Psychiatry’s Problem With Paranoia—Is Digital Part of the Solution?

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Paranoia, or fear of deliberate harm from others, is among the most common symptoms of schizophrenia-spectrum psychoses, and it also occurs in emotional disorders and other severe mental illnesses, placing a significant burden on the lives of patients and their families.¹ Innovative therapeutic interventions are desperately needed to overcome paranoia and improve outcomes.

Existing therapies, whether pharmacological or psychotherapeutic, have widely recognized limitations in engagement, adherence, and effectiveness. Antipsychotic medication is the mainstay of treatment for most patients. However, distressing symptoms persist in 30% to 50% of those who take them, functional outcomes are frequently poor, and many discontinue treatment periodically or permanently, concerned about adverse effects, such as weight gain and metabolic syndrome.² Psychological therapies, such as cognitive behavioral therapy for psychosis (CBTp), have been shown to improve psychotic symptoms, including paranoia, when added to treatment as usual in large clinical trials.³ But effects need to be improved, and implementation in routine care is poor. Individuals are often not willing or able to access and make use of therapy, particularly those from minoritized groups. There is a scarcity of trained therapists, with estimates suggesting only 0.3% of mental health consumers in the United States have access to CBTp.⁴

A transformation in psychosis care is needed; digital technology has the potential to deliver it by improving the patient experience, therapy effectiveness, and clinical implementation.⁵ Digital interfaces can be designed to support personalization and accessibility, and they can assist engagement and adherence. Web and mobile technologies are also more readily scaled up than traditional interventions and can be designed to reduce training demands.

A New Frontier: Digital Therapeutics for Paranoia

To the best of our knowledge, metacognitive training (MCT), developed by Steffen Moritz, PhD, MSc, and colleagues, was the first psychological intervention for delusional beliefs that incorporated technology. It used desktop programming and presentation software to provide illustrative games and tasks. Group versions of this training approach were shown to have small to moderate effects on delusions, although it is important to note that patients with severe delusions were excluded and the basic digital materials were not personalized, limiting its ability to address challenges to therapy accessibility and adherence. More recently, individualized delivery of metacognitive therapy (MCT+) has been developed and evidence suggests it may have better effects on delusions, though there are only a few relatively small trials.⁶

Building on this pioneering work, recent digital therapeutics for psychosis have sought to harness innovative technology such as virtual reality, social networking, mobile apps, and web-based therapies. Whilst preliminary findings are encouraging, few of these have been tested in large clinical trials, and those targeting paranoia are in their infancy.⁷ In 1 of the largest trials to date, Depp et al (2019)⁸ investigated the effects of augmenting a single session of CBTp with an app, CBT2Go, compared to a single session of self-monitoring supported by an app or treatment as usual (TAU), in individuals with severe mental illness (N = 255). They found a small effect on general symptomatology favoring the CBT2Go and self-monitoring conditions over TAU. However, the impact on paranoia was not specifically examined, and the authors also note that baseline levels of psychosis symptoms were low. The FOCUS mobile app adopts a similar therapeutic approach, although it was investigated as a standalone app to support self-management in its most rigorous evaluation. Ben-Zeev et al (2019)⁹ compared FOCUS to a recovery group intervention in 163 patients with severe mental illness. They found no between-group differences on clinical outcomes, nor any within-group changes in psychosis symptoms.

These trials suggest that app-based technologies may safely and acceptably augment therapy for paranoia although, but they have yet to demonstrate meaningful clinical outcomes in robust designs. Crucially, there is little evidence that digital therapeutics have been designed to address healthcare inequalities. Indeed, emerging findings indicate digital therapies may actually exacerbate exclusion, with those from privileged demographic groups more likely to access and benefit from them.⁷

A New Digital Therapeutic for Paranoia

In addressing the challenge of transforming psychosis care, we have developed SlowMo, an innovative digitally supported therapy for paranoia. SlowMo is based on the principles of CBTp and leverages technology to address health care inequalities, through enhancing therapy appeal and user friendliness for a wide range of individuals.¹⁰ SlowMo therapy targets an evidence-based mechanism, or active ingredient, that we and others have shown can fuel paranoia.^11,12 Drawing on the term popularized by Daniel Kahneman, PhD,¹³ we describe this ingredient as fast thinking, comprising of a jumping to conclusions bias (forming rapid judgements using limited information) and belief inflexibility bias (reduced capacity for reflecting on one’s own beliefs, changing them in the light of new evidence, and considering alternatives). SlowMo is designed to help patients to slow down for a moment, encouraging awareness of a tendency to jump to conclusions and find new ways of feeling safer.

Figure 1. The SlowMo Webapp (left) Synchronized With a Mobile App (right) for Use in Daily Life

We followed human-centered design principles in the hopes of improving the user experience of therapy and radically enhancing engagement and adherence.¹⁰ Our multidisciplinary collaboration of individuals with lived experience, industrial designers, software developers, clinicians, and researchers developed SlowMo over 3 years through 7 cycles of prototyping. To address health care inequalities, we codesigned with stakeholders from diverse demographic backgrounds, who could identify therapy barriers and facilitators, and optimize the inclusivity of the design. SlowMo therapy consists of a web app delivered on a touchscreen laptop to support the delivery of face-to-face individual cognitive-behavioral therapy sessions, which is synchronized with a mobile app for use in daily life (Figure 1).¹⁰

A Journey of Visualizing Thoughts and Thinking Habits

SlowMo uses new, responsive technologies to support the visualization of thoughts—as bubbles—and their associated thinking habits. This visual concept aims to enhance cognitive therapy by providing an appealing and tangible means of communicating subjective experience. The design minimizes the information processing demands, thereby lowering a significant barrier to engagement with traditional talking therapies. Patients interact with their personalized SlowMo thought bubbles using a touchscreen, altering speed, size, and transparency to reflect related thinking habits, distress, and conviction.

The SlowMo webapp used during sessions presents therapy as a journey, with interactive features including information, animated stories, and games. As well as tailoring worry and positive thought bubbles, patients record key learning points and future plans, with all content synchronized to the mobile phone app for access outside of sessions. The mobile app allows patients to notice their fears and thinking habits as they occur in daily life and helps them to find other ways of managing distressing experiences. It consists of a redesigned CBT thought record for managing paranoia and attempts to overcome the limitations of paper versions, which can be an inaccessible means of support during peak moments of distress. SlowMo uses a native mobile app with opt-in data transfer, addressing patients’ privacy concerns, which was a salient theme during the design research. The mobile app relies on user-initiated interaction and optional push notifications, to accommodate those who wish to have control over their data and find passive monitoring intrusive.

Delivering Evidence-Based Benefits for Recovery in Psychosis

Figure 2: SlowMo Therapy Trial Outcomes at 12 and 24 Week Follow-Up

Figure 2: SlowMo Therapy Trial Outcomes at 12 and 24 Week Follow-Up

SlowMo therapy has been iteratively developed over the past 10 years, with a number of studies demonstrating the efficacy of previous versions of the intervention.¹¹ SlowMo has recently been tested in a large-scale randomized controlled trial with N = 362 participants recruited from United Kingdom (UK) clinical psychosis services (Figure 2).^14,15 The therapy consists of only 8 sessions, compared to the minimum 16 sessions recommended by the UK’s National Institute of Health and Care Excellence guidelines for schizophrenia treatment.

Remarkably, despite being half the minimum recommended length, SlowMo had a moderate effect on the measures of delusion severity commonly used in trials (Scales for Assessment of Positive Symptoms, SAPS¹⁶ and Psychotic Symptom Rating Scales, PSYRATS¹⁷)—for which meta-analyses have found only small effects.³ These positive effects sustained or grew over 6 months, with benefits cascading into other areas, including self-concept, wellbeing, and quality of life. Less consistent improvements were found for referential delusions, meaning that the Green Paranoid Thoughts Scale (GPTS)¹⁸ total, which is comprised of ideas of reference and persecution subscales, was not significant at 6 months. However, a psychometrically improved version of this measure, published whilst the trial was being conducted, did reach conventional levels of significance.¹⁹ Importantly, the SlowMo software design appeared to work as intended and was inclusive for a wide range of individuals. Whilst Black people and older patients were found to be less confident and less frequent users of mobile phones prior to doing SlowMo, these differences did not translate to their experience of the therapy, with paranoia outcomes, adherence, and patient experience comparable across groups.²⁰ SlowMo is one of the first digital therapeutics for paranoia to overcome the digital divide associated with age and ethnicity.

The trial also had limitations. First, despite clear improvements in more severe persecutory delusions, consistent improvements were not found in milder referential delusions. One explanation is that SlowMo helped patients manage ideas of reference and their experiential components (eg, being watched by others), which prevented their elaboration into persecutory delusions (eg, being hunted by the mafia) but had less of an effect on directly modifying these underlying ideas of reference. This suggests that digital therapeutics for paranoia need to consider the broader phenomenological context fueling worries.

Accordingly, future versions of SlowMo will incorporate content on how to notice, understand, and manage the sensory-perceptual experiences (including altered salience and anomalous experiences) that are common obstacles to therapeutic change. The trial also did not control for effects of time with a therapist. TAU was chosen as the comparator condition because there is a low penetration of evidence-based psychological treatment in mental health care, thus the key question is whether SlowMo therapy confers benefits over and above standard care. Further, we had previously established the superiority of an earlier brief version of the intervention against an active control intervention, suggesting SlowMo’s positive effects are not attributable to nonspecific therapeutic factors.²¹

Case Vignette

Figure 3: Personalized Content from the Webapp

To illustrate SlowMo, Alex (name changed to protect their identity) has kindly agreed to us sharing their experience of therapy. Alex (a Black British Caribbean man in his late 20s) came to therapy reporting a strongly held distressing belief that he was being followed by a past acquaintance who intended to harm him and his family. In early sessions, he used the webapp to visualize these fears as personalized worry bubbles, and to build a picture of his fast thinking, including triggers and the impact on his life (Figure 3).

Alex could view and modify his personalized worry bubbles on the mobile app, which helped him develop an awareness of times when he thought fast. The SlowMo sessions then supported Alex to find ways to slow down for a moment and feel safer.

Figure 4: Images From ‘Alex’s’ SlowMo Mobile App Screens for Noticing Fast Thinking (Top), Slowing Down Fast Thinking (Middle) and Using Personalized Safer Thought Bubbles (Bottom).

Alex connected with interactive stories of others discussing their own worries and tendency to jump to conclusions in everyday life. Reflecting on how these stories related to his own experiences, Alex audio-recorded messages to remind him how to slow down his worries. Using SlowMo tips, he created colorful, safer thought bubbles as he progressed through the therapy. Crucially, the synchronization of the web app with the mobile app meant that he could access this personalized helpful content (SlowMo strategies, messages and safer thoughts) when he needed them most. This helped him to consider alternative explanations when fast thoughts were triggered in daily life, for example recognizing that screams and laughter on the street could just be “people having fun” and not specifically related to him (see Figure 4). Alex described how the principle of slowing down his thinking became “almost automatic” through early and regular use of the mobile app. By the end of therapy, Alex reported reduced fast thinking, distress, and conviction related to the fear of harm from others. He described how SlowMo therapy had helped him to “slow down…think different, act different, and feel different.”

Clinical Take-Home Messages

As discussed in this article and exemplified by the SlowMo approach, therapy is likely to be most effective when it targets evidence-based processes that maintain distress (eg, fast thinking) whilst also being tailored to individual needs. Close attention to the patient experience of therapy is critical to deliver interventions that are accessible, engaging, and memorable.

A guiding principle of SlowMo is that assessment and intervention should include working with the patient in real-life environments, where fears of others are triggered (eg, public transport or crowded markets). This allows therapeutic targets to be understood in the broader context of the individual’s life, including relevant social factors such as experiences of poverty and discrimination.

It is crucial to promote and consolidate helpful learning and embed this into daily life, and digital tools represent a powerful method of achieving this. While SlowMo utilizes carefully designed digital tools, aspects reported by people as helpful (eg, recording and accessing helpful messages) may be replicated in simplified form using functions typically available on mobile devices.

Clinical Application

Having found evidence for SlowMo’s efficacy and user friendliness, we are developing a new version for rollout in mental health services, which will build on its strengths while also addressing some of its limitations. We are encouraged by our findings to date, but the reality is that most digital therapeutics fail to be implemented outside of clinical contexts, due to organizational, provider, and consumer barriers.²² Further development is therefore required to deliver the benefits of SlowMo in routine care. Some challenges are beyond the direct control of developers and require governmental and provider intervention, such as access to hardware and data, and opportunities to acquire digital literacy skills. In line with these concerns, the next version of SlowMo will provide training on how to use the software, focus on a broader range of worries, and include additional tools to support therapists in providing evidence-based strategies to their patients. Implementation research is now required to establish whether efficacious digital therapeutics for paranoia can deliver on their promise of being a solution for transforming psychosis care.

Dr Garety is a professor of clinical psychology at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She is one of the pioneers of cognitive-behavioural therapy for psychosis and has led evaluations of innovative digital therapeutics for psychosis, including AVATAR and SlowMo therapy. Dr Hardy is a clinical psychologist lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She led on the development of SlowMo therapy and investigates the user experience of digital therapeutics. Dr Ward is a research clinical psychologist at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He is the therapy lead for the AVATAR and SlowMo therapy teams.

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