Helen Walker Consultant Nurse Forensic Network [email protected].

39
Helen Walker Consultant Nurse Forensic Network [email protected]

Transcript of Helen Walker Consultant Nurse Forensic Network [email protected].

Page 1: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Helen WalkerConsultant Nurse Forensic Network [email protected]

Page 2: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Introduction to psycho-education Describe research project Present a summary of key findings for Part 1

and Part 2 Draw conclusions and make

recommendations

Page 3: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Research Assistant The State Hospital-Lindsay Tulloch Principal Investigators The State Hospital – Alan Steele Orchard Clinic – Mark Ramm Rowanbank Clinic & Leverndale Hospital – Dr Emma DrysdaleClinical Advisor The State Hospital - Dr Gary MacPhersonFunded by The State HospitalSupervised by Professor Colin Martin at The

University of the West of Scotland

Page 4: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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).

Page 5: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Up to 1980s Relapse and re-hospitalisation

(Neuman and Fuenning 1977) Compliance with medication

(Roccella 1976) Knowledge gain (Gillum,

1974, Goldman and 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)

Page 6: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

PSYCHOEDUCATI ON PROGRAMME

CLI NICIAN’S MANUAL &

PARTICIPANT’S MANUAL

Page 7: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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.

Page 8: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

Page 9: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

Page 10: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

Page 11: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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)

Crossed over to become experimental participants at this stage – therefore unable to do six month assessment

Completed 6 month follow up (n = 30 )Did not complete 6 month follow up (n= 6)Moved outwith area (n = 10)

Registered as eligible participants (N= 107 )

Received intervention (experimental group) as allocated (n = 46)Did not receive intervention as allocated (n = 0)

Received treatment as usual (TAU) as allocated (n = 35)Did not receive treatment as usual as allocated (n = 0)

Completed trial (n= 35) Completed trial (n= 30)

Page 12: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Hospital Site Male Female Total

The State Hospital

35 0 35

Rowanbank Clinic

8 1 9

The Orchard Clinic

24 1 25

Leverndale Hospital

12 0 12

79 2 81

Page 13: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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.

Page 14: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.
Page 15: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

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Page 17: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.
Page 18: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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.

Page 19: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

Assessment tools Treatment Mean

Control Mean

F Level of significance

FAKT pre 30 29    

FAKT post 36 29 9.45 p=.003*

SAI pre 10.9 10.6    

SAI post 12.2 10.7 2.34 p=.13

PANSS +ve pre 13.8 14.6    

PANSS +ve post 12.4 14.3 1.92 p=.17

PANSS –ve pre 16.7 17.5    

PANSS –ve post 15.2 17.9 1.22 P=.17

BEST-Index empathy pre

100 100

BEST-Index empathy post

109 103 4.965 p = .029*

Page 20: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Assessment tools

Treatment Mean pre

TreatmentMean post

Treatment Mean 6 month Fup

Level of significance

SQLS-R4 36 30 29 p=.475

HADS Anxiety 7.5 6 5.9 p=.989

HADS Depression

5.1 4.4 3.6 p=.601

Rosenberg 18 19 20 p=.835

BEST-Index(total score)

563 572 559 p=.417

MHLC-C 63 64 62 p=.526

LUNSERS 28 23 24 p=.845

Page 21: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Assessment tools Level of significance

CALGARY Kruskal-Wallis Test1.121

p=.290

Insight Scale Chi-square (χ 2)

24.78p=.16

Page 22: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

 

Paired Differences pre and post intervention

t dfSig. (2-tailed)Mean

Std. Deviation

Std. Error Mean

95% Confidence Interval of the Difference

Lower UpperSAI -1.254 3.555 .463 -2.181 -.328 -2.710 58 .009

FAKT -5.316 7.527 .997 -7.313 -3.319 -5.332 56 .000

Rosenberg -.579 4.656 .617 -1.814 .656 -.939 56 .352

PANSS positive .847 3.398 .442 -.038 1.733 1.916 58 .060

PANSS negative 1.288 4.764 .620 .047 2.530 2.077 58 .042

HADS anxiety .614 4.754 .630 -.647 1.875 .975 56 .334

HADS depression .404 3.122 .413 -.425 1.232 .976 56 .333

MHLC-C -.965 10.712 1.419 -3.807 1.877 -.680 56 .499

BEST-Index (total) -7.052 20.735 2.723 -12.504 -1.600 -2.590 57 .012

SQLS-R4 3.947 14.785 1.958 .024 7.870 2.016 56 .049

LUNSERS 2.772 16.893 2.237 -1.710 7.254 1.239 56 .221

Page 23: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

George Kelly (1905-1967) American Psychologist, developed a theory of personality Personal Construct Psychology (PCP)

Page 24: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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”.

Page 25: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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.

Page 26: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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.

Page 27: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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).

Page 28: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

1 How I was 10 years ago

How I am now

How my Dr sees me

How I would like to be (ideal self)

How I expect to be (expected self)

7

Have hope to move on

          Have no sense of hope to move on

Have confidence to engage in groups

          Negative feelings about groups

Understand my own illness and how it affects me

          Have no understanding of what illness is all about

Don’t realise others have the same problems

          Realise that others have the same problems

Realise I am a valuable person in society

          Think I am worthless

Have little or no control over how I think and feel

Have control of my illness

Feel normal Don’t feel normal

Page 29: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

Grid Suite (Fromm 2011)

Cluster Analysis using dendograms

Principal Component Analysis

GridSuite.lnk

Page 30: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.
Page 31: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

Page 32: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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’.

Page 33: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

“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”.

Page 34: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

•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).

Page 35: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

“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.

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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).

Page 37: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

PSYCHOEDUCATI ON PROGRAMME

CLI NICIAN’S MANUAL &

PARTICIPANT’S MANUAL

Page 38: Helen Walker Consultant Nurse Forensic Network Helen.walker6@nhs.net.

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

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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.