Cognitive Behavioural Therapy (CBT) for psychosis and personality disorder in a high-secure forensic setting. An evaluation of the impact of an integrated treatment programme using a mixed method design.

It has been estimated that between 30-60% of patients with a psychotic disorder also have a personality disorder (Casey, 2000); this figure is possibly even larger for inpatient populations (Cutting et al, 1986). In keeping with these clinical practice estimates, 33% (42/126) of the population of a high-secure forensic hospital in the UK have been found to have a diagnosis of schizophrenia (a psychotic disorder), plus a co-morbid personality disorder, mainly Antisocial Personality Disorder (ASPD) or one of the other DSM-IV categorised (American Psychiatric Association, 2000) ‘Cluster B’ personality disorders. This group of patients is therefore significant. However, despite the high prevalence of this common dual diagnosis and its known detrimental effect on treatment outcome, which includes an increased risk of violence, the evidence base for treatment interventions in this group is extremely limited (Tyrer & Simmons, 2003). A previous Cochrane review (Malone et al, 2007) identified just three randomised controlled studies, which consisted of community care management interventions. Interestingly, no published studies of CBT interventions were found for this group, in any settings, despite present ‘What Works’literature (both mental health and criminogenic), which consists largely of treatment interventions that are underpinned by CBT approaches (Duggan, 2008).

I am currently undertaking a doctoral research study to evaluate the effectiveness of a CBT treatment programme that has been specifically designed to address the co-morbid needs of this group within this specialist setting. It is anticipated that this study could act as a vehicle to assist in the development of a specific therapy framework for this specialist population. The main goals of this study are to:

  1. Develop an understanding of the feasibility and acceptability of a CBT for psychosis and co-morbid personality disorder treatment programme for patients in high secure care
  2. Develop a treatment manual for the programme
  3. Gain feedback from service users and health professionals on the potential utility of such a programme

This Research Scholarship supported the first year of my development of this study. During this time I undertook an extensive review of the literature in this area and I developed several drafts of the research proposal which were submitted to my academic and clinical supervisors, then resubmitted after modification before achieving a final version that is currently being processed through the Integrated Research Application System (IRAS). In addition, I successfully submitted a paper outlining this proposal and other work in this area, which I presented as part of a CBT for psychosis symposium at the International Association of Forensic Mental Health Services (IAFMHS) conference held in Toronto, Canada in June 2014.

It is anticipated that upon successful attainment of IRAS approval, this three-part mixed method (quantitative and qualitative) study will begin before the end of December 2014 and will be completed by the end of March 2016. It is recommended that this study will comprise of the following:

  • Part 1: Single case experimental design will test specific hypotheses that clinically significant improvement will be noted in the domains of mental health, social functioning and risk, following programme completion. It is also anticipated that a further outcome from this specific part of the overall study will be that participating therapists will have been able to identify ‘key active components’ of the treatment programme, and that this information will subsequently be used to help shape the development of a therapy manual.
  • Part 2: Participant interview will be used to elicit patients’ views on the acceptability and utility of the treatment programme.
  • Part 3: Focus groups will be used to explore health professionals’ views of the programme’s impact

It is further anticipated that outcomes from this study will be published in peer review journals and will thus contribute to the limited evidence base in this area.

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