Bonus Episode: What is SlowMo? And how can it help with paranoid thoughts?
In this bonus episode of Let's Talk About CBT, hear Dr Lucy Maddox interview Dr Tom Ward and Angie about SlowMo: digitally supported face-to-face CBT for paranoia combined with a mobile app for use in daily life. Transcript Dr Lucy Maddox: Hello and welcome to Let’s Talk about CBT, the podcast from the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it’s not, and how it can be useful. In this episode, I’ll be finding out about an exciting new blended therapy, SlowMo, for people who are experiencing paranoia. This digitally supported therapy has been developed over 10 years with a team of people including designers from the Royal College of Art in London, a team of people who have experienced paranoia. And a team of clinical researchers, including Professor Philippa Garety, Dr Amy Hardy and Dr Tom Ward. The design of this intervention really prioritised the experience of people using the therapy in what’s called a design led approach. To understand more I video called Tom Ward, research clinical psychologist based in Kings College London, and I had a phone call with Angie, who’s experienced using the therapy. Here’s Angie’s story. Angie: I mean, I’ve had psychosis for many years. About 20 years ago I was really poorly, I was in and out of hospital. Going back about 20 years ago they kept giving me different diagnoses and I expect everybody else had the same thing. Anyway, then I met a psychiatrist and I was with him for over 20 years until he retired. And he really helped me a lot, I was actually diagnosed with schizophrenia. Part of me was really scared and another part of me was sort of relieved that I knew that I was dealing with. I get voices, sometimes I see or feel things that aren’t really there. But part of my diagnosis is I also get very depressed. And when I get very depressed, that’s when the voices are at their worst because I haven’t got the strength to sort of fight them off, if you like. If I’m having a good day, then I can use the skills I’ve learnt in the past to not listen to the voices and to have a reasonably good day. If I’m having a bad day and it’s a duvet day, then that’s when I really suffer with the voices. Unless you can actually accept that you have this issue, and you actually accept that you need the help, it doesn’t matter what they do to help you, you’re just not going to take it on board. Dr Lucy Maddox: Angie wanted some help, specifically with paranoid thoughts she was experiencing about people looking at her or laughing at her. She found out about the SlowMo trial and applied to be a part of it. And ended up being one of the very first people to try the therapy. Tom led on the delivery of therapy in the trial. Dr Tom Ward: I’ve worked and have worked for the last couple of years trying to develop and test digital interventions for people experiencing psychosis. So I’ve been involved in developing interventions that help people who are experiencing distressing voices. And been involved in work in a therapy called avatar therapy and more recently I’ve been working with colleagues to develop an intervention designed to help people who are experiencing fear of harm from others, which we would sometimes refer to as paranoia. Dr Lucy Maddox: In case listeners wonder what avatar therapy is could you just briefly say what that is? Dr Tom Ward: So in avatar therapy, digital technology is used with the person to create a representation of the distressing voice that they hear. So we work with the person to create an avatar which has an image which matches the image the person has of their distressing voice. And which comes to sound like the voice that they hear. And we use this avatar direct in dialogue. Very much with the rationale that many people who are experiencing distressing voices have relationships with their voice where they feel disempowered and lacking power and control. And we try to use the work with avatars and the dialogue with avatars to provide an opportunity for the person to reclaim power and control. And so we’re very much working directly with the experience in quite a potentially powerful way for people. Dr Lucy Maddox: Could you tell me about the current project you’re working on, so SlowMo? Dr Tom Ward: Yeah, so the first thing to say is that SlowMo stands for slow down for a moment. And so, it’s a therapy which is a targeted therapy for people who are experiencing paranoia. And it’s based in the idea that’s been popularised by Daniel Kahneman and other people that human thinking can be sort of thought about in terms of two different types of thinking. There’s fast thinking where we approach situations and we go with our first impression. We go with our intuition and gut feeling and we don’t take time to think it through. And slow thinking is more around taking a step back from situations and weighing things up and considering different ways of looking at situations. So one of the things to say is that fast thinking is part of human nature, we all do it and in many different times in our lives. But what we know from research into the experiences of people with psychosis is that people who worry about harm from other people, people who have significant paranoia can often be very likely to engage in this fast thinking. And find it difficult to feel safe in situations and to slow down and consider what else might be going on in the situation. So the therapy is designed to help people build an awareness of this fast thinking which is a part of human nature but can be particularly difficult if we’re feeling unsafe. And it’s designed to support people to be able to slow down and feel safer in their lives. And managing situations so they can really engage and enjoy their lives in a way that perhaps in the past has been difficult. Dr Lucy Maddox: Fast thinking I guess that’s something like you were saying that we all can get into a bit. Dr Tom Ward: The first message that we try to get across within the therapy is that fast thinking is part of human nature, it’s natural. And there are times when thinking fast is actually very helpful for people, sometimes we need to react to situations, and we need to recognise where we are unsafe and there’s danger. But in the context of when people are feeling unsafe throughout so much of their life, and in situations where perhaps the danger isn’t quite as much as the fear suggests it is, fast thinking can leave people feeling unsafe in situations where it might start to be a barrier to people living their lives. And slow thinking is something that we’re all capable of, but all human beings find it difficult and people experiencing psychosis and worrying can find this difficult as well. But we’re really trying to find ways to support people to do that, to feel safe in their lives. Dr Lucy Maddox: And how does the therapy work? What does it look like? Dr Tom Ward: We would describe it as a blended digital therapy. And it’s important to explain what that means. The blending aspect of this is that we try to take the best of face-to-face therapy and the building of a relationship with someone. But we try to improve the therapy through using, through blending digital technology into what we do. So the therapy involves eight face-to-face sessions, but each of these sessions is supported by an easy to use website effectively, an interactive website. So within a session, you’d be talking to the person or the person would be talking with the therapist but also interacting with a touchscreen laptop. And this provides information, it provides interactive ways that the person can build a picture of their own worries about other people or situations. And really visualise what’s happening in a way that in psychological therapy we talk about a formulation. A formulation, an understanding of somebody’s difficulties. But the digital technology in SlowMo is trying to really bring the person into that process of understanding what’s going on and making it very engaging and interactive and visual and memorable for the person. In order to try to support the person to make changes in their daily life, there’s also a mobile app that comes alongside the therapy, which is very much aimed at taking what the person has learnt in the therapy and applying it into their daily life. Dr Lucy Maddox: Here’s Angie on what she remembers this digitally supported therapy being like. Angie: You could choose pretty much where you wanted to do the therapy, you could have it at home, or you could have it in a café or somewhere else where you felt comfortable. So I did it in a café, a local café, with a lady called Alison. And what it consists of the clinician, Alison, she had a laptop. My heart sank originally because I thought oh no, I’m no good on computers. And I explained to her that I wasn’t very good on a computer. And she was so lovely, so patient, she said, “I can do most of it for you.” So that was fine. What the therapy was it did what it says on the tin, really. It taught you to slow your mind down, and to break things up into little pieces, like for instance I used to be terrified of getting on the bus because I thought people were talking about me and laughing at me. Dr Lucy Maddox: That’s a horrible feeling. Angie: Yeah, yeah. And this sort of therapy taught me to break it up. To say myself, “Well, hang on a minute, these people aren’t looking at you. They’re talking to their friends, they’re on their phone.” Just take it easy. And it’s a very simple idea but it works because although you know in your heart of hearts that that is the way to do it, when you’re actually in the situation, you forget. You just panic and to learn these skills was really good. Dr Lucy Maddox: I asked Tom to describe what the digital component of the treatment looks like. Dr Tom Ward: The website allows a person to build a picture of their worries. And these are using thought bubbles effectively, but really engaging well presented thought bubbles. And the idea of these is that they’re personalised and tailored for the person. So within a session, the person will be describing their worries but also creating these worry bubbles on the website. And the idea of fast thinking and slow thinking is represented by the way in which these bubbles spin. So when we’re talking about building an awareness of fast thinking, the person is actually able to control how fast their worry bubbles are spinning. And when we’re talking about maybe ways of slowing down the person can see visually how the worry is slowing down. So they build a picture of their worries and also importantly are building a kind of access to safer or more positive thoughts. And these are visualised as again bubbles the person creates, which can be made into different colours, depending on the person’s preference and can be linked into the worries and can be used on the mobile app outside of sessions. As somebody who’s worked in more traditional face-to-face CBT therapy, having these in the session and the person in control and interacting is a really significant thing to have in the session, really enhances the experience. Dr Lucy Maddox: I like the idea of the different colours and the different movement. Can you make the bubbles bigger and smaller as well? Dr Tom Ward: Absolutely. As you would have in a more traditional CBT session, at the beginning of a session, the person’s asked about how their week has gone, how much of the worry has been on your mind, how distressing has it been. And ratings are done on the touchscreen app, so the person is able to rate and see the change in the bubble. So if it’s been a week where it’s been a little bit less distressing, the person changes the slider and there’s that visual change as well that the person can see. And also, through the course of the therapy, we talk about different ways to slow down. And people develop their own strategies for slowing down in the situations that they’re struggling with. And the idea of the mobile app is that these strategies that the person might be able to think of in the session. They can be very difficult to think about when you’re actually in a situation where you’re worried if you’re on a bus or on a tube. So the idea is that these tips, these colourful tips can be brought into the mobile app. And the person can be just one or two touches away from something which they’ve created themselves and they know can help them in that situation. Dr Lucy Maddox: Angie used the app when she was out and about. Angie: They gave you a phone with an app on it. You put in all your fears, like getting on the bus or being in a crowd, and then you put in what they called your support bubbles. They came up on screen in little bubbles and it had what you used to cope with these voices and delusions. And you could look on your phone, and it would come up. Like for instance if I was in a crowd and I wanted to get away, you’d go onto your phone. And it would say things like just remember no one’s looking. Just slow down. And you could use this phone on the bus because nobody knew you weren’t just using a normal smartphone. Dr Lucy Maddox: Yeah, absolutely. That sounds really, really useful to have it on you all the time. Angie: It was very useful, very useful. And yeah, nobody looks at anybody now, everybody’s got a phone, so nobody thinks that you’re doing anything different. Dr Lucy Maddox: It’s so true, it’s more unusual not to have a phone actually now, isn’t it? Angie: (Laughs) It is. Yeah. Dr Lucy Maddox: Tom thought those blended approach meant that there was more chance that people could carry on learning from therapy into their day-to-day life. Dr Tom Ward: Having worked with people for many years, my experience is that really important things can be discussed during a therapy session and really meaningful understanding can emerge. And yet, that can actually be difficult to remember or to use when you need it, when the person needs it, which is in the flow of their life. So that’s really what the digital technology is allowing us to try to do here in SlowMo. Dr Lucy Maddox: And were the sessions weekly and how long were they for? Dr Tom Ward: It involved eight sessions conducted weekly. On average they’d range between 60 and 75 minutes across the trial. Given that it’s not simply talking one to one, face-to-face talking for 50, 60 minutes. Given that there’s interaction with the website, where people are listening to the experiences of other people with similar experiences it struck me that actually people were able to engage for slightly longer than we might expect within a more traditional approach. And also, the other thing that we were very keen to do is where the person was willing, we wanted to take the therapy out into situations where the person was most worried. So this meant taking the phone out with the person to try their slowing down strategies in situations they were fearing. Dr Lucy Maddox: Yeah, that’s really interesting what you said about people being able to tolerate slightly longer makes me think about sometimes how having difficult conversations can be easier if you’re not having to look at each other all the time. So like if you’re driving or something, sometimes you can have a more in depth conversation. And I was just wondering if you thought that tolerance of slightly longer was to do with the conversation being triangulated through something else as well or whether it was for another reason? Dr Tom Ward: I absolutely agree with that. I think prior to having delivered the therapy I had some worries or reflections about what would it be like to not have a one-to-one discussion where you’re going back and forth in that way? Because that’s what I’d known, and I wondered whether it might be clunky in some way to have the structure of the website and the material and how that would work in the process of a session. I wondered how that was going to go. And how it went is exactly how you’ve described it. That the fact that the attention was triangulated, and the person could click and listen to people who had experiences that they may connect with or they might not connect with. And that could be used as a springboard back into a discussion around how the person’s situation was similar or different. That really did seem to facilitate a really therapeutic process, which to me had some significant benefits over the classic mode of delivery of cognitive interventions. It naturally lent itself towards collaboration because the person was actually controlling the touchscreen and clicking on things. And true collaboration in that way was facilitated. One of the sessions towards the end talks about how our past experiences of relationships can affect how we worry about things in the here and now. And that can bring up some of the experiences of the people that we’ve worked with involve experiences of trauma and bullying and discrimination are very painful experiences, which can be really painful and difficult to discuss in sessions. And the fact that they were able to hear the experiences of other people and choose the extent to which they wanted to discuss their own experiences. It felt to me that the power was very much with the person in the session and the triangulation really helped in that respect. Dr Lucy Maddox: And eight sessions is kind of not that long actually, I was thinking. What happens in those sessions? Is there quite a similar content that they tend to follow? Or is it a bit flexible? Dr Tom Ward: So partly the answer to that question is that it’s targeted and structured. And the evidence from the trial was that therapy was delivered very much as planned. And there are issues within psychological interventions, particularly in the context of psychosis where there’s so much complexity to the situation that it can be hard to retain the clear focus across longer periods of work. Very much what we were able to do here is provide an engaging way for somebody to really understand and make changes in one very specific area which proved helpful. Having said that, what we’ve also found and we might talk about the findings in a bit more detail. We’ve found that the improvements that we saw in the trial were not limited to the people’s experience of paranoia. But we actually saw more general improvements in wellbeing, quality of life and the person’s self concept and positive sense of themselves. And that showed that as well as targeting fast and slow thinking, we were able to work with this flexibility to be able to bring in other aspects that might have been relevant for the person. And we know within the context of psychosis how the person sees themselves and self esteem can be so critical. So we were able to target other areas as well within our main focus also. Angie: I’ve suffered with psychosis for many years and I found this probably one of the most helpful tools that I’ve been offered. Dr Lucy Maddox: What do you think made the difference? What do you think made it more helpful? Angie: Probably I was in the right frame of mind. I think it’s important that you accept that you do need some help. So I think that made a difference. Also, it was such a simple idea that you could grasp. And they’d show you little pictures of things. For instance there was a picture of a man with a wallet in his hand, and he was running. And you had to say what you thought was happening, just to show how your thoughts can be different. I said that it looked like he might have pinched it and was running away. And she said, “Yes, that’s one option.” Or she said that he could have found it and was chasing after the person that had lost it. So it was just a way of learning how to think, to rethink it. Dr Lucy Maddox: So like opening up just the possibility of there being other explanations for something? Angie: Exactly. Yes, exactly. Dr Lucy Maddox: Sometimes people can experience worried or paranoid thoughts about the internet. And I was curious to know how that fed into the design of the app. Here’s Tom. Dr Tom Ward: It was something that we were considering at the beginning of the trial as something that was potentially something that people might worry about. And one of the ways in which the phone was set up is such that it was possible to use it without connecting it to the internet. So it was possible to have the phone just as a sort of a standalone resource that wouldn’t be connected to the internet and wouldn’t be synchronised with the session. Given that people might potentially have concerns about information that they were adding to a phone being transferred across. But in effect in the trial, actually people didn’t commonly express those concerns and liked the fact that what they were doing with the phone was actually linked into the session, and it was automatically bringing that into the session. So the concerns around the technology and the surveillance were actually not as significant across the trial as perhaps one might think at the beginning. It was quite interesting to see how naturally people were engaging with the technology in the session. Dr Lucy Maddox: That’s really interesting and I bet it took so much thinking through at the start to think through all of these potential problems. Dr Tom Ward: Absolutely, and part of the blending of therapy so that you have face-to-face therapy which is augmented by digital therapies you have an opportunity to develop a therapeutic relationship. To develop trust, which is so crucial when we’re working with anybody but particularly people who’ve experienced worries about other people and paranoia. So in a sense that relationship is facilitating the person engaging with technology, because there is an element of trust, hopefully in the person that they’re seeing. Dr Lucy Maddox: Sounds like it was a nice experience for you as a therapist as well. Dr Tom Ward: Absolutely. It’s a nice experience to feel that it’s a really clear and collaborative thing that we’re doing with the person. And it’s thought and designed in a way to make it engaging and easy to use and enjoyable. Yeah, that was a real pleasure to be delivering a therapy that people were engaging with in that way. I sometimes feel you sometimes hear people talk about discussions about whether people are, the idea of socialising people to a psychological model. Or you even hear sometimes people say, “Perhaps somebody is not psychologically minded.” And you still hear that. And it always really surprises me because it implies somehow that we have the great therapies already and the issue is really the person is not really getting it or able to get it. Whereas the reality is that we need to develop and provide psychological interventions that meet the needs of a diverse range of people. And actually, in a room face-to-face talking for 50 minutes can be really helpful for lots of people, but it’s not for everybody. And so, I felt really privileged that in collaboration with others like Dr Amy Hardy who really led on this, that we were able to deliver something that really seemed to meet the needs of a really diverse range of people. And so that felt really good to do that. Dr Lucy Maddox: I was just thinking the only time it would be less accessible I guess is if someone doesn’t have so much access to the internet or to digital technologies. Is that a kind of barrier that’s come up at all or have you mostly found that people tend to have access? Dr Tom Ward: This is a really important question because it’s about the extent to which some of the people that we work with may be excluded digitally. As you say, maybe don’t have access to wifi, don’t have access to smartphones. Within the trial, we are looking to develop an intervention that works for everybody, regardless of their prior experience or confidence with technology. We had quite a few people in the trial that would come having not had any access to smartphones, using digital technology or laptops. And one of the interesting things that we’re looking at is just that actually this is an intervention that was engaging for people regardless of their other experiences of digital technology. But what we actually did within the therapy is that we provided the phone, the app that was loaded onto a smartphone. So that it meant that people could use that and take that away and could have access to that. And it didn’t need to be connected to wifi at all during the week, it was something that the person could take away, and engage with and use. And when they came back into the session, it would be synchronised with the website so that anything that they’d added they might have noticed the worry or created a helpful positive thought. It would all be synchronised so that it was held within the website. So no learning was lost, it was facilitating in that way. Dr Lucy Maddox: I asked Angie what had changed for her in her life since SlowMo. Angie: Before I couldn’t always get on the bus, that was a tricky one. I didn’t like going into crowds, I’d stay home quite a bit. Then I did the SlowMo and the SlowMo made a real difference because it taught me how to think in a positive way and not in a negative way. And it meant that I could actually sit on a bus and not have to get off at a stop because I was feeling conscious of people looking at me. I could go out and meet friends. It really made a difference. Dr Lucy Maddox: That’s so good. A trial of the effects of SlowMo has recently been published. So what did you find? Dr Tom Ward: So what we found is that this was an intervention that was designed to help people who were experiencing worries about harm from others or experiencing paranoia. And what we found was that people who received the therapy did show reduced levels of worries about harm from others or paranoia at our follow up periods. So it was effective in what it was designed to do. One of the other things that we were trying to do here is that it’s designed as a targeted intervention. So we wanted to know is it effective in helping people reduce paranoia? And if it is, does it work in the way in which it’s been designed to work? And that means does it help people to slow down their fast thinking? And is that part of what helps them reduce paranoia? And so what we found is that people that had the intervention were showing significant reductions in paranoia at the follow ups, compared to people who had standardised treatment as usual. And we also found that it did work in the way that we’d anticipated, it seemed to work by allowing people to slow down their thinking and worry less. So that was really, really encouraging evidence of the effectiveness of the intervention. And as I’ve mentioned before, the significant changes were not limited to the paranoia measures that we had. We also found really important changes in areas such as quality of life, wellbeing and positive beliefs about the self, really. These are outcomes that are really valued by service users. If you think about what people want from psychological interventions and therapies, people would often say, “I want my life to be better. I want to be enjoying myself. I want to be able to go out and work.” So we were really, really happy to see that not only was SlowMo effective in reducing paranoia in the way that we expected it to. We were also seeing broader improvements in those important areas as well, so that was really good to see. Dr Lucy Maddox: That’s fantastic. And really great that it’s actually effective in reducing paranoia as well as reducing those other outcomes to do with quality of life and how people feel. That’s really exciting. Dr Tom Ward: Absolutely. Other things that we were interested in that I’d mentioned before. We wanted to see the extent to which we were successful in designing an intervention that was engaging and accessible and liked by people. And so we’re really encouraged by the evidence that we’ve got that this was something that people engaged with. Actually, delivering psychological therapy in the context of people who experience paranoia and may have difficulties building trusting relationships it can be challenging. And drop out from therapy is something that is a significant issue in our field. And so, from the perspective of someone who was responsible for the therapy across the trial, I was so happy to see that we managed to have 80% of the people in the trial who were allocated to receive the therapy completed all of the planned sessions. And in the context of the field that we work in, this was something that we’re really happy with and speaks to an intervention that people engaged with. And we’re going to be looking at also measures of enjoyment that we’ve also collected. And they’re also showing signs that people found this an enjoyable and engaging experience. So excited about those areas of the outcomes as well as the main outcomes on paranoia and other areas. Dr Lucy Maddox: That’s great, great results. And really promising, I guess, for using this approach in the future for other sorts of interventions as well, using this design led approach. Dr Tom Ward: Some of the things that we do take from what we’ve learnt is that yeah, this approach to human centred design and this engagement with thinking about making our interventions more appealing to people. This is really something that people are beginning to think about, but we need to take very seriously. Yeah, we need to start to make interventions look and feel the way people want them to. And that’s something important. And the other thing is about the blending of digital therapy with face-to-face therapy. I think some people understandably worry when they hear about digital therapy. And they worry that maybe we’ll lose something important. That most psychologists and clinicians will think about therapeutic relationship and how central that is. And I think people worry sometimes that digital technology might end up lead us away from that important truth. But what we’re trying to do with the blending of digital technology is to take what we do well in face-to-face therapy and just make it better. And make it more effective, make it more engaging and make it work for people in their lives, because that’s where the important change should be occurring. Dr Lucy Maddox: I asked Angie if there was anything else she wanted to say about the therapy. Angie: I’d just like to say that if you’re offered a therapy, then it’s worth having a go. If you feel that you’re in the right place in your head, and you’re offered some sort of therapy, it’s a good idea to embrace it and use all the help that you can. Because like me, many years ago I used to think I could cope with it and the voices would go away, and I’d be okay. But if you don’t take up opportunities when you feel like it, then you’ll miss out and people are there to help you. And you’ve got to try and understand that. And also, with the SlowMo, you’ve got the beauty of the technology with the laptop, but you’ve still got the clinician working with you. So you’ve still got a person that you can talk to. So that’s my advice to try. I know it’s not always easy but try and take up things that you’re offered and don’t be frightened to ask, if there’s anything. Dr Lucy Maddox: Yeah, that’s really, really helpful advice. And actually, you asked, didn’t you? And then you got on the trial, so that was really good. Angie: That’s right, I had to keep on. But as I say, I got there, and it worked. Dr Lucy Maddox: Yeah, it’s great, good for you. Angie: Thank you. Dr Lucy Maddox: Thank you to both my experts, Angie and Tom Ward. If you’d like more information on the SlowMo therapy, have a look at the show notes where you can find the website link. There’s a link in there as well to Angie talking on the One Show about the therapy. For more on CBT in general, and for our register of accredited therapists, check out www.babcp.com. And have a listen to our other podcast episodes for more on different types of CBT and the problems that it can help with. I hope you’ve enjoyed this bonus episode. I hope things are going well for you. END OF AUDIO Show Notes Websites For more about the research check out: http://slowmotherapy.co.uk Angie talks about SlowMo on The One Show: https://youtu.be/lCI7LKFbyrw For more on BABCP visit www.babcp.com Articles These academic journal articles below are all produced by the SlowMo team to investigate the therapy. Ward, T., Hardy, A., Holm, R., et al. (2022) 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. DOI : 10.1111/papt.12377 Garety P, Ward T, Emsley R, et al. (2021) Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial. JAMA Psychiatry. 2021 Jul 1;78(7):714-725. doi: 10.1001/jamapsychiatry.2021.0326. PMID: 33825827; PMCID: PMC8027943. Hardy A, Wojdecka A, West J, et al. (2018) How Inclusive, User-Centered Design Research Can Improve Psychological Therapies for Psychosis: Development of SlowMo. JMIR Ment Health ;5(4):e11222 doi: 10.2196/11222 Garety, P.A., Ward, T., Freeman, D. et al. (2017) SlowMo, a digital therapy targeting reasoning in paranoia, versus treatment as usual in the treatment of people who fear harm from others: study protocol for a randomised controlled trial. Trials 18, 510 . https://doi.org/10.1186/s13063-017-2242-7 Books Overcoming Paranoid and Suspicious Thoughts by Freeman, Freeman & Garety https://overcoming.co.uk/600/Overcoming-Paranoid-And-Suspicious-Thoughts---FreemanFreemanGarety