Improving staff and patient relationships in psychiatric rehabilitation settings Katherine Berry Clinical Research Fellow School of Psychological Sciences

Acknowledgements  Christine Barrowclough  Gillian Haddock  Chris Roberts  Yvonne Awenat  All participating staff and service users  NIHR

Background  Schizophrenia is significant mental health problem, characterised by psychotic symptoms, which alter perceptions, thoughts, affect and behaviour (NICE, 2009).  The diagnosis is frequently associated with high levels of distress in both service users and those who support them (NICE, 2009).  Schizophrenia Commission Report (2012) ‘The Abandoned Ilness’ highlighted the inadequate care people with the diagnosis receive in the NHS.

Background  In particular the report emphasised the anti- therapeutic nature of inpatient care and high costs incurred by people being detained in secure services over long periods of time.  Hence the need to improve inpatient environments and improve outcomes in long-stay secure settings.

Background  One key predictor of outcome across a range of different settings and clinical groups, including inpatients with schizophrenia is the quality of relationships between staff and patients (McCabe & Priebe, 2004; Berry et al., 2011).   In patient surveys, the therapeutic relationship has also repeatedly been reported as the most important component of care (e.g. MIND, 2011).

Background  Long stay secure services or psychiatric rehabilitation services can be highly stressful environments, not only for service users, but also staff, as service users typically have complex presentations and are hard to engage (RCP, 2009)  Front line staff have direct and regular exposure to ‘challenging behaviours’, but often limited training in psychological models or interventions. (Endley & Berry, 2011; Berry et al., 2012).

Background  With high stress levels and limited understanding, staff may respond with criticism, hostility, increasing restraints or reducing helping behaviour (Berry et al., 2011).  But limited research on interventions to improve staff-service user relationships and stand alone training sessions have limited impact on practice (Berry et al., 2011).  Therefore need to develop a more effective intervention and evaluate it.

Developing the intervention  Starting point: Family interventions which have been shown to improve outcomes and relationships for people with schizophrenia and their relatives (e.g. Pharoah et al., 2010).  Successful family interventions are individualised, involve psychoeducation and problem solving and focus on the relationship between the carer and service user (NICE, 2009).

Developing the intervention  Clinical practice: Improving staff understanding and relationships by developing formulations of individual service users’ psychological needs with teams of staff (BPS, 2011).

Aims of the intervention  To emphasise staff members’ own skills in understanding and working with service users.  To provide a framework for thinking about psychological factors motivating individual service users and driving problems.  To use psychological explanations to develop support plans.  To give everybody in the team an opportunity to input into support plans.

Intervention  Initial meetings with key workers to establish background information.  Team meetings organised and attended by all available staff on the ward.  ½ hours long carried out over ‘handover’ period.  Focused on specific service user each meeting.

Intervention  Staff asked to identify service user strengths and followed by any issues they are struggling with or want to understand better.  Examples identified include: aggression, paranoia, poor motivation, social withdrawal or ‘attention seeking’.  List significant events and relationships in the service user’s life pre- and post- diagnosis.

Intervention  Staff asked to think about impact of events on the service user’s beliefs, including positive and negative beliefs about self, others and world in general.  Generate hypotheses about triggers for stress and preferred ways of coping.  Ways of coping linked to ‘problem’ behaviours.  Discuss maintenance cycles, with an emphasis on the role of staff responses.

Intervention  Concludes by discussing implications for support plans.  Following the team meeting, a report detailing the key issues discussed is fed back to the team and service user.  Intervention is carried out over 6 months in each rehabilitation unit and each service user is discussed and reviewed at least once.

Formulation framework Life events and interpersonal relationships Beliefs about self, other people and world in general Ways of coping with stress and ways of relating to others

Example Physically abused by parents Bullied at school Violence in adulthood relationships ‘I’m vulnerable’, ‘Other people are aggressive’, ‘The world is a dangerous place’ Defensive, hostile and aggressive towards other people and when challenged.

Preliminary evaluation  Pilot study developing formulations with 30 staff in psychiatric rehabilitation units which showed promising results in terms of staff perceptions of their relationships (Berry et al 2009).  But limitations of pilot work - Small uncontrolled study with no follow-ups. - Lack of established measures of relationships and no assessment of changes in practice.

NIHR Project  Aims to develop this programme of research by assessing the feasibility and acceptability of the intervention on a larger scale with more valid outcomes and controls.  Recruitment target is 80 staff and 40 service users from 10 psychiatric rehabilitation units in Greater Manchester.  Uses a cluster randomised design with 5 units receiving the intervention and 5 units receiving treatment as usual.

NIHR project  Standardised interviews and questionnaires to assess service user symptoms, staff stress and relationships at baseline, 6- months and 12-month follow-ups.  Feedback interviews post-intervention analysed for key themes.  Data on uptake to study and intervention.  Results of study will be used to inform larger scale RCTs.

Progress so far  Recruited 87 staff and 50 service users at baseline across 10 units.  Intervention has been carried out in 4 units, with 5 control units.  Currently carrying out interventions in unit 5.

Progress so far  Achieved target of recruiting 50% of staff and 25% of service users from each unit.  Although some loss of service users at follow- up, due to ‘move-ons’ (so far, 80% retained at 6- months and 56% at 12-months).  Initial target of 10 meetings per staff member, but so far staff have only attended a mean of 5 meetings (range = 1-8).

Progress so far  Meetings have been attended by 1-15 members of staff (mean = 6).  All staff have attended at least one meeting.  All service users who were not scheduled for discharge have been discussed.

Experiences so far  Intervention well received by managers and all levels of staff.  Key themes from feedback interviews - Importance of recognising staff view points - Recognising strengths of the team - Understanding why service users might be behaving in a certain way and increased empathy - Generates new ideas for support plans - Opportunity to “off load” about daily hassles

Experiences so far  Need to flexible with days of meetings and the need for interruptions.  Importance of non-expert stance.  Emphasis on support plans.  Limited remit of intervention and other aspects of psychologist’s role.  Experiences of control group and importance of offering them the intervention.

‘Add-on’ projects  When follow-ups are complete interventions are being carried out in control units with the aim of developing a fidelity measure.  Evaluation of reports from intervention meetings as part of an assessment of fidelity.  Investigating factors associated with relationship quality using baseline data.  Diary study to investigate the influence of social relationships on symptoms.

Key references Berry, K., Barrowclough, C., Innes, C., Fitzgerald, M., Hartley, S., & Haddock, G. (2012). A description and evaluation of a challenging behaviour workshop. Journal of Mental Health, 21, Berry, K., Barrowclough, C., Innes, C., Fitzgerald, M., Hartley, S., & Haddock, G. (2012). A description and evaluation of a challenging behaviour workshop. Journal of Mental Health, 21, Berry, K., Barrowclough, C. & Haddock, G. (2011). The role of Expressed Emotion in relationships between psychiatric staff and people with a diagnosis of psychosis: A review of the literature. Schizophrenia Bulletin, 37, Berry, K., Barrowclough, C. & Haddock, G. (2011). The role of Expressed Emotion in relationships between psychiatric staff and people with a diagnosis of psychosis: A review of the literature. Schizophrenia Bulletin, 37, Berry, K., Barrowclough, C. & Wearden, A. (2009). A pilot study investigating the use of psychological formulations to modify psychiatric staff perceptions of service users with psychosis. Behavioural and Cognitive Psychotherapy, 37, Berry, K., Barrowclough, C. & Wearden, A. (2009). A pilot study investigating the use of psychological formulations to modify psychiatric staff perceptions of service users with psychosis. Behavioural and Cognitive Psychotherapy, 37, Endley, L., & Berry, K. (2011). Increasing awareness of Expressed Emotion in Schizophrenia: An evaluation of a staff training session. Journal of Psychiatric and Mental Health Nursing, 18, Endley, L., & Berry, K. (2011). Increasing awareness of Expressed Emotion in Schizophrenia: An evaluation of a staff training session. Journal of Psychiatric and Mental Health Nursing, 18,