Welcome to the Oxford University Psychology Podcast series brought to you today by me,
Daniel Moore of the honour of having professor of clinical psychology, Daniel Freeman with me today.
Good morning, Daniel. Morning. Thank you for joining us. You've got a really interesting programme of work being developed here in Oxford.
And will you run the Oxford Cognitive Approaches to Psychosis programme?
And you you're looking into the understanding and treatment of delusions and hallucinations.
That's right. Yeah. So it'd be great to just hear a little bit about your work, because I think lots of people,
when I think about psychosis and the treatment of psychosis,
they think about medications, they think about admission's and medications and those sorts of things.
But you're thinking about from quite a different angle, really. Well, I'm very much taking a psychological approach to it.
There's a real UK strength, I think, in understanding and also developing treatments for delusions.
But my ambition really is to produce a much, much better treatment for delusions, particularly persecutory delusions is the real focus.
I think we've come on in leaps and bounds and understanding what the causes are,
and I think we can really translate them, which is a much better treatment.
So a big shocker really is to have effect sizes that are much better than current treatments,
but also that we're beginning to even shift towards targeting recovery.
There's a lot of people who, you know, don't respond enough to the treatments that we have that certainly help many people.
But we could be doing well, but I don't think we can. What first got you interested in this area?
And I think the simple answer is actually just talking to patients with psychosis.
And I remember now thinking back in meeting the first patients and also remembering probably what I've been taught at university,
which was the very standard view that these are just pathological conditions are pretty understandable
and that psychology didn't have much understanding approximately how much you use these problems.
And yet when you talk to patients, the accounts are so psychologically rich.
And if I thought it was, I was still hear that. Now it's incredibly psychologically rich.
I listen to patients. They were their inspiration. And just from the doctors first patients and particularly I think it was paranoia.
Some of the first things just hearing, for example, the anxiety there, I think it just made me realise what anxiety is around here.
But I actually was the first research path that I went on because there seemed to be so much overlap in those two conditions,
anxiety being very much so understood by the psychological models and paranoia, much less so.
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.
You've split it down into different sort of elements and you've looked at different
components of that and the different targeted treatments for the different elements.
And that's, I think, fascinating. And be interesting to hear your opinion on where you're at with your work on persecutory delusions.
I know you've published lots about this. Yeah. I mean, so the whole diagnosis issue is very interesting.
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,
I think, because it's been more and more problematic diagnosis.
So we basically try to sidestep the issue by diagnosis of working on the individual psychotic experiences themselves, such as paranoia,
not getting caught up so much in diagnosis and approach, and where much with the paranoia, such as a really exciting stage, actually.
I mean, I was clinically qualified in about 15 years ago and the first stage really was developing a good theoretical model.
And the last five years in Oxford has been taking elements of the model because there's no one simple cause of delusion.
There are many developing treatments that target each the causes and evaluating them.
And that's over the last five years have been doing that.
And then over the last year or two, putting the elements together in a very kind of personalised treatment for patients,
which also includes patient preference. So we get a menu of treatment options focussing on the causal factors relevant to that person,
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.
And we're now running a just started last month and asked you to really put this to the test.
But we think we have a much better theoretical driven, targeted treatment for Perski delusions.
And so I'm very optimistic. I think it's based on a strong theoretical bedrock.
We've been carefully testing at the individual events and studies over the last few years.
So I'm hopeful. But of course, we've got to put it to the test. We've got to show it.
So we're trying to do so. You've got you break down to.
Three different reasons why people might have developed delusions and then you tailor treatment according to those sort of hypotheses.
What does the treatment look like? Yes, so in essence, what I think about paranoia is that arises from normal psychological process.
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.
That could be a form of paranoia.
Says unfounded beliefs are under threat, but not this clearly develops on the basis of genetic and environmental risk.
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,
such as worrying too much, feeling very low self-esteem to feel vulnerable, sleeping badly.
I you think if one explanation for events, putting up lots of defences that get locked into your face.
So the treatment, what we do, we do we don't really want to worry about what was true or not in the past.
We want to find out what the person is safe now, whether safe enough to get on with their life.
And therefore we want to realign safety by going back into situations they're worried about and doing that by dropping the defences,
but also trying to remove the maintenance factors, the individual persons that can make the full learning of safety.
The paranoia then hopefully should melt away as the beliefs about safety are built up again, so that the kind of model for person,
what we end up doing typically is the most common things rarely, especially often get people to sleep nights.
It's so common to me, to me in the first session and you can see that it shattered.
So we know you can sort of sleep very good effects for that sort of sought out sleep.
Where would use worrying preoccupation with build up self-confidence. Typically after that work,
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.
So they get for learning because many of our patients, well, they typically avoid going outside,
but even when they're outside, they might have a gaze or be very hyper vigilant or only got the seven times a day.
So we try and stop some of these defensive countermeasures so we can really find out.
Let's find out how the environment is now. Let's do some planning.
So authorities are active of about getting out into towns, city streets, cafes, all some of that.
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?
Is that is that right? Yes. This is one observed. So this is one one of the other angles we take on this.
And I think there's a real potential. The virtual reality can can potentially reshape mental health services, both for assessment and treatment,
where there's very good high quality consumer equipment available now,
where you can basically take people back into situations and see how they're out there.
And then we started to use that in paranoia.
And the great beauty of this is that people know it's not real and yet their mind body behaviours is real.
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.
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.
And the first results we've got are very, very good.
And this is what I want to take home. But I think has a real potential.
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.
And also to think of psychiatric ward, a place where there's too much activity.
But we through these sorts of devices, you could actually help people prepare people going back to their home environments.
What does that look like? Somebody has got a headset on and they they're looking at a different scene.
What are the scenes? Is the therapist standing next to them and can they see their therapist and what actually goes on?
Yeah, so this is this is it's all changing in a way.
And know we have a wonderful visual appearance by Mr. Carter.
Whether we use you put a headset on, you can walk around a large room and we give you virtual train rides.
It is a virtual lift and things like that. And so we've got a great high end state of the art.
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.
So much cheaper equipment and experience is great. So we're starting to transfer our work into the more portable, affordable equipment.
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.
So you do have systematic desensitisation sort of work, is that right?
Well, it depends on who they are. Expect if you say so.
Actually, the study we compared just an exposure based treatment with the treatment where you test your police for dropping your defences,
dropping your safety papers. And that's a more combative approach.
He basically compared a cognitive approach to an exposure approach, both graded and it's the cognitive approach is way better.
OK, because you could be in a situation not be fully exposed because you're averting your gaze or keeping away from the people.
Try to, you know, just plan your escape route.
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,
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.
Find out what the Fed cognition is, what the social behaviours are preventing that body from being discovered,
drug and social workers and testing on the belief that it's psychological.
It's really helpful to hear that level of detail actually in what you're doing.
We've talked about persecutory delusions quite a bit.
Is your thinking completely different when it comes to hallucinations and all that seems to be what and what has discussions about this?
Well, I always think delusions are much more understandable, untreatable than hallucinations.
And then to be working this, I should say, the opposite about delusions.
So I think it's interesting question there, which we think I I think at least physicians psychologically,
a lot of it is focussed upon the reactions to the voices,
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.
And it's helping people to have a psychological stance to voices that achieves that.
And I think that's why we are in current approaches.
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.
And it's certainly harder to make those Meccans mechanisms directly through the techniques that we have at the moment.
So I think that's an area where there's a lot of potential for growth and improvement, an exciting area to be on,
if I may be biased, because some people say solutions are harder on some of these nations, I find it the other way around.
Tell me what you'd like to achieve with your your current programme of work in psychosis.
And it's pretty clear in the current trial we're going to be recruiting patients who got their first
delusion despite being in services and having had treatments that make medication treatments.
In most cases, some people had some psychological therapy.
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.
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,
because it's all well and good having these treatments. But we've got to get into the health services as well.
So we need treatment that can be used. I think sometimes cycles, treatments suffer from that complexity.
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.
But I also think that regardless of the research institutions or any other mental health,
so there's lots of common processes that cut across mental health problems, bad sleep, worry, rumination, low self-esteem.
All those things cuts across, I think every mental health condition and mental professionals I think should be able to achieve them.
We certainly know there's techniques that can work. So with that, that's the other I raised.
And it's you have the dream that really works, but the one that we can actually train and use in services.
Professor Daniel Freeman, it's been great to speak to you today. Thank you for sparing time to contribute.
Thank you. Pleasure. Thank you. And thank you for tuning in to another episode of the psychiatry podcast series.
Goodbye.