Michael Marriott

What is psychosis? A meta-synthesis of inductive qualitative studies exploring the experience of psychosis

Qualitative studies have played an important role in elucidating the lived experience of psychosis and there has recently been an increase in the number of such studies. There is now an urgent need to draw together the findings of these studies. This paper performed a meta-synthesis of inductive qualitative peer-reviewed research into psychosis. Ninety-seven articles were identified for systematic appraisal. Four themes, “Losing,” “Identifying a need for, and seeking, help,” “Rebuilding and reforging,” and “Better than new: gifts from psychosis,” were identified. Central to the first and third themes were the loss and regaining of basic human needs such as sleep, physical and financial security, relationships with friends and family, self-esteem, and hope. The important implications of the four themes for clinical practice, and for future research are examined, and it is demonstrated how the experience of psychosis is much more than simply just hallucinations and/or delusions.

Implementation of routine outcome measurement in child and adolescent mental health services in the United Kingdom: a critical perspective

The aim of this commentary is to provide an overview of clinical outcome measures that are currently recommended for use in UK Child and Adolescent Mental Health Services (CAMHS), focusing on measures that are applicable across a wide range of conditions with established validity and reliability, or innovative in their design. We also provide an overview of the barriers and drivers to the use of Routine Outcome Measurement (ROM) in clinical practice.

The use of routine outcome measures in two child and adolescent mental health services: a completed audit cycle.

BackgroundRoutine outcome measurement (ROM) is important for assessing the clinical effectiveness of health services and for monitoring patient outcomes. Within Child and Adolescent Mental Health Services (CAMHS) in the UK the adoption of ROM in CAMHS has been supported by both national and local initiatives (such as government strategies, local commissioning policy, and research).MethodsWith the aim of assessing how these policies and initiatives may have influenced the uptake of ROM within two different CAMHS we report the findings of two case-note audits: a baseline audit conducted in January 2011 and a re-audit conducted two years later in December 2012-February 2013.ResultsThe findings show an increase in both the single and repeated use of outcome measures from the time of the original audit, with repeated use (baseline and follow-up) of the Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) scale increasing from 10% to 50% of cases. Re-audited case-notes contained more combined use of different outcome measures, with greater consensus on which measures to use. Outcome measures that were applicable across a wide range of clinical conditions were more likely to be used than symptom-specific measures, and measures that were completed by the clinician were found more often than measures completed by the service user.ConclusionsThe findings show a substantial improvement in the use of outcome measures within CAMHS. These increases in use were found across different service organisations which were subject to different types of local service priorities and drivers.

A qualitative process evaluation of electronic session-by-session outcome measurement in child and adolescent mental health services

BackgroundRegular monitoring of patient progress is important to assess the clinical effectiveness of an intervention. Recently, initiatives within UK child and adolescent mental health services (CAMHS) have advocated the use of session-by-session monitoring to continually evaluate the patient’s outcome throughout the course of the intervention. However, the feasibility and acceptability of such regular monitoring is unknown.MethodSemi-structured qualitative interviews were conducted with clinicians (n = 10), administrative staff (n = 8) and families (n = 15) who participated in a feasibility study of an electronic session-by-session outcome monitoring tool, (SxS), which is based on the Strengths and Difficulties Questionnaire (SDQ). This study took place in three CAMHS clinics in Nottinghamshire. The interview transcripts were thematically analysed.ResultsWe found clinicians accepted the need to complete outcome measures, particularly valuing those completed by the patient. However, there were some difficulties with engaging clinicians in this practice and in the training offered. Generally, patients were supportive of completing SxS in the waiting room prior to the clinic session and assistance with the process from administrative staff was seen to be a key factor. Clinicians and families found the feedback reports created from SxS to be helpful for tracking progress, facilitating communication and engagement, and as a point of reflection. The use of technology was considered positively, although some technological difficulties hindered the completion of SxS. Clinicians and families appreciated the brevity of SxS, but some were concerned that a short questionnaire could not adequately encapsulate the complexity of the patient’s issues.ConclusionsThe findings show the need for appropriate infrastructure, mandatory training, and support to enable an effective system of session-by-session monitoring. Our findings indicate that clinicians, administrative staff and young people and their parents/carers would support regular monitoring if the system is easy to implement, with a standard ‘clinic-wide’ adoption of the procedure, and the resulting data are clinically useful.

Evaluating a cognitive analytic therapy service; practice‐based outcomes and comparisons with person‐centred and cognitive‐behavioural therapies

OBJECTIVES Evaluations of the clinical effectiveness of cognitive analytic therapy (CAT) are scarce and therefore represent an urgent service and research need. This paper sought to evaluate a CAT service by profiling CAT clients, examining the outcomes achieved by the CAT service and also comparing such outcomes with those achieved by other services, namely the person-centred service and the cognitive-behavioural service. DESIGN Patients in routine practice were matched according to the amount of therapy time received (either brief or medium-term contracts) and the degree of initial presenting psychological distress. METHODS Patients completed a variety of validated scales of psychological functioning (Beck Depression Inventory-II (BDI-II), Brief Symptom Inventory (BSI), and Inventory of Interpersonal Problems (IIP-32)) at assessment and termination of psychological intervention. RESULTS The results indicate broad similarities between the outcomes achieved by the services, with rates of clinically significant improvement comparable, in the main, across the three services. CONCLUSIONS The results are discussed in terms of (a) the service delivery implications and (b) future indicated pragmatic research and evaluation efforts.

Adolescents with a diagnosis of anorexia nervosa: Parents' experience of recognition and deciding to seek help

Background: Adolescents with anorexia nervosa rarely present themselves as having a problem and are usually reliant on parents to recognise the problem and facilitate help-seeking. This study aimed to investigate parents’ experiences of recognising that their child had an eating problem and deciding to seek help. Methods: A qualitative study with interpretative phenomenological analysis applied to semi-structured interviews with eight parents of adolescents with a diagnosis of anorexia nervosa. Results: Parents commonly attributed early signs of anorexia nervosa to normal adolescent development and they expected weight loss to be short-lived. As parents’ suspicions grew, close monitoring exposing their child’s secretive attempts to lose weight and the use of internet searches aided parental recognition of the problem. They avoided using the term anorexia as it made the problem seem ‘real’. Following serial unsuccessful attempts to effect change, parental fear for their child’s life triggered a desire for professional help. Conclusions: Parents require early advice and support to confirm their suspicions that their child might have anorexia nervosa. Since parents commonly approach the internet for guidance, improving awareness of useful and accurate websites could reduce delays in help-seeking.

The importance of social identities in the management of and recovery from ‘Diabulimia’: a qualitative exploration

Introduction A significant barrier to recovery for individuals with co-morbid eating disorders and type 1 diabetes is the way in which group members self-categorise. Nonetheless, identity issues are neglected during the recovery process. The aim of this paper is to explore how group memberships (and the associated identities) both contribute to and hinder recovery in this cohort. Method Transcripts from five online focus groups with 13 members of an online support group for individuals with ‘Diabulimia’ were thematically analysed. Results Findings suggested that those with whom one shares a recovery identity can be well placed to provide psychological resources necessary for successful recovery although such connections can be damaging if group norms are not managed. Members recognised that other important relationships (including family and friends and health professionals) are also key to recovery; these other group memberships (and the associated identities) can be facilitated through the recovery identity group membership, which allows for external validation of the recovery identity, provides encouragement to disclose the illness to supportive others, and provides information to facilitate positive service interactions. Conclusions While clinical interventions typically focus on eliminating disordered behaviours, we suggest that these should also include strengthening important group memberships that promote recovery.

Narrative insight in psychosis: The relationship with spiritual and religious explanatory frameworks

Objective When considering psychosis, the concept of narrative insight has been offered as an alternative to clinical insight in determining individuals’ responses to their difficulties, as it allows for a more holistic and person‐centred framework to be embraced within professional practice. This study aims to explore the validity of the narrative insight construct within a group of people who have experienced psychosis. Design Inductive qualitative methods were used to explore how eight participants utilized spiritual or religious explanatory frameworks for their experiences of psychosis and to consider these in relation to the construct of narrative insight. Methods Semi‐structured interviews were undertaken with individuals who identified themselves as interested in spiritual or religious ideas and whose self‐reported experiences which were identified as akin to psychosis by experienced academic clinicians. Transcriptions from these interviews were subject to interpretative phenomenological analysis within a broader research question; a selection of themes and data from the resultant phenomenological structure are explored here for their relevance to narrative insight. Results Participants discussed spiritual and biological explanations for their experiences and were able to hold alternative potential explanations alongside each other. They were reflective regarding the origins of their explanations and would describe a process of testing and proof in relation to them. Conclusions These findings suggest that the narrative insight construct has the potential to be a valid approach to understanding experiences of psychosis, and challenge the dominance of the clinical insight construct within clinical practice. Practitioner points Clinicians should value the explanatory framework for experiences which are provided by individuals experiencing psychosis, and encourage them to develop a framework which is coherent to their own world view rather than predominantly pursuing a biomedical explanation. Assessments of psychosis should be adapted to include an understanding of the cohesiveness of the individuals explanatory framework and personal value to them, with a reduced focus on their acceptance of biomedical models of ‘illness’. Care and care research for individuals experiencing psychosis should consider the value of narrative insight within future developments.

Social cognition in intellectually disabled male criminal offenders: a deficit in affect perception?

Purpose Although intellectual disability (ID) and criminal offending have long been associated, the nature of this link is obfuscated by reliance on historically unrigorous means of assessing ID and fractionating social cognitive skills. The purpose of this paper is to review and report current findings and set an agenda for future research in social perception, social inference and social problem solving in ID violent offenders. Design/methodology/approach The literature is reviewed on comorbidity of criminal offending and ID, and on social cognitive impairment and ID offending. In an exploratory case-control series comprising six violent offenders with ID and five similarly able controls, emotion recognition and social inference are assessed by the Awareness of Social Inference Test and social problem-solving ability and style by an adapted Social Problem-Solving Inventory. Findings Violent offenders recognised all emotions except “anxious”. Further, while offenders could interpret and integrate wider contextual cues, absent such cues offenders were less able to use paralinguistic cues (e.g. emotional tone) to infer speakers’ feelings. Offenders in this sample exceeded controls’ social problem-solving scores. Originality/value This paper confirms that ID offenders, like neurotypical offenders, display specific deficits in emotion recognition – particularly fear recognition – but suggests that in ID offenders impairments of affect perception are not necessarily accompanied by impaired social problem solving. The implication for therapeutic practice is that ID offenders might be most effectively rehabilitated by targeting simpler, low-level cognitive processes, such as fear perception, rather than adapting treatment strategies from mainstream offenders.