‘Opening the gates to enable curiosity and exploration of occupation in a high secure forensic environment’. Johnston, P: NHS Greater Glasgow & Clyde, Offerdal, J: NHS State Hospital, Smith, J: NHS State Hospitals Board for Scotland & Totten, C: NHS State Hospitals Board for Scotland.

The Setting The State Hospital provides 140 high secure beds for male patients requiring maximum secure care due to their dangerous, violent or criminal propensities (The State Hospital Annual Report, 2017-18). The State Hospital is a special health board that caters for both Scotland and Northern Ireland. It is one of the four UK wide special hospitals providing high secure forensic care. The principal aim is to rehabilitate patients to go onto lower levels of security. Occupation is seen as a key component of this in terms of positive risk taking (Roberts, 2015). The States Hospitals Board is a special Health Board. It is one of the four U.K. wide Special Hospitals providing high secure forensic care / services.

Model of Practice The Model of Human Occupation (MOHO) is the theory underpinning Occupational Therapy practice within the State Hospital. The re-motivation process (de Las Heras, 2003) derived from MOHO was the approach used for the group which aimed to help enhance a patients level of motivation through the use of arts and crafts as the therapeutic medium, which appears to compliment this approach. Emotional Touch Points process was used to capture the patients unique experience of participating in the group. Emotional Touch Points has been described as a powerful means of helping people share aspects of their experiences that is important to them (Dewar et al, 2010).

Group Objectives based on re-motivation process Exploration Competency Achievement Invests additional energy/emotion/attention Seeks challenges Tries to solve problems Initiates actions/tasks Stays engaged Seeks additional responsibilities Shows pride Shows that an activity is special or significant Indicates goals The Remotivation Process details this clinical intervention. The process is based on the idea that individuals move through a continuum of volition that can roughly be broken down into three phases: 􀂃 Exploration 􀂃 Competency 􀂃 Achievement Pursues activity to completion/ accomplishments Tries to correct mistakes Shows preferences Tries new things

Use of arts and crafts as therapeutic medium within Occupational Therapy The use of arts and crafts as a therapeutic medium within Occupational Therapy practice is well established (Lenerts et al, 2016; Caddy et al, 2012 & Stickley, 2012) Arts and crafts was the chosen activity due to it’s ‘non-threatening approach’, whereby there was no expectation of a completed project, but in fact attending and being able to sit around the table was progression in it’s own right when considering the re-motivation process. Sensory stimulus would be provided given that there was different colours, textures and materials on offer for the patients to explore. The Occupational Therapists had difficulty identifying interests through the collaborative use of an Interest Checklist (Matsutsuyu, 1969), due to some of the patients having experienced occupational deprivation in past environments, lack of opportunity in childhood or because of chronic institutionalization making it difficult for them to know what they enjoy and gain satisfaction from doing.

Aims 1. To promote opportunity for occupational engagement through the provision of arts and crafts materials 2. To describe any change in the VQ, single observation MOHOST and present the patient’s perception of group participation. 3. To discuss the effectiveness of the intervention. 4. To discuss any challenges of this intervention.

Methodology Recruitment: Crafts group poster was placed on each ward and recreation area to enable patients to sign up to the group if they wished. The poster provided information on time, place and activities on offer (pictures included) alongside space to add any other ideas. 24 patients signed up therefore those presenting with really low volition were firstly prioritised due to the aims of the group (exploratory stage). The group was closed once places were allocated. The group ran for one hour on a Tuesday afternoon with half hour preparation time prior; one facilitator setting up the group and the other two facilitators spending time with the patients on ward to encourage participation.

Methodology cont… Facilitation: The group will be facilitated by both hub Occupational Therapists and the Occupational Therapy Technical Instructor in the hub area. Assessments: The facilitators aim to capture the patient’s volition at first and last group session attended using the VQ to observe if any change has occurred. The single observation MOHOST was also completed at first and last session attended to evaluate any change regarding participation.

Methodology cont… Analysis of data: Descriptive statistics will be used to analyze and summarize the data collected through evaluating changes in scores for first and last session attended for both the volitional questionnaire and MOHOST. Qualitative data is collected to ascertain the patient’s experience of the group through the use of ‘Emotional Touch Points’. This information will be collated to establish commonalties and differences in the patient experience of the group. Analysis of data: Descriptive statistics will be used to analyze and summarize the data collected through evaluating changes in scores for first and last session attended for both the volitional questionnaire and MOHOST. Qualitative data is collected to ascertain the patient’s experience of the group through the use of ‘Emotional Touch Points’. This information will be collated to establish commonalties and differences in the patient experience of the group.

Outcomes Three patients regularly attended allowing for the outcome measures to be completed (first and last session scores). The other three patients attended only one session for different reasons (i.e one patient moved ward, other two patients mental health impacted on enabling consistent participation). From evaluation of the VQ scores, patients level of volition appears to have improved, from patients participating in a hesitant and passive manner, to showing spontaneity within engagement towards the latter. Despite an increase in the patient’s level of volition, the evaluation of the single observation MOHOST shows an over-all decline for two patients, when considering external influences such as their peers poor social interaction skills thus in turn also impacting on how supportive the over-all group environment was.

Outcomes cont… From engagement in the Emotional Touch Points process, we can see that patients were very aware of their own functional abilities during the group. Many patients reported increased self-worth and autonomy by being given the opportunity to use equipment that they were not routinely given access to. Main themes included feelings of being ‘excited’, ‘pleased’, ‘trusted’, and ‘welcome’ within the group alongside the Therapists’ therapeutic use of self, which was apparent through the feedback received within the patient’s narrative.

Learning for future groups… To consider the logistics of the wider hospital services when planning to run the group in future, given the challenges faced during this group. To evaluate the impact this intervention has in enhancing participation within groups and activities offered in the wider hospital environment. To enhance the group intervention based on the feedback received from patient engagement in the Emotional Touch Points process. To consider the wider application of this intervention within the hospital.

References Bate, P. & Robert, G. (2007) Bringing User Experience to Healthcare Improvement. Oxford: Radcliffe Publishing. Caddy, L., Crawford, F. & Page, A.C. (2012) 'Painting a path to wellness': correlations between participating in a creative activity group and improved measured mental health outcome. Journal of Psychiatric Mental Health Nursing, 19(4), pp.327-33. De las Heras, C.G., Geist, R., Kielhofner, G & Li, Y (2007) The volitional questionnaire (VQ) Version 4.1 CG. Chicago: University of Illinois. De las Heras, C.G., V Llerena, G Kielhofner (2003) A User's Manual for Re-motivation Process: Progressive Intervention for Individuals with Severe Volitional Challenges:(version 1.0). Chicago: University of Illinois. Dewar, B., Mackay, R., Smith, S., Pullin, S. & Tocher, R. (2010) Use of emotional touchpoints as a method of tapping into the experience of receiving compassionate care in a hospital setting. Journal of Research in Nursing. (15)1, pp.29-41. Farnworth, L., Nikitin, L., & Fossey, E. (2004). Being in a secure forensic psychiatric unit: Every day is the same, killing time or making the most of it. British Journal of Occupational Therapy, 67(10), pp. 430-438.

References cont… Matsutsuyu, J. S (1969). The Inrerest Checklist. American Journal of Occupational Therapy, 23, pp. 323-328. Parkinson S., Forsyth K. & Kielhofner G (2006) User's Manual for the Model of Human Occupation Screening Tool (MOHOST) (version 2.0). Chicago: Model of Human Occupation Clearinghouse. Roberts, C (2015) Structured community activity for forensic mental health – a feasibility study. The Journal of Forensic Practice, 17 (3). Scottish Government. (2017) Allied Health Professions Co-creating Wellbeing with the people of Scotland: The Active and Independent Living Programme in Scotland. [online] Available from: http://www.gov.scot/Publications/2017/06/1250 [Accessed: 30 October 2017]. Stickley, T. (2012). ‘Creating Something Beautiful: Art in Mind’, in T.Stickley (ed.), Qualitative Research in Arts in Mental Health, 58-74, Ross-on-Wye: PCCS Books. The State Hospital’s Board for Scotland (2017) Annual Report 2017/18 [online] Available from: http://www.tsh.scot.nhs.uk/Board/Annual_Reports.htm [Accessed 4 December 2017].