“ Mental Health Research: What are the risks of that happening ?

1. Professor Paul Rogers Professor of Forensic Nursing Faculty of Health, Sports and Science “ Mental Health Research: What are the risks of that happening?

2. Aim Give a rough overview of my career. Present two examples of research which examines the evidence base examining mental health and the issue of “risk” of violence. Of note, these are areas where the “evidence” or the “clinical practice” had already been very firmly established. So there was “no need” to do the research!!! Available to download from - http://office.research.glam.ac.uk/

3. Forensic (psychiatric) Nursing Forensic – pertaining to the law Nursing ........those who by the nature of their health condition are likely to come into contact with the legal / criminal justice system. Historically related to mental health Offenders of Crime (UK) Victims of Crime (USA)

4. Why Psychiatric Nursing? Nature versus Nurture Mother and Father are Psychiatric Nurses. My Father was the eldest of 9 siblings, of whom 7 became psych nurses My mother has one sister who is a psych nurse My Maternal Grandmother was one of the first ever Registered Psychiatric Nurses in Ireland (Kilkenny). Y C S H I P

5. My background - Is there a gene for “psychiatric nursing”? = Psychiatric nurse gene??!

7. I was told that I had to do …………………………………………………………………………………………………“the obligatory baby photos”!

8. The obligatory baby snapshot!!! TO INSERT

10. Early career • Aged 16. Tomato picking, Southport • Aged 16. Psychiatric Nursing Home, Southport • Aged 17. General Nursing Home, Southport • Aged 17. GNC Nursing entrance test – Park Lane Hospital • Aged 18. Student Psychiatric Nurse – Fairfield Hospital, Beds

11. Fairfield Hospital, Bedfordshire

12. Fairfield Hospital • Opened in 1860 - Three Counties • Asylum (Beds., Bucks., Herts.) • 350 Acres • In 1986 had 63 wards; All were • full with a patient population • in excess of 2000 • Approximately 25% of Wards were “locked” • Most Secure Ward = M8 Ward

13. M8 Ward 36 bedded Male Ward (mostly from Bedford Prison) Four staff 18 Seclusion rooms

14. Fairfield Hospital – In short • Met Allison • Practices were “staff focussed” • Control & Restraint training • Why wasn’t violence “predicted” • How are things “prevented” • What is Psychiatric nursing?

15. National Brain Injury Unit • Aged 21 (1989) – Staff Nurse - National Brain Injury Rehab Service, St Andrew’s Hospital, Northampton • Applied Behaviourism • 15 minute token economy programme • Time Out for Aggression & Ind. Programmes • Last ward in the UK to use “Food” as a “reinforcer” • Moving to a culture of “positive programmes” • Became a Home Office “approved” Control and Restraint Instructor

16. Caswell Clinic, Bridgend & District NHS Trust • Aged 23 – Charge Nurse • Intensive Care Unit, • Caswell Clinic, • Interim Medium Secure Unit • “Humanistic approaches” • No seclusion rooms • Care was focussed through the Nursing Care Plans • At that time - No real “Risk assessment” • Cert ENB 650 Course

17. Cert ENB 650 - 99 Denmark Hill, Maudsley Hospital

18. Cert ENB 650 - 99 Denmark Hill, Maudsley Hospital • ● 18 month, Full time course; we were Course 15 • ● Started in 1971, National Referral Centre • ● Clinical Director - Prof Isaac Marks • ● Trained nurses to deliver Behaviour Therapy • ● Previous Students – Prof Kevin Gournay, Prof Charlie Brooker • ● 1n 1994 - Approx 12 National Training places • ● “De-constructed” what we did and then ++ training • ● Treated out-patients (OCD, PTSD, Agoraphobia, Social Phobias, Habit Disorders, Body Dysmorphic Disorder, Specific phobias) • ● The Single Case Study Experimental Design

19. The Single Case Study Experimental Design

20. Caswell Clinic - The Single Case Study Experimental Design • Aged 28 (1995) returned to the Caswell Clinic - CNS in CBT • Rogers, P. (1997). Posttraumatic stress disorder following male rape. Journal of Mental Health, 6(1), 5-9. • Rogers, P. and Darnley, S. (1997). Self-monitoring, competing response and response cost in the treatment of trichotillomania. Behavioural and Cognitive Psychotherapy, 25, 281-290. • Rogers, P. & Gronow, T. (1997). Anger Management: Turn down the heat. Nursing Times, 93(3), 26-29. • Rogers, P., Gray, N.S., Williams, T. & Kitchener, N.J. (2000). The behavioural treatment of PTSD in a perpetrator of manslaughter. Journal of Traumatic Stress, 13, 511-519. • .

21. Clinically • CBT – seeing two main sets of clients • 1. Males with horrendous personal histories who developed PTSD • 2. Those with “command hallucinations” who had acted on their commands with very serious consequences • The psychiatric research at that time reported that Command hallucinations were NOT dangerous (either suicide / violence)!

22. Preliminary study – examining command hallucinations and “risks” • We examined whether patients in a Medium Secure Unit were more likely than other clients to: • Engage in self harm / suicidal behaviour • 2. Engage in violence to others • Main issues that we found were 1. What about the “content” of the command & 2. What about possible confounding • Rogers, P., Watt, A., Gray, N.S., MacCulloch, MM & Gournay, K. (2002) Content of command hallucinations predicts self harm but not violence in a medium secure unit. Journal of Forensic Psychiatry, 13(2), 251-262.

23. PhD - The Association between Command Hallucinations and Violence

24. 1999 - PhD The Association between Command Hallucinations and Violence • Full time funded PhD – Wales Office of Research and Development • Undertook PhD at the Institute of Psychiatry with Professors Kevin Gournay and Professor Graham Thornicroft as supervisors • Advisors – Professor Nicola Gray, Cardiff University and Professor Glyn Lewis, Bristol University

25. “Command hallucinations are auditory hallucinations that order particular acts, often violent or destructive ones and instruct a patient to act in a certain manner” (Hellerstein et al, 1987) Command Hallucinations

26. By the mid 90’s, UK policy / politicians had tasked forensic and mental health practitioners to improve risk assessment and management In the past 60 years, international research has examined the associations between 1. Diagnosis and 2. Symptoms of mental disorder and violence. No strong association between diagnosis and violence Some positive associations found for delusions and violence No association found for command hallucinations Command hallucinations and risk

27. Clinical wisdom from the past 70 years has assumed and directed that command hallucinations are associated with and lead to violence. Bleuler, E. (1930). Textbook of Psychiatry (trans A.A. Brill), New York, Macmillan. Schneider, K. (1959) Clinical Psychopathology. New York. Stratton. Clinical Wisdom

28. The research just didn’t make sense!! Clinically, we had encountered many people who report having been violent as a direct result of hearing command hallucinations. Personal experience = high proportion of clients in forensic services report command hallucinations. Many of the patients in the homicide inquiries had command hallucinations Real World experiences

29. Violence to others (Good, 1997) Self amputation of a limb (Hall et al, 1981) Swallowing objects (Karp et al, 1991) Plucking out own eyes (Field & Waldfogel, 1995) Self inflicted lacerations (Rowan & Malone, 1997) Suicide (Zisook et al, 1995) Numerous Case Reports

30. By year 1999, 7 controlled studies had found NOrelationship between command hallucinations and an increased risk of violence Therefore, 3 systematic reviews had also found NO relationship between command hallucinations and an increased risk of violence Command Hallucinations & Violence (Pre-2000)

31. Have psychiatric practitioners and services been unnecessarily detaining people due to a 70 year old “myth” about the association between command hallucinations and violence? Bleuler, E. (1930). Textbook of Psychiatry (trans A.A. Brill), New York, Macmillan. Clinical wisdom or “psychiatric myth”

32. None of the studies were prospective. Research evidence was based upon a total population of 237! Only 13% of cases had reported commands directing violence Time for some critical appraisal

33. Study examples

34. Are the pre-2000 studies that found no association accurate ??? or …................... Could they possibly be misleading Clinicians into discharging people who “may” be a risk? Trying to make sense of the “evidence”

35. SECONDARY ANALYSES OF THE MACARTHUR VIOLENCE RISK ASSESSMENT DATAResearch grant provided by the Wales Office of Research and Development for Health and Social Care (S98/004)

36. Are violent-content command hallucinationsassociated with 1yr FU violence compared with all other patients? What happens to the association if we examine those with non-violent content command hallucinations? Research Questions

37. Secondary data epidemiological analysis of the MacArthur Violence Risk Study Data Largest worldwide study of its kind which used multiple methods for determining whether violence occurred after discharge 1,136 patients were randomly selected from 12,873 patients who were admitted to any of three large US hospitals Patients followed up every 10 weeks for 1 year Sample

38. All participants were followed up every 10 weeks for 1-year after discharge Subject self-reports Collateral informant reports Official arrest records Hospital admitting incident chart information Rehospitalisation records All violent incidents were systematically reviewed, independently coded and a decision was made as to whether it occurred Outcome Measure: Violence

39. THE AUDITORY HALLUCINATIONS SCHEDULE Have you more than once had the experience of hearing things or voices other people couldn't hear? Do the voices tell you to do anything? What is the highest level of violence they have commanded? This allowed us to categories commands in to two groups: - violent or non violent Exposure: Command Hallucinations

40. Age Gender Marital status Ethnicity Beaten as a child Beaten as a teenager History of drug abuse History of alcohol abuse Severity of symptoms (BPRS) Impulsivity (BIS) Any delusions Persecutory delusions Psychopathy (PCL:SV) Living with relative post discharge Prior arrests for “crimes against the person” Adjusted confounders

41. Random-effects, repeated measures, logistic regression Unadjusted and then adjusted Odds ratios -adjusted for time, and a range of confounders (with 95% C.I.’s) Odds ratios: Anything above “1” = an increased risk of violence. Anything below “1” = a reduced risk of violence Statistical Analysis

42. The words - “all your eggs” and............... “one basket” - spring to mind! Results

44. There was good evidence that violent-content command hallucinations were associated with future violent incidents both before and after adjustment for confounding. There was no evidence that any-content command hallucinations were associated with future violent incidents either before or after adjustment for confounding. Conclusions

45. We need to consider the content of command hallucinations when making decisions about future violence risk We need to trust our clinical “uncertainty” We need to critically appraise the quality of research when making conclusions about their findings What training are staff getting regarding risk assessments and the evidence base??? Real world implications

46. 2002. Left the NHS for University Life! And properly joined the Section of Nursing, Health Service Research Department, Institute of Psychiatry, Kings College. Professor Kevin Gournay, Dr Sue Plummer, Dr Richard Gray, Dr Mark Haddad, Jimmy Noak, Edwin Gwenzie, et al. Awarded £220,000 by the Medical Research Council to conduct secondary analysis of two cross sectional surveys in order to investigate the aetiology of high rates of psychiatric morbidity and suicidal thoughts among prisoners. MRC Special Training Fellowship (Health Services Research and Public Health). (2002-2006). MRC Post Doctoral Fellowship

47. Involved in a range of studies: Connolly A, Rogers P, Taylor D. (2007). Antipsychotic prescribing quality and ethnicity: a study of hospitalized patients in south east London. Maudsley Hospital (£60,000) £34,000 study from the National Programme on Forensic Mental Health Research & Development. Assessing the utility of the Offenders Group Reconviction Scale-2 in predicting the risk of reconviction within 2 & 4 years of discharge from English & Welsh Medium Secure Units. (2004-06). Amos, T., et al. A review of forensic and prison reviews. (£35,000). The National Programme for Forensic Mental Health Research, Department of Health. (2005-2006). Harrison, G. et al. The DEBIT Trial (A Clustered Randomised Controlled Trial to reduce anti-psychotic polypharmacy (£430,000). Funded by an NHS Regional R&Dgrant (2000-2005). Developed a bid to WAG for £90,000 to set up WARRN through the NHS Post Doc / University of Glamorgan

48. Main theme / My main interest ● Examining issues related to imminent or real violence. ● What does one actually do in these circumstances? ● Linked to my earlier experiences on “M8” ward at Fairfield Hospital and my “Control and Restraint” Instructor training Current main research interest

49. Latest Research Findings on “Breakaway” training

50. We know that violence to healthcare staff is a major problem