Raising Psychosis Awareness

Discussion

Analysis of a group-based psychoeducational programme aimed at increasing forensic clients’ awareness and knowledge of psychosis revealed statistically significant differences between pre and post administrations on two of three assessment measures used.  A statistically significant difference between pre and post administration of the Schizophrenia Questionnaire indicates that participants’ factual knowledge about schizophrenia improved as a result of the programme.  A statistically significant difference between pre and post administration of the Thoughts and Feelings about Medicines Questionnaire indicates that participants’ attitudes toward taking antipsychotic medication became more positive as a result of the programme.  Analysis of pre and post administration of the third assessment measure, the Beliefs Questionnaire, did not reach statistical significance, indicating that participants’ beliefs about their mental health did not change as a result of the programme. 

The Beliefs Questionnaire was introduced at a later stage and this may account for the non-significant finding.  Trend analysis revealed a higher mean score on the post-measure and furthermore, the presence of an outlier in the sample skewed the results.   Of note, this outlier reflected a group member whom it was felt did not fully comprehend items on the measure (posing a question as to whether this participant also understood the entirety of the programme content).  Given the reduced sample size on this measure and presence of an outlier, a higher sample size, as with the other measures, may well have yielded a significant finding. 

Overall, analysis of this programme provides preliminary support for group-based treatments aimed at increasing clients’ knowledge of psychosis, which satisfies part of the overall guidelines stipulated by NICE in 2002.  The general principle that psychoeducation aims to improve awareness about psychological or psychiatric symptoms has been demonstrated by this study.  As such, evidence that psychoeducation comprises a primary and prerequisite stage of cognitive-behavioural therapy (in that awareness of symptoms forms the necessary basis to progress to more skills-based interventions) has also been highlighted.  Other benefits of psychoeducational groups, for example improved insight (Wykes et al, 1999) have also been demonstrated by the present study (although not to a significant degree).

Conclusions drawn from the present study however must be tentative, given its small scale.  A larger sample would allow for more rigorous analytic methods to be applied, and given the positive feedback from staff, inclusion of structured qualitative data would provide further information about progress, insight and recovery.  One of the authors (Luisa Williams) is in process of gathering data from further administrations of the programme.  Gathering this data has included gaining permission of participants, which was not sought for the present study. 

Extraneous variables, such as whether participants were receiving other psychologically based interventions at the time of the programme were not controlled for.  As such, some of the positive changes found may have been as a result of this intervention rather than as a result of the programme per se.  Further research therefore needs to control for such variables in order to more accurately assess the efficacy of the programme.  Although the programme utilised a number of handouts for the sessions, participants often had difficulties recalling what had been discussed in the previous week’s session.  As such, session summaries in the form of leaflets have now been included in the programme package.

Although the aims of this programme were relatively simple in terms of providing psychoeducation as a primary stage of cognitive-behavioural therapy for psychosis, engaging a generally difficult client group often proved challenging.  Facilitators were selected on their ability to discuss acute mental health issues in a non-judgmental, de-stigmatising way.  In addition, emphasis on empowerment, judicious use of humour and warmth were encouraged as a core part of the programme delivery style.  Participant’s feedback of the benefits of sharing experiences in an atmosphere of warmth mirrors the findings of previous studies (McInnis et al, 2006 and Yalom, 1983; 1995).  

Although psychoeducational group-based programmes aimed at improving knowledge and understanding of psychosis may provide a core part of interventions in general mental health services, they have not been a central concern for forensic services.  An emphasis on reducing risk and offending behaviour underpins the services provided to forensic clients, and is viewed to be its core purpose.  In many cases however there is clear evidence of an association between acute mental health and risk, in such cases therefore this type of intervention is a crucial aspect of risk reduction.  In addition, where the link between acute mental health and risk is less clear, such interventions serve to improve of quality of life, the absence of which may contribute to a criminal lifestyle. 

This research represents the very clinical end of forensic psychology practice and as such a question over the skills and experience of a forensic psychologist managing such a programme exists.  Concerns regarding forensic psychologists delivering mental health interventions were recently raised and responded to by the DFP and DCP (The Psychologist, Letters, Volume 21, Part 12, December 2008; The Psychologist, Forum, Volume 22, Part 2, February 2009).  The programme was initially developed under the supervision of a Consultant Clinical Forensic Psychologist in order to assist with clinical understanding and adopts a multidisciplinary approach to facilitation, drawing on the input of psychiatric nurses and a psychiatrist to aide an understanding of antipsychotic medication.  In addition, the forensic psychologist involved has undergone further training in cognitive-behavioral treatments and psychosocial interventions for psychosis as recommended by the National Schizophrenia Guideline 2003. 

Finally, due to success of this programme and a need for more in-depth cognitive-behavioural treatments of psychosis among forensic clients, development of further group-based treatments are a work in progress.  The second programme aims to provide a more skills-based individualised approach to understanding acute mental health and the third to encompass a relapse prevention model to prevent future deteriorations in mental state and associated increased risks.