Living with Mental Illness: A Cognitive Behavioural Group Psycho-education Programme with Women in Secure Settings.

UNLABELLED: The provision of psycho-educational groups for people diagnosed with schizophrenia is an important part of successful treatment. The value of such interventions is less clearly established in secure settings with no reports on women. Gender differences in the manifestation of schizophrenia highlight the importance of a gender-specific intervention. A 'Living with Mental Illness' group programme for women in a secure psychiatric setting is described and evaluated. Those who completed group treatments (n = 20; 63%) showed improved knowledge of schizophrenia, decreased fear of schizophrenia, greater insight and increased optimism and perceived control of the illness. They also showed increased hope and greater self-compassion. Pre-post group findings reflected improved ratings of compliance with drug treatments, appropriate behaviour and insight into risk. This was reflected in a decrease in risk behaviours, improved attendance at treatment sessions and a reduction in symptomatology. Group members also reported a positive group therapeutic alliance. Findings are discussed in the context of gender-specific treatment, research, methodological issues characteristic of a real-world evaluations and the need to assess the long-term benefits of such treatment. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Psycho-educational groups for secure inpatients with schizophrenia need to address gender-specific differences in the manifestation of the condition. Such interventions as part of a broader treatment initiative can be associated with clinical improvement that is both illness specific and leads to improved engagement with care initiatives. The needs of patients who do not complete treatments needs to be regularly reassessed.

Transitions of females from adolescent secure to adult secure services: a qualitative pilot project.

BACKGROUND: For young people, the transition from adolescent to adult services is particularly problematic. This may be particularly difficult for female service users. AIMS: The aim of this study is to gain a fuller account of the experience of young people during transition from adolescent services to adult services and to add to the knowledge around the transitional process. METHOD: This study used a qualitative analysis of female adolescents' experience of transition to adult secure services. A four-layer coding structure grouped responses by time frame. RESULTS: The results were consistent with previous research indicating that adolescents are sensitive to the behaviour of others throughout the transition process. Particularly, strong themes were the negative impact of aggression from other patients, the importance of relationships with staff and other patients, and the need for informed involvement in all aspects of the transition process. CONCLUSIONS: An increase in positive statements regarding the post-transition experience suggests that moves have been positive although this could be explained by admission to settings of lower security. The discussion highlights the importance of moving beyond procedural issues of transition to a focus on the social and culture gaps that appear to divide CAMHS and AMHS.

Effective therapeutic milieus in secure services for women: the service user perspective.

BACKGROUND: Women in secure setting represent a group for whom gender sensitive treatments are only emergent. Service users are viewed as participants in treatment developments. However, the opinions of forensic patients have, in contrast to other service users, been under researched. AIMS: To identify service users' views of the constituents of an effective therapeutic milieu for women in secure settings and to help identify the extent to which services need to be specifically tailored for women. METHOD: A qualitative service user-led participatory research approach was used. Two focus groups with service users from low and medium secure settings discussed the ingredients of an effective therapeutic milieu based on their experience of gender-specific treatment. Group transcripts were subjected to thematic analysis. RESULTS: Themes identified covered interpersonal relationships; treatment programming; service user empowerment; the ward as a place of safety; and hope for the future. Participants did not highlight gender-specific issues despite this being implicit in focus group questions. CONCLUSIONS: Findings echo themes from other psychiatric settings and provide a much needed consensus between service providers and users on which to base healthcare planning. The elucidation of gender-specific factors in effective therapeutic milieus requires more focussed research.

Social problem-solving interventions in medium secure settings for women.

Problem-solving interventions are a feature of overall medium secure treatment programmes. However, despite the relevance of such treatment to personality disorder there are few descriptions of such interventions for women. Beneficial effects for women who completed social problem-solving group treatment were evident on a number of psychometric assessments. A treatment non-completion rate of one-third raises questions of both acceptability and timing of cognitive behavioural interventions.

Social climate along the pathway of care in women's secure mental health service: variation with level of security, patient motivation, therapeutic alliance and level of disturbance.

BACKGROUND: Social climate has been measured in a variety of therapeutic settings, but there is little information about it in secure mental health services, or how it may vary along a gender specific care pathway. AIM: To assess social climate in women's secure wards and its variation by level of security and ward type, therapeutic alliance, patient motivation, treatment engagement and disturbed behaviour. METHOD: Three-quarters (80, 76%) of staff and nearly all (65, 92%) of patients in the two medium-security wards and two low-security wards that comprised the unit completed the Essen Climate Evaluation Schema (EssenCES) and the California Psychotherapy Alliance Scale (CALPAS); patients also completed the Patient Motivation Inventory (PMI). Pre-assessment levels of disturbed behaviour and treatment engagement were recorded. RESULTS: Social climate varied according to ward type and level of security. EssenCES ratings indicative of positive social climate were associated with lower levels of security; such ratings were also associated with lower behavioural disturbance and with higher levels of motivation, treatment engagement and therapeutic alliance. CONCLUSION: This serial cross-sectional survey indicated that use of the EssenCES alone might be a good practical measure of treatment progress/responsivity. A longitudinal study would be an important next step in establishing the extent to which it would be useful in this regard.

Nuclear magnetic resonance and circular dichroism studies of a triple-helical peptide with a glycine substitution.

The triple-helical conformation has the stringent amino acid sequence constraint that every third residue must be a glycine, (X-Y-Gly)n. We use nuclear magnetic resonance and circular dichroism to quantify the consequences of a substitution in the glycine position of a triple-helical peptide, and to enhance our understanding of interactions in this basic structural motif. A 30-residue peptide with a Gly----Ala change forms a stable trimer at a folding rate somewhat less than that of the unsubstituted peptide, and the substitution results in a marked decrease in thermal stability and a conformational perturbation of about 30% of the triple-helical structure. Two models were generated for this peptide, one with the alanine residues packed inside the triple helix and one with a looping out of the chain at the substitution site. Studies on the Gly----Ala peptide are useful in understanding connective tissue diseases which result from the substitution of one glycine residue in the triple-helix of fibrillar collagens.

Treating alcohol problems: a study of programme effectiveness and cost effectiveness according to length and delivery of treatment.

AIMS: To compare effectiveness and cost-effectiveness of a 5-week inpatient and a two week in- and day-patient regime. DESIGN: Pre-post assessment of consecutive treatment referrals with follow-up at 6 and 12 months. In a sequential study design, 112 patients underwent a 5-week residential programme while a subsequent 100 patients underwent a 2-week in- and day-patient programme. To investigate the effect of changing programme delivery, patient groups from before and after the programme changes were compared. SETTING: Addiction treatment unit in an independent hospital. PARTICIPANTS: One hundred and thirty-six males and 76 female patients with an ICD-10 diagnosis of Alcohol Dependence Syndrome. MEASUREMENTS: Self-report (Comprehensive Drinkers Profile: Follow-Up Drinkers Profile: SADQ), collateral report (Collateral Interview Form) and blood test (MCV & GGT) data were used to categorize patients into abstinent, non-problem drinker, drinking but improved and unimproved groups. Percentage of days abstinent, intensity of drinking, length of time in treatment, treatment cost and use of aftercare were also measured. FINDINGS: Abstinence or non-problem drinking was achieved by 55.6% of all patients at 1 year. Change in programme delivery did not affect outcome but treatment costs and mean length of stay for the revised programme were significantly reduced. CONCLUSIONS: A two week in- and day-patient treatment was more cost effective than a 5-week inpatient treatment. Design limitations make these conclusions tentative pending a randomized controlled trial.

Within-program factors as predictors of drinking outcome following cognitive-behavioral treatment.

The relationship between a variety of within-treatment factors and the outcome of treatment for alcoholism was examined. One hundred and twenty-eight male and 68 female participants (consecutive referrals with an ICD-10 diagnosis of alcohol dependence syndrome) were followed at 12 months following in- and day-patient cognitive behavioral treatment on an addiction unit. Within-treatment factors (of self-efficacy, psychological symptoms, expectations for treatment, treatment satisfaction, treatment climate, therapeutic alliance, and treatment evaluation), were assessed to determine their relationship to global outcome categorization into abstinent, nonproblem drinker, drinking but improved, and unimproved participant groups. A logistic regression analysis identified five variables that were predictive of a more favorable outcome: higher self-efficacy in positive social situations, greater treatment program involvement, a lower perception of staff control, a greater perception of treatment as helpful, and a reduction in psychological symptoms during treatment. Findings confirm previous research that pinpoints the importance of self-efficacy as a treatment variable of significance in treatment planning and delivery. It also highlights the prognostic significance of a reduction in psychological distress and, thus, the value of dynamic predictors of treatment outcome. The failure of the therapeutic alliance to predict outcome is discussed. It is concluded that time-limited alcoholism treatment programs need to give equal emphasis to within-treatment change via the promotion of patient confidence and the perception of helpfulness, as well as to skill-based relapse prevention strategies.

The behavioral treatment of self-starvation and severe self-injury in a patient with borderline personality disorder.

The successful treatment by behavioral methods of self-starvation and self-injury in a 35-year-old psychiatric in-patient, with a diagnosis of borderline personality disorder, is described. An individualized program using positive and negative reinforcers to increase food and fluid intake was used, while a token economy therapeutic milieu with time out was used to decrease acts of self-injury and aggression. Progress in treatment generalized to a non-secure treatment environment, and was maintained at an 8-month follow-up. The study illustrates the differential response of active and passive self injurious behaviors to group-based and individual treatments, respectively.

Smoking behaviour, motives, motivation to quit and self-efficacy among patients in a secure mental health service: comparison with staff controls.

People with mental disorder account for a disproportionately large amount of smokers, and the problem is greatest in inpatient settings. 'Stop smoking' services should be tailored to the needs of individual patient groups. It is important therefore to investigate factors relevant to different groups in order to inform future quit smoking interventions. We compared 50 patients and 50 staff in a secure mental health hospital on measures of smoking and smoking motives, nicotine dependence, craving, previous cessation attempts, motivation to quit and quit smoking-related self-efficacy. Patients were significantly more dependent on nicotine with higher levels of craving; were more likely to smoke to cope with stress, for something to do when bored, for enjoyment and pleasure; and reported significantly less readiness to quit smoking. Staff were more likely to cite health concerns as reasons for quitting. Future pre-intervention work with inpatients should focus on increasing their readiness to quit smoking. Once motivation is increased, interventions should include advice on reducing cravings, finding alternative methods for coping with stress and boredom and achieving enjoyment and pleasure from alternative sources.

Nursing and health-care assistant experience of supervision in a medium secure psychiatric service for women: implications for service development.

In secure psychiatric services where the potential for 'burnout' by nurses is high, clinical supervision is viewed as a key to reflective practice to support staff in stressful working environments. Barriers to the uptake of clinical supervision in such service settings are personal and organizational. The study was prompted by the need to evaluate the effectiveness of supervision for registered nurses and health-care assistants (HCAs) and a desire to use survey findings to improve the quality and uptake of supervision. The study examined the perceived benefits, the best practice elements and the practical aspects of clinical supervision including how to improve practice. An approximate uptake of clinical supervision by 50% of staff confirmed previous findings; that HCAs were significantly less likely to engage in supervision and less likely to perceive benefit from it. Initiatives to address the training and managerial obstacles to the provision of formal supervision are described.

Factors predictive of length of stay for women in medium secure settings.

Attempts to understand determinates of length of stay in secure settings has been given increased impetus by minimum standard setting and payment by results initiatives. Factors predictive of length of stay in the extant literature include, index offence, previous engagement in therapy, symptomatology, personality pathology and need. These factors were assessed for their predictive validity in a sample of 70 consecutive admissions to a women's medium secure service. Patients were divided into short- and long-stay groups A loglinear analysis of intake variables indicated that the highest order interaction (duration of stay × diagnosis × index offence/previous engagement in therapy) was significant. Analysis of dynamic variables indicated that longer stays were associated with total symptomatology, paranoid pathological personality scale scores and Camberwell Assessment of Need Forensic Version need items of psychotic symptoms and psychological distress. Short-stay patients showed higher levels of therapy engagement. Findings are confirmatory of some of the key variables to be considered when estimating length of stay and when planning treatment.

Women in medium secure care: tracking treatment progress for changes in risk profiles and treatment engagement.

The treatment and risk management programmes in a women's medium secure service are described. Changes in risk profiles and its relationship to treatment engagement are examined in a cohort of women during their stay in a medium secure service. Findings show that clinically significant reductions in risk behaviours were paralleled by increases in treatment engagement. The clinical healthcare implications of these findings are discussed along with the need for further research.

Linking professional and self-help resources for anxiety management: a community project.

The first two years of an anxiety management project involving close liaison between general practitioners, clinical psychologists and a self-help group is described. The apparent benefits of this programme to clients in terms of prompt delivery of service and symptom and medication reduction are discussed. In the light of this a model that combines the benefits of the self-help movement with an appropriate level of professional support is advocated as a viable referral option for the large number of patients with anxiety related problems that present to general practitioners.

Group coping skills training for anxiety and depression: its application with chronic patients.

The literature on group coping skills training is reviewed and a model involving the use of a wide range of coping strategies with patients heterogeneous in terms of presenting problem is advocated. This study evaluates the effect of such an approach with a chronic inpatient and day-hospital patient population (n = 36) presenting with problems of anxiety and depression. Results suggest that the use of such groups can facilitate the transition from hospital to community. Further they are associated with symptomatic improvement that is of clinical significance in up to 50% of cases, which is largely maintained at 1 year follow-up and which is associated with a positive change in social functioning. In the light of this experience suggestions are made regarding the screening of patients and ways of enhancing group cohesion.

Low alcohol beers and wines: attitudes of problem drinkers to their use and their effect on craving.

Thirty-one inpatient and 67 expatient problem drinkers' use of low alcohol drinks and their attitudes towards them were assessed using questionnaire measures. Self ratings of craving for alcohol were made before and after exposure to and optional tasting of low alcohol drinks. Problem drinkers were found to have a generally favourable view of low alcohol drinks, and they claimed that use of these drinks did not contribute to relapse. However, craving for alcohol was found to be significantly raised over baseline after exposure to low alcohol drinks. A significant correlation was found between this increase in craving and severity of dependence as assessed by the SADQ.

GM1 gangliosidosis type 1 in twins.

This report describes 7-month-old monozygotic twin female infants with GM1 gangliosidosis type I. In addition to the usual clinical and biochemical abnormalities generalized intracutaneous telangiectasis were present in both infants.

Parental pressure for tonsillectomy: attitudes and knowledge of parents accompanying their children to an ear, nose and throat clinic.

The parents of 120 children referred for possible tonsillectomy to an ear, nose and throat (ENT) surgeon were studied. There was no evidence that a desire for the operation fulfilled 'psychological needs' for parents or was a means of coping with a 'deviant' child. Parents favouring tonsillectomy were less well informed, and the educational role of the general practitioner in reducing the small number of those who inappropriately pressurize medical services is highlighted.