A pilot study of BRAVE, a CBT intervention to reduce violence risk in early psychosis

Violence risk is elevated during the early phase of psychosis and can have significant consequences for engagement, recovery, and safety. BRAVE (Behavioral Response Against Violence Engagement) is a cognitive-behavioural intervention adapted from the PICASSO model for use in early intervention services (EIS) that targets dynamic, modifiable mechanisms associated with psychosis-related violence. This open pilot trial evaluated the feasibility, acceptability, fidelity, and preliminary target engagement of BRAVE when delivered by clinicians within routine EIS care. Seven clinician-client dyads were enrolled across OnTrackNY sites; five completed the intervention, with a mean of 11.4 sessions. Feasibility and acceptability were high: clinicians rated BRAVE as useful and deliverable within standard visit structures. Fidelity ratings were high across both clinician and client checklists. Although violent behaviour was infrequent at baseline, exploratory clinical outcomes suggested reductions in violent ideation over time. The primary hypothesized mechanistic target, impulsivity, remained stable but secondary mechanistic outcomes showed directionally positive movement across the affective, cognitive, behavioural, and physiological domains expected to shift with BRAVE, including reductions in hostility, negative self-appraisal, persecutory thinking, substance use, and sleep disturbance, alongside increased coping self-efficacy. Overall, findings indicate that BRAVE can be implemented with high fidelity and strong acceptability within participating clinician-client dyads in EIS settings, and offer preliminary descriptive patterns consistent with the hypothesized mechanistic model.