Louise Braham

Outcomes of therapeutic community treatment for personality disorder

Purpose – The purpose of this paper is to review quantitative research since 1999 evaluating the effectiveness of democratic therapeutic community (DTC) treatment for individuals with personality disorders (PD) with reference to interpersonal and offending risk outcomes. Design/methodology/approach – A systematic search resulted in the review of ten studies. All of the studies investigated DTCs treating PD in community, inpatient residential and forensic settings. Only peer-reviewed, English-language articles employing a quantitative design were included. Findings – The majority of studies were conducted poorly and of low methodological quality, with limitations located in the representativeness of participants, limited use of control and comparison groups, follow up periods and controls for confounders. Heterogeneity remained in use of measures and limited consideration was given to the validity of interpersonal measures used. While improved interpersonal outcomes post DTC treatment were noted in forensic and residential settings, results were mixed in day and mini TC settings. Inconsistent findings in offending risk outcomes were also indicated. A study with increased methodological rigour indicated residential treatment had limited effects on interpersonal outcomes, when compared to combination treatment (residential TC and step-down treatment). Originality/value – The study provided an evaluation of the limitations of DTC research across a range of settings and highlighted a combination of residential TC and step-down treatment may achieve superior outcomes to residential TC treatment alone in a community inpatient population. Recommendations are made for future research to contribute to the treatment of PD.

How reliable are case formulations? A systematic literature review

OBJECTIVES This systematic literature review investigated the inter-rater and test-retest reliability of case formulations. We considered the reliability of case formulations across a range of theoretical modalities and the general quality of the primary research studies. METHODS A systematic search of five electronic databases was conducted in addition to reference list trawling to find studies that assessed the reliability of case formulation. This yielded 18 studies for review. A methodological quality assessment tool was developed to assess the quality of studies, which informed interpretation of the findings. RESULTS Results indicated inter-rater reliability mainly ranging from slight (.1-.4) to substantial (.81-1.0). Some studies highlighted that training and increased experience led to higher levels of agreement. In general, psychodynamic formulations appeared to generate somewhat increased levels of reliability than cognitive or behavioural formulations; however, these studies also included methods that may have served to inflate reliability, for example, pooling the scores of judges. Only one study investigated the test-retest reliability of case formulations yielding support for the stability of formulations over a 3-month period. CONCLUSIONS Reliability of case formulations is varied across a range of theoretical modalities, but can be improved; however, further research is required to strengthen our conclusions. PRACTITIONER POINTS Clinical implications: The findings from the review evidence some support for case formulation being congruent with the scientist-practitioner approach. The reliability of case formulation is likely to be improved through training and clinical experience. Limitations: The broad inclusion criteria may have introduced heterogeneity into the sample, which may have affected the results. Studies reviewed were limited to peer-reviewed journal articles written in the English language, which may represent a source of publication and selection bias.

Service user experiences of a motivational group

Purpose – The Forward Motion Motivational Group (FMMG) is a psychological group intervention facilitated in the Mental Health Directorate of a high-secure Hospital. Research has highlighted a limited amount of service user involvement within secure settings. The aims of the study were to explore participants experiences of FMMG, to establish whether these reflected the aims of the programme, to provide participants with the opportunity to recommend changes to the current service provision and to explore whether the programme supported engagement in further psychological interventions. Design/methodology/approach – Ten programme completers were interviewed using a semi-structured interview. The interview transcripts were analysed using thematic analysis (Braun and Clarke, 2006) alongside Beutow (2010) Saliency Analysis Guidelines. Findings – Thematic analysis of the data resulted in five key themes: expectations, group experience, programme facilitators, learning and programme aims and programme developme...

Pathways to episodes of deliberate self‐harm experienced by mentally ill men in a high‐secure hospital over the course of their lives: an exploratory study

Purpose – There is a dearth of research exploring pathways to episodes of deliberate self‐harm (DSH) within mentally ill men in high‐secure hospitals. This study aims to explore pathway(s) to episodes of self‐harm experienced by this group over the course of their life.Design/methodology/approach – A total of seven men with a history of repetitive DSH participated in audio‐taped semi‐structured interviews. Transcribed interviews were analysed using grounded theory methods.Findings – Two pathways to episodes of DSH emerged and were termed: the relief, and the response to mental health problems pathways. Participation within a dyadic suicide pact emerged as an unexpected theme.Research limitations/implications – There were a number of limitations within this study. Participants did not describe DSH episodes, which occurred within the high‐secure hospital and it was unclear as to the stage of their illness or whether co‐morbid difficulties were present during the episodes of DSH. Further research is required...

Violence and aggression towards staff in secure settings

Purpose The purpose of this paper is to undertake a systematic literature review to appraise the current evidence relating to the factors associated with violence and aggression in adult psychiatric hospital inpatient settings. Design/methodology/approach A systematic search of following four databases was conducted: Scopus, PsychINFO Medline, CIHAHL and PsychArticle. Following the application of the inclusion criteria, ten papers were extracted and included in the review. A quality appraisal tool, Mixed Methods Appraisal Tool (MMAT) version 2011 (Pluye et al., 2011), was employed for the appraisal of the qualitative and quantitative studies. MMAT has been designed for systematic literature reviews that include qualitative, quantitative and mixed methods studies. Of these, eight were of quantitative methodology and two were of qualitative studies. Findings These ten papers provide an insight into factors associated with violence and aggression towards nursing staff. Three main themes were identified: the environment, attitudes/interaction of staff, and the patient’s mental illness. The themes were important factors in the causes of violence but were interlinked highlighting the complex nature of violence towards nursing staff. The findings support the need for training for nursing staff and the development of ongoing support and for organisations to consider both the environment and the restrictive procedures to help reduce violence and aggression towards nursing staff. Practical implications The paper concludes by outlining the importance of considering the three main themes for clinical practice, training and development of secure services. Originality/value This paper gives insight into the factors associated with patient violence and aggression towards nursing staff in a secure setting.

Comparison of outcomes of patients with personality disorder to patients with mental illness, following discharge from medium secure hospital: systematic review

Abstract Background: Medium secure hospitals (MSHs) are costly yet outcome studies, particularly regarding the differential effects of diagnosis, are scant. Research Question: Are there differences in outcomes after MSH discharge for patients with PD compared to patients with mental illness (MI): systematic review. Method: Systematically reviewed studies which distinguished outcomes for patients with PD from those with MI, regarding reconvictions, readmissions and/or mortality rates. Results: From eight studies, comprising 1017 patients, mean reconviction rates per 100,000 person-years for patients with PD were higher (14,369) than those with MI (7799). However, mean readmission and mortality rates were lower (8403 and 668 per 100,000 person-years) compared to those with MI (13,390 and 1083) per 100,000 person-years. Conclusions: Diagnosis appears to differentially impact on reconviction, readmission and mortality rates. Services could tailor pathways to prioritise symptom management and promoting healthy lifestyles for patients with MI, and reducing reoffending for patients with PD.

Perceptions of therapeutic principles in a therapeutic community

Purpose: This study aimed to explore staff and service users’ perceptions of therapeutic principles within a unique male high secure learning disability therapeutic community (LDTC). Design/methodology/approach: A qualitative approach was adopted using deductive content analysis and inductive thematic analysis. Twelve participants took part in a semi-structured interview to explore their perceptions of Haigh’s (2013) quintessence principles and any further additional therapeutic features in the environment not captured by the theory. Findings: All five quintessence principles were identified in the LDTC environment. Some limits to the principle of ‘agency’ were highlighted, with specific reference to difficulties implementing a flattened hierarchy in a forensic setting. Additional therapeutic features were identified including; security and risk, responsivity, and more physical freedom which appear to aid implementation of the quintessence principles. Research limitations/implications: The study was performed within a single case study design. Therefore results remain specific to this LDTC. However, the finding of these principles in such a unique setting may indicate Haigh’s (2013) quintessence principles are evident in other TC environments. Originality/value: This is the first research paper that has attempted to test whether Haigh’s (2013) quintessence principles are evident within a given therapeutic community. The research provides empirical evidence for the quintessence principles in a novel TC setting and suggests recommendations for future research.