ComQuol: Users Focused Outcomes Dr Janet Parrott, Consultant Forensic Psychiatrist Principal Investigator (ComQuol) Oxleas NHS Foundation Trust

Service User Focused Outcome Measures Primary Outcome Quality of Life (MANSA) Secondary Outcomes Recovery (Process of Recovery Questionnaire) Therapeutic Relationship (Helping Alliance Scale)

Outcome Assessments Time Point 1 – Baseline – Before intervention Time Point 2 – 6-Months – Following completion of intervention Time Point 3 – 12-Months The primary endpoint will be measured at three time points. To ensure results are not affected by a secular trend, each intervention group will be paired with a control unit group. Time Point 1 – baseline assessment of patients for the intervention group this will be prior to their first structured communication session while for the control group this will be at the same time as when the intervention group are assessed. Time Point 2 – within the two weeks following the intervention; the last DIALOG approach meeting (after six months from Time Point 1 assessment). Time Point 3 – six months post intervention (twelve months after time point 1 assessment).

Definition of Quality of Life (QoL) Broad agreement about characteristics: Subjective experience Multidimensional nature (physical, psychological, social, environmental) Positive and negative aspects (WHOQOL, 1998) WHOQOL = World Health Organisation Quality of Life Group

Quality of Life and Forensic Mental Health Fitzpatrick et al (2010) - Rated 17th out of 21 variables regarding importance of outcome. QoL has not been extensively employed in forensic mental health research but is a relevant and important issue. Research shows that quality of life is important although a systematic review by Fitzpatrick et al (2010) found the quality of life was rated 17th out of 21 regarding important of outcomes placing violence, disturbance, and reoffending has been seen as more important to focus on.

(1 = couldn’t be worse to 7 = couldn’t be better) Outcome Assessments Primary outcome = Quality of Life Assessed using Manchester Short Assessment of Quality of Life scale (MANSA) (Priebe et al, 1999) Short form of the Lancashire Quality of Life Profile (Oliver et al 1996) Twelve questions rated on 7-point Likert scale (1 = couldn’t be worse to 7 = couldn’t be better) Generates overall summary mean score (from 1 to 7)

Comparison of Mean Quality of Life Scores Domain Mean (range 1-7) (SD) Baseline 6-Months 12-Months Control (N = 52) 4.2 (0.2) 4.3 (0.1) 4.3 (0.3) Intervention (N = 53) 4.4 (0.3) 4.5 (0.4) 4.7 (0.2) Put in ICC and confidence interval

Comparison of Treatment Effect Quality of Life Scores Treatment Effect (intervention – control) and Confidence Interval 6-Month 12-Month 0.2 (-0.4 to 0.8) 0.4 (-0.3 to 1.1) ICC (CI) 0.04 (0.00 to 0.17) 0.05 (0.00 to 0.18) ICC = Intracluster Correlation Coefficient

Recovery in Forensic Settings Definition of Recovery “A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony, 1993)

Recovery in Forensic Settings Other important aspects of recovery include spirituality, peer support, self-management, creativity, housing, finances, work and hobbies (Roberts & Hollins, 2007) Forensic services definition must acknowledge the challenge of dual recovery from mental illness and offending behaviour, and recognise that risk management is equally necessary and can happen alongside restoration of a meaningful and satisfying life (Aldred & Drennan, 2010)

(0 = disagree strongly to 4 = agree strongly) Outcome Assessment Recovery Measure Assessed using Process of Recovery Questionnaire (QPR) (Neil et al, 2007) 22-item measure rated on 5-point Likert scale (0 = disagree strongly to 4 = agree strongly) Score generated: Intrapersonal mean score (from 0 to 51) Relating to intrapersonal tasks that an individual is responsible for carrying out and that they complete in order to rebuild their life Interpersonal mean score (from 0 to 15) Relating to interpersonal ability to reflect on their value in the external world and how recovery is facilitated by external processes in interpersonal relationships with others The Process of Recovery Questionnaire (QPR) will be used, which is a 22-item measure that asks about aspects of recovery that are meaningful to patients

Comparison of Mean Recovery Scores Domain Mean (range 0-51)(SD) Baseline 6-Months 12-Months Control (N = 52) Intrapersonal 45.6 (4.1) 47.1 (2.0) 46.9 (1.1) Interpersonal 13.9 (0.8) 14.0 (0.7) 14.7 (0.9) (range 0-15) (SD) Intervention (N = 53) 48.4 (1.7) 49.4 (2.0) 48.6 (1.0) 14.1 (0.3) 13.9 (0.4) 13.9 (0.7) Subtract 17 from intra and 5 from inter

Comparison of Treatment Effect Recovery Scores Treatment Effect (intervention – control) and Confidence Interval 6-Months 12-Months Intrapersonal 2.2 (-2.3 to 6.7) 1.7 (-0.7 to 4.1) Interpersonal -0.1 (-1.3 to 1.2) -0.9 (-2.7 to 1.0)

Therapeutic Relationship in Forensic Settings Best Practice Guidelines in Medium Secure Units Therapeutic alliance between staff and patients is at the centre of high-quality care and treatment Research in Mental Health Setting: Influential in predicting positive outcomes such as reducing hospitalisation, symptomatology and social disability, increasing engagement with services, medication, adherence and global functioning. (Priebe & Gruyters, 1993; Tatten & Tarrier, 2000) Relational Security: described as therapeutic alliance between staff and patient in continuing risk assessment ad detailed knowledge of patient (Diamond & Chiweda, 2011)

(0 = not at all to 10 = entirely) Outcome Assessment Therapeutic Relationship Assessed using the Helping Alliance Scale 3-item questionnaire rated on a 11-point Likert scale (0 = not at all to 10 = entirely) Three domain scores generated (from 0 to 10) and total score Feeling clinician understands you and is engaged in your treatment Belief about getting right treatment Feeling respected Item 1: Feeling understood by clinicial staff (Clinican understanding and engaged in treatment) Item 2: Belirefs about receving right treatment (Belief about treatment) Item 3: Respected and well regarded (Respect and Regard) Overall: Total sum score

Comparison of Mean Therapeutic Relationship Scores Domain Mean (range 0-10) (SD) Baseline 6-Months 12-Month Control N = 52 N = 41 Understanding/Engaged 6.9 (0.2) † 6.4 (0.3) 7.1 (0.3) Belief 5.6 (0.8) 6.2 (0.3) 6.2 (0.6) Respected 6.0 (0.9) 6.0 (0.2) 6.7 (0.6) Total Score 6.2 (0.2) † 6.3 (0.5) 6.7 (0.2) Intervention N = 46 N = 47 6.4 (0.4) 6.9 (0.5) 7.0 (0.4) 6.1 (0.8) 6.2 (1.0) 6.9 (1.3) 6.1 (0.5) 6.4 (0.6) 7.1 (0.7) 6.6 (0.6) 7.0 (0.8) † N = 51

Comparison of Treatment Effect Therapeutic Relationship Scores Treatment Effect (intervention – control) and Confidence Interval 6-Month 12-Months Understanding/Engaged 0.4 (-0.5 to 1.4) -0.1 (-0.9 to 0.7) Belief 0.1 (-1.6 to 1.7) 0.8 (-1.6 to 3.1) Respected 0.5 (-0.6 to 1.5) 0.3 (-1.1 to 1.8) Total Score 0.3 (-0.9 to 1.6) 0.3 (-1.0 to 1.7)

Concluding Remarks Outcome assessments understood by participants and gave relevant information outcomes QoL treatment effect is viewed as clinically important A difference of 0.2 equates to a increase in 1 point on the MANSA for 2-3 items A difference of 0.4 equates to a 1 point difference in 5 items Recovery indicates estimated treatments effect increase intrapersonal scores a 6- and 12-months, and decrease in interpersonal scores at 12- months In line with non-forensic scores Therapeutic Relationship Overall score shows good improvements Equates to approx 1-point increase in one of the domains ‘Understanding’ has improvement at 6-monts but not at 12-months (Reduction in feeling of being cared for after completing of intervention) ‘Belief’ most improved Consistent improvement in ‘Respect and Regard’