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Welcome to the Oxford University Psychology Podcast series brought to you today by me,

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Daniel Moore of the honour of having professor of clinical psychology, Daniel Freeman with me today.

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Good morning, Daniel. Morning. Thank you for joining us. You've got a really interesting programme of work being developed here in Oxford.

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And will you run the Oxford Cognitive Approaches to Psychosis programme?

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And you you're looking into the understanding and treatment of delusions and hallucinations.

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That's right. Yeah. So it'd be great to just hear a little bit about your work, because I think lots of people,

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when I think about psychosis and the treatment of psychosis,

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they think about medications, they think about admission's and medications and those sorts of things.

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But you're thinking about from quite a different angle, really. Well, I'm very much taking a psychological approach to it.

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There's a real UK strength, I think, in understanding and also developing treatments for delusions.

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But my ambition really is to produce a much, much better treatment for delusions, particularly persecutory delusions is the real focus.

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I think we've come on in leaps and bounds and understanding what the causes are,

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and I think we can really translate them, which is a much better treatment.

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So a big shocker really is to have effect sizes that are much better than current treatments,

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but also that we're beginning to even shift towards targeting recovery.

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There's a lot of people who, you know, don't respond enough to the treatments that we have that certainly help many people.

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But we could be doing well, but I don't think we can. What first got you interested in this area?

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And I think the simple answer is actually just talking to patients with psychosis.

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And I remember now thinking back in meeting the first patients and also remembering probably what I've been taught at university,

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which was the very standard view that these are just pathological conditions are pretty understandable

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and that psychology didn't have much understanding approximately how much you use these problems.

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And yet when you talk to patients, the accounts are so psychologically rich.

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And if I thought it was, I was still hear that. Now it's incredibly psychologically rich.

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I listen to patients. They were their inspiration. And just from the doctors first patients and particularly I think it was paranoia.

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Some of the first things just hearing, for example, the anxiety there, I think it just made me realise what anxiety is around here.

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But I actually was the first research path that I went on because there seemed to be so much overlap in those two conditions,

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anxiety being very much so understood by the psychological models and paranoia, much less so.

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And that's quite interesting about your work, because what you've done is you've not just looked at psychosis as a as a whole entity.

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You've split it down into different sort of elements and you've looked at different

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components of that and the different targeted treatments for the different elements.

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And that's, I think, fascinating. And be interesting to hear your opinion on where you're at with your work on persecutory delusions.

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I know you've published lots about this. Yeah. I mean, so the whole diagnosis issue is very interesting.

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And I think in the world of Scotland psychology, we're still trying to get how we classify disorders in the best possible way in schizophrenia,

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I think, because it's been more and more problematic diagnosis.

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So we basically try to sidestep the issue by diagnosis of working on the individual psychotic experiences themselves, such as paranoia,

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not getting caught up so much in diagnosis and approach, and where much with the paranoia, such as a really exciting stage, actually.

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I mean, I was clinically qualified in about 15 years ago and the first stage really was developing a good theoretical model.

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And the last five years in Oxford has been taking elements of the model because there's no one simple cause of delusion.

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There are many developing treatments that target each the causes and evaluating them.

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And that's over the last five years have been doing that.

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And then over the last year or two, putting the elements together in a very kind of personalised treatment for patients,

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which also includes patient preference. So we get a menu of treatment options focussing on the causal factors relevant to that person,

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putting it together into full treatment called the feeding side programme, which I mean, the first patients who've had this have done really well.

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And we're now running a just started last month and asked you to really put this to the test.

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But we think we have a much better theoretical driven, targeted treatment for Perski delusions.

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And so I'm very optimistic. I think it's based on a strong theoretical bedrock.

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We've been carefully testing at the individual events and studies over the last few years.

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So I'm hopeful. But of course, we've got to put it to the test. We've got to show it.

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So we're trying to do so. You've got you break down to.

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Three different reasons why people might have developed delusions and then you tailor treatment according to those sort of hypotheses.

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What does the treatment look like? Yes, so in essence, what I think about paranoia is that arises from normal psychological process.

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We all try to decide whether to trust people, not trust people in various situations when we get it wrong inaccurately or we're inaccurate about it.

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That could be a form of paranoia.

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Says unfounded beliefs are under threat, but not this clearly develops on the basis of genetic and environmental risk.

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But at the heart is this unfounded idea that there's this threat occurring to you and then that's maintained by a number of psychological processes,

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such as worrying too much, feeling very low self-esteem to feel vulnerable, sleeping badly.

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I you think if one explanation for events, putting up lots of defences that get locked into your face.

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So the treatment, what we do, we do we don't really want to worry about what was true or not in the past.

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We want to find out what the person is safe now, whether safe enough to get on with their life.

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And therefore we want to realign safety by going back into situations they're worried about and doing that by dropping the defences,

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but also trying to remove the maintenance factors, the individual persons that can make the full learning of safety.

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The paranoia then hopefully should melt away as the beliefs about safety are built up again, so that the kind of model for person,

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what we end up doing typically is the most common things rarely, especially often get people to sleep nights.

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It's so common to me, to me in the first session and you can see that it shattered.

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So we know you can sort of sleep very good effects for that sort of sought out sleep.

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Where would use worrying preoccupation with build up self-confidence. Typically after that work,

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we get people back into some of the situations they want to be in but are very frightened of and do that while they lower the defences.

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So they get for learning because many of our patients, well, they typically avoid going outside,

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but even when they're outside, they might have a gaze or be very hyper vigilant or only got the seven times a day.

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So we try and stop some of these defensive countermeasures so we can really find out.

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Let's find out how the environment is now. Let's do some planning.

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So authorities are active of about getting out into towns, city streets, cafes, all some of that.

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Some of it isn't getting out to towns. Is it because you're actually using an innovative virtual reality reality model in your recent research?

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Is that is that right? Yes. This is one observed. So this is one one of the other angles we take on this.

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And I think there's a real potential. The virtual reality can can potentially reshape mental health services, both for assessment and treatment,

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where there's very good high quality consumer equipment available now,

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where you can basically take people back into situations and see how they're out there.

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And then we started to use that in paranoia.

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And the great beauty of this is that people know it's not real and yet their mind body behaviours is real.

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So they're getting real learning experiences. But there's enough for people to say, well, it's okay, I know it's not real.

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I can go to these people in the virtual situation, try now so they can do things that I actually would take a lot longer to achieve without using VR.

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And the first results we've got are very, very good.

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And this is what I want to take home. But I think has a real potential.

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You know, we want to help people, we safety and we can do a lot of that learning of virtual environments and people find that easier.

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And also to think of psychiatric ward, a place where there's too much activity.

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But we through these sorts of devices, you could actually help people prepare people going back to their home environments.

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What does that look like? Somebody has got a headset on and they they're looking at a different scene.

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What are the scenes? Is the therapist standing next to them and can they see their therapist and what actually goes on?

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Yeah, so this is this is it's all changing in a way.

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And know we have a wonderful visual appearance by Mr. Carter.

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Whether we use you put a headset on, you can walk around a large room and we give you virtual train rides.

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It is a virtual lift and things like that. And so we've got a great high end state of the art.

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But of course, things light up this rift. Another one's coming available, which I get headsets, but you can sit at a much cheaper computer.

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So much cheaper equipment and experience is great. So we're starting to transfer our work into the more portable, affordable equipment.

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You know, I think we'll see big changes in that. So you put it on and, you know, everyone knows it's not real, but you voted to that.

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So you do have systematic desensitisation sort of work, is that right?

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Well, it depends on who they are. Expect if you say so.

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Actually, the study we compared just an exposure based treatment with the treatment where you test your police for dropping your defences,

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dropping your safety papers. And that's a more combative approach.

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He basically compared a cognitive approach to an exposure approach, both graded and it's the cognitive approach is way better.

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OK, because you could be in a situation not be fully exposed because you're averting your gaze or keeping away from the people.

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Try to, you know, just plan your escape route.

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So we try and get people to do the opposite, to actually go up to the computer covid characters and take the table must have a bit of fun as well,

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because you can do things you can't do real life in. So, yeah, it's tell not just not just an exposure versus a very specific cognitive one.

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Find out what the Fed cognition is, what the social behaviours are preventing that body from being discovered,

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drug and social workers and testing on the belief that it's psychological.

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It's really helpful to hear that level of detail actually in what you're doing.

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We've talked about persecutory delusions quite a bit.

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Is your thinking completely different when it comes to hallucinations and all that seems to be what and what has discussions about this?

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Well, I always think delusions are much more understandable, untreatable than hallucinations.

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And then to be working this, I should say, the opposite about delusions.

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So I think it's interesting question there, which we think I I think at least physicians psychologically,

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a lot of it is focussed upon the reactions to the voices,

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helping people have a relationship to the voices that enables them to still get out and do the things they want to do in their lives.

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And it's helping people to have a psychological stance to voices that achieves that.

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And I think that's why we are in current approaches.

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But in terms of the mechanisms of this nation's, I think, you know, I think that's a bit harder to be sure about.

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And it's certainly harder to make those Meccans mechanisms directly through the techniques that we have at the moment.

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So I think that's an area where there's a lot of potential for growth and improvement, an exciting area to be on,

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if I may be biased, because some people say solutions are harder on some of these nations, I find it the other way around.

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Tell me what you'd like to achieve with your your current programme of work in psychosis.

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And it's pretty clear in the current trial we're going to be recruiting patients who got their first

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delusion despite being in services and having had treatments that make medication treatments.

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In most cases, some people had some psychological therapy.

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I won't say it's a recovery rate of at least half the patients no longer meeting criteria for delusion by the end of our full treatment.

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That's the ambition that we have. And all of this is trying to build us up in a way where to where monetising a lot of this work and a lot of detail,

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because it's all well and good having these treatments. But we've got to get into the health services as well.

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So we need treatment that can be used. I think sometimes cycles, treatments suffer from that complexity.

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So we tried to distil the key essences of the treatment approaches in a way that many more people and health services can can use.

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But I also think that regardless of the research institutions or any other mental health,

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so there's lots of common processes that cut across mental health problems, bad sleep, worry, rumination, low self-esteem.

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All those things cuts across, I think every mental health condition and mental professionals I think should be able to achieve them.

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We certainly know there's techniques that can work. So with that, that's the other I raised.

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And it's you have the dream that really works, but the one that we can actually train and use in services.

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Professor Daniel Freeman, it's been great to speak to you today. Thank you for sparing time to contribute.

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Thank you. Pleasure. Thank you. And thank you for tuning in to another episode of the psychiatry podcast series.

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Goodbye.