Raising Psychosis Awareness
Raising Psychosis Awareness
This paper evaluates a group-based psychoeducational programme aimed at raising forensic clients’ awareness of psychosis, which has been administered repeatedly over the course of four years.
In collaboration with pharmacological treatments of psychotic symptoms, cognitive-behavioural therapy for psychosis has been recognised as a critical adjunct. In 2002, this recognition was adopted into the National Institute of Clinical Excellence (NICE) Guidelines. These guidelines set a treatment standard that every client diagnosed with schizophrenia who has persistent psychotic symptoms should be offered at least ten sessions of cognitive-behavioural therapy over a six-month period (NICE, 2002).
Psychoeducation, the teaching of factors involved in psychological or psychiatric conditions or difficulties can be viewed as a primary and prerequisite stage of cognitive-behavioural therapy. In addition, group-based programmes enable the cost-effective delivery of psychological treatments with the added advantage of peer support and challenge.
A wide range of research has highlighted the success of treating psychosis using group-based psychoeducational approaches. A group-based learning environment combats feelings of loneliness, stigma, isolation and confusion surrounding psychiatric diagnosis (Kanas, 1988) as well as encouraging an understanding that other people share similar difficulties; the concept of ‘universality’ (Yalom, 1983). In group-based programmes, participants are also afforded the opportunity to build relationships with other group-members who they have resided on a ward with for some time but had never been acquainted (McInnis et al, 2006). This is most likely to have led to a sense of belonging and acceptance, receiving empathy from individuals with similar experiences and communicating ideas not previously expressed (Yalom, 1995).
Group-based treatments for psychosis have also yielded positive results in terms of improving symptomatology, particularly in ameliorating positive symptoms (Caley, 1996). Similarly, an evaluation of a group-based programme for voice hearers found a reduction in symptoms as well as improved insight (Wykes et al, 1999). A reduction in depression has also been observed in such groups, along with improved self-esteem (Gledhill et al, 1998).
Despite the obvious benefits of group-based psychoeducational programmes for psychosis, to date there has been a limited number of published reports concerning their application to forensic clients. A sizeable majority of forensic inpatients experience psychotic symptoms and in many cases this psychosis underpins offending behaviour and risk. Encouraging such individuals to understand psychosis and encouraging a more positive attitude towards medication is therefore critical in the amelioration of risk. Furthermore, given that relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004) provision of psychoeducation relating to acute mental health issues is also crucial.
Aim and Structure of the Programme
The aims of the programme are to provide information about psychosis, its causes (within a vulnerability-stress framework), duration and treatment as well as learning to recognise and prevent relapse by adopting effective cognitive and behavioural coping mechanisms (see Kingdon and Turkington, 2005 for examples). As a by-product of this, it was anticipated that anxieties about psychosis would reduce and insight would be improved to some degree.
The programme consists of 10 two hour sessions, with a short break in the middle. Participants were expected to attend all sessions, although were only excluded from the programme if a total of three or more sessions were missed. In the case of missing a session, participants would be updated on the content of the session outside of the group. The programme ran eight times over the course of four years with an average of four or five participants in each group.
The content of the programme builds over the sessions from a general consideration of illness, to mental illness, psychosis, its development, risk factors and available treatments. The programme is largely based on an understanding of psychosis in terms of symptoms and treatments, but also draws on theory, for example the vulnerability-stress framework (Zubin & Spring, 1977) to aid deeper understanding. The vulnerability-stress framework allows for a discussion of risk factors; one session focuses on the links between mental illness and the use of illicit substances for example. This session draws on the available hypotheses of causation, for example that heavy cannabis use can cause psychotic symptoms (Andréasson et al, 1987).
The programme took place within secure mental health services in the North East of England.
Facilitators of the group included one forensic psychologist and one other staff member, usually a psychiatric nurse. There were two observers; usually either an assistant psychologist and a psychiatric nurse or two psychiatric nurses.
Referrals came via multidisciplinary teams, psychiatrists or psychiatric nurses involved in the client’s care. Referrals consisted of adult forensic clients attached to the service with either a primary or secondary diagnosis of psychosis, or significant difficulties associated with acute mental health. Exclusion criteria included those clients who were actively psychotic, unable to work in a group-setting, and those who were due to be transferred out of the unit imminently.
A total of 56 clients from inpatient and outpatients services were referred to the programme over the course of four years, 39 were accepted. Of the 39, 36 (92%) were inpatients and three were outpatients (8%). Inpatient services have a maximum capacity of 35 whereas there are approximately 40 outpatients attached to the service at any one time. Approximately 5 participants were involved in each running of the programme, representing 14% of the inpatient population at any one time and less than 1% of the outpatients attached to the service at any one time. Of the total number accepted 37 (95%) were male and two (5%) were female. The mean age of the participants was 34 years (SD = 6.44 years). All participants had a psychiatric diagnosis involving psychosis and the majority (35 of the 39, 90%) had a primary diagnosis of schizophrenia.
All of the 39 participants completed the programme (participants were required to attend at least seven of the ten sessions), however, a reduced number completed all the pre and post-measures. Non-completion of measures was due to a variety of factors such as group members being transferred to a different unit or a decline in mental health for example.
Formal ethical approval was not required (due to this study being a service evaluation), however although it is current NHS good practice to ensure that local Research & Development (R & D) permissions are still obtained, this was overlooked in this study. This represents a significant criticism, which would be addressed in any future evaluations of the group programme.
In order to evaluate the efficacy of the programme, three questionnaires were administered before and after the programme.
- Schizophrenia Questionnaire (Ascher-Svanum and Martin, 1999) – a 23 item self-report measure measuring factual knowledge about schizophrenia. A higher score indicates a greater factual knowledge about schizophrenia. This measure tests the factual component of the programme, such as what percentage of the population is diagnosed with schizophrenia and common symptoms for example.
79% of the participants completed this measure pre-group and post-group (N = 31).
2. Thoughts and Feelings about Medicines Questionnaire (Ascher-Svanum and Krause, 1991) – a 36 item self-report measure measuring beliefs about medication. A higher score indicates a more positive attitude towards taking antipsychotic medication. This measure relates to the treatment component of the programme and the emphasis placed on taking medication.
72% of the participants completed this measure pre-group and post-group (N = 28).
3. Beliefs Questionnaire (Birchwood et al, 1994) – an 8 item self-report measure measuring an individual’s beliefs about his or her mental health. A higher score indicates a greater acceptance of acute mental health issues, whereas a lower score indicates a lesser acceptance, or denial of acute mental health issues. This measure relates to a subsidiary aim of the programme concerned with improving participants’ insight into mental health.
54% of the participants completed this measure pre-group and post-group (N = 21).
The Beliefs Questionnaire was introduced after several administrations of the programme. Staff had observed improvements in participants’ insight after completing the programme; this measure was included therefore to evaluate this observation.
The study used a Repeated Measures Design.
The study used both descriptive statistics (means, standard deviations and percentages) and parametric statistics (repeated measures t-test) to analyse the data.
Table 1: Outcomes of the Programme
There was a statistically significant difference between pre and post programme scores on two measures (the Schizophrenia Questionnaire and the Thoughts and Feelings about Medicines Questionnaire) although there was no statistical difference on the Beliefs Questionnaire.
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.
Luisa Williams, Chartered Forensic Psychologist, Northumberland, Tyne and Wear NHS Trust.
The authors would like to thank particularly Nina Detlif, Julia Harrison and Janette Marshall, Eddy Newton and all the dedicated staff that have been involved in facilitating and observing this programme, without whom the success of this programme would not have been possible.
Luisa Williams, Chartered Forensic Psychologist and David Blakelock, Assistant Psychologist. firstname.lastname@example.org
Almond, S., Knapp, M., Francois, C., Toumi, M. and Brugha, T. (2004) Relapse in Schizophrenia: Costs, Clinical Outcomes and Quality of Life. British Journal of Psychiatry, 184, 346-351.
Andréasson S, Allebeck P, Engström A, Rydberg U. (1987) Cannabis and schizophrenia: a longitudinal study of Swedish conscripts. Lancet. 1483–1485.
Ascher-Svanum, H., and Krause A.A. (1991) Psychoeducational groups for patients with Schizophrenia: A guide for practitioners. Rockville, Maryland: Aspen Publishers Inc.
Ascher-Svanum, H., Martin, E. (1999) Development and validation of a measure of patient’s knowledge about schizophrenia, Psychiatry Services, 50, 561-563.
Birchwood, M., Smith, J., Drury, V., Healey, J., Macmillan, F. and Slade, M. (1994) A Self-Report Insight Scale for Psychosis: Reliability, Validity and Sensitivity to Change. Acta Psychiatrica Scandinavica, 89, 62-67.
Caley, J. (1996) The Application of the Thorn Model to Group Work for People with Serious Mental Illness. London Thorn Initiative. Unpublished Dissertation.
Gledhill, A., Lobban, F. and Sellwood, W. (1998) Group CBT for People with Schizophrenia: A Preliminary Evaluation. Behavioural and Cognitive Psychotherapy, 26, 63 – 75.
Kanas, N. (1988) Therapy Groups for Schizophrenic Patients on Acute Care Units. Hospital and Community Psychiatry, 39, 546 – 549.
Kingdon, D., and Turkington, D. (2005) Cogntive Therapy of Schizophrenia. The Guilford Press.
McInnis, E., Sellwood, W. and Jones, C. (2006) A cognitive behavioural group-based educational programme for psychotic symptoms in a low secure setting: a pilot evaluation. The British Journal of Forensic Practice, 8, 36-46.
NICE. (2002) National Institute for Clinical Excellence. Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: NICE.
The Psychologist. (December 2008), Letters, Volume 21, Part 12.
The Psychologist. (February 2009), Forum, Volume 22, Part 2.
Wykes T, Parr A and Landau S. (1999) Group Treatment of Auditory Hallucinations British Journal of Psychiatry, 175, 180-185
Yalom, I.D. (1983) In-Patient Group Psychotherapy. New York: Basic Books.
Yalom, I.D. (1995) The Theory and Practice of Group Psychotherapy (4th edition). New York: Basic Books.
Zubin J. & Spring B. (1977) Vulnerability – a new view of schizophrenia. Journal of Abnormal Psychology Vol.86, No.2, 103-124.
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