a long duration of panic disorder. In general, the greatest improvements in both CBT and ACT were in older subjects, women, those with a long duration of panic disorder, those in the contemplation stage, and those with high experiential avoidance. Conclusions: Although future studies are necessary, there appear to be predictors and moderators of the effectiveness of CBT and ACT. Taking these variables into account can help improve treatment for people with panic disorder.

Introduction: Attachment style and working alliance are two fundamental variables in psychotherapy. This systematic review aims to provide data on the relationship between therapist attachment and alliance in psychotherapy, updating a previous review and providing a quantitative synthesis (meta‐analysis).Method: The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) Statement recommendations were followed. The databases PsycINFO, PubMed and Web of Science were searched from June 1, 2016, to May 30, 2024, supplemented by a manual search. A regulated study selection process was performed, followed by data extraction and risk of bias assessment. A qualitative and quantitative analysis of the included studies was performed.Results: Nine studies were selected for the systematic review that included 354 patients and 741 mental health professionals. In five studies, different types of attachment (secure, anxious and avoidant) were related to the alliance. In addition, this relationship was partially mediated by therapeutic optimism, role security, therapeutic commitment or emotional regulation strategy. Of the 23 articles selected from both systematic reviews, 12 studies were included in the meta‐analysis. A systematic correlation between anxious attachment style and the alliance was found only when the assessment of the alliance was performed by therapists (r = −0.31).Conclusions: There is evidence that therapist attachment may influence the formation and maintenance of a higher‐quality working alliance. However, further studies with more precise measures of both constructs are needed to better understand this relationship and its clinical implications.

Objectives: We investigated the effect of the therapeutic alliance on both change in social recovery outcomes and usage of a moderated online social therapy platform for first‐episode psychosis (FEP), Horyzons. Design: Secondary analysis of a single group pilot trial. Methods: Clients completed an alliance measure adapted for guided digital interventions at mid‐treatment. A series of multi‐level models evaluated change in outcomes by mid‐ and post‐treatment assessments (relative to baseline) as a function of the overall alliance. Quasi‐Poisson models evaluated the effect of the overall alliance on aggregated counts of platform usage. Exploratory analyses repeated these models in terms of the bond (human–human) or the task/goal (human–program) alliance. Results: Stronger overall alliance at mid‐treatment predicted lower loneliness at mid‐treatment and lower social anxiety at mid‐ and post‐treatment. It was also associated with higher completion of therapy activities and authoring of comments and reactions. A strong bond with an online therapist was associated with lower loneliness and higher perceived social support at mid‐treatment, lower social anxiety at post‐treatment as well as a higher number of reactions made on the social network. Stronger alliance with the platform's tasks and goals facilitated lower social anxiety at both follow‐up assessments and was further associated with higher completion of therapy activities and reactions in the social network. Conclusions: The alliance may impact aspects of social recovery and usage in digital interventions for FEP. Specific aspects of the alliance (human–human and human–program relationships) should be considered in future research.

Objectives: The current study sought to qualitatively characterize the experiences of American users in a recent open trial of the Horyzons digital platform. Methods: In total, 20 users on Horyzons USA completed semistructured interviews 12 weeks after their orientation to the platform and addressed questions related to (1) the platform, (2) their online therapist, and (3) the peer workers and community space. A hybrid inductive-deductive coding strategy was used to conduct a thematic analysis of the data (NCT04673851). Results: The authors identified seven prominent themes that mapped onto the three components of self-determination theory. Features of the platform itself as well as inter- and intra-personal factors supported the autonomous use of Horyzons. Users also reflected that their perceived competence in social settings and in managing mental health was increased by the familiarity, privacy, and perceived safety of the platform and an emphasis on personalized therapeutic content. The behaviors or traits of online therapists as perceived by users and regular contact with peers and peer support specialists satisfied users’ need for relatedness and promoted confidence in social settings. Users also described aspects of Horyzons USA that challenged their satisfaction of autonomy, competence, and relatedness, highlighting potential areas for future iterations of the platform's content and interface. Conclusions: Horyzons USA is a promising digital tool that provides young adults with psychosis with the means to access tailored therapy material on demand and a supportive digital community to aid in the recovery process.

Impact and Implications The Psychosis Attitudes Scale (PAS) appears to tap into practitioner's self-confidence in working with individuals with psychosis, recovery orientation, expectations of professional fulfillment, and adoption of a stress-vulnerability framework for conceptualizing psychosis risk. As these themes are relevant to competent delivery of Cognitive Behavioral Therapy for psychosis (CBTp), the PAS appears to have utility as a process measure for training and supervising practitioners who work therapeutically with individuals with psychosis. Objective: Practitioner attitudes regarding the nature of psychosis and prospects of recovery are important targets in supervision and training of practitioners who work therapeutically with this population. The 19-item Psychosis Attitudes Scale (PAS) was developed as a way to monitor changes in psychosis-related attitudes among practitioners being trained in an Evidence Based Treatment (EBT) for psychosis. This study reports the development and underlying factor structure of the PAS. Method: Three hundred twenty-five community mental health clinicians completed the PAS following a Cognitive Behavioral Therapy for psychosis (CBTp) multiday workshop training. We conducted an exploratory factor analysis to investigate the underlying structure of the initial set of items. Results: Our analyses suggest that the PAS taps into four attitude groupings, which can be conceptualized as perceived confidence in working with individuals with psychosis (Factor 1), a recovery orientation (Factor 2), expectations of fulfillment (Factor 3), and a stress-vulnerability orientation (Factor 4). Conclusions and Implications for Practice: Factors 1 and 3 appear to tap into general themes relevant to training practitioners in an evidence-based psychotherapeutic intervention for psychosis. Factors 2 and 4 are consistent with guiding principles of high-fidelity CBTp. At the individual level, practitioner attitudes have implications for training retention and treatment delivery. At the organizational level, the collective attitudes of staff in a given setting may serve as an indicator of readiness for EBT for psychosis implementation.

BACKGROUND Increasingly, digital technology is used to engage individuals with first episode psychosis (FEP) with continued evidence-based recovery support beyond traditional outpatient mental health settings. Young people with FEP respond positively to the idea of receiving mental health support online, with many actively seeking information about and support for their mental illness through social media. Based on the moderated online social therapy (MOST) model and informed by self-determination theory (SDT), the Horyzons USA digital intervention blends interactive therapy material, peer-to-peer social networking, and expert moderation. OBJECTIVE The current study sought to qualitatively characterize the experiences of American users in a recent open trial of the Horyzons platform. METHODS Twenty users on Horyzons USA completed semi-structured interviews at post-treatment, 12 weeks after their orientation to the platform. The interview guide was built around questions addressing (1) the platform, (2) their online therapist, and (3) the peer workers and community space to elicit expressions of specific user experiences across different aspects of the platform in addition to potential suggestions for improvement. A hybrid inductive-deductive coding strategy was used to conduct a thematic analysis of the data. RESULTS The authors identified seven prominent themes of user experiences with Horyzons USA which were subsequently mapped onto one or more of the three primary components of SDT: Autonomy, competence, and relatedness. CONCLUSIONS Features of the platform itself as well as inter- and intra-personal factors supported autonomous use of Horyzons. Users also reflected that their perceived competence in social settings as well as their competence in managing mental health, was increased respectively by the familiarity, privacy, and perceived safety of the platform and an emphasis on personalized therapeutic content. We additionally found that users expressed satisfaction of a need for relatedness by the behaviors or traits of their online therapists or accessing shared experiences with peers and peer support specialists (PSS). This sense of community was further facilitated by bi-weekly virtual get-togethers which promoted further confidence in social settings. Users also described aspects of Horyzons USA that challenged their satisfaction of autonomy, competence, and relatedness, highlighting potential areas for future iteration of the platform’s content and interface. Based on these findings, Horyzons USA is a promising digital tool that provides young adults with psychosis with the means to access tailored therapy material on demand and a supportive digital community to aid in the recovery process.