Improving staff and patient Improving staff and patient relationships in psychiatric relationships in psychiatric

rehabilitation settingsrehabilitation settings

Katherine Berry Katherine Berry

Clinical Research FellowClinical Research Fellow

School of Psychological SciencesSchool of Psychological Sciences

AcknowledgementsAcknowledgements

Christine Barrowclough Christine Barrowclough Gillian HaddockGillian Haddock Chris Roberts Chris Roberts Yvonne Awenat Yvonne Awenat All participating staff and service usersAll participating staff and service users NIHR NIHR

BackgroundBackground Schizophrenia is significant mental health Schizophrenia is significant mental health

problem, characterised by psychotic problem, characterised by psychotic symptoms, which alter perceptions, thoughts, symptoms, which alter perceptions, thoughts, affect and behaviour (NICE, 2009).affect and behaviour (NICE, 2009).

The diagnosis is frequently associated with The diagnosis is frequently associated with high levels of distress in both service users high levels of distress in both service users and those who support them (NICE, 2009).and those who support them (NICE, 2009).

Schizophrenia Commission Report (2012) ‘The Schizophrenia Commission Report (2012) ‘The Abandoned Ilness’ highlighted the inadequate Abandoned Ilness’ highlighted the inadequate care people with the diagnosis receive in the care people with the diagnosis receive in the NHS.NHS.

BackgroundBackground In particular the report emphasised the anti-In particular the report emphasised the anti-

therapeutic nature of inpatient care and high therapeutic nature of inpatient care and high costs incurred by people being detained in costs incurred by people being detained in secure services over long periods of time. secure services over long periods of time.

Hence the need to improve inpatient Hence the need to improve inpatient environments and improve outcomes in long-environments and improve outcomes in long-stay secure settings. stay secure settings.

BackgroundBackground

One key predictor of outcome across a range One key predictor of outcome across a range of different settings and clinical groups, of different settings and clinical groups, including inpatients with schizophrenia is the including inpatients with schizophrenia is the quality of relationships between staff and quality of relationships between staff and patients (McCabe & Priebe, 2004; Berry et al., patients (McCabe & Priebe, 2004; Berry et al., 2011).2011).

In patient surveys, the therapeutic relationship has also repeatedly been reported as the most important component of care (e.g. MIND, 2011).

BackgroundBackground Long stay secure services or psychiatric Long stay secure services or psychiatric

rehabilitation services can be highly rehabilitation services can be highly stressful environments, not only for service stressful environments, not only for service users, but also staff, as service users users, but also staff, as service users typically have complex presentations and are typically have complex presentations and are hard to engage (RCP, 2009) hard to engage (RCP, 2009)

Front line staff have direct and regular Front line staff have direct and regular exposure to ‘challenging behaviours’, but exposure to ‘challenging behaviours’, but often limited training in psychological often limited training in psychological models or interventions. (Endley & Berry, models or interventions. (Endley & Berry, 2011; Berry et al., 2012). 2011; Berry et al., 2012).

BackgroundBackground

With high stress levels and limited With high stress levels and limited understanding, staff may respond with understanding, staff may respond with criticism, hostility, increasing restraints or criticism, hostility, increasing restraints or reducing helping behaviour (Berry et al., 2011).reducing helping behaviour (Berry et al., 2011).

But limited research on interventions to But limited research on interventions to improve staff-service user relationships and improve staff-service user relationships and stand alone training sessions have limited stand alone training sessions have limited impact on practice (Berry et al., 2011).impact on practice (Berry et al., 2011).

Therefore need to develop a more effective Therefore need to develop a more effective intervention and evaluate it.intervention and evaluate it.

Developing the interventionDeveloping the intervention

Starting point: Family interventions which Starting point: Family interventions which have been shown to improve outcomes and have been shown to improve outcomes and relationships for people with schizophrenia relationships for people with schizophrenia and their relatives (e.g. Pharoah et al., 2010).and their relatives (e.g. Pharoah et al., 2010).

Successful family interventions are Successful family interventions are individualised, involve psychoeducation and individualised, involve psychoeducation and problem solving and focus on the problem solving and focus on the relationship between the carer and service relationship between the carer and service user (NICE, 2009).user (NICE, 2009).

Developing the interventionDeveloping the intervention

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

Aims of the interventionAims of the intervention To emphasise staff members’ own skills in To emphasise staff members’ own skills in

understanding and working with service users.understanding and working with service users.

To provide a framework for thinking about To provide a framework for thinking about psychological factors motivating individual psychological factors motivating individual service users and driving problems.service users and driving problems.

To use psychological explanations to develop To use psychological explanations to develop support plans. support plans.

To give everybody in the team an opportunity To give everybody in the team an opportunity to input into support plans. to input into support plans.

InterventionIntervention

Initial meetings with key workers to establish Initial meetings with key workers to establish background information. background information.

Team meetings organised and attended by all Team meetings organised and attended by all available staff on the ward.available staff on the ward.

1 - 1 ½ hours long carried out over ‘handover’ 1 - 1 ½ hours long carried out over ‘handover’ period.period.

Focused on specific service user each Focused on specific service user each meeting.meeting.

InterventionIntervention Staff asked to identify service user strengths Staff asked to identify service user strengths

and followed by any issues they are and followed by any issues they are struggling with or want to understand better.struggling with or want to understand better.

Examples identified include: aggression, Examples identified include: aggression, paranoia, poor motivation, social withdrawal paranoia, poor motivation, social withdrawal or ‘attention seeking’.or ‘attention seeking’.

List significant events and relationships in List significant events and relationships in the service user’s life pre- and post-the service user’s life pre- and post-diagnosis. diagnosis.

InterventionIntervention Staff asked to think about impact of events Staff asked to think about impact of events

on the service user’s beliefs, including on the service user’s beliefs, including positive and negative beliefs about self, positive and negative beliefs about self, others and world in general. others and world in general.

Generate hypotheses about triggers for Generate hypotheses about triggers for stress and preferred ways of coping.stress and preferred ways of coping.

Ways of coping linked to ‘problem’ Ways of coping linked to ‘problem’ behaviours.behaviours.

Discuss maintenance cycles, with an Discuss maintenance cycles, with an emphasis on the role of staff responses.emphasis on the role of staff responses.

InterventionIntervention

Concludes by discussing implications for Concludes by discussing implications for support plans.support plans.

Following the team meeting, a report detailing Following the team meeting, a report detailing the key issues discussed is fed back to the the key issues discussed is fed back to the team and service user.team and service user.

Intervention is carried out over 6 months in Intervention is carried out over 6 months in each rehabilitation unit and each service user each rehabilitation unit and each service user is discussed and reviewed at least once.is discussed and reviewed at least once.

Formulation frameworkFormulation 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

ExampleExample

Physically abused by parentsBullied at schoolViolence in adulthood relationships

‘I’m vulnerable’, ‘Other people are aggressive’, ‘The world is a dangerous place’

Defensive, hostile and aggressive towards otherpeople and when challenged.

Preliminary evaluationPreliminary evaluation

Pilot study developing formulations with 30 Pilot study developing formulations with 30 staff in psychiatric rehabilitation units which staff in psychiatric rehabilitation units which showed promising results in terms of staff showed promising results in terms of staff perceptions of their relationships (Berry et al perceptions of their relationships (Berry et al 2009). 2009).

But limitations of pilot workBut limitations of pilot work- Small uncontrolled study with no follow-ups.- Small uncontrolled study with no follow-ups.- Lack of established measures of - Lack of established measures of

relationships and no assessment of changes relationships and no assessment of changes in practice.in practice.

NIHR ProjectNIHR Project

Aims to develop this programme of research by Aims to develop this programme of research by assessing the feasibility and acceptability of the assessing the feasibility and acceptability of the intervention on a larger scale with more valid intervention on a larger scale with more valid outcomes and controls. outcomes and controls.

Recruitment target is 80 staff and 40 service Recruitment target is 80 staff and 40 service users from 10 psychiatric rehabilitation units in users from 10 psychiatric rehabilitation units in Greater Manchester. Greater Manchester.

Uses a cluster randomised design with 5 units Uses a cluster randomised design with 5 units receiving the intervention and 5 units receiving receiving the intervention and 5 units receiving treatment as usual.treatment as usual.

NIHR projectNIHR project Standardised interviews and questionnaires to Standardised interviews and questionnaires to

assess service user symptoms, staff stress and assess service user symptoms, staff stress and relationships at baseline, 6-months and 12-month relationships at baseline, 6-months and 12-month follow-ups.follow-ups.

Feedback interviews post-intervention analysed Feedback interviews post-intervention analysed for key themes. for key themes.

Data on uptake to study and intervention.Data on uptake to study and intervention.

Results of study will be used to inform larger scale Results of study will be used to inform larger scale RCTs.RCTs.

Progress so farProgress so far Recruited 87 staff and 50 service users at Recruited 87 staff and 50 service users at

baseline across 10 units.baseline across 10 units.

Intervention has been carried out in 4 units, with Intervention has been carried out in 4 units, with 5 control units.5 control units.

Currently carrying out interventions in unit 5. Currently carrying out interventions in unit 5.

Progress so farProgress so far

Achieved target of recruiting 50% of staff and Achieved target of recruiting 50% of staff and 25% of service users from each unit.25% of service users from each unit.

Although some loss of service users at follow-Although some loss of service users at follow-up, due to ‘move-ons’ (so far, 80% retained at 6-up, due to ‘move-ons’ (so far, 80% retained at 6-months and 56% at 12-months).months and 56% at 12-months).

Initial target of 10 meetings per staff member, Initial target of 10 meetings per staff member, but so far staff have only attended a mean of 5 but so far staff have only attended a mean of 5 meetings (range = 1-8).meetings (range = 1-8).

Progress so farProgress so far

Meetings have been attended by 1-15 Meetings have been attended by 1-15 members of staff (mean = 6).members of staff (mean = 6).

All staff have attended at least one meeting.All staff have attended at least one meeting.

All service users who were not scheduled for All service users who were not scheduled for discharge have been discussed.discharge have been discussed.

Experiences so farExperiences so far Intervention well received by managers and all levels Intervention well received by managers and all levels

of staff.of staff.

Key themes from feedback interviews Key themes from feedback interviews - Importance of recognising staff view pointsImportance of recognising staff view points- Recognising strengths of the teamRecognising strengths of the team- Understanding why service users might be behaving Understanding why service users might be behaving

in a certain way and increased empathyin a certain way and increased empathy- Generates new ideas for support plansGenerates new ideas for support plans- Opportunity to “off load” about daily hassles Opportunity to “off load” about daily hassles

Experiences so farExperiences so far Need to flexible with days of meetings and the need for Need to flexible with days of meetings and the need for

interruptions.interruptions.

Importance of non-expert stance.Importance of non-expert stance.

Emphasis on support plans.Emphasis on support plans.

Limited remit of intervention and other aspects of psychologist’s Limited remit of intervention and other aspects of psychologist’s role. role.

Experiences of control group and importance of offering them the Experiences of control group and importance of offering them the intervention.intervention.

‘‘Add-on’ projectsAdd-on’ projects When follow-ups are complete interventions are being carried out When follow-ups are complete interventions are being carried out

in control units with the aim of developing a fidelity measure.in control units with the aim of developing a fidelity measure.

Evaluation of reports from intervention meetings as part of an Evaluation of reports from intervention meetings as part of an assessment of fidelity. assessment of fidelity.

Investigating factors associated with relationship quality using Investigating factors associated with relationship quality using baseline data.baseline data.

Diary study to investigate the influence of social relationships on Diary study to investigate the influence of social relationships on symptoms.symptoms.

Key referencesKey references

Berry, K., Barrowclough, C., Innes, C., Fitzgerald, M., Hartley, Berry, K., Barrowclough, C., Innes, C., Fitzgerald, M., Hartley, S., & Haddock, G. (2012). A description and evaluation of a S., & Haddock, G. (2012). A description and evaluation of a challenging behaviour workshop. challenging behaviour workshop. Journal of Mental HealthJournal of Mental Health, , 21, 21, 478-484.478-484.

Berry, K., Barrowclough, C. & Haddock, G. (2011). The role of Berry, K., Barrowclough, C. & Haddock, G. (2011). The role of Expressed Emotion in relationships between psychiatric staff Expressed Emotion in relationships between psychiatric staff and people with a diagnosis of psychosis: A review of the and people with a diagnosis of psychosis: A review of the literature. literature. Schizophrenia Bulletin, 37, Schizophrenia Bulletin, 37, 958-972958-972. .

Berry, K., Barrowclough, C. & Wearden, A. (2009). A pilot study Berry, K., Barrowclough, C. & Wearden, A. (2009). A pilot study investigating the use of psychological formulations to modify investigating the use of psychological formulations to modify psychiatric staff perceptions of service users with psychosis. psychiatric staff perceptions of service users with psychosis. Behavioural and Cognitive Psychotherapy, 37, Behavioural and Cognitive Psychotherapy, 37, 39-48.39-48.

Endley, L., & Berry, K. (2011). Increasing awareness of Endley, L., & Berry, K. (2011). Increasing awareness of Expressed Emotion in Schizophrenia: An evaluation of a staff Expressed Emotion in Schizophrenia: An evaluation of a staff training session. training session. Journal of Psychiatric and Mental Health Journal of Psychiatric and Mental Health NursingNursing, , 1818, 277-280, 277-280..