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In blended therapy, sessions with a therapist are supported by technology, such as a mobile app. New research found that a blended therapy called SlowMo reduced paranoia in people with psychosis, when added to usual treatment. It slowed down their unhelpfully fast thinking and reduced worry. Their confidence, wellbeing and quality of life also improved over the 6 months they were in the programme.

People with psychosis may have delusions (firm beliefs that are not shared by others), for example, that others are making plans to hurt or kill them. They may also have hallucinations and see, hear, smell, taste or feel things that others cannot.

The National Institute for Health and Care Excellence (NICE) recommends medications and psychological therapy for psychosis. This is often cognitive behavioural therapy (CBT), a talking therapy that works on the links between people's habits of thoughts, emotions and behaviours. The demand for this treatment is high and, in practice, not everyone who might benefit receives it.

The therapy, SlowMo, was developed over 10 years to increase the numbers of people who can access treatment. Researchers say its design goes beyond standard CBT, and systematically addresses the fast reasoning at the heart of someone’s paranoia. It is intended to be easy to use and engaging, to encourage long-term use. Blending app use with face-to-face sessions is a novel approach to addressing paranoia.

This study found that blended therapy can engage people with psychosis, and help them deal effectively with paranoia.

Further information on psychosis is available on the NHS website.

This Alert features in our evidence Collection: What is digital health technology and what can it do for me? Read the Collection

What’s the issue?

People with psychosis lose some contact with reality. They might see or hear things that other people cannot see or hear (hallucinations) or believe things that are not believed by others (delusions). A common delusion is that there is a conspiracy to harm them. This paranoia can cause distress and disruption to people’s lives, sometimes requiring inpatient treatment.

Usual treatment, recommended by NICE, is medication, contact with a mental health team and at least 16 one-to-one sessions of CBT. Recent studies have shown that this CBT leads to a small to medium improvement in paranoia. However in practice, some people either are not offered CBT because of a lack of trained therapists, or are reluctant to engage with it.

SlowMo therapy was designed to identify and compensate for the specific reasoning style that can cause paranoia. It helps people become aware of their tendency for 'fast-thinking'. They may jump to conclusions, have less flexible beliefs and be less likely to make slow, considered judgments.

People with paranoia and their carers were involved in developing the SlowMo therapy to make it as user-friendly and enjoyable to use as possible. The therapy combines a web app for use with therapists, and a mobile app. SlowMo visualises someone's fast-thinking as fast-spinning grey worry bubbles. People are supported to use tips to shrink their grey bubbles and, in their place, grow colourful slow-spinning bubbles, representing positive thoughts.

People learn to use SlowMo in 8 face-to-face meetings with a therapist, and practice in real-life settings such as busy shops and buses. The app is designed to help them notice unhelpful fast-thinking, find ways to slow down for a moment and cope with distressing thoughts and experiences. At the end of therapy, they can continue to use the mobile app at any time to access recorded messages, tips and interactive features.

The study was set up to see whether SlowMo therapy was effective when added to treatment as usual for reducing paranoia.

What’s new?

Researchers recruited 362 people with psychosis from community mental health trusts. They all received usual treatment (drugs, community health worker contact and appointments with a psychiatrist). Half the group were then randomly allocated to receive an additional 8 sessions of SlowMo therapy, plus access to the mobile app whenever they needed it.

Everyone had assessments when they signed up to the study, after 12 weeks and after 24 weeks. The assessments measured paranoia in several ways, as well as how people were thinking, their quality of life and feelings of wellbeing.

People who had the additional SlowMo therapy did better than people given treatment as usual, both immediately after treatment and after six months.

People on SlowMo therapy had:

  • lower levels of paranoia on all three measurement scales used
  • improvements in some aspects of reasoning; they had more flexible beliefs and were more likely to admit the possibility of being mistaken but remained as likely to jump to conclusions
  • reduced worry, improved quality of life, wellbeing and a positive view of themselves; these outcomes improved slightly, particularly at 24 weeks.

The therapy was equally effective for people with more or less severe symptoms and there was no evidence that it caused harm; serious or long-lasting harms were similarly likely in both groups.

Interviews with some of the participants showed that they liked the therapy and enjoyed using the app, even if they had not previously used a smartphone. Many described feeling stuck before the therapy. They found the concepts of slow and fast-thinking helpful, and liked the stories of others' experiences on the app. The researchers said the app was effective, and there was a clear sense that user, therapist and app all shared the same goal.

This positive feedback was backed by high engagement: 80% of participants attended all therapy sessions and 71% used the app as intended between sessions.

Why is this important?

The researchers believe that this is the largest trial of a psychological therapy for paranoia in people with psychosis, and the first to use a blended digital approach. It found that SlowMo therapy is effective, with results that lasted for at least 6 months. The results are at least as good or better than with other CBT programmes for people with psychosis, which require more sessions.

Current NICE guidance on CBT for psychosis says people should be offered at least 16 sessions. SlowMo therapy takes half that number and could be a good way to offer an effective therapy to more people with paranoia.

What’s next?

The therapy and moblile app in this study were developed to address reasoning, which is believed to underpin paranoia. Unexpectedly, the research revealed that worry could also change paranoia. This finding supports the idea that addressing worry directly could also be helpful.

The researchers are now revising the mobile app, so it can be used on all devices. They plan to improve it using the results of the study, to overcome some technical challenges identified by people in the study.

The app is registered as a medical device, and the researchers will study how best to roll the SlowMo therapy out more widely. They will also approach NICE for its appraisal. The therapy was delivered mostly by clinical psychologists in this study. The team hopes to test whether clinicians with other qualifications can deliver the programme and achieve the same results.

You may be interested to read

This Alert is based on: Garety P, Ward T, Emsley R and others. Digitally supported CBT to reduce paranoia and improve reasoning for people with schizophrenia-spectrum psychosis: the SlowMo RCT. Efficacy and Mechanism Evaluation 2021;8:11

A paper on the patient and public involvement in the study: Greenwood K, Robertson S, Vogel E and others. The impact of Patient and Public Involvement in the SlowMo study: Reflections on peer innovation. Health Expectations 2022;25:1

A paper about how to personalise therapy within the SlowMo targeted intervention: Ward T, Hardy A, Holm R, and others. SlowMo therapy, a new digital blended therapy for fear of harm from others: An account of therapy personalisation within a targeted intervention. Psychology and Psychotherapy: Theory, Research and Practice 2022;95:2

A paper exploring the service-user experience of the SlowMo therapy: Greenwood KE, and others. The service user experience of SlowMo therapy: A co‐produced thematic analysis of service users’ subjective experience. Psychology and Psychotherapy: Theory, Research and Practice 2022;95:3

A study exploring the “digital divide” and mobile app engagement in the SlowMo trial: Hardy A, and others. Bridging the Digital Divide in Psychological Therapies: Observational Study of Engagement With the SlowMo Mobile App for Paranoia in Psychosis. JMIR Human Factors 2022;9:3

Funding: This research was funded by the Efficacy and Mechanism Evaluation (EME) programme, a partnership between the NIHR and the Medical Research Council (MRC).  

Conflicts of Interest: Philippa Garety is part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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