Il cibo e la storia

This chapter commenced with a summary of the literature into first episode psychosis whereby it was argued that contemporary notions of outcome as measured in such studies are limited to symptomatic and functional outcomes, which emphasise the importance of an “end-point” in an individual’s experience of psychosis. Proponents of the recovery movement have highlighted that the concept of recovery is a dynamic process that is constantly being shaped through the interplay between the individual and their environment. The environment and hence the individual, is shaped by international, national and local policies. Within this social context, exists psychological processes; the identification of which through research helps to inform the challenges and opportunities faced by the individual and the wider system in fostering a recovery focused approach to psychosis. Recent studies into CBT for psychosis have contributed to a recovery focused approach through focusing on the development of a shared understanding of experiences with the individual and by focusing on reducing distress associated with experiences. It is the individual’s personal meaning, understanding and coping with symptoms, that forms the basis of treatment (Tai & Turkington, 2009). The philosophy underpinning this confers with a recovery-focused approach that values the individual’s experience and meaning (SRN, 2007).

Over the past twenty years, there have been many controlled and randomised controlled trials into CBT for psychosis. Meta-analytic reviews have found evidence to support the use of CBT as an adjunctive therapy for both chronic and acute patients (see previous review of

studies). Although there are limitations to these studies, the findings have informed clinical practice through the development of guidelines and standards created by NICE.

There has been a considerable lack of research into CBT for psychosis in forensic mental health settings. Although there are commonalities in the presentations and histories of individuals presenting in such settings with general adult mental health, there are also notable differences. All patients admitted to forensic mental health settings are subject to some form of compulsory detention, either under the requirements of the Mental Health (Care &

Treatment) (Scotland) Act (2003) or other legislation specifically related to the criminal justice system. Most, if not all, of the patients experience a high level of co-morbidity (e.g.

schizophrenia or other psychosis, plus personality disorder, plus substance misuse, plus trauma), often linked with serious offending behaviour - thus they often have a number of co-occurring complex needs that require specialist assessment and treatment. This issue presents a particular challenge to the delivery of psychological therapies in terms of how to determine the most appropriate method for ensuring that patients have access to appropriately sequenced complex treatment interventions designed to minimise both the risk they present to others and their personal and therapeutic needs.

Research looking at interventions and treatment with patients in forensic settings has pointed to the need for an eclectic approach that delivers an integrated combination of pharmacologic and psychotherapeutic interventions from different schools. The “What Works for Whom?”

literature (Roth and Fonagy, 2006) for this patient group suggests that interventions and therapies are most successful when they are:-

• Intensive

• Long term

• Theoretically coherent

• Well structured

• Engage the service user and make sense to them

• Take account of their hopes and aspirations

• Well integrated with other services

• Tied into follow up care

Setting of Thesis

The State Hospital is “the national centre providing high security services for patients with mental disorders (including learning disabilities) who are likely seriously to threaten others on account of their dangerous, violent and criminal propensities, and whose condition is characterized by actions outside the normal range of aggressive or irresponsible behaviour

and which can cause damage, injury or real distress to others” (Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland, 1999).

The Psychological Therapies Service (PTS) was formally established in 2000. This service fulfils a crucial role in supporting the hospital towards attainment of its two main aims:

1. To provide care and treatment that maximises rehabilitation and the individual’s chance of an independent life and;

2. To provide care and treatment under conditions of appropriate security with due regard for public safety ;

The principle of reciprocity underlies both these aims in that, “where society imposes an obligation on an individual to comply with a programme of treatment and care, it should impose a parallel obligation on the health and social care authorities to provide safe and appropriate services, including ongoing care following discharge from compulsion”. Risk assessment, risk management, and risk reduction is central to the work of the PTS, where we aim to help patients to improve their mental health as well as reduce and manage any future risk that they may present to others.

The next three chapters present a programme of research carried out at the State Hospital.

The first programme of research involved a grounded theory exploration of recovery in patients presenting with psychosis in forensic mental health. The themes of recovery from this study led to the development of two group interventions. The first, a self-esteem programme, was piloted and the findings of this, alongside the themes from the grounded theory study, led to the development of a compassion focused group intervention for recovery after psychosis. This findings of this intervention, along with the results from the two other research papers will be critically reviewed with implications for future clinical interventions and research discussed.

CHAPTER FOUR: A GROUNDED THEORY STUDY OF THE EXPERIENCES OF