Forensic matrix guide to delivering psychological therapies in forensic mental health services in Scotland

Abstract

Forensic mental health patients present with multiple and complex problems relating to their mental health, offending behaviour and risks. Forensic psychological therapies services are tasked with assessing and treating forensic patients’ mental health problems, reducing their risk of future reoffending and promoting recovery. The Forensic Matrix was produced in 2011 as a guide to help providers of NHS mental health services deliver evidence based psychological therapies for forensic mental health patients in Scotland. This development followed a global trend of embedding routine evaluation and implementing effective and quality interventions in forensic mental health care, a field which had traditionally relied on bespoke and highly individualised treatments. The Forensic Matrix guidance challenged traditional thought embedded in prior clinical guidance that forensic patients’ needs always justify highly specialist interventions. A stepped care model for the delivery of psychological treatment in forensic mental health services was proposed in the Forensic Matrix, which would match the nature and severity of patients’ presenting needs to the appropriate level of intervention and practitioner with the appropriate psychological therapy competencies. In accordance with the stepped care model, simpler underlying needs common to forensic patients, including poor insight, limited coping skills, and emotional regulation difficulties, can be treated using brief, low intensity group interventions prior to more intensive and specialist interventions focussed on more complex needs and behaviours. A critical review of the treatment evaluation evidence formed the basis for recommendations of existing interventions to treat a range of offending behaviours in the context of this stepped care model.

To assist services in implementing this new model of care, a set of recommendations were offered in the Forensic Matrix relating to assessment and treatment, staff training and supervision, and arrangements for local governance and routine evaluation. Since the publication of the Forensic Matrix, several low and high intensity intervention protocols have been developed and rolled out for use by forensic mental health services to support services in adopting the stepped care model. This thesis examines the Forensic Matrix guidance relating to the delivery and evaluation of psychological interventions in Scottish forensic mental health services, and reports the first evidence of the effectiveness of the low intensity intervention protocols.

Chapter 2 sets the stage for the programme of research by introducing the Forensic Matrix principles and recommendations. The findings from a survey completed by service leads are presented which detail uptake of the low and high intensity intervention protocols and assess adherence to recommended local governance arrangements relating to the routine evaluation of these programme. Chapters 3 and 4 critically examine the evidence base for psychological interventions in forensic hospitals. A meta-analysis was undertaken to quantitatively summarise the effects of psychological therapies in addressing forensic patients’ needs across 14 outcome domains. In response to growing evidence that potential negative effects of treatment are systematically ignored in research and practice, a systematic review of the reporting of adverse effects associated with psychological treatment in forensic hospitals was undertaken. The findings from these studies reveal only modest effects of psychological treatment observed for a limited number of outcome domains, and point to methodological problems in the evaluation literature which contribute to bias in the evidence-base.

Chapters 5 and 6 describe studies undertaken in response to the Forensic Matrix’s recommendation that forensic mental health services embed outcome measures developed in non-forensic populations to monitor forensic patients’ progress during psychological treatment. Chapter 5 assesses the psychometric properties and test structure of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) measure of psychological distress in a large sample of high security patients. Chapter 6 applies a similar approach to the Questionnaire on the Process of Recovery (QPR), a tool to measure progress made in supporting patients’ mental health recovery, in a sample of current and former high security patients. Both studies demonstrated the importance of research to establish adequate measurement properties of self-report questionnaires in this population in order to inform meaningful clinical use in the context of psychological therapy.

Chapters 7, 8, and 9 detail evaluations of the low intensity intervention ‘On the Road to Recovery’ (OTRTR), which was developed for this population and has been delivered in Scottish forensic mental health services for several years without an evaluation of its effectiveness. A preliminary, retrospective evaluation of the implementation and effectiveness of OTRTR in a high secure hospital (Chapter 7) was undertaken, which then informed the design of a multi-site feasibility randomised controlled evaluation within the Scottish forensic estate (Chapters 8 and 9). These studies indicate that OTRTR has a limited effect on the needs it was developed to address, including insight and coping skills. Additionally, the studies highlight problems with respect to how OTRTR has been implemented within the forensic estate which hinder future evaluation of this programme.

Taken together, the findings challenge several of the recommendations made in the Forensic Matrix pertaining to the delivery and evaluation of psychological therapies for forensic mental health patients. A critical review of the treatment literature led to conclusions which conflict with the treatments recommended as evidence-based in the Forensic Matrix.

The results also reveal incomplete and inconsistent implementation of the Forensic Matrix principles and recommendations across the Scottish forensic estate in the absence of a central governance framework monitoring the implementation. A re-evaluation of the guidance in the Forensic Matrix is warranted given these findings. The thesis closes with practical implications and recommendations for the delivery of psychological services in forensic mental health services in Scotland in light of this research.