Thomas K J Craig

• King's College London

AVATAR therapy (AT) works by facilitating a ‘face‐to‐face’ dialog between the person and a digital representation (avatar) of their persecutory voice. Although there is cumulative evidence of this way of working with voices, enhancing the therapeutic focus on improved confidence and a sense of control of the voices in social situations represents a...

This article describes a Patient and Public Involvement (PPI) led creative workshop space held within a clinical trial of a talking therapy for distressing voices (AVATAR2). PPI adds significant value to clinical research and ensures the work is meaningful to patients and their supporters. However, known issues include tokenism, a common power imba...

Aim To explore the distributed impact of severe mental health conditions (SMHCs) among people with lived experience of SMHCs, their family members, and community members. Methods We conducted in-depth interviews with family key informants of people with SMHCs (n = 32), people with SMHCs (schizophrenia, bipolar disorder, and major depression) (n =...

Aim There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses deg...

This paper explores AVATAR therapy, an innovative therapeutic intervention for people experiencing auditory verbal hallucinations (AVH) where participants interact with their 'voice' in the form of a co-designed visual representation of their voice. Previous research has found AVATAR therapy to be successful in its aim to initiate change in the par...

Purpose We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS. Methods We used incidence data linked to the Clinical Record Interactive Search—First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We...

Social psychiatry is a discipline that focuses on the social dimension of mental health, mental illness, and mental healthcare. It uses concepts and methods of biological and social sciences, including sociology, psychology, and anthropology, to investigate social factors influencing and relevant to occurrence, expression, course, and care of menta...

Introduction Many people suffering from psychotic disorders report persistent auditory verbal hallucinations (‘voices’) despite pharmacological and psychological therapy. Interest is growing in approaches that emphasise the personal relationship between the patient and their voice(s). AVATAR therapy is one such approach that uses a digital represen...

Human beings are social animals, and social psychiatry is a key discipline within psychiatry around the world. The impact of social factors on the genesis and perpetuation of mental illnesses and maintenance of well-being of individuals and families is well recognized. Exploring social factors is the key to understanding aetiology and developing th...

Human beings are social animals, and social psychiatry is a key discipline within psychiatry around the world. The impact of social factors on the genesis and perpetuation of mental illnesses and maintenance of well-being of individuals and families is well recognized. Exploring social factors is the key to understanding aetiology and developing th...

Human beings are social animals, and social psychiatry is a key discipline within psychiatry around the world. The impact of social factors on the genesis and perpetuation of mental illnesses and maintenance of well-being of individuals and families is well recognized. Exploring social factors is the key to understanding aetiology and developing th...

Aim: To explore the distributed impact of Severe Mental Disorders (SMD) among people with lived experience of SMD, their family members, and community members. Methods: We conducted in-depth interviews with family key informants of people with SMD (n=32), people with SMD (schizophrenia, bipolar disorder, and major depression) (n=10), and community...

Background AVATAR therapy is an innovative therapy designed to support people with distressing voices. Voice hearers co-create a digital representation of their voice and engage in dialogue with it. Although it has been successfully tested in a powered randomised controlled trial (ISRCTN65314790), the participants’ experience of this therapy has no...

Background ‘Open Dialogue’ is a social network model of crisis and continuing mental healthcare which involves elements of service delivery such as immediate response and a style of therapeutic meeting called network meetings. Although there are indications from non-randomised studies that it may help people in their recovery from severe mental hea...

Background Severe Mental Disorders (SMDs) affect multiple generations although this is poorly studied. The aim of this study was to investigate the intergenerational and multidimensional impacts of SMD in rural Ethiopia. Methods This comparative study was nested within an existing population-based cohort study. We collected data from a total 5762...

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outline...

According to the latest figures from the UNHCR, we are now witnessing the highest number of displaced people in modern times. These displaced people have not only lost the security of familiar surroundings and kinship networks, but also many are leaving war-torn societies and have witnessed or experienced extremes of violence and abuse. It is not s...

Background People with schizophrenia have shortened lives. This excess mortality seems to be related to physical health conditions that may be amenable to better primary and secondary prevention. Better continuity of care may enhance such interventions as well as help prevent death by self-injury. Aims We set out to examine the relationship betwee...

Mind, State and Society examines the reforms in psychiatry and mental health services in Britain during 1960–2010, when de-institutionalisation and community care coincided with the increasing dominance of ideologies of social liberalism, identity politics and neoliberal economics. Featuring contributions from leading academics, policymakers, menta...

Objectives There is inconsistent evidence on the influence of ethnicity on duration of untreated psychosis (DUP). We investigated ethnic differences in DUP in a large epidemiological dataset of first episode psychosis patients in an inner city area of south London, UK.Methods We analysed data on 558 first episode psychosis patients at the South Lon...

Introduction Between one fifth and one quarter of people who become unwell with a psychotic disorder will develop particularly complex problems (1). These include severe, treatment-resistant symptoms and cognitive impairments that affect motivation, organizational, and social skills. Co-existing mental, neurodevelopmental, and physical health condi...

Background AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucinations (henceforth ‘voices’). A digital simulation (avatar) of the voice is created and used in a three-way dialogue between participant, avatar and therapist. To date, therapy has been delivered over 6 sessions, comprising an initial phase, focusing on...

Objectives: AVATAR therapy is a novel relational approach to working with distressing voices by engaging individuals in direct dialogue with a digital representation of their persecutory voice (the avatar). Critical to this approach is the avatar transition from abusive to conciliatory during the course of therapy. To date, no observational study...

Background Voices are commonly experienced as communication with a personified ‘other’ with ascribed attitudes, intentionality and personality (their own ‘character’). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural enga...

Background Long-acting injectable (LAI) antipsychotic medications are used to optimise treatment outcomes in schizophrenia. Guaranteed medication delivery increases the responsibility of prescribers to monitor and manage adverse effects. Methods In the context of a quality improvement programme conducted by the Prescribing Observatory for Mental H...

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outline...

The number of people displaced from their homes as the result of war, civil unrest, and persecution worldwide is now at the highest level on record. Around a fifth make it to affluent Western nations, prompting a marked rise in tension and in efforts to stem the tide by tightening quotas, clamping down on ‘illegals’, and erecting physical barriers....

Purpose Although participation is key to community mental health, the concept remains elusive. The study explored a conceptualization of participation in the community-based mental health agencies context from a first-person perspective, using the Clubhouse model as an example. Methods Qualitative data, collected from 21 Clubhouse service users th...

Background The poor translation of research findings into routine clinical practice is common in all areas of healthcare. Having a better understanding of how researchers and clinicians experience engagement in and with research, their working relationships and expectations of each other, may be one way to help to facilitate collaborative partnersh...

AVATAR therapy is a newly developed treatment for auditory verbal hallucinations (AVH) that uses virtual reality technology to allow a three-way interaction between therapist, participant, and the entity the person believes is the source of their distressing auditory verbal hallucinations with the aim of reducing the perceived power and hostility o...

Psychotic Disorders: Comprehensive Conceptualization and Treatments emphasizes a dimensional approach to psychosis that cuts across a broad array of psychiatric diagnoses from schizophrenia to affective psychosis and organic disorders like epilepsy and dementias. Written by an international roster of over seventy leading experts in the field, this...

AVATAR therapy offers a unique therapeutic context that uses virtual reality technology to create a virtual embodiment of the voice-hearing experience, enabling the person to visualize their persecutory voice and engage in real-time “face-to-face” dialogue. The present study explores, for the first time, the contribution of sense of voice presence,...

Background A growing body of research suggests that childhood adversities are associated with later psychosis, broadly defined. However, there remain several gaps and unanswered questions. Most studies are of low-level psychotic experiences and findings cannot necessarily be extrapolated to psychotic disorders. Further, few studies have examined th...

Author’s reply - Volume 217 Issue 1 - Alastair Macdonald, Dimitrios Adamis, Tom Craig, Robin Murray

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets...

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets...

This study aimed to investigate potential ethnic differences in cognitive responses to caregiving in psychosis that might be relevant to the delivery of caregiver interventions for difficulties related to psychosis. We compared cross-sectional outcomes across early-stage caregivers who self-identified as white British ( n = 37) and those who self-i...

Objective: Stressful life events have been implicated in the onset of psychotic disorders, but there are few robust studies. We sought to examine the nature and magnitude of associations between adult life events and difficulties and first-episode psychoses, particularly focusing on contextual characteristics, including threat, intrusiveness, and...

The typical reliance on self-report questionnaires in retrospective case-control studies of childhood abuse and psychotic disorders has been criticised, due to the potential for recall bias associated with, amongst other factors, cognitive impairments and detachment from reality, among individuals with psychosis. One way to establish if any substan...

Objective The impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children...

Background A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time. Methods We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May...

Background: Cardiovascular disease (CVD) is the leading cause of premature death among people with serious mental illness (SMI). Sedentary behaviour (SB) is an independent risk factor for CVD and mortality and people with SMI are highly sedentary. We developed a health coaching intervention called 'Walk this Way' to reduce SB and increase physical...

The development of effective preventions for psychosis is hindered by conceptual challenges underlying diagnosis and the fact that few of the many biological risk factors identified to date are sufficiently well understood to form the basis of a targeted intervention. On the other hand, a great deal is known of the psychosocial conditions that incr...

Background: Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has...

Background: Cannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive c...

Objectives Compared with the majority population, those from minority ethnic groups in the UK are more likely to be admitted compulsorily during a first episode of psychosis (FEP). We investigated whether these disparities in pathways in to care continue. Methods We analysed data from two first episode psychosis studies, conducted in the same geog...

The association between unemployment and mental disorders is complex. Some of the strongest evidence for the causal impact of losing employment on mental health comes from studies carried out during and in the years following national and international financial crises and economic recession. Mental health problems can also lead to unemployment and...

Conversion disorder and the trouble with trauma - Volume 49 Issue 10 - Richard A. A. Kanaan, Thomas K. J. Craig

Studies in the 1990s showed that, compared with the majority populations, people from minority ethnic groups in England were more likely to access psychiatric care via crisis routes. This chapter, and the studies it is based on, explore whether this adverse pattern continues. The authors analysed data from two population-based studies of first-epis...

Background Duration of untreated psychosis (DUP) is identified as a major contributor to the variation in outcomes following first episode psychosis. We investigated to what extent differences in pathways to care and DUP by ethnicity is associated with the type of specialist mental health service the patients encounter during first contact with men...

Background Effective interventions are needed to prevent cardiovascular disease (CVD) in people with severe mental illnesses (SMI) because their risk of CVD is higher than that of the general population. Objectives (1) Develop and validate risk models for predicting CVD events in people with SMI and evaluate their cost-effectiveness, (2) develop a...

The field of digital mental health is rapidly expanding with digital tools being used in assessment, intervention , and supporting self-help. The application of digital mental health to hallucinations is, however, at a very early stage. This report from a working group of the International Consortium on Hallucinations Research considers particular...

Background Although patients value evidence-based therapeutic activities, little is known about nurses' perceptions. Aims To investigate whether implementing an activities training programme would positively alter staff perceptions of the ward or be detrimental through the increased workload (trial registration: ISRCTN 06545047). Method We conduc...

Patient-initiated violence may pose a significant risk to the strength and longevity of informal caregiving relationships in psychosis. We aimed to assess caregiver reports of patient-initiated violence in early psychosis and to examine the relationship between violent incidents and appraisals of caregiving, perceived mental wellbeing in caregivers...

Background High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinica...

Background Despite the movement towards care in the community, 40% of the NHS budget on mental health care is still attributed to inpatient services. However, long before the Francis Report highlighted grave shortcomings in inpatient care, there were reports by service user groups on the poor quality of these services in mental health. The programm...

The social environment plays a significant role in the onset, course and outcome of mental disorders. The impact has been conceptualised in two broad ways. First, in terms of unspecified aspects of how society is structured, as for example the observation of much higher rates of mental illness in areas of high population density or among minority e...

There are strong links between housing quality and ill health, in particular infections, chronic diseases, and injuries. Poor-quality housing is associated with mental illness, although the links are complex given the fact that decrepit housing is often also high rise, multiple occupancy, and located in neighbourhoods characterized by vandalism, gr...

Background Both childhood maltreatment and insecure attachment are known to be associated with depression in adulthood. The extent insecure attachment increases the risk of adult clinical depression over that of parental maltreatment among women in the general population is explored, using those at high risk because of their selection for parental...

This study is aimed at the importance of social care in rehabilitation. A brief overview of the social care theme is used as the methodology. There is a tension in mental health care between biological and psychological treatments that focus on deficits at the individual level (symptoms, disabilities) and social interventions that try to address lo...

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10–20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in...

Background While the neighborhood community literature well documents a link between participation in supportive and effective community groups or activities and empowerment, there is as yet little empirical evidence of this relationship in the context of community mental health programs. Aim The primary purpose of the study was to examine the rel...

Since the 1960s, we have witnessed the development and growth of community mental health care that continues to dominate mental health policy and practice. Several high-income countries have implemented community mental health care programmes but for many others, including mostly low- and middle-income countries, it remains an aspiration. Although...

Maudsley International was set up to help improve people's mental health and well-being around the world. A variety of programmes have been developed by Maudsley International over the past 10 years, for planning and implementing services; building capacity; and training and evaluation to support organisations and individuals, professionals and man...

Objective: To describe the characteristics of individuals with early sustained recovery following first episode psychosis. Methods: Individuals with a first episode psychosis were followed-up for ten years. Comparisons were made between those with Early Sustained Recovery and those with Other Course types. Results: Of 345 individuals, n=43 (12...

Aim: Looking after someone in the early stages of psychosis can have a negative impact on caregivers, but there is little clarity about which interventions, if any, caregivers should be offered. This study investigated sleep disturbances in early psychosis caregivers and the relationship between their sleep quality and distress. Method: In all,...

This study assessed the subjective experience of participating in a clinical trial, specifically positive and negative experiences and the experience of audio recording assessment sessions. The study was cross-sectional from a single blinded randomised controlled trial. Forty participants with a primary diagnosis of non-organic psychosis completed...

Background: people with severe mental illnesses, including psychosis, have an increased risk of cardiovascular disease. We aimed to evaluate the effects of a primary care intervention on decreasing total cholesterol concentrations and cardiovascular disease risk in people with severe mental illnesses. Methods: we did this cluster randomised trial...

Improving access to psychotherapies in psychosis requires workforce expansion in resource-challenged systems. The GOALS feasibility randomized controlled trial assessed training and implementation of an evidence-based intervention by frontline workers, targeting recovery goals. Training uptake and therapy fidelity were good. Case managers with cris...

Background and objectives: There is a pressing need to improve access to evidence-based practice for people with psychosis. The primary aim of this study was to assess clinical feasibility of a manualised, evidence-based CBT intervention (GOALS) targeting a personalised recovery goal, delivered by the frontline workforce, following brief training....

Background: A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less...

Background: Recovery in mental health services is defined as living a satisfying, hopeful, and contributing life even with any limitations caused by illness. An evidence base for understanding and supporting recovery is needed. Objectives: To carry out a programme of linked research studies to understand how mental health services can promote recov...

Objectives Key challenges for mental health healthcare professionals to implement research alongside clinical activity have been highlighted, such as insufficient time to apply research skills and lack of support and resources. We examined the impact of employing dedicated staff to promote research in community mental health clinical settings. Des...

Over the last two decades, there has been a rapid increase of studies testing the efficacy and acceptability of virtual reality in the assessment and treatment of mental health problems. This systematic review was carried out to investigate the use of virtual reality in the assessment and the treatment of psychosis. Web of Science, PsychInfo, EMBAS...

Background Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients’ views of ward care. Method Cluster randomised trial with stepped wedge...

Objective Our primary objective was to identify cognitive behavioural therapy (CBT) delivery for people with psychosis (CBTp) using an automated method in a large electronic health record database. We also examined what proportion of service users with a diagnosis of psychosis were recorded as having received CBTp within their episode of care durin...

Background Smoke-free policies are important to protect health and reduce health inequalities. A major barrier to policy implementation in psychiatric hospitals is staff concern that physical violence will increase. We aimed to assess the effect of implementing a comprehensive smoke-free policy on rates of physical assaults in a large UK mental hea...

A small-scale consultation of care leavers in South London was undertaken in 2013–2014, in order to inform a pilot mentoring scheme to reduce depression in young women through supporting their transition from care to independence. Research on the social factors implicated in the onset and course of depression indicates that social support during st...

![Figure][1] James (Jim) Watson, who died after a stroke on 3 August 2016 aged 80, was among a small band of British psychiatrists who trained in the 1960s and 70s to take psychiatry out of the asylums and establish robust services in general hospital and community settings. They were also

Mental health rehabilitation services work with people with severe and complex mental health problems: a ‘low-volume, high-needs’ group. Our research programme involved a national survey of NHS inpatient mental health rehabilitation services, the development of a staff training programme to help staff engage service users in activities, a trial to...

Objective: The proportion of people with mental health disorders who participate in clinical research studies is much smaller than for those with physical health disorders. It is sometimes assumed that this reflects an unwillingness to volunteer for mental health research studies. We examined this issue in a large sample of patients with psychosis....

Background: The negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation and socialization that tend to be persistent despite standard antipsychotic treatment. Two sub-domains of expressive deficits (affective flattening and poverty of speech) and avolition-amotivation for daily-life and social activities (a...

Background: A shorter duration of untreated psychosis (DUP) is associated with better outcomes following first-episode psychosis (FEP; Power et al., 2007; Birchwood et al., 2013; McGorry et al., 2008). However, the evidence on social and clinical factors that may predict to DUP is inconsistent. Aims: To investigate the association between DUP and s...

Introduction: This article introduces the SAINT (Self-Assessment and INTervention), a guided self-help intervention for the treatment of mild depression in people with intellectual disabilities. Method: The study used a single-case experimental design and adopted quality frameworks specific to the approach to describe the participants and to standa...