REFLECT: A Novel Group-Based Compassion-Focussed Cognitive Behavioural Approach to Core Beliefs in Psychosis

• REFLECT: REFlecting on and Learning to Evaluate Core beliefs in real Time (Other): REFLECT is a six-week group therapy intervention delivered remotely on a video conferencing platform that is compliant with health information privacy laws in Ontario. This intervention is additionally supported by remote homework delivery, completion, and review through a secure online database that allows homework to be delivered and completed through email or a smartphone app. Weekly group sessions are 2 hours each and explore negative core beliefs related to symptoms of psychosis through a CBT framework to support the development of more balanced beliefs to support functional and personal recovery.

Primary outcomes

• Brief Core Schema Scale [The BCSS is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The BCSS is a validated and widely used self-report measure that quantifies the endorsement of positive and negative self- and other- core beliefs. There are four subscales (positive self, negative self, positive other, negative other). Higher scores on these scales indicate more endorsement of these types of core beliefs: Higher scores on the negative scales indicate a stronger endorsement of dysfunctional schemas, whereas higher scores on the positive scales indicate a stronger endorsement of adaptive, positive views. Subscale scores range from 0-24, and total scores range from 0-96.

Secondary outcomes

• Scale for the Assessment of Positive Symptoms [The SAPS is administered at screening (Day 1), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: A validated and widely used clinician-rated interview that includes subscales on hallucinations, delusions, and disorganized behaviour and thought disorder. Higher scores on this scale indicate greater symptom severity or intensity. Scores range from 0-170.
• Psychotic Symptom Rating Scales [The PSYRATS is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The PSYRATS is a validated and widely used clinician-rated interview that measures the severity and impact of hallucinations and delusions (subscales). Higher scores indicate more impact on the individual and a higher symptom severity. Scores on the auditory hallucination subscale range from 0-44 and 0-24 on the delusion subscale, with a total score range from 0-68.
• Scale for the Assessment of Negative Symptoms [The SANS is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: This is a clinician-rated interview that assesses the severity of negative symptoms. Higher scores indicate greater severity of negative symptoms. There are four subscales: Affective Flattening, Alogia, Avolition, and Anhedonia. Total scores range from 0-95.
• Referential Thinking Scale [The REF Scale is administered at Baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The REF scale is a validated self-report measure examining a particular type of biased thinking known as referential thinking. The scale includes 34 True-False questions, with a total score ranging from 0-34. Higher scores on this scale indicate higher endorsement of referential thinking.
• Experiences Questionnaire - Decentering [The EQ is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The EQ Decentering Scale is a self-report measure of self-referential interpretations/biases and the ability to decenter. Higher scores indicate greater ability to decenter. Individual items are rated on a scale from 1 to 5, with total scores ranging from 11-55.
• Davos Assessment of the Cognitive Biases Scale [The DACOBS is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The DACOBS is a validated and widely used self-report measure used to quantify endorsement of different types of cognitive biases and safety behaviours. Higher scores indicate higher endorsement of these biases or thinking patterns. The following are the subscales and their score ranges. Cognitive Biases Subscales: Jumping to conclusions bias (7-42), Belief Inflexibility bias (7-42), Attention for Threat bias (7-42), External Attribution bias (7-42), and Total Cognitive Bias Score (28-168). Cognitive Impairment Subscales: Social Cognition problems (7-42), Subjective Cognitive problems (7-42), and Total Cognitive Problems (14-84). Safety Behaviours Subscale (7-42).
• Aberrant Salience Inventory [The ASI is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The ASI is a validated self-report inventory that measures a neurocognitive bias known as aberrant salience. Higher scores on this scale indicate higher endorsement of experiences related to aberrant salience. Total scores range from 0-29.
• Recovery Assessment Scale [The RAS is administered at baseline (pre-intervention; Day 1-14), post-intervention (Weeks 7-9), and a three-month follow-up (Weeks 19-21).]: The RAS is a validated self-report measure quantifying endorsement of experiences related to personal recovery. Higher scores on this scale indicate more endorsement of personal recovery. Over time, increasing scores would indicate improvements in personal recovery. Total scores range from 41-205.

Other outcomes

• Usefulness, Satisfaction, and Ease of Use Questionnaire [The USE Questionnaire is administered once at the end of the study (at 3-month follow-up visit; Weeks 19-21).]: The USE Questionnaire is a self-report survey that allows participants to provide feedback on the technology used in the project (i.e., video conferencing, remote homework completion). Total scores range from 18-90 with higher scores indicating better satisfaction.
• Satisfaction With Therapy and Therapist Scale-Revised [STTS-R is administered once post-intervention (Weeks 7-9).]: This self-report survey allows participants to provide feedback about the group therapy and group therapy facilitators. Total scores range from 12-60, with higher scores indicating higher satisfaction. The last item asks participants for an overall rating from 1-5 on how much the therapy helped them.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1. Above the age of 18.
2. Diagnosis of SSD (i.e., Schizophrenia, Schizophreniform, Schizoaffective Disorder, or Delusional Disorder), confirmed based on self-report.
3. Have current symptoms related to psychosis (as determined by a score of 2 or higher on the SAPS).
4. Engaged in current outpatient treatment for psychosis (e.g., medication management by psychiatrist or general practitioner, case management, community mental health treatment, etc.).
5. Has or has access to personal technology (e.g., smartphone, tablet, or laptop/computer) with access to wifi or cellular data.

Exclusion Criteria:

1. Not capable of providing informed consent (see Consent Procedures).
2. Does not have an SSD diagnosis.
3. Does not experience current delusions.
4. Not currently involved in outpatient treatment.
5. Is currently receiving CBTp.
6. Does not own or have access to personal technology (e.g., smartphone, tablet, or laptop/computer) with access to wifi or cellular data.

• Micheal W Best, PhD, Principal investigator, University of Toronto
• Sean A Kidd, PhD, Study director, University of Toronto