Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs

1. Randomised Controlled Trial of a psycho-education programme for patients with psychosis in forensic settings Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net

2. Introduction to psycho-education Describe research project Present a summary of key findings for Part 1 and Part 2 Draw conclusions and make recommendations

3. Supported by Research Assistant • The State Hospital-Lindsay Tulloch Principal Investigators • The State Hospital – Alan Steele • Orchard Clinic – Mark Ramm • Rowanbank Clinic & Leverndale Hospital – Dr Emma Drysdale Clinical Advisor • The State Hospital - Dr Gary MacPherson Funded by The State Hospital Supervised by Professor Colin Martin at The University of the West of Scotland

4. Why psycho-education? Psycho-education for psychosis has been developed to explain illness and treatment to people with psychosis, in order to enable them to cope more effectively with their illness Favrod et al (2011).

5. Up to 1980s Relapse and re-hospitalisation (Neuman and Fuenning 1977) Compliance with medication (Roccella 1976) Knowledge gain (Gillum, 1974, Goldmanand Quinn 1988) Post 1990s Relapse and re-hospitalisation (Auguglia 2007, Lincoln 2007, Rummel-Kluge 2008, Xia et al 2011) Compliance with medication (Cunningham Owens 2001) Symptomatology (Pekkala 2002) Insight (Merinder 1999) Knowledge gain (Jones 2001, Jennings 2002, Sibitz 2007) Quality of life (Cross 2002, Bauml 2007) Social functioning (Atkinson & Coia 1996) Patient satisfaction (Merinder 1999, Aho-Mustonen 2011)

6. Coping With Mental Illness 11 week group programme Foundation: understanding mental illness and personality disorder, Stigma and myths, Looking at ‘symptoms’ of psychosis, what caused my illness The Legal System: risk assessment and risk planning, legal issues around admission and discharge Coping skills and recovery: relapse and early warning signs, problem solving

7. The study – two parts • Aim: Evaluate the effectiveness of a psycho-education programme (Coping With Mental Illness) in a population of mentally disordered offenders with psychosis and capture therapeutic change • Part 1: Multi-site Randomised Controlled Trial (cluster trial): The State Hospital (high), Orchard Clinic (med), Rowanbank (med) and Leverndale (low) • Part 2: Structured interview using Repertory Grid technique across two sites (TSH and OC) • The RCT will establish what might change for the individuals concerned and the interviews will explore why this has occurred.

8. Process Part 1 - RCT • Participants referred by multi-disciplinary team • When adequate numbers were available, patients randomly allocated to either treatment or control (waiting list) group by Principle Investigator (PI) at each site • Sealed envelope was issued to each (PI) at the outset with computer generated numbers for allocation-this was undertaken by UWS • Chief Investigator and Research Assistant were blind to allocation • Assessments undertaken at three stages, pre intervention, post intervention and six month follow up, over 3 ½ year period

9. Clinician rated Schedule for the Assessment of Insight [SAI](David 1990) Positive and Negative Syndrome Scale [PANSS](Kay 1987) Calgary Depression Scale for Schizophrenia [CDSS] (Addington 1993) Behavioural Status Index [BEST-Index] (Woods and Reed 2000) Self rated Forensic Assessment of Knowledge Tool (Walker 2012) Assessment of Insight (Markova 2003) Rosenberg Self Esteem Inventory (Rosenberg1965) Locus of Control (Jomeen 2005) Liverpool University Neuroleptic Side Effect Rating Scale [LUNSERS] (Day 1995) Schizophrenia Quality of Life Scale-Revision 4 [SQLS-R4](Martin 2007) Hospital Anxiety and Depression Scale(Snaith 1994) Patient satisfaction Assessment tools

10. Data analysis • Demographic details : descriptive statistics • Analysis of Variance (ANOVA) and Analysis of Covariance (ANCOVA) where appropriate • IQ was the covariate -because there was a statistically significant difference in baseline scores between treatment and control groups • Also significant difference between groups in age of illness onset and age of first conviction • Non-parametric tests used where data was ordinal level or not normally distributed

11. Registered as eligible participants (N= 107 ) Not randomised (n= 26 ) Reasons: no patient consent (5), staff resources (3), took ill (2), died (1), decided to do 1:1 treatment (2), errors in randomisation process (n=13) Randomised (n= 81) Completed post TAU (n = 35) Did not complete post TAU (n = 0) Completed post intervention (n = 46) Did not complete post intervention (n = 0) Completed 6 month follow up (n = 30 ) Did not complete 6 month follow up (n= 6) Moved outwith area (n = 10) Crossed over to become experimental participants at this stage – therefore unable to do six month assessment Received treatment as usual (TAU) as allocated (n = 35) Did not receive treatment as usual as allocated (n = 0) Received intervention (experimental group) as allocated (n = 46) Did not receive intervention as allocated (n = 0) Completed trial (n= 35) Completed trial (n= 30)

12. Study sample

13. Study sample: characteristics • Age: range 19-57, mean 37 years (sd 9.39). • Ethnic origin: (n=75) were of White British or Irish origin, (n=2) Black/Black African, (n=1) Asian Bangladeshi,(n=1)Chinese and (n=2) of other mixed background. • 44% of the sample originated from the West of Scotland. • Marital status: majority single (n=60), only (n=1) was married, (n=20) were divorced, separated or widowed. • Employment status: prior to admission (n=76) were unemployed. Only two participants were involved in professional trades, one was an apprentice and one was a student, (n=15) had never been employed in their life.

14. IQ scores using Wechsler Abbreviated Scale of Intelligence

15. Education • Most educated in mainstream schools (n=74), only one participant had no formal education, seven had behavioural problems and had special schooling

18. Offending characteristics • Index offence • No offence (n=30) • Serious assault, murder, attempted murder, culpable homicide (n=38) • Sexual related offences (n=3) • Other (n=10) • History of drug (n=64) and or alcohol misuse (n= 68) • On most occasions it was not known whether this was linked to the index offence or not. • Although over half of the participants had never entered high secure hospital prior to the current admission, (n=32) had multiple re-admissions.

19. Comparison of treatment versus control group scores pre and post group (ANCOVA)

21. Non parametric tests

23. Part 2 George Kelly (1905-1967) • American Psychologist, developed a theory of personality • Personal Construct Psychology (PCP)

24. Why use Personal Construct Psychology (PCP); part 2 Capture patient perspective. • PSI is based within the person-centred tradition. • Person-centred theory starts from a process theory of authenticity, not from a theory of disorders (Schmid, 2006). • All participants bring with them their own ideas, experiences and opinions. • Patients should be acknowledged as experts in their own experiences; recent advances in understanding mental illness and psychotic experiences(The British Psychological Society, 2000). • Kingdon & Turkington (2005) report, “Individualising psycho-education helps people feel listened to and understood, and this approach adds to its effectiveness”.

25. Using personal construct theory/psychology In essence, PCT is a theory about how people make sense of the world around them. • Personal construct psychology (PCP) describes the way in which this theory applies to an individual, based on the following underlying principles: • The explanation for any individual’s behaviour lies within that individual. • People are active in the world and not passive recipients of events going on around them. • Change is always possible – no one is the victim of their own history. The four key concepts which are important in understanding PCP are: the process of construing, people as ‘active scientists’, constructive alternativism and PCP as a universal theory.

26. The process of construing • Construing refers to how people interpret events, and constructs are personal discriminations that individuals make between people, events or situations (Houston 1998). • Construing is not the same as thinking because it involves the notion of contrast, and of making an active interpretation or discrimination. • Example: if a person described herself and her mother reliable, in direct contrast to her brother, then the discrimination ‘reliable versus not reliable’, is a construct which the person uses. This construct contributes to their view of the world, i.e. it is part of their construct system.

27. Use of PCP with mentally disordered offenders A number of studies have been undertaken with a different focus: • mental illness and offending (Norris 1977, Goold 1998) • alcohol, drugs and offending (Blackburn 1993), • sex offenders (Marshall and Barbaree 1990b), • young offenders and delinquency (Stanley 1983, Viney 2002), • violence and aggression (McCoy 1981, Blackburn 1993) • personality disordered offenders (Blackburn 1990, Dolan 1995).

28. Sample repertory grid

29. Grid Suite (Fromm 2011) Cluster Analysis using dendograms Principal Component Analysis Data analysis

31. Elements are indicated by red dots and positive / negative constructs by green dots.

32. Case study: Dave • Dave was born in the West of Scotland, dual diagnosis of paranoid psychosis and anti-social personality disorder and has been a patient in a high secure hospital for 2 years, following the attempted murder of his uncle. Aged 31, Dave is white, single and was unemployed prior to his admission, his IQ is in the low average category (80-89) and he has a history of both drug and alcohol misuse since his early teens. During the initial interview, undertaken prior to attendance at the group, Dave was particularly anxious about a pending court appearance and was very unsure as to whether his ‘head was in the right place’ for doing the group. By his own admission he was ‘feeling low’ and was worried about the potential success of his appeal to a lower level of security. He thought the group might ‘be no more than a useful distraction at this point in time’ but did state he was ‘keen to learn more about psychosis and how it affects you’.

33. Case study • “Before the programme, I felt that people I didn’t like and those I admired saw me and my future negatively. I felt that I wanted to be and expected to be how I was ten years ago, even though at that time I had little control over my illness. I felt that a person I didn’t like saw me before the programme as not being able to do stuff without being annoyed and having little control over my illness”.

34. Dave’s pre group psychometric scores • SAI score (16) higher than the group as a whole (mean = 10, standard deviation (sd) 5.2, n=18). • FAKT was poor (13) lower than the rest of the group (mean=29, sd=9.3, n=18). • Self esteem (14), lower than group average (mean=19, sd=5.8, n=18) would fall into the category of ‘low self esteem’. • Locus of Control (MHQL) low (40), by comparison to a group average of (mean=61, sd=12.6, n=18). • HADS (10) depression scale (mean=5, sd=4.2, n=18) and 14 on HADS anxiety (mean=7, sd=5.2, n=18) • CDSS (8 )(mean=2, sd=4.S, n=18) - higher than group average. • PANSS +ve symptom (13) (mean=14, sd=5.1, n=18) • PANSS -ve symptom score (25) (mean=17.5, sd=7.1, n=18) and general 32 (mean=29, sd=8.6, n=18).

35. Case study: post group “Having confidence to engage with the group helped me to feel hopeful to move on. I felt more normal and that I could be a valuable person in society”. There is evidence to suggest that Dave has accepted his past self maybe wasn’t as idealistic as he initially thought and that there are ‘areas of life that will need to change’, if a successful future is what is wanted. A clear example of this is his drug use. Dave was ‘getting by’ through regular use of ‘hash, amongst other things’ and a few members of his family actively encouraged this, indeed it seemed to be the norm for both family and many of his closest friends. He was able to identify the links between the effect of drugs on his anti-social behaviour and the deterioration in his mental state, causing an increase in paranoid ideation.

36. Dave’s post group psychometric scores • Insight improved to (17) post intervention, again higher than the group (mean = 11, (sd) 5.1, n=18). • Knowledge of illness much improved at (32) and on a par with others (mean=32, sd=9.5, n=18). • Self esteem improved slightly (15) - still lower than the group average (mean=19, sd=5.8, n=18)- but on the threshold of low self esteem. • Locus of Control increased to (48), group average of (mean=62, sd=11.3, n=18). • Dave improved on both HADS sub-scales, (9) on the HADS depression scale (mean=4.8, sd=4.7, n=18) and (12) on the HADS anxiety (mean=6.5, sd=5.7, n=18), both within normal range. • CDSS score lowered to (5) (mean=1.9, sd=4, n=18), still higher than the group average. • PANSS =ve symptom score improved lowering to (12) (mean=13.4, sd=5.3, n=18), -ve symptom score was also slightly better (23) (mean=16.4, sd=6.7, n=18) and general remained the same (32) (mean=29, sd=8.5, n=18).

37. Summary Advantages Improved knowledge Trend indicating improved insight, mental health, social behaviour and quality of life Patients like it Established programme protocol driven Meets low secure care standard Meets low intensity intervention criteria for Scottish Government HEAT target

38. Limitations • Difficulties associated with randomisation had impact on results • Sample size too small to allow many of the psychometrics to reach significance, reducing generalisability beyond forensic context

39. Recommendation for clinical practice Suggest this programme – which has demonstrable benefits to the target population – is utilised in clinical practice, across the forensic network, in its current or a (recognisable) modified form.