A Trial of Group Cognitive Behavioral Therapy for Psychosis (the Feeling Safe Programme)

With a lifetime prevalence rate of \~0.5%, schizophrenia is a serious psychiatric disorder characterized by negative (e.g., anhedonia, apathy) and positive symptoms (e.g., hallucinations, delusions) that can vary in presentation. Although treatments for schizophrenia and psychosis have improved significantly, up to 34% of clients do not respond to conventional pharmacological treatment, including first and second-generation antipsychotics. In addition, as treatment resistance in schizophrenia is defined as less than 20% improvement on standardized rating scales, and with only about 20% of individuals reporting favourable outcomes, a significant percentage of treatment responders will experience persistent symptoms. Persistent persecutory delusions in particular cause significant impairment of psychological well being, with 47% scoring lower than 2 standard deviations below the mean of non-clinical individuals. Thus, there is a need for additional treatment strategies to promote quality of life and meaningful recovery.

Cognitive Behavioural Therapy (CBT) is comprised of a wide range of techniques and interventions, and is broadly described as a structured, symptom-focused, goal-oriented therapy that aims to improve quality of life by changing a patient's thoughts or thinking patterns considered to maintain problematic symptoms. There is consistent support for CBT treatment for a range of psychiatric and psychosocial difficulties including depression, anxiety disorders, substance abuse, eating disorders, and personality disorders. CBT for psychosis (CBTp) interventions have been developed to reduce distress associated with psychotic symptoms, promote hope, and increase functioning. Qualitative research embedded within trials demonstrates that when service users are exposed to high quality CBT-P, delivered by competent trial therapists, they have high satisfaction and experience it as recovery-orientated, collaborative and validating.

The Feeling Safe Programme was recently developed by a team at University of Oxford. The aim was to develop a CBT treatment for people with schizophrenia that had a success rate for psychosis that was more similar to CBT treatments for anxiety disorders. Developed with over a decade's research, The Feeling Safe Programme has proved to be an effective psychological treatment for persecutory delusions. For example, in a recent randomized controlled trial, half of the outpatient participants recovered from their persecutory delusions after undergoing individual treatment through the Feeling Safe Programme, and these gains were maintained at 12 months. Specifically, The Feeling Safe Programme led to significant reductions in delusional conviction and severity.

There is some evidence that group CBTp is an effective and promising intervention and group CBTp may be more cost effective than individual CBTp. In a recent Cochrane systematic review of group cognitive behavioural therapy for schizophrenia, group CBT appeared to be better than standard care or other psychosocial interventions on improving total symptoms of schizophrenia and global functioning. The authors also note that due to low sample sizes, no firm conclusions concerning the efficacy of group CBTp for people with schizophrenia can be made and that more high-quality research, reporting useable and relevant data is needed. This study would help to fill that need.

Goals and Aims of the Study: While there is some limited evidence of the effectiveness of group CBT for schizophrenia, there are no published findings on the effectiveness of this Feeling Safe Programme delivered in a group format. The proposed study will explore the efficacy of the Feeling Safe Programme in a group format compared to treatment as usual (TAU). Further, it will explore the experiences of individuals participating in the Feeling Safe Programme delivered in a group format.

• Cognitive Behavioral Therapy for Psychosis (Behavioral): Feeling Safe CBT: The treatment approach is modular and manualised. Group modules will include: Sleep (7 sessions), Worry (6 sessions), Self-Confidence (5 sessions) and Feeling Safe Enough (6 sessions), targeted at dropping safety behaviours in behavioural tests in order to reduce threat beliefs and build safety beliefs. Participants who experience auditory hallucinations will have the option to do the module: Feeling Safe Alongside Hearing Voices (5 sessions) individually. Clients will choose the modules they wish to participate in. They will be required to choose a minimum of 2 modules, and will be encouraged to do the Feeling Safe Enough module. The minimum number of sessions a participant can attend will be 10. The maximum number of group sessions participants can attend will be 24. Groups will run weekly for 75-90 minutes. Each CBT group will have approximately six participants. The same therapists will provide the individual therapy.

Primary outcomes

• World Health Organization Quality of Life - Brief Version (WHOQOL-BREF) [At baseline and at end of study arm (week 24)]: The World Health Organization Quality of Life - Brief Version (WHOQOL-BREF; WHOQOL Group, 1998) is a 26-item self-report questionnaire (with a scoring range 1-5) which assesses 4 domains of quality of life: physical health, psychological health, social relationships, and environment. It also includes a measure of overall quality of life and general health. Scores are converted to a 0-100 scale, where higher scores are indicative of better quality of life.

Secondary outcomes

• Modified Psychotic Symptoms Rating Scale (PSYRATS) [At baseline and at end of study arm (week 24)]: The Modified Psychotic Symptoms Rating Scale (PSYRATS; Haddock et al., 1999) is a 17-item measure of delusions and auditory hallucinations. Rated on a five-point scale (0-4; none to severe). Rates symptoms from the previous week. Two subscales obtained: Auditory Hallucinations Scale (11 items, scores range from 0-44) and Delusions Scale (6 items, scores range from 0-24). Higher scores reflect greater symptom severity.
• Paranoid Thoughts Scale (GPTS) [At baseline and at end of study arm (week 24)]: The Paranoid Thoughts Scale (GPTS; Green et al., 2008) is a 32-item self-report measure of paranoia comprised of two subscales to assess: ideas of reference and ideas of persecution. Each item is rated on a five-point scale (1-5). Scores on each scale can range from 16-80. Higher scores indicate greater levels of paranoid thinking.
• Alcohol Use Disorders Identification Test (AUDIT-C) [At baseline and at end of study arm (week 24)]: The Alcohol Use Disorders Identification Test (AUDIT-C; Saunders et al., 1993; Bush et al., 1998) is a short 3-item alcohol screening tool. Questions are rated on a scale from 0-4, giving a possible total score from 0-12, with lower scores indicative of lower risk.
• Drug Abuse Screening Test (DAST-10) [At baseline and at end of study arm (week 24)]: The Drug Abuse Screening Test (DAST-10; Skinner, 1982; Yudko, Lozhkina \& Fouts, 2007) is a brief 10-item self-report measure for identifying individuals who are abusing psychoactive drugs. It also provides a score of the degree of problems related to drug use and misuse. Total score can range from 0-10, with higher scores indicative of more severe levels of drug abuse.
• Safety Behaviours Questionnaire-Persecutory Beliefs (SBQ) [At baseline and at end of study arm (week 24)]: The Safety Behaviours Questionnaire-Persecutory Beliefs (SBQ; Freeman et al., 2001) is a semi-structured interview assessing safety behaviours used in the last month. Seven types of safety behaviours are assessed including: avoidance, in-situation, escape, compliance, help-seeking, aggression, delusional. When safety behaviours are indicated, the frequency is rated on a 4-point scale (1-4). The total score can range from 0-28. Higher scores reflect greater frequency and reliance on defensive/safety behaviours.
• Brief Core Schema Scales (BCSS) [At baseline and at end of study arm (week 24)]: The Brief Core Schema Scales (BCSS; Fowler et al, 2006) is a 24-item self-report concerning beliefs about the self and others. Items are assessed on a 5-point rating scale (0-4). Scores are obtained for 4 subscales including negative-self, positive-self, negative-others, and positive-others, with a range from 0-24 for each. Higher scores on negative subscales indicate pathology while higher scores on positive subscales suggest adaptive functioning.
• Interpretation of Voices Inventory (IVI) [At baseline and at end of study arm (week 24)]: The Interpretation of Voices Inventory (IVI; Morrison, Wells \& Nothard, 2002) is a 26-item assessment of positive and negative interpretations of voice hearing. Items are divided into three subscales including: meta-physical beliefs about voices (13 items), positive beliefs about voices (8 items), and interpretations of loss of control (5 items). Items are rated from 1 (not at all) to 4 (very much). Totals for the subscales range from 13-52 for the meta-physical subscale, 8-32 for the positive beliefs subscale and 5-20 for the loss of control subscale. Higher scores indicate more identification with the experience.
• Insomnia Severity Index (ISI) [At baseline and at end of study arm (week 24)]: The Insomnia Severity Index (ISI; Morin et al., 2011) is a 7-item self-report questionnaire assessing the nature, severity and impact of insomnia. The ISI uses a 5-point Likert scale to rate each item (0-4). The total score can range from 0-28 and is interpreted as: absence of insomnia (0-7), subthreshold insomnia (8-14), moderate insomnia (15-21), severe insomnia (22-28). Higher scores are indicative of more severe symptoms of insomnia.
• Dunn Worry Questionnaire (DWQ) [At baseline and at end of study arm (week 24)]: The Dunn Worry Questionnaire (DWQ; Freeman et al., 2020) is a 10-item self-report questionnaire asking how a person typically thinks about negative problems. Items are scored on a scale from 0-4, with higher scores indicative of more worry. The total score is obtained by adding all 10 items together, with a score of 21 or higher indicating clinically high levels of worry.
• Beck Depression Inventory-II (BDI-II) [At baseline and at end of study arm (week 24)]: The Beck Depression Inventory-II (BDI-II; Beck et al., 1996) is a 21-item self-report inventory that measures severity of depression. Items are rated on a scale from 0-3 for severity. The total score can range from 0-63, where a score of 0-13 is considered minimal range, 14-19 is mild, 20-28 is moderate, and 29-63 is severe.
• Social Phobia Inventory (SPIN) [At baseline and at end of study arm (week 24)]: The Social Phobia Inventory (SPIN; Connor et al., 2000) is a 17-item self-rating questionnaire for social anxiety disorder. The scale includes items assessing the following domains: fear, avoidance, physiologic arousal. Items are rated on a scale from 0-4, with a score range of 0-68. A score above 19 may indicate the presence of social anxiety disorder.
• Columbia-Suicide Severity Rating Scale (C-SSRS) [At baseline and at end of study arm (week 24)]: The Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011) is a suicide risk assessment tool that helps to identify if someone is at risk for suicide, to assess the severity and immediacy of that risk and gauge the level of support needed. Interpretation of the scale is based on a stratification into low, medium and high risk categories. Lower risk would require further evaluation, moderate risk indicates a more significant concern requiring a comprehensive risk assessment and a higher risk warrants immediate intervention and a thorough safety assessment.

Other outcomes

• Process of Recovery Questionnaire (QPR) [At baseline and at end of study arm (week 24)]: The Process of Recovery Questionnaire (QPR; Law et al., 2014) is a 15-item self-report measure that asks people about aspects of recovery that are meaningful to them. Items are scored on a 4-point scale (0-4). The total score ranges from 0-60, with higher scores indicative of greater personal recovery.
• Feeling Safe Weekly Rating Scale [At baseline and weekly during group (up to 24 weeks)]: At the start of each group session, participants will be asked to complete the Feeling Safe Weekly Rating Scale. Rated on a scale from 0-100, questions assess intensity of delusional conviction, distress, feelings of safety, happiness and engagement in valued activities. Higher scores are indicative of more intensity of the item being measured.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Diagnosis of schizophrenia, schizoaffective disorder, delusional disorder based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, (American Psychiatric Association, 2013), as assessed by a Royal staff psychiatrist or psychologist.
* From the Outpatient Integrated Schizophrenia Recovery Program (includes the Outpatient service, Day Program, and Regional Psychosis Clinic)
* Ability to read and write English
* Able to talk openly about psychotic symptoms even if they don't recognize them as such.
* Interested in learning ways to cope with symptoms
* Able to participate regularly, for 75 minutes once per week, in person
* Willingness and capacity to be a participant in the study as evidenced by a signed written informed consent

Exclusion Criteria:

* Current participation in individual or group CBT
* Previous participation in the Feeling Safe Programme
* Acute psychotic episode
* Have a current primary diagnosis of substance use disorder or personality disorder
* A stated inability to refrain from using substances before/during study visits
* Have an organic syndrome such as delirium, dementia, or amnesia
* Have a moderate to severe intellectual disability

• Yudko E, Lozhkina O, Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007 Mar;32(2):189-98. doi: 10.1016/j.jsat.2006.08.002. Epub 2006 Nov 21. PMID 17306727
• Wongpakaran T, Wongpakaran N, Intachote-Sakamoto R, Boripuntakul T. The Group Cohesiveness Scale (GCS) for psychiatric inpatients. Perspect Psychiatr Care. 2013 Jan;49(1):58-64. doi: 10.1111/j.1744-6163.2012.00342.x. Epub 2012 Jun 12. PMID 23293998
• Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998 May;28(3):551-8. doi: 10.1017/s0033291798006667. PMID 9626712
• Skinner HA. The drug abuse screening test. Addict Behav. 1982;7(4):363-71. doi: 10.1016/0306-4603(82)90005-3. PMID 7183189
• Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II. Addiction. 1993 Jun;88(6):791-804. doi: 10.1111/j.1360-0443.1993.tb02093.x. PMID 8329970
• Salkovskis PM Ed. (1996). Frontiers of Cognitive Therapy. New York: Guilford.
• Rosebrock L, Lambe S, Mulhall S, Petit A, Loe BS, Saidel S, Pervez M, Mitchell J, Chauhan N, Prouten E, Chan C, Aynsworth C, Murphy E, Jones J, Powling R, Chapman K, Dudley R, Morrison A, O'Regan E, Clark DM, Waite F, Freeman D. Understanding agoraphobic avoidance: the development of the Oxford Cognitions and Defences Questionnaire (O-CDQ). Behav Cogn Psychother. 2022 May;50(3):257-268. doi: 10.1017/S1352465822000030. Epub 2022 Feb 15. PMID 35166196
• Potkin SG, Kane JM, Correll CU, Lindenmayer JP, Agid O, Marder SR, Olfson M, Howes OD. The neurobiology of treatment-resistant schizophrenia: paths to antipsychotic resistance and a roadmap for future research. NPJ Schizophr. 2020 Jan 7;6(1):1. doi: 10.1038/s41537-019-0090-z. PMID 31911624
• Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77. doi: 10.1176/appi.ajp.2011.10111704. PMID 22193671
• Nucifora FC Jr, Woznica E, Lee BJ, Cascella N, Sawa A. Treatment resistant schizophrenia: Clinical, biological, and therapeutic perspectives. Neurobiol Dis. 2019 Nov;131:104257. doi: 10.1016/j.nbd.2018.08.016. Epub 2018 Aug 29. PMID 30170114
• Morrison AP, Wells A, Nothard S. Cognitive and emotional predictors of predisposition to hallucinations in non-patients. Br J Clin Psychol. 2002 Sep;41(Pt 3):259-70. doi: 10.1348/014466502760379127. PMID 12396254
• Morin CM, Belleville G, Belanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011 May 1;34(5):601-8. doi: 10.1093/sleep/34.5.601. PMID 21532953
• Millan MJ, Andrieux A, Bartzokis G, Cadenhead K, Dazzan P, Fusar-Poli P, Gallinat J, Giedd J, Grayson DR, Heinrichs M, Kahn R, Krebs MO, Leboyer M, Lewis D, Marin O, Marin P, Meyer-Lindenberg A, McGorry P, McGuire P, Owen MJ, Patterson P, Sawa A, Spedding M, Uhlhaas P, Vaccarino F, Wahlestedt C, Weinberger D. Altering the course of schizophrenia: progress and perspectives. Nat Rev Drug Discov. 2016 Jul;15(7):485-515. doi: 10.1038/nrd.2016.28. Epub 2016 Mar 4. PMID 26939910
• Lincoln TM, Ziegler M, Mehl S, Kesting ML, Lullmann E, Westermann S, Rief W. Moving from efficacy to effectiveness in cognitive behavioral therapy for psychosis: a randomized clinical practice trial. J Consult Clin Psychol. 2012 Aug;80(4):674-86. doi: 10.1037/a0028665. Epub 2012 Jun 4. PMID 22663901
• Lecomte T, Leclerc C, Corbiere M, Wykes T, Wallace CJ, Spidel A. Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. J Nerv Ment Dis. 2008 Dec;196(12):866-75. doi: 10.1097/NMD.0b013e31818ee231. PMID 19077853
• Leclerc C (1998). Conceptualization et evaluation d'une intervention de readaptation visant la gestion du stress aupres de groups de personnes atteintes de schizophrenie. These de doctorat, Universite de Montreal.
• Law H, Neil ST, Dunn G, Morrison AP. Psychometric properties of the questionnaire about the process of recovery (QPR). Schizophr Res. 2014 Jul;156(2-3):184-9. doi: 10.1016/j.schres.2014.04.011. Epub 2014 May 9. PMID 24816049
• Lambe S, Bird JC, Loe BS, Rosebrock L, Kabir T, Petit A, Mulhall S, Jenner L, Aynsworth C, Murphy E, Jones J, Powling R, Chapman K, Dudley R, Morrison A, Regan EO, Yu LM, Clark D, Waite F, Freeman D. The Oxford Agoraphobic Avoidance Scale. Psychol Med. 2023 Mar;53(4):1233-1243. doi: 10.1017/S0033291721002713. Epub 2021 Aug 23. PMID 37010211
• Kessler RC, Birnbaum H, Demler O, Falloon IR, Gagnon E, Guyer M, Howes MJ, Kendler KS, Shi L, Walters E, Wu EQ. The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R). Biol Psychiatry. 2005 Oct 15;58(8):668-76. doi: 10.1016/j.biopsych.2005.04.034. Epub 2005 Jul 14. PMID 16023620
• Howes OD, McCutcheon R, Agid O, de Bartolomeis A, van Beveren NJ, Birnbaum ML, Bloomfield MA, Bressan RA, Buchanan RW, Carpenter WT, Castle DJ, Citrome L, Daskalakis ZJ, Davidson M, Drake RJ, Dursun S, Ebdrup BH, Elkis H, Falkai P, Fleischacker WW, Gadelha A, Gaughran F, Glenthoj BY, Graff-Guerrero A, Hallak JE, Honer WG, Kennedy J, Kinon BJ, Lawrie SM, Lee J, Leweke FM, MacCabe JH, McNabb CB, Meltzer H, Moller HJ, Nakajima S, Pantelis C, Reis Marques T, Remington G, Rossell SL, Russell BR, Siu CO, Suzuki T, Sommer IE, Taylor D, Thomas N, Ucok A, Umbricht D, Walters JT, Kane J, Correll CU. Treatment-Resistant Schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) Working Group Consensus Guidelines on Diagnosis and Terminology. Am J Psychiatry. 2017 Mar 1;174(3):216-229. doi: 10.1176/appi.ajp.2016.16050503. Epub 2016 Dec 6. PMID 27919182
• Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychol Med. 1999 Jul;29(4):879-89. doi: 10.1017/s0033291799008661. PMID 10473315
• Guaiana G, Abbatecola M, Aali G, Tarantino F, Ebuenyi ID, Lucarini V, Li W, Zhang C, Pinto A. Cognitive behavioural therapy (group) for schizophrenia. Cochrane Database Syst Rev. 2022 Jul 12;7(7):CD009608. doi: 10.1002/14651858.CD009608.pub2. PMID 35866377
• Green CE, Freeman D, Kuipers E, Bebbington P, Fowler D, Dunn G, Garety PA. Measuring ideas of persecution and social reference: the Green et al. Paranoid Thought Scales (GPTS). Psychol Med. 2008 Jan;38(1):101-11. doi: 10.1017/S0033291707001638. Epub 2007 Oct 1. PMID 17903336
• Gaynor K, Dooley B, Lawlor E, Lawoyin R, O'Callaghan E. Group cognitive behavioural therapy as a treatment for negative symptoms in first-episode psychosis. Early Interv Psychiatry. 2011 May;5(2):168-73. doi: 10.1111/j.1751-7893.2011.00270.x. PMID 21535424
• Freeman D, Garety PA, Kuipers E. Persecutory delusions: developing the understanding of belief maintenance and emotional distress. Psychol Med. 2001 Oct;31(7):1293-306. doi: 10.1017/s003329170100455x. PMID 11681555
• Freeman D, Startup H, Dunn G, Wingham G, Cernis E, Evans N, Lister R, Pugh K, Cordwell J, Kingdon D. Persecutory delusions and psychological well-being. Soc Psychiatry Psychiatr Epidemiol. 2014 Jul;49(7):1045-50. doi: 10.1007/s00127-013-0803-y. Epub 2013 Dec 3. PMID 24297621
• Freeman D, Emsley R, Diamond R, Collett N, Bold E, Chadwick E, Isham L, Bird JC, Edwards D, Kingdon D, Fitzpatrick R, Kabir T, Waite F; Oxford Cognitive Approaches to Psychosis Trial Study Group. Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: a parallel, single-blind, randomised controlled trial. Lancet Psychiatry. 2021 Aug;8(8):696-707. doi: 10.1016/S2215-0366(21)00158-9. Epub 2021 Jul 8. PMID 34246324
• Freeman D, Bird JC, Loe BS, Kingdon D, Startup H, Clark DM, Ehlers A, Cernis E, Wingham G, Evans N, Lister R, Pugh K, Cordwell J, Dunn G. The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry. Psychol Med. 2020 Apr;50(5):771-780. doi: 10.1017/S0033291719000588. Epub 2019 Apr 5. PMID 30947766
• Fowler D, Freeman D, Smith B, Kuipers E, Bebbington P, Bashforth H, Coker S, Hodgekins J, Gracie A, Dunn G, Garety P. The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychol Med. 2006 Jun;36(6):749-59. doi: 10.1017/S0033291706007355. Epub 2006 Mar 27. PMID 16563204
• Fordham B, Sugavanam T, Edwards K, Stallard P, Howard R, das Nair R, Copsey B, Lee H, Howick J, Hemming K, Lamb SE. The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis. Psychol Med. 2021 Jan;51(1):21-29. doi: 10.1017/S0033291720005292. Epub 2021 Jan 18. PMID 33455594
• Elkis H, Buckley PF. Treatment-Resistant Schizophrenia. Psychiatr Clin North Am. 2016 Jun;39(2):239-65. doi: 10.1016/j.psc.2016.01.006. Epub 2016 Mar 30. PMID 27216902
• Connor KM, Davidson JR, Churchill LE, Sherwood A, Foa E, Weisler RH. Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale. Br J Psychiatry. 2000 Apr;176:379-86. doi: 10.1192/bjp.176.4.379. PMID 10827888
• Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998 Sep 14;158(16):1789-95. doi: 10.1001/archinte.158.16.1789. PMID 9738608
• Brabban A, Byrne R, Longden E & Morrison AP. (2017). The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis. Psychosis, 9:2, 157-166.
• Beck AT, Steer RA, & Brown G. (1996). Beck Depression Inventory-II (BDI-II).
• Beck JS. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.
• Bechdolf A, Knost B, Nelson B, Schneider N, Veith V, Yung AR, Pukrop R. Randomized comparison of group cognitive behaviour therapy and group psychoeducation in acute patients with schizophrenia: effects on subjective quality of life. Aust N Z J Psychiatry. 2010 Feb;44(2):144-50. doi: 10.3109/00048670903393571. PMID 20113303
• American Psychiatric Association. (2013). Schizophrenia and other psychotic disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C.; American Psychiatric Association; 89-122.

• Deanna Mercer, M.D., Principal investigator, Royal Ottawa Mental Health Centre
• Lisa Murata, BScN, MEd, Principal investigator, Royal Ottawa Mental Health Centre