“

Mental Health Research:

What are the risks of that happening?

Professor Paul RogersProfessor of Forensic NursingFaculty of Health, Sports and Science

Aim

Give a rough overview of my career.

Present two examples of research which examines the evidence base examining mental health and the issue of “risk” of violence.

Of note, these are areas where the “evidence” or the “clinical practice” had already been very firmly established. So there was “no need” to do the research!!!

Available to download from - http://office.research.glam.ac.uk/

Forensic (psychiatric) Nursing

Forensic – pertaining to the law

Nursing ........those who by the nature of their health condition are likely to come into contact with the legal / criminal justice system.

Historically related to mental health

Offenders of Crime (UK)

Victims of Crime (USA)

P H IS Y C

Why Psychiatric Nursing? Nature versus Nurture

Mother and Father are Psychiatric Nurses.

My Father was the eldest of 9 siblings, of whom 7 became psych nurses

My mother has one sister who is a psych nurse

My Maternal Grandmother was one of the first ever Registered Psychiatric Nurses in Ireland (Kilkenny).

= Psychiatric nurse gene??!

PaulRogers

EddieRogers

MargaretRogers

SeanRogers

MaryRogers

(Grennan)

Oliver Monica Joe Bernadette Gabriel Mary Jimmy Frank

MargaretFitzgerald(Brennan)

TomFitzgerald

AllisonRogers

(Farrelly)

My background - Is there a gene for “psychiatric nursing”?

I was told that I had to do …………………………………………………………………………………………………“the obligatory baby photos”!

The obligatory baby snapshot!!!

TO INSERT

Early career

Aged 16. Tomato picking, Southport

Aged 16. Psychiatric Nursing Home, Southport

Aged 17. General Nursing Home, Southport

Aged 17. GNC Nursing entrance test – Park Lane Hospital

Aged 18. Student Psychiatric Nurse – Fairfield Hospital, Beds

Fairfield Hospital, Bedfordshire

Fairfield Hospital

Opened in 1860 - Three Counties Asylum (Beds., Bucks., Herts.)

350 Acres

In 1986 had 63 wards; All were full with a patient population in excess of 2000

Approximately 25% of Wards were “locked”

Most Secure Ward = M8 Ward

M8 Ward

36 bedded Male Ward (mostly from Bedford Prison)

Four staff

18 Seclusion rooms

Fairfield Hospital – In short

Met Allison

Practices were “staff focussed”

Control & Restraint training

Why wasn’t violence “predicted”

How are things “prevented”

What is Psychiatric nursing?

National Brain Injury Unit

Aged 21 (1989) – Staff Nurse - National Brain Injury Rehab Service, St Andrew’s Hospital, Northampton

Applied Behaviourism

15 minute token economy programme

Time Out for Aggression & Ind. Programmes

Last ward in the UK to use “Food” as a “reinforcer”

Moving to a culture of “positive programmes”

Became a Home Office “approved” Control and Restraint Instructor

Caswell Clinic, Bridgend & District NHS Trust

Aged 23 – Charge NurseIntensive Care Unit, Caswell Clinic, Interim Medium Secure Unit

“Humanistic approaches”

No seclusion roomsCare was focussed through the Nursing Care Plans

At that time - No real “Risk assessment”

Cert ENB 650 Course

Cert ENB 650 - 99 Denmark Hill, Maudsley Hospital

Cert ENB 650 - 99 Denmark Hill, Maudsley Hospital

● 18 month, Full time course; we were Course 15● Started in 1971, National Referral Centre● Clinical Director - Prof Isaac Marks● Trained nurses to deliver Behaviour Therapy● Previous Students – Prof Kevin Gournay, Prof Charlie Brooker

● 1n 1994 - Approx 12 National Training places● “De-constructed” what we did and then ++ training● Treated out-patients (OCD, PTSD, Agoraphobia, Social Phobias,

Habit Disorders, Body Dysmorphic Disorder, Specific phobias)

● The Single Case Study Experimental Design

The Single Case Study Experimental Design

Caswell Clinic - The Single Case Study

Experimental DesignAged 28 (1995) returned to the Caswell Clinic - CNS in CBT

Rogers, P. (1997). Posttraumatic stress disorder following male rape. Journal of Mental Health, 6(1), 5-9.

Rogers, P. and Darnley, S. (1997). Self-monitoring, competing response and response cost in the treatment of trichotillomania. Behavioural and Cognitive Psychotherapy, 25, 281-290.

Rogers, P. & Gronow, T. (1997). Anger Management: Turn down the heat. Nursing Times, 93(3), 26-29.

Rogers, P., Gray, N.S., Williams, T. & Kitchener, N.J. (2000). The behavioural treatment of PTSD in a perpetrator of manslaughter. Journal of Traumatic Stress, 13, 511-519.

.

Clinically

CBT – seeing two main sets of clients

1. Males with horrendous personal histories who developed PTSD

2. Those with “command hallucinations” who had acted on their commands with very serious consequences

The psychiatric research at that time reported that Command hallucinations were NOT dangerous (either suicide / violence)!

Preliminary study – examining command hallucinations and “risks”

We examined whether patients in a Medium Secure Unit were more likely than other clients to:

1. Engage in self harm / suicidal behaviour

2. Engage in violence to others

Main issues that we found were 1. What about the “content” of the command & 2. What about possible confounding

Rogers, P., Watt, A., Gray, N.S., MacCulloch, MM & Gournay, K. (2002) Content of command hallucinations predicts self harm but not violence in a medium secure unit. Journal of Forensic Psychiatry, 13(2), 251-262.

PhD - The Association between Command Hallucinations and Violence

1999 - PhD The Association between Command

Hallucinations and Violence

Full time funded PhD – Wales Office of Research and Development

Undertook PhD at the Institute of Psychiatry with Professors Kevin Gournay and Professor Graham Thornicroft as supervisors

Advisors – Professor Nicola Gray, Cardiff University and Professor Glyn Lewis, Bristol University

Command Hallucinations

“Command hallucinations are auditory hallucinations that order particular acts,

often violent or destructive ones and instruct a patient to act in

a certain manner”

(Hellerstein et al, 1987)

Command hallucinations and risk

By the mid 90’s, UK policy / politicians had tasked forensic and mental health practitioners to improve risk assessment and management

In the past 60 years, international research has examined the associations between 1. Diagnosis and 2. Symptoms of mental disorder and violence.

No strong association between diagnosis and violence

Some positive associations found for delusions and violence

No association found for command hallucinations

Clinical Wisdom

Clinical wisdom from the past 70 years has assumed and directed that command hallucinations are associated with and lead to violence.

Bleuler, E. (1930). Textbook of Psychiatry (trans A.A. Brill), New York, Macmillan.

Schneider, K. (1959) Clinical Psychopathology. New York. Stratton.

Real World experiences

The research just didn’t make sense!!

Clinically, we had encountered many people who report having been violent as a direct result of hearing command hallucinations.

Personal experience = high proportion of clients in forensic services report command hallucinations.

Many of the patients in the homicide inquiries had command hallucinations

Numerous Case Reports

Violence to others (Good, 1997)Self amputation of a limb (Hall et al, 1981)Swallowing objects (Karp et al, 1991)Plucking out own eyes (Field & Waldfogel, 1995)Self inflicted lacerations (Rowan & Malone, 1997)Suicide (Zisook et al, 1995)

Command Hallucinations & Violence (Pre-2000)

By year 1999, 7 controlled studies had found NO relationship between command hallucinations and an increased risk of violence

Therefore, 3 systematic reviews had also found NO relationship between command hallucinations and an increased risk of violence

Clinical wisdom or “psychiatric myth”

Have psychiatric practitioners and services been unnecessarily detaining people due to a 70 year old “myth” about the association between command hallucinations and violence?

Bleuler, E. (1930). Textbook of Psychiatry (trans A.A. Brill), New York, Macmillan.

Time for some critical appraisal

• None of the studies were prospective.

• Research evidence was based upon a total population of 237!

• Only 13% of cases had reported commands directing violence

Study examples

Study Sample size

Command content

Hellerstein et al, (1987)

58 30 suicide7 self-harm3 homicide8 non violent acts 10 unspecified

Zisook et al, (1995)

46 20 violent (self/others) 19 benign 7 unspecified

Trying to make sense of the “evidence”

Are the pre-2000 studies that found no association accurate ???

or …...................

Could they possibly be misleading Clinicians into discharging people who “may” be a risk?

SECONDARY ANALYSES OF THE MACARTHUR VIOLENCE

RISK ASSESSMENT DATA

Research grant provided by the Wales Office of Research and Development for Health and Social

Care (S98/004)

Research Questions

• Are violent-content command hallucinations associated with 1yr FU violence compared with all other patients?

• What happens to the association if we examine those with non-violent content command hallucinations?

SampleSecondary data epidemiological analysis of the

MacArthur Violence Risk Study Data

Largest worldwide study of its kind which used multiple methods for determining whether violence occurred after discharge

1,136 patients were randomly selected from 12,873 patients who were admitted to any of three large US hospitals

Patients followed up every 10 weeks for 1 year

Outcome Measure: Violence

All participants were followed up every 10 weeks for 1-year after discharge

Subject self-reportsCollateral informant reportsOfficial arrest recordsHospital admitting incident chart information Rehospitalisation records

All violent incidents were systematically reviewed, independently coded and a decision was made as to whether it occurred

Exposure: Command Hallucinations

THE AUDITORY HALLUCINATIONS SCHEDULE

Have you more than once had the experience of hearing things or voices other people couldn't hear?

Do the voices tell you to do anything?

What is the highest level of violence they have commanded?

This allowed us to categories commands in to two groups: - violent or non violent

Adjusted confounders

Age GenderMarital status EthnicityBeaten as a child Beaten as a teenagerHistory of drug abuse History of alcohol abuseSeverity of symptoms (BPRS) Impulsivity (BIS)Any delusions Persecutory delusionsPsychopathy (PCL:SV)Living with relative post discharge Prior arrests for “crimes against the person”

Statistical Analysis

Random-effects, repeated measures, logistic regression

Unadjusted and then adjusted Odds ratios -adjusted for time, and a range of confounders (with 95% C.I.’s)

Odds ratios:Anything above “1” = an increased risk of

violence.

Anything below “1” = a reduced risk of violence

Results

The words - “all your eggs”

and...............

“one basket” - spring to mind!

Proportion who had a violent incident over 1 yr

Unadjusted OR (95% C.I.)

Fully adjusted (time and confounders) OR (95% C.I.)

All others(Reference group) (n=887)

26.7% (199/745) 1.00 1.00

Non-violent content command hallucinations (n=125)

23.9% (26/109) 0.87 (0.53-1.41)

0.66 (0.37-1.16)

Violent content command hallucinations (n=105)

44.4% (36/81) 2.03 (1.25-1.30)

1.86 (1.09-3.18)

.005 .05 .0001

Conclusions

There was good evidence that violent-content command hallucinations were associated with future violent incidents both before and after adjustment for confounding.

There was no evidence that any-content command hallucinations were associated with future violent incidents either before or after adjustment for confounding.

Real world implications

We need to consider the content of command hallucinations when making decisions about future violence risk

We need to trust our clinical “uncertainty”

We need to critically appraise the quality of research when making conclusions about their findings

What training are staff getting regarding risk assessments and the evidence base???

MRC Post Doctoral Fellowship

2002. Left the NHS for University Life! And properly joined the Section of Nursing, Health Service Research Department, Institute of Psychiatry, Kings College.

Professor Kevin Gournay, Dr Sue Plummer, Dr Richard Gray, Dr Mark Haddad, Jimmy Noak, Edwin Gwenzie, et al.

Awarded £220,000 by the Medical Research Council to conduct secondary analysis of two cross sectional surveys in order to investigate the aetiology of high rates of psychiatric morbidity and suicidal thoughts among prisoners. MRC Special Training Fellowship (Health Services Research and Public Health). (2002-2006).

Post Doc / University of GlamorganInvolved in a range of studies:

Connolly A, Rogers P, Taylor D. (2007). Antipsychotic prescribing quality and ethnicity: a study of hospitalized patients in south east London. Maudsley Hospital (£60,000)

£34,000 study from the National Programme on Forensic Mental Health Research & Development. Assessing the utility of the Offenders Group Reconviction Scale-2 in predicting the risk of reconviction within 2 & 4 years of discharge from English & Welsh Medium Secure Units. (2004-06).

Amos, T., et al. A review of forensic and prison reviews. (£35,000). The National Programme for Forensic Mental Health Research, Department of Health. (2005-2006).

Harrison, G. et al. The DEBIT Trial (A Clustered Randomised Controlled Trial to reduce anti-psychotic polypharmacy (£430,000). Funded by an NHS Regional R&D grant (2000-2005).

Developed a bid to WAG for £90,000 to set up WARRN through the NHS

Current main research interest

Main theme / My main interest

● Examining issues related to imminent or real violence.

● What does one actually do in these circumstances?

● Linked to my earlier experiences on “M8” ward at Fairfield Hospital and my “Control and Restraint” Instructor training

Latest Research Findings on “Breakaway” training

We know that violence to healthcare staff is a major

problem

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SHOCKING NHS VIOLENCE FIGURES RELEASED (2002)

The NHS executive has reported upon a national cross sectional survey and found that in the last year there were 65 000 violentincidents reported against staff in the NHS.

Healthcare & Violence

Scottish Health Service Management Executive (1996)Royal College of Psychiatrists (1998)NHS Executive (2000)Nursing & Midwifery Council (2001)NHS Security Management Service (2001)National Audit Office (2003)World Health Organization (2003)Welsh Assembly Government (2004)National Institute for Clinical Excellence (2005)National Institute for Mental Health England (2005)Wales Audit Office (2005)

Protecting NHS staff from V&A – Welsh violence data

8,000 incidents of violence and aggression, in Welsh NHS Trusts = 22 incidents per day (2003-04 )

Mental Health staff most likely to be assaulted, followed by Learning Disability then A+E

Cost due to consequences of violence or investment in training- £6.3 million in (03-04)

Lets recommend “breakaways”

Scottish Health Service Management Executive (1996)Royal College of Psychiatrists (1998)NHS Executive (2000)United Kingdom Central Council (1999)Nursing & Midwifery Council (2001)NHS Security Management Service (2001)Welsh Assembly Government (2004)National Institute for Clinical Excellence (2005)National Institute for Mental Health England (2005)

Welsh Assembly Government - Passport scheme

Breakaway training must be available to all employees who require it

Aims of breakaway training - To provide practical techniques enabling breakaway from violent/aggressive situations

History of breakaway training

“Breakaway training” is a part of the wider “Control & Restraint training” (from Ju Jitsu)

Home Office adoption for Prison Service in 1981

4 UK High Secure Hospitals 1985 onwardsCascaded downwards

Breakaway refresher training

Scotland - 1 yearEngland - 1 yearNorthern Ireland - 1 year

Wales - 2 years!!!!

Examples of breakaways

Breaking away from …..

Wrist grabBear hugs Hair pull“Standing up” Strangle / neck locks Clothes grab

What is the evidence base supporting

“breakaway training”?

NICE Guidelines/ systematic review

5 UK studies which attempted to evaluate the effectiveness of breakaway training in mental health

Only one found any difference; that staff felt satisfied and slightly more confident as a result of the training

(Southcott, et. al. (2002).

Study 1 – Do staff recall their breakaway training?

An opportunistic sample of 47 nurses in a MSU

We would expect these 47 nurses to be able to breakaway from holds as the service they work within holds the most dangerous psychiatric patients in Wales.

Do staff recall their breakaway training?

Nurses approached on the ward with no warning

Asked to participate in a study evaluating breakaway techniques

Picked one of 6 envelopes which contained a named “hold” (strangle, grab, hair-pull)

Nurse had 10 seconds to prepare

One staff initiated the hold

2 staff recorded time and whether the correct technique was used

Do staff recall their breakaway training?

50 nurses approached / 47 agreed (94%) to take part.

One of the nurses who refused was a “C&R Instructor”

All had had previous breakaway training.

11 staff had received the full breakaway training more than once.

24 had at least one update since their original breakaway training course.

Do staff recall their breakaway training?

Forty percent (19/47) were unable to breakaway within the ten second period.

Of those that did breakaway - 60% did not employ the “correct” breakaway technique.

One of the sample who did not employ the correct technique was one of the Instructor’s

Although violence was a problem within the Clinic, none of the sample (0/47) had used a breakaway technique in the preceding 12 months!!!!!

A big surprise!

Despite exposure to violence (mostly kicks and punches)…NONE of the 47 nurses had needed to use a breakaway technique in the last year!

Maybe this was a weird sample?

St. Andrews Hospital (Northampton) have replicated the study with a larger sample.....

Of 147 healthcare staff only 15% were able to breakaway from a hold within 10 seconds using correct technique.

Is breakaway training sufficient?

Staff just can’t remember it…. But we shouldn’t really be determining the training that staff need until we know more about what the violence that staff have to face actually is…..

What are the realities of NHS Violence?

Problem = Despite the headline news items about NHS Violence, no responsible body is able to provide detailed data on the type of assaults staff face!

Research question = What is the reality of violence to NHS staff??

Study 2

We surveyed all mental health nurses in 2 Welsh NHS Trusts in all clinical areas

Total n = 471

340 from Trust 1121 from Trust 2

Over 75% return rate

Percentage of staff who have had access to breakaway training in last 2 years

Study 2 - ? Assaulted in last 2 years

Some members of staff who did report an assault also reported being subjected to more than one type of assault and experiencing same type of assault on more than one occasion.

Therefore, over the two year period a total of 5866 assaults were reported

This reflects an average of 6.74 assaults per staff member over a 12 month period.

Study 2 - ? Assaulted in last 2 years

However, majority of these assaults were reported by staff working with elderly patients

Elderly = total of 5626, 25.8 assaults per person per 12 months

Adult = total of 207 0.38 assaults per person per 12 months

Study 2 – assaults by type

1 Grabbed (Yes)2 Punched (No)3 Pushed (No)4 Kicked (No)5 Slapped (No)6 Spat at (No)7 Pinched (No)8 Hair pull (Yes)9 Head butt (No)10 Weapon (No)11 Strangle (Yes)12 Other (No)

Breakaway studies - Conclusions

We now have evidence that:

Where nurses are “held” and try to breakaway, they are unlikely to use the correct technique

Even if they could remember all of the correct techniques, it is likely that they won’t actually be able to deal with the majority of NHS violence (blows and strikes)

Therefore, evidence base for “Breakaway training” is poor

Where next?

Large £40,000 funded study into breakaway retention of approx 160 participants

Ensuring that our courses are linked to our research and the evidence we develop – (BSc in Violence Reduction)

Violence Research Group (N=90) – Academics and Clinicians

Inaugural summary

It has been an interesting career thus far; with many excellent influences.

The studies I have most enjoyed are the ones presented – where “wisdom” or practice had already been “established”.

Critical appraisal and knowledge of the real world experiences can lead to the challenge of existing “wisdom” / evidence.

The evidence base for most mental health nursing activity is tenuous due to research funding access and due to design issues

Thank You

perogers@glam.ac.uk