The next great challenge in mental health research is bringing innovation into care.

Professor Philippa Garety 

Professor Philippa Garety has spent more than four decades shaping the cognitive understanding of psychosis. A pioneer of cognitive behavioural approaches for psychosis, she and her colleagues have developed innovative therapies such as SloMo and contributed to the development of AVATAR therapy. In this interview for Fondation FondaMental, she reflects on the evolution of the field, the role of digital innovation, and the challenge of bringing research breakthroughs into routine clinical care. 

Your work has been central in shaping cognitive models of psychosis. For someone unfamiliar with the subject, how would you describe psychosis in simple, everyday terms? 

Psychosis involves being confronted with unusual experiences that can profoundly change the way a person experiences their own thoughts and the world around them. People may feel fearful, confused, or convinced that others want to harm them. They may feel that their thoughts are being interfered with or controlled, or they may hear voices without being able to identify where they are coming from. When these experiences occur, people naturally try to make sense of them. Often, that search for explanation creates a strong feeling of threat. As a result, many people withdraw socially or become hypervigilant. 

“Most experiences associated with psychosis exist on a continuum with everyday human experience” 

There are still many misconceptions about psychosis in the general public. One important point is that people living with psychosis are far more likely to be victims of violence or crime than perpetrators. Because they may be frightened, vulnerable, or struggling to interpret situations clearly, they can actually become more exposed to harm from others. 

How has your understanding of the mechanisms underlying hallucinations and delusions evolved over the past four decades? 

It has changed enormously, and in some ways, come full circle. When I began my work in the early 1980s, I was primarily interested in delusions, especially persecutory beliefs: the feeling that other people intend to harm you. I wanted to understand what kinds of reasoning processes could lead someone to reach those conclusions. My early work, influenced by cognitive psychology and philosophy of reasoning, showed that people experiencing delusions often display what we called a “jumping to conclusions” bias: reaching firm conclusions on the basis of very little evidence. 

Over time, I became increasingly interested in the emotional dimension of psychosis. Fear, anxiety, depression, low self-esteem and past adversity all strongly influence the way people interpret their experiences. I also worked extensively on hallucinations and voice hearing. 

One of the major conclusions I reached, together with other psychologists in the United Kingdom at that time, is that many experiences associated with psychosis exist on a continuum with everyday human experience. Many people occasionally experience unusual thoughts, fleeting suspicions, or even hear a voice when nobody is there. What becomes crucial is the appraisal people make of those experiences: how threatening or meaningful they perceive them to be. 

For many years, this led us toward complex, multifactorial models that attempted to integrate reasoning styles, emotional states, trauma histories and social experiences into a broad cognitive behavioural framework. 

Interestingly, when you work effectively on one central process, many other aspects of well-being often improve alongside it. 

More recently, however, I have come to believe that while these complex models remain valuable for understanding psychosis, they are not always the most effective therapeutic tools. If both therapist and patient try to work simultaneously on too many different mechanisms, it can become difficult to maintain a clear therapeutic focus. 

Today, I increasingly favour interventions that target one or two key processes very precisely. For example, with paranoia, we may focus specifically on rapid threat-based thinking and help people learn to slow down and review their interpretations more carefully. With distressing voices, we may focus on reducing the perceived power and dominance of the voice. Interestingly, when you work effectively on one central process, many other aspects of psychosis and more general well-being often improve alongside it. 

You have pioneered innovative approaches such as SloMo. Could you explain how this therapy works? 

SloMo, which stands for “Slow Down for a Moment”, is based on research showing that people experiencing persecutory delusions tend to rely heavily on rapid, automatic reasoning processes. They are less likely to engage in slower, more analytical thinking. 

The therapy uses the brilliantly accessible language coined by Daniel Kahneman’s work on “fast and slow thinking”¹. The goal is to help people notice when they are thinking quickly and automatically, especially in moments of paranoia or threat. Through cognitive behavioural techniques, patients learn to pause, step back, review the evidence, and generate what we call “safer thoughts”. 

One distinctive feature of SloMo is that it is a blended digital therapy. Together with designers from the Royal College of Art in London, we developed web-based resources and a personalised mobile application. The app visualises thoughts as spinning bubbles, allowing people to identify and slow down escalating thought patterns in real time. The therapy usually takes place over 8 to 12 sessions and has shown significant reductions in paranoia, alongside improvements in quality of life. 

You have also contributed to the development of AVATAR therapy, which directly engages with distressing voices. How does this approach differ from more traditional treatments? 

AVATAR therapy is quite different. It is designed for people who experience distressing voices. Research has shown that voices become particularly distressing when they are experienced as powerful, dominant and controlling. People often develop a relationship with their voices: they attribute intentions, personalities or identities to them. 

AVATAR therapy allows patients to engage directly with a digital representation of the voice. Together with the therapist, the patient creates a face and a voice corresponding to what they hear. Special software then transforms the therapist’s voice into the voice of the avatar. 

During sessions, the therapist and patient engage in a structured dialogue with the avatar. Initially, the work often focuses on assertiveness, by helping the person stand up to the voice and refuse abusive or controlling behaviour. Over time, the dialogue can become more complex and emotionally meaningful. 

For some patients, the avatar may represent unresolved relationships or past experiences. The therapy can therefore evolve toward acceptance, reconciliation, or a redefinition of the relationship with the voice. The goal is not necessarily to eliminate voices entirely, but to reduce distress and help people regain a greater sense of control over their lives. 

These approaches have shown promising results in research settings. What are the main challenges in bringing them into routine clinical practice? 

The challenge today is no longer only innovation, it is implementation. We now have therapies that show strong evidence of effectiveness, and both SloMo and AVATAR therapy have received preliminary positive recommendations from NICE, the UK’s National Institute for Health and Care Excellence. The next step is integrating them into everyday healthcare systems, but digital therapies face several specific barriers.  I discussed these with Dr Amy Hardy and Dr Tom Ward, who have been key members of our SloMo and AVATAR therapy teams, and, as I am now retired, they are now taking the leadership of the programmes of work focussed on implementation. 

They both highlighted two major challenges which resonated with my experience. The first is trust. People naturally worry about the use and sharing of personal data, and this concern may be particularly important for individuals experiencing paranoia. We therefore worked very carefully to ensure that patients maintain genuine control over what information is shared between digital tools and therapists. 

We have found that successful implementation depends heavily on the presence of “champions” within healthcare systems.  

The second challenge is confidence and competence, for both patients and clinicians. Many clinicians are already under considerable pressure, and introducing new digital tools requires time, training and support. We have found that successful implementation depends heavily on the presence of “champions” within healthcare systems: clinicians who support colleagues, troubleshoot difficulties, and encourage adoption. Technical support staff and people with lived experience also play an essential role. 

Importantly, the issue is not limited to younger or highly digitally skilled patients. SloMo was deliberately designed with a very wide range of users in mind, including older adults and people with low confidence using technology. Encouragingly, our trials showed that outcomes remained positive across very different patient profiles. 

Similarly, for AVATAR therapy, we expected certain groups of patients to benefit more than others, but the research did not confirm this. The therapy appeared effective across age groups, illness duration and symptom profiles. 

If you had unlimited resources, what would be your top research priority for the next decade? 

My biggest priority would be closing the gap between innovation and clinical reality. Too often, we develop innovative therapies that never truly reach patients on a large scale. I would love to see the creation of large networks of clinical centres, similar in spirit to the Fondation FondaMental’s Expert Centres, dedicated not only to testing treatments, but also to studying how to implement them effectively in real-world settings. We need what are called “living laboratories” of implementation: clinical environments able to adapt quickly, evaluate usability as well as effectiveness, and continuously refine how therapies are delivered. 

One encouraging development is that major research funders have started recognising implementation itself as a major scientific challenge. When I began my career, implementation research was often considered outside the scope of “real” research. Over the past decade, organisations such as the Wellcome Trust have increasingly recognised the importance of ensuring that advances in mental health research translate into tangible benefits for patients. This shift gives me hope. 

Professor Philippa Garety is Emeritus Professor of Clinical Psychology at King’s College London. Following her retirement, ongoing research and implementation work on SloMo and AVATAR therapy are being led by Dr Amy Hardy and Dr Tom Ward at King’s College London.