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2An_Investigation_into_the_Feas.pdf
An Investigation into the Feasibility of Intensive Cognitive
Behavioural Therapy
A thesis submitted to The University of Manchester for the degree of Doctor of Clinical Psychology
in the Faculty of Biology, Medicine and Health
2019
Lauren Hampson
School of Health Sciences Division of Psychology and Mental Health
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Table of Contents
Figures and Tables .................................................................................................... 5
Table of Appendices ................................................................................................. 6
Word Counts ............................................................................................................. 8
Overall Abstract ....................................................................................................... 9
Declaration ............................................................................................................. 10
Copyright Statement ............................................................................................... 10
Acknowledgments .................................................................................................. 11
Dedication .............................................................................................................. 12
Introduction to Paper I ........................................................................................ 13
Paper I Systematic Review .................................................................................. 14
1. Abstract .............................................................................................................. 15
2. Introduction ........................................................................................................ 16
2.1 Mental Health and Psychological Distress ....................................................... 16
2.2 Cognitive Behavioural Therapy ....................................................................... 17
2.3 Components of Cognitive Behavioural Therapy .............................................. 18
2.4 Clinical Guidelines for Delivery of CBT ......................................................... 19
2.5 Intensive CBT ................................................................................................... 21
2.6 Review Aims .................................................................................................... 22
3. Method ................................................................................................................ 23
3.1 Review Protocol ............................................................................................... 23
3.2 Search strategy ................................................................................................. 23
3.3 Inclusion Criteria .............................................................................................. 25
3.4 Quality Assessment .......................................................................................... 25
3.5 Analysis of Studies ........................................................................................... 26
4. Results ................................................................................................................ 28
4.1 Description of Papers ....................................................................................... 28
4.2 Quality of Studies ............................................................................................. 34
4.3 Participants ....................................................................................................... 36
4.4 Characteristics of Intensive CBT ..................................................................... 36
4.5 Effects of Intensive CBT .................................................................................. 37
4.6 Long Term Follow Up ...................................................................................... 43
4.7 Acceptability .................................................................................................... 43
3
5. Discussion .......................................................................................................... 45
5.1 Summary of Evidence ...................................................................................... 45
5.2 Strengths and Limitations ................................................................................. 48
5.3 Clinical Implications and Future Directions .................................................... 50
5.4 Conclusions ...................................................................................................... 52
6. References .......................................................................................................... 53
Introduction to Paper II ....................................................................................... 62
Paper II Research Study ...................................................................................... 63
1. Abstract .............................................................................................................. 64
2. Introduction ........................................................................................................ 65
3. Method ................................................................................................................ 69
3.1 Study Design .................................................................................................... 69
3.2 Participant Sample ............................................................................................ 69
3.3 Inclusion Criteria .............................................................................................. 69
3.4 Recruitment ...................................................................................................... 70
3.5 Procedure .......................................................................................................... 72
3.6 Measures ........................................................................................................... 72
3.7 Intervention ...................................................................................................... 75
3.8 Data Analysis ................................................................................................... 77
3.9 Ethical Approval ............................................................................................... 78
4. Results ................................................................................................................ 80
4.1 Demographic and Clinical Characteristics ....................................................... 80
4.2 Feasibility Outcome Measures (Hypothesis One) ............................................ 80
4.3 Clinical Outcome Measures (Hypothesis Two) ............................................... 84
5. Discussion .......................................................................................................... 87
5.1 Acceptability and Feasibility ............................................................................ 87
5.2 Clinical Outcome .............................................................................................. 90
5.3 Strengths and Limitations ................................................................................. 92
5.4 Further Clinical and Research Considerations ................................................. 93
6. References .......................................................................................................... 95
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Introduction to Paper III ................................................................................... 102
Paper 3: Critical Reflection Paper .................................................................... 103
Overview ................................................................................................................ 104
1. Paper I: Systematic Review .............................................................................. 105
1.1 Rationale for the Review ................................................................................ 105
1.2 Scoping and Database Searching.................................................................... 106
1.3 Quality Appraisal ........................................................................................... 107
1.4 Synthesising Results ....................................................................................... 108
1.5 Limitations ...................................................................................................... 108
1.6 Clinical Implications and Future Directions .................................................. 109
1.7 Conclusions .................................................................................................... 110
2. Paper II: Empirical Study ................................................................................. 111
2.1 Study Aims and Rationale .............................................................................. 111
2.2 Development Stage ......................................................................................... 111
2.3 Recruitment Considerations ........................................................................... 112
2.4 Conducting Research in Prison ...................................................................... 114
2.5 The Role of Clinical Psychology in Prison .................................................... 117
2.6 Delivering Psychological Intervention in Prison ............................................ 118
2.7 System-level Considerations .......................................................................... 120
2.8 Final Considerations ....................................................................................... 121
3. References ........................................................................................................ 123
Appendices .......................................................................................................... 128
1. Paper I: Systematic Review .............................................................................. 128
2. Paper II: Empirical Study ................................................................................. 144
3. Paper III: Critical Review Paper....................................................................... 229
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Figures and Tables
Paper I: Systematic Review
Figure 1: A PRISMA Chart to Outline Screening and Eligibilty Procedures ........ 24
Table 1: Characteristics of Studies ................................................................... 29-33
Table 2: Component and Global Quality Ratings using the EPHPP ...................... 35
Table 3: Changes to Mean Scores and Calculated Effect Sizes for Psychological
Distress Associated with Mental Health ............................................................... 39
Table 4: Changes to Mean Scores and Calculated Effect Sizes for Pain .............. 41
Table 5: Changes to Mean Scores and Calculated Effect Sizes for Distress
following Trauma ................................................................................................... 42
Paper II: Empirical Paper
Figure 1: Consort Diagram of Recruitment and Study Retention .......................... 71
Figure 2: A Box Plot to Demonstrate Therapists Rating of Adherance to Therapy
................................................................................................................................ 83
Figure 3: Suicide Ideation as Rated by Participants and Therapists, across all Five
Sessions .................................................................................................................. 86
Table 1: An Overview of the Therapeutic Modules Delivered During the
Programme ............................................................................................................ 82
Table 2: CSQ Mean Scores and Overall Satisfaction Score .................................. 84
Table 3. Mean Scores and Effect Sizes at Baseline and Follow Up....................... 84
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Table of Appendices
Paper I: Systematic Review
Appendix 1: Clinical Psychology Review Guidance for Authors .................... 129
Appendix 2: EPHPP Quality Tool .................................................................... 140
Paper II: Empirical Paper
Appendix 3: Archives of Suicide Research Guidance for Authors ..................... 145
Appendix 4: University of Manchester Ethical Approval .................................... 147
Appendix 5: Health Research Authority Ethical Approval .................................. 149
Appendix 6: Favourable Research and Ethics Committee Letter ........................ 152
Appendix 7: HMPSS Ethical Approval ................................................................ 157
Appendix 8: Clinical Trial Registration ............................................................... 159
Appendix 9: Participant Information Sheet .......................................................... 161
Appendix 10: Summary Participant Information Sheet ....................................... 166
Appendix 11: Informed Consent Form ................................................................ 168
Appendix 12: Prison GP Letter ............................................................................ 171
Appendix 13: The InSPire Programme: What to Expect ..................................... 173
Appendix 14: Participant Debriefing Sheet .......................................................... 176
Appendix 15: Certificate of Completion .............................................................. 178
Appendix 16: Demographics Questionnaire ........................................................ 180
Appendix 17: Additional Study Metrics .............................................................. 185
Appendix 18: Therapist Session Summary Sheet ................................................ 187
Appendix 19: Therapist Rating Scale ................................................................... 190
Appendix 20: Client Satisfaction Questionnaire .................................................. 192
Appendix 21: Discharge Summary Sheet ............................................................ 196
Appendix 22: Beck Suicide Scale ........................................................................ 198
Appendix 23: The Difficulties in Regulating Emotions Scale ............................. 201
Appendix 24: Social Problem Solving Inventory ................................................. 207
Appendix 25: Multi-dimensional Scale of Percieved Social Support .................. 209
Appendix 26: Participant Sessional Measure ....................................................... 211
Appendix 27: Therapist Sessional Measure ......................................................... 213
Appendix 28: Qualitative Interview Topic Guide ................................................ 215
Appendix 29: CBSP Therapy Modules ................................................................ 219
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Appendix 30: Distress Protocol ............................................................................ 221
Appendix 31: Safe Working Practices and Risk Management Protocol .............. 223
Paper III: Critical Review
Appendix 32: EPHPP Dictionary ......................................................................... 230
Appendix 33: InSPire Appointment Slips ............................................................ 235
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Word Counts
(excluding abstracts, references, tables, figures and appendices) Papers Paper I: Systematic Review Paper II: Empirical Paper Paper III: Critical Reflection Total word count
Word Counts 8456 8275 5966 22, 697
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Overall Abstract
Background Paper I: Intensive Cognitive Behavioural Therapy (CBT) is an emerging intervention for psychological distress and mental health. There is no known review in this area in an adult population. Paper II: The InSPire programme was developed to deliver intensive cognitive behavioural suicide prevention (CBSP) therapy within a prison, to address barriers to long term engagement in previous psychological intervention studies (i.e. attrition). Aims Paper I systematically reviewed studies which have delivered intensive CBT within an adult population experiencing psychological distress. Paper II aimed to determine the feasibility of intensive CBSP in a prison, with individuals experiencing suicidal thoughts and behaviours. Methods Paper I was a systematic review of 17 studies delivering intensive CBT across populations experiencing psychological distress associated with mental health, addiction, chronic pain and following a traumatic incident. Paper II was a feasibility case series with single baseline and single follow up. Thirteen individuals consented to the InSPire programme, delivering an intensive CBSP intervention within a three week period (five two-hourly sessions were offered). Outcome measures assessed suicidality (including thoughts of self-harm) and client satisfaction. Psychological mechanisms associated with suicide were measured, including perceived social support, emotional regulation and problem solving. Results Paper I found promising results in the efficacy and feasibility of intensive CBT, particularly in the population experiencing distress associated with mental health difficulties. The review unearthed a number of recommendations for further research in this field. Paper II found the InSPire programme to be feasible, as determined by successful recruitment and retention across the study, including high participant satisfaction. The programme appeared to have an efficacious benefit for those who took part across all outcomes measured. Conclusions Paper I highlights the promising feasibility and efficacy of intensive CBT, yet more rigorously designed studies (i.e. RCTs) must be conducted before firm conclusions can be drawn and prior to a future repeat review. Paper II highlighted the potential benefit of conducting intensive CBSP in prison. Given the limited generalisability of this study, a larger scale feasibility trial would now be warranted to determine more conclusive evidence. Paper III was a critical review paper appraising papers I and II. This included consideration of the methodological process, strengths and limitations, and considerations alongside further literature.
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Declaration
No portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning.
Copyright Statement
i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents, designs, trademarks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. iv. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=2442 0), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see http://www.library.manchester.ac.uk/about/regulations/) and in The University’s policy on Presentation of Theses
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Acknowledgments
I would like to thank the participants for taking part in the InSPire programme.
Involvement has allowed us to further our understanding of psychological therapy
in prison for those experiencing suicidal thoughts and behaviours. Thank you to all
prison and NHS staff who worked alongside us to make this programme possible.
Thank you to Dr Daniel Pratt, for this incredible opportunity, and for the ongoing
inspiration, patience and guidance throughout. Thank you to Dr Charlotte Lennox
for research support and guidance throughout.
Thank you to Minjae Kim for data entry. Thank you to Claire Steele and Megan
McKenna for support with inter-rater reliability. Thank you to Jemma Gaskell,
Martin Parrington and Claire Oakes for support with proof reading.
Thank you to Jessica Killilea, for being my ‘wingman’ on this project, for always
having a listening ear and encouraging voice.
Thank you to the incredible cohort that I have been so lucky to have been a part of
during the three years.
Finally, thank you to Gareth Moore, without whom none of this would be possible.
Thank you for being you.
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Dedication
To those who have lost their lives to suicide.
To families and friends who have been affected by suicide.
To the individuals who continue to fight every day.
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Introduction to Paper I
Paper I is a systematic review written in accordance with the author guidance for
submission to the journal Clinical Psychology Review (Appendix 1). The authorship
for this paper will be as follows: Hampson, L., Killilea, J., Lennox, C., & Pratt, D.
(2019).
Previous years have seen the emergence of innovative and adapted formats in the
delivery of Cognitive Behavioural Therapy (CBT), across all clinical populations. The
NHS adapts and shapes services based upon clinical need and cost-effectiveness.
Intensive CBT is one method of therapeutic delivery which has attracted research
interest over the past decade. Although there is one published review in this field
that investigates intensive CBT with children with anxiety disorders, there are no
known equivalent reviews which investigate intensive CBT in an adult population.
This review takes a broader approach into investigating the use of intensive CBT
across clinical populations experiencing psychological distress. This review seeks to
understand more about how intensive CBT has been delivered so far, and the
efficacy of its delivery. This review will be relevant for clinicians delivering CBT, in
highlighting the importance of patient choice in the delivery of services, as well as
providing recommendations in terms of overall service delivery. First and foremost,
this review will provide a foundation for future, larger scale, reviews of this type.
Paper I explores the components of an intensive delivery of CBT, as was delivered in
the research study of Paper II. This gave the author a broader understanding of
what intensive CBT is and the areas in which it has been delivered to date.
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Paper I Systematic Review
Intensive Cognitive Behavioural Therapy for Psychological
Distress: A Systematic Review
Written in preparation for submission to
Clinical Psychology Review
Word count: 8456 (excluding abstract, tables, figures and references)
15
1. Abstract
Delivery of Cognitive Behavioural Therapy (CBT) has adapted over time in response
to the need for more streamlined services. This systematic review aims to examine
existing literature to understand the primary characteristics and efficacy of
‘intensive’ CBT across clinical populations experiencing psychological distress.
Intensive CBT offers a quicker intervention which is completed in a much shorter
time than the traditional weekly delivery.
Seventeen papers were included in this review. Four categories of clinical
population were defined, including psychological distress associated with mental
health, chronic pain, addiction and following a traumatic incident. Delivery of
intensive CBT differed across the studies. An average of 17 hours of therapy was
received per participant. Studies delivered a variety of different components of
CBT, most often being cognitive restructuring. Effect sizes were promising at post-
intervention and longer term follow-up, particularly within studies investigating
mental health difficulties.
This review has collated information on the delivery of intensive CBT and highlights
the promising results in the efficacy of intensive CBT. However, most studies were
exploratory in design, with small sample sizes and weak methodological quality.
Recommendations are given for larger scale trials of intensive CBT to be conducted
in order to establish a more reliable evidence base.
Key words: Systematic, Review, Intensive, Cognitive Behavioural Therapy.
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2. Introduction
2.1 Mental Health and Psychological Distress
It is widely reported that one in four people in the UK will experience a mental
health difficulty during their lifespan (Ginn & Horder, 2012), with one in six
reporting symptoms of anxiety or depression within the past week (McManus,
Bebbington, Jenkins, & Brugha, 2016). Mental health retains a significant focus in
the government’s political agenda, as it holds considerable bearing upon rates of
employment, housing, debt and poverty (Mental Health Foundation, 2016). There
are financial consequences both on an individual and societal level. Costs to the UK
economy are substantial and taking into account the associated reduced quality of
life, the cost in England alone in 2010 reached £105.2 billion (Centre for Mental
Health, 2010). Both nationally and globally the investment into resources for
prevention and treatment is outweighed by the cost. Despite this, mental health
remains a political focus, as outlined in many Government initiatives, emphasising
the importance of effective service provision and investment into both physical and
mental health (Department of Health [DH], 2011; Mental Health Taskforce, 2016).
Whilst mental health difficulties are generally captured within a diagnostic
framework, (American Psychiatric Association [APA], 2013), ‘psychological distress’
is a broader term used throughout the literature. Mirowsky (2007) offers an
understanding of ‘distress’ as being beyond concepts or diagnoses, which
essentially captures the emotional suffering experienced by the individual. Ridner
(2004) suggested that psychological distress is most often, although not exclusively,
pre-empted by a stressor for which coping is ineffective. Ridner (2004) defines
psychological distress as the “unique discomforting, emotional state experienced by
an individual in response to a specific stressor or demand that results in harm, either
temporary or permanent, to the person” (p. 539). The description by Ridner (2004)
was the working definition of psychological distress for the current review.
Psychological distress is commonly measured using the General Health
Questionnaire [GHQ] (Goldberg, 1972) or Kessler Psychological Distress Scale [K10]
(Kessler et al., 2002). According to these measures, prevalence of psychological
distress has been shown to vary greatly from 7% to 33% in general populations
17
across the world (Australia: Chittleborough, Winefield, Gill, Koster, & Taylor, 2011;
Phongsavan, Chey, Bauman, Brooks, & Silove, 2006; Spain: Gispert, Rajmil,
Schiaffino, & Herdman, 2003; Japan: Kuriyama et al., 2009). There are further
variations within particular population groups. Using the GHQ, Gispert et al. (2003)
found psychological distress was reported by 15.4% of females, compared to 9.2%
of males within a Catalan community. Using the K10, Phongsavan et al. (2006)
reported even higher rates of distress within the Australian population, with up to
35.5% in females compared to 29.9% in males. Furthermore, chronic physical health
conditions or severe ill health were found to greatly increase prevalence of
psychological distress (Arvidsdotter, Marklund, Kylén, Taft, & Ekman, 2016;
Drapeau, Marchand, & Beaulieu-Prévost, 2012). Chittleborough et al. (2011)
reported a prevalence of 15.8% in a population with chronic health conditions.
Further social factors were found to increase psychological distress: being young or
old age; being a smoker or drinker; having a low or high BMI; having lower social
capital or education levels; unemployment; restricted or reduced daily physical
activity; and a lack of social support or integration within a community
(Arvidsdotter et al., 2016; Drapeau et al., 2012; Kuriyama et al., 2009; Gispert et al.,
2003; Phongsavan et al., 2006).
2.2 Cognitive Behavioural Therapy
Cognitive Behavioural Therapy (CBT) has been identified as the primary
psychological intervention in many disorders of psychological distress, with
particular effectiveness noted in disorders of anxiety (Stewart & Chambless, 2009;
Hofmann & Smits, 2008) and depression (Butler, Chapman, Forman, & Beck, 2006).
CBT is recommended as first-line treatment before pharmacological intervention
for anxiety disorders (National Institute for Health and Care Excellence [NICE],
2014). Specific anxiety disorders and other disorders (i.e. depression; NICE, 2011)
have individual quality standards recommending the appropriate level of
psychological input.
Beyond anxiety and depression, a number of meta-analyses highlight the efficacy of
CBT across populations with psychological distress: behavioural parent training
(BPT) for antisocial behaviour in young people (post-treatment ES = 0.35; follow up
18
ES = 0.31) (McCart, Priester, Davies, & Azen, 2006); male offenders experiencing
anger management issues, with treatment aimed to reduce recidivism (ES = 0.77)
(Henwood, Chou, & Browne, 2015); difficulties with insomnia (medium to large
effects; Okajima, Komada, & Inoue, 2011); chronic pain, improvements noted in
mood (standardised mean difference [SMD] = -0.24; p = 0.004) and pain coping
(SMD = 0.85; p = 0.006; Bernardy, Füber, Köllner, & Häuser, 2010); and problem
gambling (large effect sizes at post treatment and follow up; Gooding & Tarrier,
2009). Finally, a Cochrane Review demonstrated the effectiveness of a CBT-based
intervention (i.e. cognitive reframing) in supporting carers of people with dementia,
with associated anxiety (SMD = -0.21), depression (SMD = -0.66) and subjective
stress (SMD = -0.23; Vernooij‐Dassen, Draskovic, McCleery, & Downs, 2011).
The studies above are important for highlighting the broad scope of CBT and its
efficacy beyond psychiatric disorders and into issues of psychological distress. CBT
has an established evidence base across a number of psychological disorders (Epp &
Dobson, 2010). More specifically, The Department of Health published a document
for the Improving Access to Psychological Therapies (IAPT) Programme (2007)
outlining the most evidence based CBT models for a number of psychological
disorders, including social phobia (Heimberg, 1995; Clark & Wells, 1995); panic
disorder (Clark, 1994; Barlow, Craske, Cerny & Klosko, 1989); obsessive compulsive
disorder (OCD) (Steketee, 1993; Kozak & Foa, 1997); generalised anxiety disorder
(GAD) (Borkovec & Ruscio, 2001; Dugas, Gagnon, Ladouceur & Freeston, 1998;
Zinbarg, Barlow, Brown & Hertz, 1992; Craske, 1999); post-traumatic stress disorder
(PTSD) (Foa & Rothbaum, 1998; Ehlers & Clark, 2000; Resick, 2000) and depression
(Beck, 1979; Jacobson, Martell & Dimidijan, 2001). CBT is therefore recommended
by the National Institute for Health and Care Excellence (NICE) for a number of
psychological disorders.
2.3 Components of Cognitive Behavioural Therapy
CBT is essentially focussed upon our thoughts, feelings and behaviours and the
interactions between them (Beck, 1979). It highlights unhelpful thinking and
behavioural patterns that emerge and maintain distress (British Association for
Behavioural and Cognitive Psychotherapies, [BABCP], 2019). The Department of
19
Health (DoH) published a document for the Improving Access to Psychological
Therapies (IAPT) Programme (2007), which provides detail of therapeutic standards
and competencies which are important for practitioners to deliver CBT to an
appropriate level according to good practice. In addition, there are variations across
the literature as to which therapeutic components make up a CBT intervention. The
Association for Behavioural and Cognitive Therapies (ABCT) condenses CBT to three
main components, each with specific therapeutic techniques. These components
are case conceptualisation, behavioural components (self-monitoring, behavioural
activation, exposure) and cognitive components (eliciting and modifying thinking)
(ABCT, 2019). Tolin (2010) determined six categories which were used as a checklist
within a meta-analysis investigating the effectiveness of CBT.
In line with Tolin’s (2010) approach, the components below were used as a
framework for this current review:
i. Psychoeducation
ii. Relaxation Training (including progressive muscle relaxation, meditation, or
breathing retraining)
iii. Exposure Therapy (imaginal or in vivo exposure, including flooding)
iv. Behaviour Rehearsal (behavioural training in social skills, habit reversal, or
problem solving)
v. Cognitive Restructuring (including direct strategies to identify and alter
maladaptive thought processes)
vi. Operant Procedures (systematic manipulation of reinforcers or punishers for
behaviour).
2.4 Clinical Guidelines for Delivery of CBT
There have been many variations across the decades in CBT delivery. Traditionally,
CBT was delivered solely by a qualified professional with specialised graduate
training (i.e. psychiatrists, psychologists, master’s-level social workers)
(Montgomery, Kunik, Wilson, Stanley, & Weiss, 2010). In recent years, CBT has been
effectively administered by ‘paraprofessionals’ (i.e. individuals without
postgraduate training) under appropriate clinical supervision (Montgomery et al.,
2010). Sessions can take place in a number of settings (i.e. hospital clinics,
20
community bases, home) and in a number of formats (i.e. 1:1, group, family).
Guidelines for standard delivery of CBT vary depending upon presenting difficulty.
For example, standard delivery of CBT for social anxiety is 14 sessions lasting 90
minutes per session, delivered 1:1 and on a weekly basis (NICE, 2013). There is a
broad literature of the many forms in which CBT delivery has been transformed
over recent years.
There is evidence for the benefit of long-term outcomes of weekly therapy
compared to an intensive delivery, although much of the evidence is focussed upon
adolescent populations, including CBT for smoking cessation (Cavallo et al., 2007)
and panic disorder (Chase, Whitton, & Pincus, 2012). However, a number of studies
found intensive CBT to be more suited to an adolescent population with Obsessive
Compulsive Disorder (OCD; Storch et al., 2008; Whiteside, Brown, & Abramowitz,
2008; Lewin et al., 2005). Each of these studies cited the challenges of weekly CBT
for some families (i.e. geographical barriers, access to appropriate specialist
services and suitability to the individual [i.e. severity of symptoms and
functioning]). Arguably, intensive delivery could be better suited to particular
populations, or individuals, and perhaps patient choice in their treatment is
important to consider.
From a health economics perspective, recent years has seen a shift in the format of
CBT delivery towards more effective streamlined services. Perhaps a considerable
amount of difference in response to treatment relates to the individual and the
difficulties they present with. Stiles, Barkham, Connell and Mellor-Clark (2008)
report that for some individuals, one or two sessions of therapy resulted in the
same positive outcome as 15 or 16 sessions. Stiles et al. (2008) introduced the
response regulation model, which recommended therapy dose determined by
recovery, as decided between the patient and therapist, rather than a standardised
dose of therapy for a fixed duration. Additionally, in line with streamlining NHS
services, the stepped care model of healthcare delivery recommends individualised
therapy durations, with patients being offered add-on sessions or more intensive
input should they not respond to briefer interventions first (Bower & Gilbody,
2005). Taking the above into account, appropriate clinical decisions must be made
concerning delivery of services in the NHS. This must consider patient choice and be
21
in keeping with national guidelines (i.e. NICE). Recent years has seen the emergence
of ‘brief’ or ‘intensive’ CBT interventions; although, there are variations in the
definition of such interventions.
2.5 Intensive CBT
Öst and Ollendick (2017) define ‘brief’ CBT as a 50% reduction of sessions compared
to standard treatment (as outlined in NICE guidelines); ‘concentrated’ CBT as being
the same number of sessions as standard treatment but delivered over a shorter
time period (i.e. daily sessions over a few weeks); and ‘intensive’ CBT as a reduction
in both the number of sessions and duration of treatment delivery compared to
standard treatment. Research so far offers promise in the feasibility and efficacy of
intensive CBT: although, the definition and delivery has somewhat varied. For
example, Storch et al. (2007) delivered ‘intensive’ CBT for 90 minute sessions, five
days per week for three weeks, in a family based intervention for childhood OCD. In
an adult OCD population, Oldfield, Salkovskis and Taylor (2011) found delivery of up
to 18 hours of CBT equally effective when delivering over five days, compared to 18
weeks. Ehlers et al. (2010) delivered novel intensive therapy to individuals with
post-traumatic stress disorder (PTSD) for up to 18 hours over five to seven working
days. Other research has involved longer session duration (i.e. up to five hours per
session) across two days, for individuals with panic disorder (Deacon & Abramowitz,
2006).
There are no known reviews published to date which explore the delivery of
intensive CBT within an adult population. One published review investigates the
delivery of ‘brief’, ‘intensive’ and ‘concentrated’ CBT in childhood anxiety disorder
(Öst & Ollendick, 2017). This review found 14 randomised control trials (RCT)
investigating the delivery of intensive CBT, with large treatment effects (g = 0.84)
overall. Two further published prospero protocols are currently exploring intensive
CBT for adults with OCD (Millar, Bauer, Salkovskis, Gregory, & Halligan, 2018) and
intensive CBT for OCD, anxiety and PTSD in children and adolescents (Clarkson,
Allcott-Watson, Shafran, & Bennett, 2018). Both reviews define intensive CBT as
being no more than four weeks in length, with at least five hours per week and a
minimum of 10 hours in total.
22
Whilst the four week completion period seems to capture the definitions used
above, a broader range of therapy dose has been delivered, with as few as two
sessions making up an intensive treatment package (i.e. Deacon & Abramowitz,
2006). This shows the varied definitions and approaches to ‘intensive’ delivery that
are currently used across the literature. Whilst this current review used the four
week delivery period, a broader definition of therapeutic dose was applied (i.e. two
or more sessions of CBT per week), to allow inclusivity and a broader understanding
of how the term ‘intensive’ is used. No minimum requirements of the hours of
therapy delivered were applied, which was appropriate for the exploratory nature
of this current review.
2.6 Review Aims
To our knowledge, this was the first systematic review to explore literature
evaluating intensive CBT with adults experiencing psychological distress. The review
aimed to synthesise what was already known about ‘intensive’ CBT, focusing upon
therapy components (i.e. number of sessions, duration and content) and efficacy
across a range of clinical populations experiencing psychological distress. Following
the exploration and synthesis of review literature, recommendations and guidance
were provided for future use of intensive CBT.
23
3. Method
3.1 Review Protocol
The review protocol was published on PROSPERO (ID: CRD42018086546) and the
review follows the ‘Preferred Reporting Items for Systematic review and Meta-
Analysis Protocols’ (PRISMA; Moher et al., 2015).
3.2 Search strategy
Online medical and psychological databases were reviewed, including EMBASE,
PsychINFO, MEDLINE and CINAHL PLUS, from point of database inception to August
2018. Search terms were first tested to ensure a specific search across a broad
enough scope of the literature. Keyword search terms were used to capture CBT
alongside the ‘intensive’ nature of delivery ([intense OR intensive] AND [cog* beh*
OR cog* treat* OR cog* ther* OR cog* int*]).
In order to maximise the ability to capture all papers in this area, no restrictions
were applied to initial searches (i.e. publication year, English language or full text
article). However, review papers, grey literature, conference abstracts and non-
English articles were not included. Rationale for the omission of such papers was
based upon the lack of guidance in systematically searching for grey literature and
the potential for a large search yield, beyond the practical scope of this review
(Mahood, Van Eerd, & Irvin, 2014).
Citations were exported to a reference management software system and all
duplicates were removed from initial search results. The first author (LH) reviewed
all titles and abstracts according to PICO (i.e. Problem or Patient or
Population; Intervention or Indicator; Comparison; Outcome of interest) inclusion
criteria (Miller & Forrest, 2001), with full-text papers then reviewed if uncertain
about eligibility from title and abstract alone. Inter-rater reliability of title and
abstract screens was conducted with a co-author (JK). Ten percent of all abstracts
and titles were co-reviewed (n = 360) and inter-rater reliability was strong (Kappa =
.88). Following title and abstract screens, full-texts were reviewed. Figure 1
presents a PRISMA diagram of the screening and eligibility procedures.
24
Figure 1. A PRISMA Chart to Outline Screening and Eligibility Procedures
In cl
u d
e d
Id
e n
ti fi
ca ti
o n
S
cr e
e n
in g
E li
g ib
il it
y
Records identified through database searches
(n = 4332)
Records after duplicates removed
(n = 3619)
Titles and abstracts screened for eligibility
(3619)
Full-text articles screened for eligibility
(122)
Studies included in the review
(17)
Records excluded (n = 3488)
Full-text articles excluded (n= 105) Justifications:
Unable to access (n = 10) Citation/conference paper only (n = 12)
Not English (n = 4) Group therapy (n = 32)
Insufficient CBT components (n = 12) Therapy surpasses four weeks (n = 17)
Non-clinical population (n = 6) Child population (n = 1)
Duplicate analyses papers (n = 6) Not ‘intensive’ (n = 2)
Wrong study design (n = 3)
25
3.3 Inclusion Criteria
General Inclusion Criteria
i. Papers published in peer reviewed journal.
ii. Papers written in English.
iii. Quantitative methodology that included pre- and post-therapy outcome
measures.
iv. Papers included more than one participant
Population Inclusion Criteria
v. Participant sample of adults (16 years and above).
vi. A clinical population with a mental health difficulty or ‘psychological
distress’.
‘Intensive’ Cognitive (Behavioural) Therapy Inclusion Criteria
vii. Face-to-face and 1:1 therapy sessions (i.e. group, computerised, or manual-
directed interventions were excluded in an attempt to mediate consistency
in the intervention delivery and limit heterogeneity of the sample).
viii. As guided by previous literature in this area, interventions were completed
within a four week period and included at least two therapy sessions per
week. To allow a more inclusive exploration of the literature, no minimum
dose (i.e. total number of hours) of therapy was applied.
ix. Eligible studies included one or more of the widely recognised variants of
CBT as defined by Tolin (2010). These included psychoeducation; relaxation
training; exposure therapy; behaviour rehearsal; cognitive restructuring; and
operant procedures (NB. not psychoeducation alone).
3.4 Quality Assessment
The Effective Public Health Practice Project (EPHPP; 1998; Appendix 2) was used to
quality assess included papers. The EPHPP includes six items which assess the
following: selection bias; study design; confounders; blinding; data collection
method and withdrawals and drop outs. The EPHPP has excellent inter-rater
reliability for final ratings of papers (i.e. weak, moderate or strong; Armijo‐Olivo,
Stiles, Hagen, Biondo, & Cummings, 2012). The EPHPP was chosen as it considers all
26
methodological designs and is reasonably straightforward to apply and to
determine and justify appropriate ratings (Voss & Rehfuess, 2013; Bennett et al.,
2018). A peer group was established with two independent researchers (clinical
psychology doctoral students). The peer group discussed the EPHPP tool in detail to
ensure consistent interpretation of questions and a robust process of decision
making. The group was then used for specific queries related to study design, and
they were used to determine inter-rater reliability. Twenty nine percent of papers
were secondary reviewed between the peer group and there was an almost perfect
agreement (Kappa = .99). Additionally, individual queries related to quality ratings
were discussed and agreed alongside co-authors (DP and CL). Outcome of the
quality assessment was used during analysis, by reviewing papers of weaker quality
with more caution upon interpretation. No studies were excluded based upon
quality.
3.5 Analysis of Studies
Descriptive analyses were explored using Microsoft Excel. Frequencies, means and
standard deviations were calculated to determine study characteristics (i.e. session
duration, length of therapy and components of CBT most frequently delivered).
Effect sizes were computed to provide an indication of changes associated with
treatment delivery. Where authors reported effect sizes, the published figures were
repeated in the analysis tables. In all other cases, effect sizes were calculated where
the studies clearly detailed pre and post means and number of participants in their
analysis. Primary outcome measures specified by the review papers were used to
generate effect sizes. Where studies identified a number of outcomes or did not
specify the primary outcome measure, the first author (LH) used the measure with
the most complete dataset or otherwise the one most relevant to psychological
distress specific to the clinical population. For studies with a comparison group,
effect sizes were calculated comparing the pre- and post- data of both intervention
and comparison group using Morris’ (2008) effect size calculation for repeated
measures designs. For all other studies without a comparison group, effect sizes
were calculated using a repeated measures method using a correlation coefficient
of 0.5. Effect sizes were interpreted using Cohen’s d (Cohen, 1977). Lastly, effect
27
sizes were calculated for those studies which included longer term follow up, to
provide an indication as to whether the effect had been sustained over time. Across
all effect size calculations, where pre and post group sizes differed, effect size was
calculated using both participant number totals. In the case of a difference, lower
effect sizes were reported to avoid over inflation.
28
4. Results
4.1 Description of Papers
Seventeen papers were identified using the outlined search strategy and inclusion
criteria, as presented in Table 1. Study designs included cohort (k = 13) [4–10, 12–
17], cohort analytic (i.e. with a matched group, k = 2) [1, 2] and randomised control
trials (k = 2) [3, 11]. It must be noted that four studies defined themselves as case
histories or series. All four studies had multiple participants and allowed for group
comparisons of the data. Therefore, for the purposes of this review, they were
classified as ‘cohort’ or ‘cohort analytic’.
A number of clinical populations were included in the review, most commonly
anxiety (including PTSD) (k = 8), OCD (k = 3) and Body Dysmorphic Disorder (BDD) (k
= 2) and pain (k = 3). Papers scope from 1993 to 2018, with much of the research in
this area taking place within the last decade and the majority of studies being
conducted in the US. A total of 647 participants were included across the papers.
An average number of 10 sessions were offered per participant, lasting just over 1.5
hours, across a period of 20 days. This equates to approximately 17 hours of
therapy per individual. Mostly commonly, CBT components of psychoeducation,
exposure and cognitive restructuring were delivered. This will be outlined in more
detail in section 4.4.
29
Table 1. Characteristics of Studies
Authors Design Clinical
Diagnosis N Intervention
Techniques No. of sessions
Session length
Therapy duration
Outcome Measures
Brief Summary of Results
1 Abramowitz, Franklin, Street,
Kozak, & Foa (2000)
(US)
Cohort Analytic
Depression & OCD
87 Exposure Therapy Behaviour Rehearsal Cognitive Restructuring Psychoeducation
15 2 hours 4 weeks BDI Y-BOCS
All groups showed significant treatment effects. Moderate treatment gains were attained for the highest severity of depression.
2 Abramowitz, Foa, &
Franklin (2003)
(US)
Cohort Analytic
OCD 40 : 20 Intensive 20 Twice weekly
Exposure Therapy Behaviour Rehearsal Cognitive Restructuring Psychoeducation
15 2 hours 3 weeks BDI Y-BOCS
Both programs were effective. Greater improvement for intensive group.
3 Bernard et al. (2011)
(US)
(Pilot) RCT
Maternal depression, trauma & anxiety
56 : 31 Intervention 25 Control
Relaxation Training Cognitive Restructuring Psychoeducation
3 45 – 55 minutes
2 weeks BDI DTS SASRQ
Mothers in the intervention group reported lower levels of depression, but trauma symptoms remained in both groups.
4 Bitran, Morissette, Spiegel, &
Barlow (2008)
(US)
(Pilot) Cohort
Panic and agoraphobia
40 Exposure Therapy Cognitive Restructuring Psychoeducation
6 Not stated
8 days ADIS APPQ ASI PDSS SEQ
Solution focussed intensive therapy reduced panic symptoms, with gains maintained at follow-up.
30
5 Deacon & Abramowitz
(2006) (US)
(Pilot) Cohort
Panic 10 Exposure Therapy Behaviour Rehearsal Cognitive Restructuring Psychoeducation
2 9 hours: (day 1 = 6 hours day 2 = 3 hours)
2 days ASI-R BAI BDI BVS PAS PDSS PAS
60% were panic- free after treatment.
6 Hickling, Blanchard, & Kuhn (2005)
(US)
Cohort PTSD 3 Relaxation Training Exposure Therapy Cognitive Restructuring Psychoeducation
2 60 – 90 minutes
Not stated
ASDS BDI CAPS-5 PCL-5
Found to be an acceptable treatment option, with improvements in symptoms of PTSD and low mood.
7 Johren, Enkling,
Dent, Heinen, &
Sartory (2007)
(Germany)
Cohort Dental phobia
160 Relaxation Training Exposure Therapy Cognitive Restructuring Psychoeducation
3 1 hour Not stated
HAQ Anxiety was higher for therapy completers, but their subsequent adherence to dental treatment was high (70%).
8 McCracken, Gross, & Eccleston
(2002) (UK)
Cohort Pain 59 Behaviour Rehearsal Psychoeducation
15 Not stated
3 weeks BDI MPI PASS
Significant improvement in pain severity, pain interference, distress, activity and depression.
31
9 McManus, Treacy, & McGuire (2014) (UK)
Cohort Pain 5 Relaxation Training Behaviour Rehearsal Cognitive Restructuring Psychoeducation
8 40 minutes
4 weeks PSEQ-C (mod’) WASI Developed for this study: - The Pain Knowledge Scale - Coping Strategies Questionnaire
Pain management knowledge and coping increased after the intervention (not maintained at follow up).
10 Morefield et al. (2014)
(US)
Cohort Addiction 53 Exposure Therapy Behaviour Rehearsal Cognitive Restructuring Psychoeducation
6 - 12 Not stated
2 weeks GHQ-28 K10 VGS WSAS
Scores on all measures improved.
11 Motivala et al. (2018)
(US)
RCT OCD 44 : 23 Treatment first 21 Waitlist then treatment
Exposure Therapy Psychoeducation
20 90 minutes
4 weeks GAS HAM-A MADRS PSWQ RRS Y-BOCS
Symptoms of OCD, depression and functioning all significantly improved.
12 Neziroglu & Yaryura-
Tobias (1993) (US)
Cohort Body dysmorphia & OCD
5 : 3 Intensive 2 Standard
Exposure Therapy Cognitive Restructuring
20 90 minutes
4 weeks Y-BOCS
80% of patients improved on measures of outcome.
13 Neziroglu, McKay,
Todaro, & Yaryura- Tobias
(1996) (US)
Cohort Body dysmorphia
17 Exposure Therapy Cognitive Restructuring
20 90 minutes
4 weeks GAF Y-BOCS-BDD
Significant decrease in preoccupation and time engaging in problem behaviours.
32
14 Stoddard, Rosellini, & Hofmann
(2008) (US)
Cohort Social anxiety
5 Exposure Therapy Behaviour Rehearsal Cognitive Restructuring Psychoeducation
6 2 - 4 hours
8 days BDI CGI ISPI SPAI SPEFI
80% improved on measures of outcome (SPAI, ISPI, SPEFI, CGI).
15 Suman et al. (2009) (Italy)
Cohort Pain 25 Exposure Therapy Cognitive Restructuring
10 90 minutes
3 week BPCI CES-D
Pain intensity significant reduced, CES-D scores reduced.
16 Wootton et al.
(2018) (Australia)
Cohort Social anxiety
17 Exposure Therapy Cognitive Restructuring Psychoeducation
12 50 minutes
4 weeks DASS-21 SIAS SPIN SPS Developed for this study: - Acceptability Scale
Moderate to large effect sizes. 59% no longer met criteria for SAD (71% at follow up).
17 Worden, David,
Genova & Tolin
(2015) (US)
Cohort Anxiety & Addiction
21 Exposure Therapy Cognitive Restructuring Psychoeducation
6 1.5 hours
3 - 5 weeks
ASI CAM CGI DASS-21 TLFB TSR Developed for this study: - Post-treatment Feedback Questionnaire
Significant reduction in anxiety and abstinence from substances.
Table Abbreviations: Acute stress disorder scale (ASDS); Agoraphobic Cognitions Questionnaire (ACQ); Albany Panic and Phobia Questionnaire (APPQ); Anxiety Disorders Interview Schedule (ADIS-IV); Anxiety Sensitivity Index (ASI); Beck Anxiety Inventory (BAI); Beck Depression Inventory (BDI); Body Vigilance Scale (BVS); Brief Pain Coping
33
Inventory (BPCI); Center for Epidemiologic Studies Depression Scale (CES-D); Choice of Outcome in CBT for psychosis (CHOICE); Clinical Global Impressions Scale (CGI); Clinician-Administered PTSD Scale for DSM-5 (CAPS-5); Cognitive-Behavioural Therapy Adherence Measure (CAM); Coping Strategies Questionnaire (CSQ); Davidson Trauma Scale (DTS); Depression Anxiety Stress Scale-21 (DASS-21); Emotion Regulation Questionnaire (ERQ); Global Assessment of Functioning (GAF); Global Assessment Scale (GAS); Goldney Scale of Suicidal Ideation (GHQ-28); Hamilton Anxiety Scale (HAM-A); Hierarchical Anxiety Questionnaire (HAQ); Hospital Anxiety and Depression Scale (HADS); Index of Social Phobia Improvement (ISPI); Kessler Psychological Distress Scale (K10); Montgomery-Ashberg Depression Rating Scale (MADRS); Multidisciplinary Pain Inventory (MPI); Overvalued Ideas Scale (OVI); Pain Anxiety Symptoms Scale (PASS); Pain Self-efficacy Scale for Children (PSEQ-C); Panic and Agoraphobia Scale (PAS); Panic Disorder Severity Scale (PDSS); Penn State Worry Questionnaire (PSWQ); Psychotic Symptom Rating Scales (PSYRATS); PTSD Checklist for DSM-5 (PCL-5); Ruminative Responses Scale (RRS); Self-efficacy Questionnaire (SEQ); Social Phobia and Anxiety Inventory (SPAI); Social Phobia Inventory (SPIN); Social Interaction Anxiety Scale (SIAS); Social Phobia Endstate Functioning Index (SPEFI); Social Phobia Scale (SPS); Stanford Acute Stress Reaction Questionnaire (SASRQ); Time Line Follow Back (TLFB); Treatment Services Review (TSR); Victorian Gambling Screen (VGS); Wechsler Abbreviated Scale of Intelligence (WASI); Work and Social Adjustment Scale (WSAS); Yale-Brown Obsessive Compulsive Scale (Y-BOCS); Yale-Brown OCD Scale for Body Dysmorphic Disorder (BDD-YBOCS).
34
4.2 Quality of Studies
The EPHPP rating tool grades papers as weak, moderate or strong in their
methodological quality. Quality varied across the 17 papers, with strong (k = 1; 6%),
moderate (k = 5; 29%) and weak (k = 11; 65%). Details of quality ratings are
presented in Table 2.
The EPHPP is influenced by methodological design and presence of a control group.
For many studies in this review this was a contribution to the weaker overall rating.
When considering studies with medium to high quality, all six studies gave evidence
to support the effectiveness of intensive CBT, with small [12], medium [1, 2] and
large [11, 13, 14] treatment effects. Three of these studies included comparison to
a control group and all were within the same participant cohort (i.e. distress
associated with mental health), as will be discussed in more detail in sections
below.
35
Table 2. Component and Global Quality Ratings (strong, moderate or weak) using
the EPHPP
Study Selection Bias
Study Design
Confounds Blinding Data Collection Methods
Withdraw and
Dropouts
Global Rating
Abramowitz et al. (2000)
M M n/a M S M
Abramowitz et al. (2003)
M M S M S M
Bernard et al. (2011)
W S S W S M
Bitran et al. (2008) M M n/a W S W
Deacon & Abramowitz (2006)
W M n/a W S S
Hickling et al. (2005)
W M n/a W S S
Johren et al. (2007)
M M n/a W S W
McCracken et al. (2002)
M M n/a W S W
McManus et al. (2014)
M M n/a M W S
Morefield et al. (2014)
S M n/a W S S
Motivala et al. (2018)
M S S M S W
Neziroglu & Yaryura-Tobias
(1993)
M M n/a W S S
Neziroglu et al. (1996)
M M n/a W S S
Stoddard et al. (2008)
M M n/a M S S
Suman et al. (2009)
M M n/a W S W
Wootton et al. (2018)
M M n/a W S M
Worden et al. (2015)
M M n/a W S W
S = Strong M = Moderate W = Weak n/a = Not Applicable
36
4.3 Participants
A total of 647 participants were included across the 17 papers, ranging from n = 3
to n = 160 (M = 38; SD 39.48). Highest numbers of participants were from clinical
populations of anxiety and PTSD (n = 326) and OCD (n = 171). Mean age of
participants was 37.3 years (SD = 7.07), and 59.4% of participants were female
(female = 384; male = 263). Studies were conducted across a number of countries,
including Australia [16]; Germany [7]; Italy [15]; UK [8, 9]; and America [1–6, 10–14,
17].
Diagnostic criteria varied greatly across studies. Four studies used the Anxiety
Disorder Interview Schedule (ADIS) [4, 7, 11, 14], four used criteria from
The Diagnostic and Statistical Manual of Mental Disorders (DSM) [1, 2, 12, 13] and
one used the Mini International Neuropsychiatric Interview (MINI) [5]. Two studies
used disorder specific diagnostic tools (i.e. The Diagnostic Interview for Anxiety,
Mood and OCD and Related Neuropsychiatric Disorders [DIAMOND] [16]; and the
American College Rheumatology [ACR] criteria for Fibromyalgia [15]). One paper
used outcome measures as diagnostic cut offs (i.e. Addiction Severity Index [ASI]
[17]) and two others quantified the presence of chronic pain (i.e. three months or
more) [8] which was then confirmed by a medical professional [9]. Two studies did
not specify their diagnostic criteria [3, 10] and one was self-referral [6].
4.4 Characteristics of Intensive CBT
Intensive CBT was offered across all studies, yet delivery specifics varied greatly.
Number of intensive sessions offered per participant ranged from two to 20
sessions (M = 10.19; SD = 6.62). Duration of individual sessions ranged from 40 to
270 minutes, with an average of just over 1.5 hours (M = 101.07 [minutes]; SD =
60.39; Mdn = 90), with sessions accessed across an average of 20.33 (SD = 9.00)
days. This equates to an average of 16.85 hours of therapy per individual. Number
of hours of therapy offered per participant varied across studies, with more hours
allocated within studies of OCD and BDD (n = 30) and less within pain (n = 12) and
anxiety (n = 9). Hours per person could not be calculated for one addiction paper
(Morefield et al., 2014).
37
Using Tolin’s (2010) criteria, the following components of CBT were identified as
having been offered across the 17 studies; psychoeducation (k = 14); relaxation (k =
4); exposure (k = 14); behavioural rehearsal (k = 7); and cognitive restructuring (k =
15). Use of operant procedures was not specifically cited within any paper. Studies
delivered either two (k = 5), three (n = 4) or four (k = 8) components of CBT, with an
average of three offered per study (M = 3.18; SD = 0.88; Mdn = 3).
4.5 Effects of Intensive CBT
There were considerable variations in study methodologies (i.e. control groups,
number of follow ups, number of outcome measures). This review structured
results by clinical populations experiencing distress, as this was the most efficient
and coherent way of synthesising results. The following group categorisations of
distress were developed: distress following trauma, chronic pain, addiction and
psychological distress associated with mental health.
i) Psychological Distress Associated with Mental Health
Ten studies investigated delivery of intensive CBT within populations experiencing
psychological distress associated with mental health difficulties [1, 2, 4, 5, 7, 11 –
14, 16]. Several studies in this group were by the same two leading authors [1 and
2; 12 and 13], albeit different time frames and a different participant pool.
Although this review aimed to deviate from psychiatric diagnoses and capture a
broader understanding of psychological distress, studies in this section correlate
with NICE guideline definitions of common mental health conditions. NICE capture
all anxiety difficulties as one mental health and behavioural condition, inclusive of
symptoms of panic, phobia, anxiety in social situations and general anxiety (NICE,
2014). Secondly, NICE capture distress associated with obsessions and compulsions
(i.e. OCD) and distress associated with preoccupations in appearance (i.e. BDD) as
one condition (NICE, 2005). The following clinical populations made up the studies
for psychological distress associated with mental health; anxiety in social situations
(k = 2) [14, 16]; dental phobia (k = 1) [7]; panic (k = 2) [4, 5]; distress associated with
obsessions and compulsions (i.e. OCD) (k = 3) [1, 2, 11]; and distress associated with
preoccupations in personal appearance (i.e. BDD) (k = 2) [12, 13].
38
As presented in Table 3, studies with a comparison group are presented first [1, 2,
12] and found small to medium treatment effect sizes. It must be noted that one
study had a particularly small sample size (n = 5) [12]. Remaining studies with pre
and post comparisons all had very large effect sizes, with one paper in particular
having a much smaller sample size (n = 5) [14].
Whilst studies offered a variety of CBT components, all offered exposure in their
delivery of CBT. Four studies specifically focussed upon exposure and response
prevention (ERP) (Skeketee & Nishith, 1993) [2, 11 – 13], each identifying ERP as an
effective treatment for their particular cohort (i.e. experiencing symptoms of
obsession, compulsion, preoccupation and low mood). For the four ERP-focussed
studies, those with comparison groups had small to medium treatment effects [2,
12] and those without found very large treatment effects [11, 13].
A number of studies (k = 4) used the Yale-Brown Obsessive Compulsive Scale (Y-
BOCS) (Goodman et al., 1989) to measure outcome, which is considered gold
standard in measuring symptoms of OCD (Deacon & Abramowitz, 2005). Scores on
the Y-BOCS were similar for all studies pre and post intervention. However, effect
sizes were greater for non-controlled studies. Although Neziroglu and Yaryura-
Tobias (1993) also aimed to measure obsessive symptoms, their Y-BOCS data was
incomplete, rendering the Overvalued Ideation Scale (OVI; for symptoms of BDD) a
more interpretable measure.
There appeared to be quite clear differences in therapeutic dose offered depending
upon symptomatology of the cohorts. For studies focussed upon symptoms of OCD
and BDD, 15 – 20 sessions were offered, with each session lasting between 90 and
120 minutes, with all sessions delivered within a 3-4 week window. For Neziroglu
and Yaryura-Tobias (1993), those participants in the intensive CBT arm opted for
that format of therapy, as opposed to weekly delivery. For studies focussed upon
anxiety, therapy delivery was more varied, with between two and 12 sessions
offered ranging from 50 minutes to nine hours per session across a span of
between two days and four weeks.
39
Table 3. Changes to Mean Scores and Calculated Effect Sizes for Psychological
Distress Associated with Mental Health
Intensive Intervention Comparison group
Study Primary Outcome Measure
No of participants a
Pre M
(SD)
Post M
(SD)
Control Groups
No of participants
Pre M
(SD)
Post M
(SD)
Effect Size (d)
Abramowitz et al. (2000)
Y-BOCS 28 26.5 (4.7)
8.9 (3.9)
Medication alongside
ERP
59 26.5 (5.1)
11.0 (6.3)
-0.43
Abramowitz et al. (2003)
Y-BOCS 20 25.8 (3.9)
11.8 (6.2)
CBT twice weekly for 8
weeks
20 25.55 (4.5)
15.3 (7.1)
-0.53
Neziroglu & Yaryura-
Tobias (1993)
OVI 2 5 (3)
3 (3)
CBT for 8 – 12 weeks
3 9 (0.8)
7.7 (1.3)
-0.30
a The same number of participants remained at both time points for both groups (for all three studies)
Study Primary Outcome Measure
No of participants
Pre- Intervention
M (SD)
No of participants
Post- Intervention
M (SD)
Effect Size (Cohen’s d)
Bitran et al. (2008)
PDSS 32 17.8 (5.7) 24 7.1 (5.2) -1.89
Deacon & Abramowitz
(2006)
PDSS 10 1.8 (0.9) 10 0.2 (0.3) -1.73b
Motivala et al. (2018)
Y-BOCS 44 24.9 (4.5) 44 14.7 (5.2) -2.27
Neziroglu et al. (1996)
YBOCS-BDD 17 26.5 (4.4) 17 12.7 (8.2) -3.13
Stoddard et al. (2008)
SPAI 5 147.9 (15.9) 5 113.6 (36.5) -2.17
Wootton et al. (2018)
SPIN 11 48.1 (11.7) 11 32.9 (13.6) -1.29
b Effect size was calculated using the reported means by Deacon and Abramowitz (2006), which is the mean of the mean totals. Table Abbreviations: Overvalued Ideas Scale (OVI); Panic Disorder Severity Scale (PDSS); Social Phobia and Anxiety Inventory (SPAI); Social Phobia Inventory (SPIN); WASI); Yale-Brown Obsessive Compulsive Scale (Y-BOCS); Yale-Brown OCD Scale for Body Dysmorphic Disorder (BDD-YBOCS).
An effect size for Johren et al. (2007) was not calculated. Johren et al. (2007) used
data of therapy completers (n = 104; M = 47.22; SD = 5.50) versus non-completers
(n = 52; M = 43.67; SD = 6.42) to measure attendance at dental appointments for
specific dental phobia, and concluded that non-completers had lower anxiety
40
scores on the Hierarchical Anxiety Questionnaire (HAQ) (p < .01), but attended
fewer subsequent dental sessions (p < .01).
Across the 10 studies in this section, four were rated as having weak
methodological quality, five rated moderate and one strong. The paper by
Abramowitz et al. (2003), which was an RCT design with a moderate treatment
effect, was the only paper rated to have a strong methodological quality. Of the
studies rated moderate in quality, two used control group comparisons (with small
to medium effect) and the other three were repeated measures designs with the
highest effect sizes. This gives more assurance in the accuracy of effect sizes
presented.
ii) Chronic Pain
Three studies explored intensive CBT for chronic pain [8, 9, 17], including chronic
low back pain (with pain-related anxiety), chronic pain in people with an intellectual
disability, and fibromyalgia. Studies recorded various outcomes, including pain
related anxiety, severity of pain symptoms and coping strategies. Studies used
different outcome measures, including the Multidisciplinary Pain Inventory (MPI)
(subscale – affective distress), the Pain Self-Efficacy Questionnaire (PSEQ) (the only
standardised measure) and the Centre for Epidemiologic Studies Depression Scale
(CES-D).
Effect sizes for interventions were small to medium (see Table 4). Studies offered
between eight and 15 sessions within three to four weeks. McManus et al. (2014)
delivered 40 minute sessions, Suman et al. (2009) 90 minutes, and McCracken et al.
(2002) did not state session duration. Treatment effect was highest for McCracken
et al. (2002), which was the study with the largest sample size (n = 59) and highest
number of sessions offered (n = 15), delivered every day for three weeks. Similarly,
Suman et al. (2009) ran a daily multidisciplinary programme of treatment for a
three week period, whilst McManus et al. (2014) delivered two sessions per week
for four weeks. In terms of therapy content, McCracken et al. (2002) included
behavioural therapies alongside physical exercise, McManus et al. (2014) offered
CBT techniques for effective pain management alongside staff support, and Suman
et al. (2009) delivered a scheduled multidisciplinary programme, with physical
41
exercise intervention (i.e. stretching, aerobics) alongside CBT. Studies offered a mix
of CBT components, with McManus et al. (2014) delivering more than the other
two studies. Methodological quality for the three studies was rated as weak and
therefore effect sizes could be overinflated.
Table 4. Changes to Mean Scores and Calculated Effect Sizes for Pain
Study Primary Outcome Measure
No of participants
Pre- Intervention
M (SD)
No of participants
Post- Intervention
M (SD)
Effect Size (Cohen’s
d)
McCracken et al. (2002)
MPI: Subscalea
59 48.8 (9.9) 59 43 (10) -0.59
McManus et al. , (2014)
PSEQ-C b 5 4 (1.9) 5 4.6 (1.1) 0.32
Suman et al. (2009)
CES-D c 25 24.8 (9.9) 25 21.5 (9.7) -0.33
a Multidisciplinary Pain Inventory, Subscale – Affective Distress; b Pain Self-efficacy Scale for Children;
c Center for Epidemiologic Studies Depression Scale
iii) Distress following Trauma
Two studies explored intensive CBT within a population experiencing distress
following a traumatic incident, including a motor vehicle accident [6] and for new
mothers whose infants were admitted to a neonatal intensive care unit (NICU) [3].
Table 5 presents data from these two studies. The RCT by Bernard et al. (2011),
presented first, reported a small effect when comparing an intensive intervention
to a control group, although this was not statistically significant (p = .23) and the
study was underpowered to detect an effect. The effect size for Hickling et al.
(2005) was large (d = -1.88), when comparing pre and post data, although this study
was not a controlled design and had a sample size of three participants. Both
studies offered a similar duration of therapy, with Hickling et al. (2005) offering two
60-90 minute sessions and Bernard et al. (2011) offering three 45-55 minute
sessions. Both studies delivered components of psychoeducation, relaxation and
cognitive restructuring, but Hickling et al. (2005) additionally delivered exposure
techniques which could arguably be more suited to that particular trauma
population. The considerable difference in treatment effect could relate to small
sample sizes and varied study designs. Hickling et al. (2005) had a particularly small
42
sample size and the RCT by Bernard et al. (2011) had superior methodological
rigour. Additionally, there is a noteworthy difference in the longer term outcomes
and expectations between the cohorts. For example, complications following an
NICU admission could be long-term, whereas Hickling et al. (2005) anticipated a
significant improvement for participants over time, even without treatment. It must
be noted that methodological quality of both studies were rated weak and
therefore results must be interpreted cautiously.
Table 5. Changes to Mean Scores and Calculated Effect Sizes for Distress following
Trauma
Intervention Control group (no intervention)
Study Primary Outcome Measure
No of participants
Pre- M
(SD)
Post- M
(SD)
Pre- M
(SD)
Post- M
(SD)
Effect Size (Morris’ d)
Bernard et al. (2011)
DTS a 25 (for all groups)
32.6 (24.7)
23.9 (21.5)
39.9 (25.6)
37.3 (35.8)
0.17
Pre- Intervention Post- Intervention
Study Primary Outcome Measure
No of participants
M (SD) No of participants
M (SD) Effect Size (Cohen’s d)
Hickling et al. (2005)
PCL-5 b 3 60.3 (8.6) 2 45.5 (4.5) -1.88
a Davidson Trauma Scale; b PTSD Checklist for DSM-5
iv) Addiction
Two studies explored intensive CBT for addiction problems, including gambling [10]
and substance use [17]. Worden et al. (2015) investigated intensive CBT for
individuals with substance use or dependence, alongside symptoms of anxiety.
Scores on the Anxiety Sensitivity Index (ASI) generated a large treatment effect (d =
-1.23) comparing pre (M = 41.6; SD = 9.7) to post (M = 29.7, SD = 13.3) intervention
scores. Morefield et al. (2014) studied an inpatient treatment program for
gambling. They used the K10 scale for psychological distress. Post-intervention
scores were not published and therefore an effect size could not be calculated,
although significant improvements in reduction of gambling behaviours (p < 0.001),
43
reduced psychological distress (p < 0.001) and improvement on the Work and Social
Adjustment Scale (p < 0.001) were reported.
Both studies included psychoeducation, exposure and cognitive restructuring, with
the intervention by Morefield et al. (2014) also featuring behavioural rehearsal.
Morefield et al. (2014) offered 6-12 sessions within two weeks, but did not specify
session length. Worden et al. (2015) offered six sessions of up to 1.5 hours, across
four weeks. Worden et al. (2015) initially intended for a group delivery of the
intensive intervention. The methodology was changed to individual therapy due to
scheduling difficulties of all participants not being able to attend simultaneously.
Both studies offered the intervention alongside intensive day programmes (Worden
et al., 2015) or within inpatient programmes (Morefield et al., 2014). This
inpatient/intensive programme delivery appears suited to the needs of the
population, which counteracts barriers people with addictions face when accessing
more general community assertive outreach programmes (i.e. client resistance,
non-participation and a more complex social population [i.e. homelessness, criminal
history]; Amodeo et al., 2011). Both studies were rated weak in quality on the
EPHPP and thus strength to detect accurate results may be insufficient.
4.6 Long Term Follow Up
Eight studies reported results of longer term follow up [2, 4, 6, 9, 12, 14, 16, 17],
ranging from one month to one year. Six studies reported a large effect size when
comparing pre intervention scores to longer term follow up [4, 6, 12, 14, 16, 17].
McManus et al. (2014) maintained the same effect at long-term follow up, which
remained small to medium. Abramowitz et al. (2003) reported a reduction in effect
at longer term follow up, from medium to small.
4.7 Acceptability
Of the studies that reported therapy completion (k = 13), an average of 88% (SD =
16.61) of participants completed the intervention. Reasons for drop out included:
time constraints, family commitments, illness or stress, transportation difficulties,
unable to be contacted, transferred services, or at a decision point during therapy
(i.e. before exposure, or at a point perceived that the therapist could provide no
44
further support). Given the high completion rate, it appears that intensive CBT was
acceptable for most individuals, although some reasons for drop out appeared to
be circumstantial (i.e. illness), whereas others (i.e. time constraints, commitments,
transportation difficulties) could relate to the demand on the participants due to
the nature of intensive delivery. This again highlights the importance of patient
choice in the delivery of clinical interventions. It must be noted, that high
completion of therapy does not fulfil the assumption of acceptability. This has been
further explored in a separate qualitative review paper of intensive versus weekly
delivery of CBT (Bevan, Oldfield & Salkovskis, 2010), which will be considered
further in section 5.3.
45
5. Discussion
5.1 Summary of Evidence
The aim of this review was to examine existing literature evaluating delivery of
intensive CBT with clinical populations. The review identified 17 studies that
evaluated this intervention. Review papers were categorised into four cohorts of
psychological distress. Most studies found promising results at post intervention,
long-term follow up and when evaluated against comparison groups. However,
most studies were exploratory in design (i.e. feasibility), without a control group,
with small sample sizes and rated weak in terms of methodological quality.
All studies evaluated intensive CBT with some variations in delivery. Therapeutic
dose ranged across studies, with an average 17 hours of therapy per person which
was implemented in different ways (i.e. daily sessions, two sessions per week,
longer session duration). Therapy dose delivered within this review was in line with
national guidance but was completed more intensively (i.e. within four weeks as
opposed to weekly). For example, for particular mental health diagnoses (i.e.
anxiety disorder, OCD, BDD), NICE (2005; 2014) recommends 7-21 hours of
therapeutic input depending upon subgroup. This demonstrates that carrying out
recommended therapeutic dose can occur within a more condensed therapy
delivery window. Similarly, all included studies delivered at least two components
of CBT during this period. Attrition was low for studies that reported it, which
appears to support to the feasibility and acceptability of an intensive delivery of
CBT.
Effect sizes for treatment for distress associated with chronic pain conditions was
small to medium. Effect size calculated for one addiction paper was large, with the
second study in this area offering promise. Effect sizes for studies exploring distress
following trauma were small and large, with the smaller effect size reported by an
RCT. Studies exploring intensive CBT for distress associated with mental health
difficulties offered most promise, with small to medium effect sizes in the three
trials, and very large effect sizes for the other six studies. Across all subgroups,
effect sizes were smaller for comparison designs (i.e. RCT’s, cohort analytic designs)
compared to non-control group comparisons. Arguably, whilst trials may not have
46
been powered enough to detect an effect, which Bernard et al. (2011) noted to be
the case in their RCT, non-control group studies may have overinflated effect sizes
based upon lack of control in their methodologies. Rigorous design and reporting of
data in RCTs limit the potential over inflation of effect sizes, therefore rendering it
more difficult to generate inaccurate results and making well-designed RCT’s more
valid and generalisable (Kraemer & Kupfer, 2006). The small sample sizes in review
papers could increase the likelihood of overinflated effect sizes. Further studies
with a more rigorous methodological design and larger sample sizes are required to
strengthen these findings.
Effect sizes of intensive CBT across review papers were promising, particularly in
areas of mental health. Whilst we address the practical factors and the importance
of patient choice in the delivery of intensive CBT in Section 5.3, it is important to
consider potential theoretical implications behind the utility of intensive CBT. There
are a number of active ingredients which have been theorised as improving
engagement and outcomes of CBT interventions, some which may be particularly
significant to the intensive delivery. Non-specific therapy factors, alongside
therapeutic alliance, are longstanding components understood to be a large
contributor to successful outcome, irrespective of the treatment modality
(Goldfried, 2013; Carter et al., 2015; Bevan, Oldfield & Salkovskis, 2010). Four non-
specific factors are identified as influencing treatment outcome during
psychotherapy, including; treatment expectancy (such as the placebo effect), extra-
therapeutic factors (i.e. factors that occur outside of the therapy space, such as
social support), common therapy factors (i.e. alliance) and therapy specific
techniques (i.e. specific components of CBT; Lambert & Barley, 2001). One non-
specific factor specific to intensive CBT is patient treatment expectancy, in how
logical the patients perceive the intervention to be beforehand being a key
predictor of outcome (Carter et al., 2011). If patients anticipate the intervention to
be effective this is more likely to improve engagement and in the long-term
contribute to symptom reduction (Meyer et al., 2002). A positive outcome is also
further intensified when therapists’ have expectancies for positive treatment
outcome. Perhaps for intensive delivery of CBT, patients will have been briefed
upon the rationale of intensive compared to traditional delivery, have an outline of
47
the treatment plan and in some cases will have opted for intensive CBT over
traditional delivery. In terms of particular mental health difficulties, Oldfield,
Salkovskis and Taylor (2011) give rationale for the delivery of intensive CBT, over
traditional delivery, due to the longstanding nature of OCD and the tendency for it
to be ‘treatment refractory’. The intensive delivery compliments the delivery of
exposure and response prevention interventions and is driven by early theories on
the success of ‘massed’ trials compared to ‘spaced’ trials of exposure (Mackintosh,
1974) and furthermore on the likelihood of avoidance behaviours and limited
exposure opportunities hampering the effects of treatment (Rachman, 1979). From
a neuropsychological perspective, it could be argued that certain cognitive factors
play an important role in engaging in intensive CBT (i.e. memory, retention of
therapy content, concentration), and furthermore, Saxena et al. 2009 found distinct
changes in regional brain functions following an intensive CBT intervention for OCD.
Beyond active therapy components Tang, DeRubeis, Beberman, and Pham (2005)
discussed the mechanisms behind ‘inter-session’ or ‘sudden gains’ (i.e. significant
symptom improvements between individuals CBT sessions). Tang et al. (2005)
reported sudden gains to occur when cognitive changes happened during
intervention sessions. This finding highlights the importance of particular therapy
sessions which target change and therefore influence treatment outcome. It could
be argued that the momentum of intensive CBT sessions could facilitate increased
motivation, with motivation being a recognised factor influencing therapy outcome.
Bevan, Oldfield and Salkovskis (2012) note the importance of momentum and
motivation specifically during the delivery of intensive CBT.
To our knowledge, no other published reviews have investigated intensive CBT in an
adult clinical population. One published review (Öst and Ollendick, 2017) focused
upon intensive CBT for anxiety disorders in children and adolescents. It would
appear that there is an interest in reviewing disorders of anxiety, perhaps due to
increased literature in this area and the effectiveness of intensive CBT in this area
to date (i.e. Deacon & Abramowitz, 2006).
48
5.2 Strengths and Limitations
This section outlines a number of limitations alongside justifications for decisions
made and descriptions of how limitations were minimised. Strengths of this review
are presented first.
Firstly, two steps were taken to minimise bias and limit subjectivity during the
abstract screening and quality appraisal stages. Interrater reliability is an important
measure in determining the accuracy of evaluations made during research (i.e.
quality) and kappa is a longstanding tool in determining this (Banerjee, Capozzoli,
McSweeney, & Sinha, 1999). Interrater reliability was ‘strong’ for abstract screening
and ‘almost perfect’ for quality appraising, which is important in highlighting the
precision and accuracy of those aspects of the review that were dual-rated. A
further strength of this review was the systematic nature in how it was conducted.
The review adhered to a number of strict processes important in developing a
robust systematic review. This included adherence to the PRISMA systematic
review protocol (Moher et al., 2015), an evidence-based approach to searching (i.e.
PICO; Miller & Forrest, 2001) and a practice guide (Boland, Cherry, & Dickson,
2017).
One limitation was operationalising the term ‘intensive CBT’, as this appeared to be
inconsistently defined within existing literature. Included papers varied in their
delivery of CBT, particularly therapeutic dose, which may undermine the reliability
of conclusions drawn in this review. The definition for intensive CBT was shaped by
previous literature (Storch et al., 2007; Oldfield et al., 2011; Ehlers et al., 2010;
Deacon & Abramowitz, 2006) and both published and ongoing reviews investigating
intensive CBT (Öst & Ollendick, 2017; Millar et al., 2018; Clarkson et al., 2018).
Whilst scoping exercises were conducted to test search terms, the final PICO
criteria resulted in the exclusion of some studies defining themselves as ‘intensive
CBT’. For example, a number of studies completed the main intervention within
four weeks, but offered ‘booster’ sessions for several weeks afterwards (Ehlers et
al., 2010; Oldfield et al., 2011; Challacombe & Salkovskis, 2011; Ehlers et al., 2014).
This meant that some potentially relevant studies were excluded. Whilst these
papers could have added to our understanding of intensive CBT delivery, the
49
decision was to remain consistent with the established PICO criteria, as published
on prospero (ID: CRD42018086546). Boland et al. (2017) highlight potential for bias
during the screening phase, particularly where supplement papers are included by
the author. Therefore, adhering to PICO criteria avoided such bias and maintained
elements of reliability and consistency with the eligibility criteria. A larger review in
the future could consider broadening the PICO criteria to allow inclusion of studies
with booster sessions.
The review included a number of clinical populations experiencing psychological
distress (i.e. pain, mental health, addiction, and trauma). The review sample was
somewhat heterogeneous which did not allow for more in depth exploration and
data synthesis (e.g. meta-analysis). Whilst this current review provided a narrative
overview of the literature, broadening inclusion criteria in the future (i.e. group or
computer delivered CBT) could allow a larger-scale review to explore more variants
of intensive delivery. This could allow a more rigorous analysis (i.e. meta-analysis) in
more specific groups (i.e. diagnostic patient groups, methods of delivery, therapy
dose). Many studies had sample sizes smaller than would be desired for
generalisable results and reliable effect sizes. As mentioned, grey literature and
non-English papers were discounted, which could have unintentionally excluded
relevant literature.
Many papers in this review (k = 11, 65%) were rated as having weak methodological
quality, as determined using the EPHPP quality tool. This was important to consider
when interpreting data, as many of the reported results may be inaccurate and
difficult to generalise beyond each individual study. EPHPP rates as Gold Standard
both RCT’s and controlled clinical trials, but only two studies used an RCT design,
which lowered the rating for remaining studies. Similarly, many studies did not
control for confounding variables as most studies did not have multiple groups and
therefore did not report any group differences. This rendered overall outcome of
confounding variables as weak for many studies. Other methodological weaknesses
included limited reporting of attrition rates (or reasons for drop out), limited
blinding of outcome assessors and participants (or otherwise not reported), and
variable clarity on the methods of sample selection. Literature exploring intensive
CBT is emerging and many studies are in an exploratory phase. Future emphasis
50
must be placed upon the design and implementation of higher quality studies (i.e.
RCT’s) before a repeat review can take place.
Whilst the EPHPP rates a number of factors relating to bias (i.e. selection bias,
confounders, blinding) it does not evaluate the reporting of treatment outcome, as
is scrutinised in other tools, such as the Cochrane Collaboration Risk of Bias Tool
(CCRBT) (Armijo et al., 2012). The way in which studies analyse and report their
data (i.e. selective reporting, intent to treat analyses) does not affect global rating
of the EPHPP and thus could lead to bias in the reporting of outcome.
5.3 Clinical Implications and Future Directions
Although further investigation is required, this current review highlighted a number
of papers evaluating intensive CBT in clinical populations experiencing psychological
distress, with some promising results in terms of feasibility, acceptability and
efficacy. There is a growing recognition within the literature of the suitability of ERP
to an intensive delivery format (Oldfield et al., 2011). In this review, many studies
delivered components of exposure therapy, particularly within the cohort
experiencing distress associated with mental health difficulties. Treatment effects
within this group were promising, which raises the question of whether some
components of CBT, such as ERP, are particularly suited to an intensive delivery
format and whether intensive CBT itself is suited to certain clinical populations.
Whilst intensive delivery appeared suited to individuals experiencing mental health
difficulties, perhaps a longer term intervention would suit those experiencing
distress associated with chronic pain. This can be hypothesised given the small
effect of treatment in this area, but also the requirement for a more multimodal
treatment programme, which arguably could be suited to a longer term delivery.
Treatment effectiveness for pain and addiction were mixed and further exploration
would be warranted before drawing any conclusions about these populations.
Participant preference seems to be a factor in the delivery of intensive or standard
CBT. For example, there were a number of drop outs related specifically to
intensive delivery (i.e. time constraints or competing commitments). There
appeared to be no clear pattern of drop-out affected by the intensity of therapy,
the cohort in which it applied to or the therapy components delivered for those
51
studies that cited such difficulties [3, 16, 17]. Neziroglu and Yaryura-Tobias (1993)
offered participants the option of an intensive delivery or weekly sessions, with half
the sample opting for each. Furthermore, Worden et al. (2015) began with the
intention of a group format, which was changed to individual therapy following
barriers to participants accessing the group sessions simultaneously. These factors
highlight the differences in treatment preference and the level of commitment
people are able to invest.
Use of intensive CBT also has implications for services whereby intensive
interventions might be favoured over weekly delivery. In some studies within this
review, intensive delivery was favoured over long-term intervention commitments
(Neziroglu & Yaryura-Tobias, 1993). Bevan, Oldfield and Salkovskis (2010)
interviewed participants following an intensive or weekly delivery of CBT for OCD,
with interviews eliciting both benefits and drawbacks. Time between therapy
sessions naturally reduced in the intensive format. Those who had weekly delivery
stated they had longer to learn and consolidate therapy material, whereas those
who had the intensive format stated a preference of having less time to ruminate
between sessions and an increased focus on the issues. The intensive group stated
that delivery was more time effective, with weekly sessions requiring a longer-term
commitment. The weekly group perceived intensive delivery to be too stressful,
although the intensive group experienced it as being more motivating with better
momentum. Overall, this challenges the view that CBT can only be delivered on a
weekly basis and highlights the importance of considering non-traditional methods
of delivery, based upon patient preference. Understanding patient preference
raises important considerations for the development, acceptability and
effectiveness of services (Bevan et al., 2010). These perspectives provide support
for the response regulation model and the stepped care model of healthcare
delivery, as discussed earlier (Stiles et al., 2008; Bower & Gilbody, 2005). Intensive
CBT could be a starting point, with further booster sessions or weekly sessions
being available as determined by need.
52
5.4 Conclusions
By conducting this review we are able to better understand the varied
characteristics of intensive CBT and its delivery across a number of clinical
populations. We were able to highlight the efficacy of intensive CBT although this is
tentative given the emerging nature of this literature. Whilst previous reviews have
focussed upon specific diagnoses or populations, this current attempt provides a
useful contribution in the broader opportunities for use of intensive CBT. Large
scale rigorously designed studies (i.e. RCTs) are now needed to establish the
efficacy of intensive CBT for clinical populations.
53
6. References
Abramowitz, J.S., Foa, E.B., & Franklin, M.E. (2003). Exposure and ritual prevention
for obsessive-compulsive disorder: Effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71(2), 394–398. http://dx.doi.org/10.1037/0022-006X.71.2.394
Abramowitz, J.S., Franklin, M.E., Street, G.P., Kozak, M.J., & Foa, E.B. (2000). Effects of comorbid depression on response to treatment for obsessive-compulsive disorder. Behavior Therapy, 31(3), 517–528. https://doi.org/10.1016/S0005- 7894(00)80028-3
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Amodeo, M., Lundgren, L., Cohen, A., Rose, D., Chassler, D., Beltrame, C., & D’ippolito, M. (2011). Barriers to implementing evidence-based practices in addiction treatment programs: Comparing staff reports on motivational interviewing, adolescent community reinforcement approach, assertive community treatment, and cognitive-behavioral therapy. Evaluation and Program Planning, 34(4), 382-389. https://doi.org/10.1016/j.evalprogplan.2011.02.005
Armijo‐Olivo, S., Stiles, C. R., Hagen, N. A., Biondo, P. D., & Cummings, G. G. (2012). Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. Journal of Evaluation in Clinical Practice, 18(1), 12-18. https://doi.org/10.1111/j.1365-2753.2010.01516.x
Arvidsdotter, T., Marklund, B., Kylén, S., Taft, C., & Ekman, I. (2016). Understanding persons with psychological distress in primary health care. Scandinavian Journal of Caring Sciences, 30(4), 687-694. https://doi.org/10.1111/scs.12289
Association for Behavioural and Cognitive Therapies. (2019). Cognitive Behavioural Therapy. Retrieved from http://www.abct.org/Resources/?m=mResources&fa=Syllabi
Banerjee, M., Capozzoli, M., McSweeney, L., & Sinha, D. (1999). Beyond kappa: A review of interrater agreement measures. Canadian Journal of Statistics, 27(1), 3-23. https://doi.org/10.2307/3315487
Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioral treatment of panic disorder. Behavior therapy, 20(2), 261-282. https://doi.org/10.1016/S0005-7894(89)80073-5
Beck, A. T. (Ed.). (1979). Cognitive therapy of depression. New York, NY: Guilford press.
Bennett, W. L., Wilson, R. F., Zhang, A., Tseng, E., Knapp, E. A., Kharrazi, H., ... & Cheskin, L. J. (2018). Methods for evaluating natural experiments in obesity: a systematic review. Annals of Internal Medicine, 168(11), 791-800. doi:10.7326/M18-0309
Bernard, R.S., Williams, S.E., Storfer-Isser, A., Rhine, W., McCue Horwitz, S., Koopman, C., & Shaw, R.J. (2011). Brief cognitive-behavioral intervention for maternal depression and trauma in the neonatal intensive care unit: a pilot
54
study. Journal of Traumatic Stress, 24(2), 230–234. http://doi.org/10.1002/jts.20626
Bernardy, K., Füber, N., Köllner, V., & Häuser, W. (2010). Efficacy of cognitive- behavioral therapies in fibromyalgia syndrome—a systematic review and metaanalysis of randomized controlled trials. The Journal of Rheumatology, 37(10), 1991-2005. https://doi.org/10.3899/jrheum.100104
Bevan, A., Oldfield, V. B., & Salkovskis, P. M. (2010). A qualitative study of the acceptability of an intensive format for the delivery of cognitive‐behavioural therapy for obsessive‐compulsive disorder. British Journal of Clinical Psychology, 49(2), 173-191. https://doi.org/10.1348/014466509X447055
Bitran, S., Morissette, S.B., Spiegel, D.A., & Barlow, D.H. (2008). A pilot study of sensation-focused intensive treatment for panic disorder with moderate to severe agoraphobia: preliminary outcome and benchmarking data. Behavior Modification, 32(2), 196–214. http://dx.doi.org/10.1177/0145445507309019
Boland, A., Cherry, G., & Dickson, R. (Eds.). (2017). Doing a systematic review: A student's guide. London: Sage.
Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. The Journal of Clinical Psychiatry.
Bower, P., & Gilbody, S. (2005). Stepped care in psychological therapies: access, effectiveness and efficiency: narrative literature review. The British Journal of Psychiatry, 186(1), 11-17. https://doi.org/10.1192/bjp.186.1.11
British Association for Behavioural and Cognitive Psychotherapies. (2019). What is CBT. Retrieved from https://www.babcp.com/public/What-is-CBT.aspx
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. https://doi.org/10.1016/j.cpr.2005.07.003
Carter, J. D., Crowe, M. T., Jordan, J., McIntosh, V. V., Frampton, C., & Joyce, P. R. (2015). Predictors of response to CBT and IPT for depression; the contribution of therapy process. Behaviour research and therapy, 74, 72-79. https://doi.org/10.1016/j.brat.2015.09.003
Carter, J. D., Luty, S. E., McKenzie, J. M., Mulder, R. T., Frampton, C. M., & Joyce, P. R. (2011). Patient predictors of response to cognitive behaviour therapy and interpersonal psychotherapy in a randomised clinical trial for depression. Journal of affective disorders, 128(3), 252-261.
Cavallo, D. A., Cooney, J. L., Duhig, A. M., Smith, A. E., Liss, T. B., McFetridge, A. K., ... & Krishnan‐Sarin, S. (2007). Combining cognitive behavioral therapy with contingency management for smoking cessation in adolescent smokers: A preliminary comparison of two different CBT formats. The American Journal on Addictions, 16(6), 468-474. https://doi.org/10.1080/10550490701641173
Centre for Mental Health. (2010). The Economic and Social Costs of Mental Health Problems in 2009/10. Centre for Mental Health. Retrieved from ispraisrael.org.il/Items/00649/Economic_and_social_costs_2010[1].pdf
Challacombe, F. L., & Salkovskis, P. M. (2011). Intensive cognitive-behavioural treatment for women with postnatal obsessive-compulsive disorder: a consecutive case series. Behaviour Research and Therapy, 49(6-7), 422-426. https://doi.org/10.1016/j.brat.2011.03.006
55
Chase, R. M., Whitton, S. W., & Pincus, D. B. (2012). Treatment of adolescent panic disorder: A nonrandomized comparison of intensive versus weekly CBT. Child & Family Behavior Therapy, 34(4), 305-323. https://doi.org/10.1080/07317107.2012.732873
Chittleborough, C. R., Winefield, H., Gill, T. K., Koster, C., & Taylor, A. W. (2011). Age differences in associations between psychological distress and chronic conditions. International Journal of Public Health, 56(1), 71-80. https://doi.org/10.1007/s00038-010-0197-5
Clark, D. M. (1994). Cognitive therapy for panic disorder. American Psychiatric Association.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Social phobia: Diagnosis, assessment, and treatment, 41(68), 00022-3.
Clarkson, H., Allcott-Watson, H., Shafran, R., & Bennett., S. (2018). The effectiveness of intensive CBT for anxiety disorders, OCD and PTSD in children and adolescents: a systematic review. PROSPERO 2016 CRD42016038783 Retrieved from http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD4201603 8783
Cohen, J. (1977). Statistical power analysis for the behavioural sciences. New York, NY: Academic Press.
Craske, M. G. (1999). Anxiety disorders: Psychological approaches to theory and treatment. Boulder, CO: Westview Press.
Deacon, B. J., & Abramowitz, J. S. (2005). The Yale-Brown Obsessive Compulsive Scale: factor analysis, construct validity, and suggestions for refinement. Journal of Anxiety Disorders, 19(5), 573-585. https://doi.org/10.1016/j.janxdis.2004.04.009
Deacon, B. J., & Abramowitz, J. S. (2006). A pilot study of two-day cognitive- behavioral therapy for panic disorder. Behaviour Research and Therapy, 44(6), 807-817. http://dx.doi.org/10.1016/j.brat.2005.05.008
Department of Health. (2011). ‘No health without mental health: a cross- government mental health outcomes strategy for people of all ages’. London: Department of Health.
Drapeau, A., Marchand, A., & Beaulieu-Prévost, D. (2012). Epidemiology of psychological distress. In L. L’Abate (Ed.), Mental illnesses-understanding, prediction and control (pp. 105-134). London: IntechOpen.
Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour research and therapy, 36(2), 215-226. https://doi.org/10.1016/S0005- 7967(97)00070-3
Effective Public Health Practice Project. (1998). Quality Assessment Tool For Quantitative Studies. Hamilton, ON: Effective Public Health Practice Project. Retrieved from: https://merst.ca/ephpp/
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour research and therapy, 38(4), 319-345. https://doi.org/10.1016/S0005-7967(99)00123-0
Ehlers, A., Clark, D. M., Hackmann, A., Grey, N., Liness, S., Wild, J., … McManus, F. (2010). Intensive cognitive therapy for PTSD: A feasibility study. Behavioural
56
and Cognitive Psychotherapy, 38(4), 383-398. https://doi.org/10.1017/S1352465810000214
Ehlers, A., Hackmann, A., Grey, N., Wild, J., Liness, S., Albert, I., … Clark, D. M. (2014). A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry, 171(3), 294-304. https://doi.org/10.1176/appi.ajp.2013.13040552
Epp, A. M., & Dobson, K. S. (2010). The evidence base for cognitive-behavioral therapy. Handbook of cognitive-behavioral therapies, 39-73.
Foa, E. B. and Rothbaum, B. O. (1998) Treating the trauma of rape: Cognitive behaviour therapy for PTSD. New York: Guilford Press.
Ginn, S., & Horder, J. (2012). “One in four” with a mental health problem: the anatomy of a statistic. British Medical Journal, 344, e1302. https://doi.org/10.1136/bmj.e1302
Gispert, R., Rajmil, L., Schiaffino, A., & Herdman, M. (2003). Sociodemographic and health-related correlates of psychiatric distress in a general population. Social Psychiatry and Psychiatric Epidemiology, 38(12), 677-683. https://doi.org/10.1007/s00127-003-0692-6
Goldberg, D. P. (1972). The detection of psychiatric illness by questionnaire. London: Oxford University Press.
Goldfried, M. R. (2013). What should we expect from psychotherapy? Clinical Psychology Review, 33(7), 862-869. https://doi.org/10.1016/j.cpr.2013.05.003
Gooding, P., & Tarrier, N. (2009). A systematic review and meta-analysis of cognitive-behavioural interventions to reduce problem gambling: hedging our bets? Behaviour Research and Therapy, 47(7), 592-607. https://doi.org/10.1016/j.brat.2009.04.002
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., … Charney, D. S. (1989). The Yale-Brown obsessive compulsive scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006-1011. doi:10.1001/archpsyc.1989.01810110048007
Heimberg, R. G. (Ed.). (1995). Social phobia: Diagnosis, assessment, and treatment. Guilford Press.
Henwood, K. S., Chou, S., & Browne, K. D. (2015). A systematic review and meta- analysis on the effectiveness of CBT informed anger management. Aggression and Violent Behavior, 25, 280-292. https://doi.org/10.1016/j.avb.2015.09.011
Hickling, E.J., Blanchard, E.B., & Kuhn, E. (2005). Brief, early treatment for ASD/PTSD following motor vehicle accidents. Cognitive and Behavioral Practice, 12(4), 461–467. http://dx.doi.org/10.1016/S1077-7229%2805%2980073-2
Hofmann, S. G. & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632.
Improving Access to Psychological Therapies (2007). The Competencies Required to Deliver Effective Cognitive and Behavioural Therapy for People with Depression and with Anxiety Disorders. London: Department of Health. Retrieved from
57
https://webarchive.nationalarchives.gov.uk/20130105063655/http://www. dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_078535.pdf
Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: science and practice, 8(3), 255-270. https://doi.org/10.1093/clipsy.8.3.255
Johren, P., Enkling, N., Dent, M., Heinen, R., & Sartory, G. (2007). Clinical outcome of a short-term psychotherapeutic intervention for the treatment of dental phobia. Quintessence International (Berlin, Germany : 1985), 38(10), E589- 596.
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L., Walters, E. E., & Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959-976. https://doi.org/10.1017/S0033291702006074
Kozak, M. J., & Foa, E. B. (1997). Mastery of obsessive-compulsive disorder: A cognitive-behavioral approach: Therapist guide. Oxford, England: Oxford University Press.
Kraemer, H. C., & Kupfer, D. J. (2006). Size of treatment effects and their importance to clinical research and practice. Biological Psychiatry, 59(11), 990-996. https://doi.org/10.1016/j.biopsych.2005.09.014
Kuriyama, S., Nakaya, N., Ohmori-Matsuda, K., Shimazu, T., Kikuchi, N., Kakizaki, M., ... & Akhter, M. (2009). Factors associated with psychological distress in a community-dwelling Japanese population: the Ohsaki Cohort 2006 Study. Journal of Epidemiology, 19(6), 294-302. https://doi.org/10.2188/jea.JE20080076
Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, research, practice, training, 38(4), 357.
Lewin, A. B., Storch, E. A., Merlo, L. J., Adkins, J. W., Murphy, T., & Geffken, G. A. (2005). Intensive Cognitive Behavioral Therapy for Pediatric Obsessive Compulsive Disorder: A Treatment Protocol for Mental Health Providers. Psychological Services, 2(2), 91. http://dx.doi.org/10.1037/1541- 1559.2.2.91
Mackintosh, N. J. (1974). The psychology of animal learning. New York: Academic Press.
Mahood, Q., Van Eerd, D., & Irvin, E. (2014). Searching for grey literature for systematic reviews: challenges and benefits. Research Synthesis Methods, 5(3), 221-234. doi:10.1002/jrsm.1106
McCart, M. R., Priester, P. E., Davies, W. H., & Azen, R. (2006). Differential effectiveness of behavioral parent-training and cognitive-behavioral therapy for antisocial youth: A meta-analysis. Journal of Abnormal Child Psychology, 34(4), 525-541. https://doi.org/10.1007/s10802-006-9031-1
McCracken, L.M., Gross, R.T., & Eccleston, C. (2002). Multimethod assessment of treatment process in chronic low back pain: Comparison of reported pain- related anxiety with directly measured physical capacity. Behaviour
58
Research and Therapy, 40(5), 585–594. http://dx.doi.org/10.1016/S0005- 7967%2801%2900074-2
McManus, S., Bebbington, P., Jenkins, R., & Brugha, T. (2016). Mental health and wellbeing in England: Adult psychiatric morbidity survey 2014. Leeds: NHS digital. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploa ds/attachment_data/file/556596/apms-2014-full-rpt.pdf
McManus, S., Treacy, M., & McGuire, B.E. (2014). Cognitive behavioural therapy for chronic pain in people with an intellectual disability: A case series using components of the Feeling Better programme. Journal of Intellectual Disability Research, 58(3), 296–306. http://dx.doi.org/10.1111/jir.12018
Mental Health Foundation. (2016). Fundamental Facts About Mental Health 2016. Mental Health Foundation: London. Retrieved from https://www.mentalhealth.org.uk/sites/default/files/fundamental-facts- about-mental-health-2016.pdf
Mental Health Taskforce. (2016). The Five Year Forward for Mental Health. Retrieved from https://www.england.nhs.uk/wp- content/uploads/2016/02/Mental-Health-Taskforce-FYFVfinal.pdf
Meyer, B., Pilkonis, P. A., Krupnick, J. L., Egan, M. K., Simmens, S. J., & Sotsky, S. M. (2002). Treatment expectancies, patient alliance and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of consulting and clinical psychology, 70(4), 1051.
Millar, J., Bauer, A., Salkovskis, P., Gregory, J., & Halligan, S. (2018). Is intensive CBT an effective treatment format for adults with OCD? A systematic review. PROSPERO 2018 CRD42018106840 Retrieved from: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD4201810 6840
Miller, S.A., & Forrest, J.L. (2001). Enhancing your practice through evidence-based decision making: PICO, learning how to ask good questions. Journal of Evidence-Based Dental Practice, 1(2):136–41. DOI: https://dx.doi.org/10.1016/S1532- 3382(01)70024-3.
Mirowsky, J. (2007). The distribution's tail: a comment. Health (London, England: 1997), 11(3), 301-2. https://doi.org/10.1177/1363459307077544
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … Stewart, L.A. (2015). Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Systematic Review, 4(1), 1. doi:10.1186/2046-4053-4-1
Montgomery, E. C., Kunik, M. E., Wilson, N., Stanley, M. A., & Weiss, B. (2010). Can paraprofessionals deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms? Bulletin of the Menninger Clinic, 74(1), 45-62. https://doi.org/10.1521/bumc.2010.74.1.45
Morefield, K., Walker, C., Smith, D., Harvey, P., Dunn, K., & Battersby, P. (2014). An inpatient treatment program for people with gambling problems: Synopsis and early outcomes. International Journal of Mental Health and Addiction, 12(3), 367–379. http://dx.doi.org/10.1007/s11469-013-9462-1
59
Morris, S. B. (2008). Estimating Effect Sizes From Pretest-Posttest-Control Group Designs. Organizational Research Methods, 11(2), 364-386. http://doi.org/10.1177/1094428106291059
Motivala, S.J., Arellano, M., Greco, R.L., Aitken, D., Hutcheson, N., Tadayonnejad, R., … Feusner, J.D. (2018). Relationships between obsessive-compulsive disorder, depression and functioning before and after exposure and response prevention therapy. International Journal of Psychiatry in Clinical Practice, 22(1), 40–46. http://dx.doi.org/10.1080/13651501.2017.1351991
National Institute for Health and Care Excellence. (2005). Obsessive-compulsive Disorder and Body Dysmorphic Disorder: Treatment (NICE Quality Standard CG31). Retrieved from https://www.nice.org.uk/guidance/CG31/chapter/1- Guidance#steps-35-treatment-options-for-people-with-ocd-or-bdd
National Institute for Health and Care Excellence. (2011). Depression in Adults (NICE Quality Standard No. 8). Retrieved from https://www.nice.org.uk/guidance/qs8
National Institute for Health and Care Excellence. (2013). Social Anxiety Disorder: Recognition, Assessment and Treatment (NICE Quality Standard CG159). Retrieved from https://www.nice.org.uk/guidance/cg159/chapter/1- Recommendations#interventions-for-adults-with-social-anxiety-disorder-2
National Institute for Health and Care Excellence. (2014). Anxiety Disorders (NICE Quality Standard No. 53). Retrieved from https://www.nice.org.uk/guidance/qs53
Neziroglu, F., McKay, D., Todaro, J., & Yaryura-Tobias, J. A. (1996). Effect of cognitive behavior therapy on persons with body dysmorphic disorder and comorbid Axis II diagnosis. Behavior Therapy, 27(1), 67–77. http://dx.doi.org/10.1016/S0005-7894%2896%2980036-0
Neziroglu, F.A., & Yaryura-Tobias, J.A. (1993). Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy, 24(3), 431–438. http://dx.doi.org/10.1016/S0005- 7894%2805%2980215-1
Okajima, I., Komada, Y., & Inoue, Y. (2011). A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep and Biological Rhythms, 9(1), 24-34. https://doi.org/10.1111/j.1479- 8425.2010.00481.x
Oldfield, V. B., Salkovskis, P. M., & Taylor, T. (2011). Time‐intensive cognitive behaviour therapy for obsessive‐compulsive disorder: A case series and matched comparison group. British Journal of Clinical Psychology, 50(1), 7- 18. https://doi.org/10.1348/014466510X490073
Öst, L. G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 97, 134-145. https://doi.org/10.1016/j.brat.2017.07.008
Phongsavan, P., Chey, T., Bauman, A., Brooks, R., & Silove, D. (2006). Social capital, socio-economic status and psychological distress among Australian adults. Social Science and Medicine, 63(10), 2546-2561. https://doi.org/10.1016/j.socscimed.2006.06.021
60
Rachman, S. (1979). The return of fear. Behaviour Research and Therapy, 17, 164– 166. doi:10.1016/0005-7967(79)90028-7.
Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of Cognitive Psychotherapy, 15(4), 321.
Ridner, S. H. (2004). Psychological distress: concept analysis. Journal of Advanced Nursing, 45(5), 536-545. https://doi.org/10.1046/j.1365-2648.2003.02938.x
Saxena, S., Gorbis, E., O'neill, J., Baker, S. K., Mandelkern, M. A., Maidment, K. M., ... & London, E. D. (2009). Rapid effects of brief intensive cognitive-behavioral therapy on brain glucose metabolism in obsessive-compulsive disorder. Molecular Psychiatry, 14(2), 197.
Steketee, G. S, & Nishith, P. (1993). Treatment of Obsessive Compulsive Disorder. Journal of Cognitive Psychotherapy, 9(4). doi:10.1891/0889-8391.9.4.293
Stewart, R. E., & Chambless, D. L. (2009). Cognitive–behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4), 595. http://dx.doi.org/10.1037/a0016032
Stiles, W. B., Barkham, M., Connell, J., & Mellor-Clark, J. (2008). Responsive regulation of treatment duration in routine practice in United Kingdom primary care settings: Replication in a larger sample. Journal of Consulting and Clinical Psychology, 76(2), 298. doi:b>10.1037/0022-006X.76.2.298
Stoddard, J. A., Rosellini, A. J., & Hofmann, S. G. (2008). Single case evaluation of an intensive cognitive behavioral treatment for generalized social anxiety disorder. International Journal of Cognitive Therapy, 1(2), 114–124. http://dx.doi.org/10.1521/ijct.2008.1.2.114
Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., … Goodman, W. K. (2007). Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child & Adolescent Psychiatry, 46(4), 469-478. https://doi.org/10.1097/chi.0b013e31803062e7
Storch, E. A., Merlo, L. J., Lehmkuhl, H., Geffken, G. R., Jacob, M., Ricketts, E., ... Goodman, W. K. (2008). Cognitive-behavioral therapy for obsessive– compulsive disorder: A non-randomized comparison of intensive and weekly approaches. Journal of Anxiety Disorders, 22(7), 1146-1158. https://doi.org/10.1016/j.janxdis.2007.12.001
Suman, A.L., Biagi, B., Biasi, G., Carli, G., Gradi, M., Patri, E., & Bonifazi, M. (2009). One-year efficacy of a 3-week intensive multidisciplinary non- pharmacological treatment program fibromyalgia patients. Clinical and Experimental Rheumatology, 27(1), 7–14.
Tang, T. Z., DeRubeis, R. J., Beberman, R., & Pham, T. (2005). Cognitive changes, critical sessions, and sudden gains in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 73(1), 168.
Tolin, D. F. (2010). Is cognitive–behavioral therapy more effective than other therapies?: A meta-analytic review. Clinical Psychology Review, 30(6), 710- 720. https://doi.org/10.1016/j.cpr.2010.05.003
Vernooij‐Dassen, M., Draskovic, I., McCleery, J., & Downs, M. (2011). Cognitive reframing for carers of people with dementia. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD005318.pub2.
61
Voss, P. H., & Rehfuess, E. A. (2013). Quality appraisal in systematic reviews of public health interventions: an empirical study on the impact of choice of tool on meta-analysis. Journal of Epidemiology Community Health, 67(1), 98- 104. http://dx.doi.org/10.1136/jech-2011-200940
Whiteside, S. P., Brown, A. M., & Abramowitz, J. S. (2008). Five-day intensive treatment for adolescent OCD: A case series. Journal of Anxiety Disorders, 22(3), 495-504. https://doi.org/10.1016/j.janxdis.2007.05.001
Wootton, B. M., Hunn, A., Moody, A., Lusk, B. R., Ranson, V. A., & Felmingham, K. L. (2018). Accelerated outpatient individual cognitive behavioural therapy for social anxiety disorder: A preliminary pilot study. Behavioural and Cognitive Psychotherapy. http://dx.doi.org/10.1017/S1352465818000267
Worden, B.L., David, E., Genova, M., & Tolin, D.F. (2015). Development of an Anxiety Sensitivity (AS) Intervention for High-AS Individuals in Substance Use Disorders Treatment. Cognitive Therapy and Research. http://dx.doi.org/10.1007/s10608-014-9666-0
Zinbarg, R. E., Barlow, D. H., Brown, T. A., & Hertz, R. M. (1992). Cognitive- behavioral approaches to the nature and treatment of anxiety disorders. Annual review of psychology, 43(1), 235-267. https://doi.org/10.1146/annurev.ps.43.020192.001315
Zuroff, D. C., Koestner, R., Moskowitz, D. S., McBride, C., & Bagby, R. M. (2012). Therapist's autonomy support and patient's self-criticism predict motivation during brief treatments for depression. Journal of Social and Clinical Psychology, 31(9), 903-932.
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Introduction to Paper II
Paper II is a research study written in preparation for submission to the Archives of
Suicide Research (Appendix 3). The authorship for this paper will be as follows:
Hampson, L., Killilea, J., Lennox, C., & Pratt, D. (2019).
Paper II investigates the feasibility of investigating an intensive cognitive
behavioural suicide prevention (CBSP) programme conducted in a male prison. The
presence of mental illness in prison is far greater than that in the community, with
an increased risk of self-harm and suicidality. Prisoners present with a much higher
risk of suicide and a number of complex factors which mediate this risk. It is
important to focus preventative interventions into this population. The outcome of
this study will highlight the feasibility of an intensive intervention in this population
and thus provide recommendations for future research studies in this area. There
are no known studies to date that have delivered intensive Cognitive Behavioural
Therapy (CBT) in this format within a prison.
The Intensive CBT for Suicide Prevention in Prison (InSPire) Programme was co-
developed and co-delivered alongside a fellow trainee (JK) on the University of
Manchester Clinical Psychology Doctoral Programme. The completion of all
research activities was equally distributed between the author and the second
trainee. A number of North West prisons were contacted in order to establish a
host prison for the InSPire programme. The required ethical applications were
submitted, with approval granted from the University of Manchester (Appendix 4),
the National Research Ethics Committee for Wales (IRAS ID: 238927) (Appendix 5
and 6), Her Majesty’s Prison and Probation Service National Research Committee
(ID: 2018-154) (Appendix 7) and from the Governor of the host prison. The study
was registered as a Clinical Trial (ID: NCT03499548) (Appendix 8). The author and
the second trainee both collected the study data and delivered the therapeutic
components of the InSPire programme, carrying an equal caseload of participants.
The author then collated all of the quantitative data for this thesis which led onto
the development of this paper.
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Paper II Research Study
Intensive CBT for Suicide Prevention in Prison:
The InSPire Programme
Written in preparation for submission to
Archives of Suicide Research
(NB. The word count has been extended for
this version to provide additional context)
Word count: 8275 (excluding abstract, tables, figures and references)
64
1. Abstract
Objectives: This study aimed to evaluate the feasibility of an intensive programme
of cognitive behavioural suicide prevention therapy within a male prison.
Methods: Thirteen participants consented to take part. Up to ten hours of therapy
were offered, across five sessions, within a three week delivery window. Outcome
measures were completed at baseline and follow up.
Results: Programme completion and client satisfaction with the intensive
programme were high. Outcomes related to suicidal distress were assessed, with
small to large effect sizes found.
Conclusions: The study holds promise for the feasibility and efficacy of delivering
intensive cognitive behaviours therapy (CBT) for suicidal prisoners. Further
exploration on a larger scale is warranted.
Key words: Prison, Suicide, Cognitive Behavioural Therapy, Intensive.
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2. Introduction
Suicide involves “the act or an instance of taking one's own life voluntarily and
intentionally” (Merriam-Webster, 2019). Suicide is recognised as the second leading
cause of death in 15-29 year olds, with previous suicide attempts being the highest
reported risk factor for death from suicide (World Health Organisation [WHO],
2017). Nearly 800,000 people lose their lives to suicide each year worldwide (WHO,
2017). There were 5,821 suicides in the UK in 2017, with males accounting for three
quarters of this number (Office for National Statistics [ONS], 2018). In 2017, the
highest risk of suicide in the UK was males aged between 45-49 years (ONS, 2018).
In a UK survey, one fifth of adults reported experiencing thoughts of suicide at
some point during their life, with one in fifteen having made an attempt (McManus
et al., 2014). These figures stress the importance of preventative and responsive
interventions.
The National Institute for Health and Care Excellence (NICE, 2018) published a
report on preventing suicide in community and custodial settings, highlighting
groups at higher risk of suicide as being young and middle aged males, those
already affected by suicide, individuals who self-harm, are under mental health
services, use substances, have a physical illness, have a diagnosis of autism, are
from a marginalised societal group (i.e. Lesbian, Gay, Bisexual, Transgender [LGBT])
or who work within a particular occupational group (see ONS, 2017). NICE (2018)
report a heightened suicide risk for individuals in contact with the criminal justice
system, especially those in prison or a detention centre.
Individuals in prison have an increased vulnerability to self-injurious behaviour and
thoughts and acts of suicide (Palmer & Connelly, 2005). Risk of suicide in prison is
reportedly five and 20 times that expected for male and females respectively (Fazel,
Benning, & Danesh, 2005; Fazel & Benning; 2009). Recent years have seen
increasing rates of suicide and self-harm in UK prisons (Georgiou et al., 2017).
Fazel and Baillargeon (2011) note the higher prevalence of mental health disorders
in prison, compared to the general population. This disparity is related to many
factors, including increased use of substances (and associated higher risks of
physical health conditions) (Fazel & Baillargeon, 2011). A number of short comings
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in health treatment are reported in recognition of, immediate response to and long
term follow up of mental and physical health conditions (Fazel & Baillargeon, 2011).
Shaw, Baker, Hunt, Moloney and Appleby (2004) reported that one third of suicides
in prison take place within seven days of reception, affirming concerns of a lack of
recognition and response to mental health.
In 2005, the National Offender Management Service (NOMS), in partnership with
the Department of Health (DoH), introduced the Assessment, Care in Custody and
Teamwork (ACCT) system. The Ministry of Justice (MoJ) (2013) states that “any
prisoner identified as being at risk of suicide or self-harm must be managed using
the Assessment, Care in Custody and Teamwork (ACCT) procedures”. The system
was developed to allow at risk individuals to be identified and appropriately
supported by prison staff. Usual care should involve active supervision and
monitoring of risk; consideration of triggers (i.e. demographics, history,
psychological and psychosocial factors); facilitation of peer support and listener
schemes; regular multidisciplinary ACCT reviews and completion of individualised
care plans (MoJ, 2013). The ACCT system is overseen by each prison’s Safer Custody
Team (MoJ, 2013).
Fraser, Gatherer and Hayton (2009) reported on the increased risk of poor mental
health within prison, with mediating factors including overcrowding; exposure to
violence; long periods of enforced solitude; lack of privacy; lack of access to
meaningful activities; insecurity about the future and a shortfall in the delivery of
health services, particularly mental health. Liebling (2011) reported about the moral
climate of prisons and how environmental influences (i.e. staff-prisoner
relationships, issues of fairness and humanity) contribute to poor mental well-
being. Experiences of perceived powerlessness and isolation feature in
psychological models that seek to explain why a person may choose to end their life
through suicide.
A number of established theoretical models seek to explain suicidal behaviour. One
pertinent to this current research is the Cry of Pain (CoP) Model (Williams, 1997),
which captures experiences of suicidal thoughts and behaviour from a cognitive
behavioural perspective. The model identifies suicidal behaviour as a reaction to
stressful situations. Six key components correlate with increased risk of suicide:
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access to means; presence of a major stressor; perception of stressors (i.e. negative
appraisal, defeat); cognitive biases and lack of problem solving skills); hopelessness
and no means of rescue (including lack of social support). The Schematic Appraisal
Model of Suicide (SAMS) (Johnson, Gooding, & Tarrier, 2008) builds upon CoP by
developing a formulaic representation of the driving mechanisms behind suicide.
This includes the CoP understanding of cognitive biases, but extends it to
encompass suicide schema and a system of appraisal (including appraisals of the
self, past, future, and current situations).
Cognitive Behavioural Therapy (CBT) is a recommended intervention for suicidal
behaviour and self-harm (NICE, 2011) with an evidence base in both community
(Stanley et al., 2009; Tarrier, Taylor, & Gooding, 2008) and prison settings (Pratt,
Gooding, Awenat, Eccles, & Tarrier, 2016; Pratt et al., 2015). A manualised Cognitive
Behavioural Suicidal Prevention (CBSP) intervention (Tarrier et al., 2013) was
developed to address underlying mechanisms of suicidal behaviour informed by the
SAMS model. The CBSP intervention is underpinned by principles of CBT with an
emphasis on building a collaborative empathic relationship, developing recovery
goals, formulating resilience, whilst continually assessing and responding to clinical
risk (Tarrier et al., 2013). CBSP has typically been delivered across 20-24 individual
sessions, for up to one hour, 1-2 times per week (e.g. Pratt et al., 2015; Haddock et
al., 2016). Delivery of the CBSP intervention is focused upon establishing safety (i.e.
risk management), assessment and engagement, socialisation to the SAMS model
and formulation development, intervention and change techniques and developing
a maintenance plan (Tarrier et al., 2013). The Prevention of Suicide in Prisons
(PROSPeR) study offered the first randomised control trial of CBSP in prison (Pratt
et al., 2015). The PROSPeR trial was successful in delivery and outcome, with
clinically significant recovery achieved by over half the sample of suicidal prisoners.
This demonstrates the feasibility of CBSP in a male prison population.
Previous research has captured challenges of attrition rates in CBT trials for suicide
prevention. Stanley et al. (2009) reported a 28% dropout rate for 12 sessions of CBT
in an adolescent population. In a randomised control trial (RCT), only 50% of the
adult sample (n = 30/60) received the intended 10 (or more) sessions of CBT (Brown
et al., 2005). These challenges are further emphasised within prisons. During the
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PROSPeR trial (Pratt et al., 2015), 35% of the prison sample were unexpectedly
released or transferred, which contributed to an overall attrition of 44%. This
impedes the long-term support available for prisoners and advocates a potential
benefit of moving away from traditional weekly delivery of CBT. Pratt et al. (2015)
recommended that future studies pilot the delivery of CBT for suicide prevention in
an intensive format.
Outside of suicide prevention, previous studies have modelled the delivery of
intensive CBT. Challacombe and Salkovskis (2011) found six sessions of CBT
delivered within a two week period to be acceptable and effective in reducing
symptoms in six women with postnatal Obsessive Compulsive Disorder (OCD).
Oldfield, Salkovskis and Taylor (2011) conducted a similar study and found that
intensive CBT was as effective as a non-intensive delivery for 22 individuals with
OCD. A further study explored feasibility for 14 people with post-traumatic stress
disorder (PTSD) (Ehlers et al., 2010). Intensive delivery was well tolerated and 86%
no longer met PTSD criteria post intervention. Compared to a weekly format,
intensive delivery was associated with a quicker and more substantial reduction in
symptoms of OCD and co-morbid depression. These studies highlight the emerging
potential of intensive CBT, which should be examined further within a prisoner
sample experiencing suicidal thoughts and behaviours. As such, the ‘Intensive
Suicide Prevention in Prison’ (InSPire) Programme was developed to explore this for
the first time.
The primary aim was to evaluate the feasibility of an intensive CBSP intervention for
individuals experiencing suicidal thoughts and behaviours in prison. Secondly,
changes on measures of three key psychological mechanisms associated with
suicidality were explored, which link to modules within the CBSP intervention
manual (Tarrier et al., 2013). These were problem solving (Biggam & Power, 1999),
emotional regulation (Pratt et al., 2015) and perceived social support (Rivlin,
Hawton, Marzano, & Fazel, 2013). Primary hypotheses related to the feasibility of
the InSPire programme delivery. Secondary hypotheses related to clinical outcome,
with participants attending the programme expected to experience reduced
suicidal ideation and beneficial changes in the three psychological mechanisms.
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3. Method
3.1 Study Design
The InSPire Programme used a feasibility case series design, with a single baseline
and single follow up.
3.2 Participant Sample
The sample was recruited from an adult male prison in the North of England, with a
capacity of approximately 1000 male prisoners. Recruitment occurred between 1st
October and 21st November 2018 and follow up between 17th October and 5th
December 2018. Participants were identified to be on an ACCT in the host prison.
The recruitment target was for 10 participants to complete the programme, in line
with previous intensive CBT feasibility studies (i.e. Challacombe & Salkovskis, 2011;
Ehlers et al., 2010). Led by previous literature (Pratt et al., 2015), it was anticipated
that a recruitment total of 16 participants would be required in order for 10
participants to complete therapy.
3.3 Inclusion Criteria
Inclusion criteria were male prisoners over 21 years, who had been identified to be
at risk of suicide, according to the host prison’s ACCT system, currently or within
the past month. Individuals were excluded from the study if they had insufficient
understanding of English language (i.e. unable to understand the participant
information sheet [PIS] and deemed unable [by programme staff] to engage in
intervention content); were unable to provide informed consent; were due to be
released from the host prison within six weeks of InSPire Programme
commencement; were considered to be under the influence of substances (based
upon prison staff report); had any underlying organic disorder (as per prison and
healthcare records); or were deemed by prison staff to pose a risk of harm to
InSPire staff. Both therapists were female, which posed a barrier to inmates whose
risk specifically applied to working with women, as it automatically denied their
access to the programme.
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All potential participants were identified and screened by the Safer Custody team
who held administrative responsibility for the ACCT system. Following agreement to
be contacted, eligible individuals were approached by a researcher and the PIS was
read and a copy provided (Appendix 9 and 10). No less than 24 hours later,
individuals were re-approached by a researcher. Participants were given the
opportunity to ask questions and discuss the study to ensure they understood what
participation would entail. Written informed consent was taken from those wanting
to take part (Appendix 11). The prison GP was notified of all participants’ entry to
the programme (Appendix 12). Administration of outcome measures was
conducted by a researcher a baseline and follow up.
3.4 Recruitment
The Safer Custody team identified a total of 83 prisoners on an ACCT during the
recruitment window. All 83 were screened for eligibility and 52 (63%) were deemed
unsuitable, as outlined in Figure 1. The remaining 31 (37%) individuals were
approached and provided with a PIS, of which 17 (55%) expressed interest in taking
part. Two interested individuals were unable to take part as the study came to its
planned end prior to their recruitment and two individuals were deemed ineligible
at point of consent, leaving 13 prisoners to be consented into the InSPire
programme.
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Figure 1. Consort Diagram of Recruitment and Study Retention
Participant pool (n = 83)
Approached (provided with PIS)
(n = 31)
Consented (n = 13)
Follow up (n = 13)
Unable to participate/Declined (n = 18)
Reasons: No current thoughts of suicide (n = 9) Refused/Reluctant to engage (n = 5) Not eligible at consent (n = 2) Interested, study ended (n = 2)
Not eligible following initial screen (n =52)
Reasons: Risk of harm to researcher (n = 17) Intoxicated (n = 9) Release or imminent release (n = 13) Located on Segregation Unit (n = 12) Judged to be self-isolative (n = 1)
Attended all five therapy sessions
(n = 10)
Did not complete therapy (n = 3)
Reasons: Did not commence programme (n = 1) Discharged from the programme following two DNAs (n = 2) (Both attended three sessions before discharge)
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3.5 Procedure
Two trainee clinical psychologists held roles of ‘researcher’ (i.e. completing study
measures) and ‘therapist’ (i.e. conducting 1:1 therapy). Participants were randomly
assigned to one of the two study therapists. Roles were coordinated between the
two trainees, so that the trainee completing study measures with a participant did
not deliver therapy to the same participant.
During baseline assessment, the researcher administered a demographic
questionnaire and psychometric battery to each participant. Participants were
informed when the InSPire programme would commence and were briefed about
what to expect (Appendix 13). Following this, participants commenced the
intervention with the therapist. Sessions took place on the wing, in education or in
chaplaincy during morning or afternoon slots, organised in conjunction with prison
movement. Within two weeks of programme completion, the researcher met again
with the participant to complete follow up measures. Participants were debriefed
on their involvement (Appendix 14) and provided with a certificate of completion,
which had been designed in one of the prison workshops (Appendix 15).
Participants were discharged from the programme if there were two ‘did not
attend’ (DNA) appointments (non-attendance without prior cancellation) or if they
opted for voluntary withdrawal. Participants were made aware upon consent that
two DNAs would result in discharge from the programme. Participants were
reminded of the rule following the first DNA. Predictable absences or ‘cannot
attend’ (CNA) appointments were considered on a case by case basis.
3.6 Measures
i) Demographic and Clinical Risk Information
Demographic information was collected using a proforma adapted from a previous
prison research study (Tucker et al., 2017). The questionnaire captured
criminological information (i.e. sentence type/length, ACCT details) and socio-
economic information (i.e. employment, marital status) (Appendix 16). Clinical risk
information was obtained from the prison’s information management system (i.e.
specific risk factors including risk to females, risk of weapons, risk of hostage).
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ii) Feasibility Outcome Measures
Feasibility measures were completed by participants and therapists;
a) Feasibility metrics were captured, including recruitment data (eligibility,
population pool, rate of recruitment) and retention (number of sessions
attended, total number of DNAs and CNAs [including reasons]; Appendix 17).
b) Therapists completed a Session Summary Sheet following each session, to
capture participants’ level of engagement and adherence to the InSPire
programme (Appendix 18). This scale has been used in previous trials delivering
CBSP therapy, in prison (Pratt et al., 2015) and in the community (Gooding et
al., 2017). Therapists reported attendance, session duration, level of
formulation and CBSP phases of therapy delivered in that session. An agenda
and ‘additional notes’ captured qualitative information about session content.
c) Upon programme completion, therapists completed a Therapist Rating Scale to
measure therapy adherence (Appendix 19), as used in previous CBSP trials
(Pratt et al., 2015; Gooding et al., 2017). The form recorded session attendance
(i.e. DNA/CNA reasons, session duration, location) and content (i.e. CBSP
intervention components delivered). Therapists rated seven questions using a
Likert format (i.e. poor [1], moderate [3], excellent [5]). Questions assessed
level of attendance, promptness, level of participation, mastery of content,
disruptive behaviour, completion of homework and overall evaluation of
programme success. Scores of five indicated optimum engagement (NB: Scores
of disruptive behaviour were reversed, therefore higher scores denote less
disruption).
d) Participant satisfaction was measured using the Client Satisfaction
Questionnaire Revised (CSQ-8-R; Larsen, Attkisson, Hargreaves, & Nguyen,
1979) (Appendix 20), upon completion of the InSPire programme. The CSQ-8-R
is a widely used tool with high internal consistency (coefficient α = .91) when
used to assess psychotherapy outcome (Attkisson & Zwick, 1982). This scale has
been used in prison to assess outcome of an alcohol recovery programme
(Johnson, Schonbrun, & Stein, 2014). Qualitative feedback was optional at the
end of the measure.
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e) Therapists completed a Discharge Summary form for participants who
terminated the programme detailing the number of sessions attended and
reasons for termination of therapy (Appendix 21).
iii) Clinical Outcome Measures
Outcome measures were completed at baseline and follow up;
a) The Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991) (Appendix 22) is a
21-item questionnaire measuring suicidal ideation over the past week. An
adapted version of this measure was also completed for ideation occurring over
the past one month to ensure eligibility and allow a broader picture of suicidal
ideation. The BSS has been widely used within prison populations (Mandracchia
& Smith, 2015; Way, Kaufman, Knoll, & Chlebowski, 2013; Pratt et al., 2016).
Excellent internal consistency of this measure has been reported (coefficient α =
.94; Mandracchia & Smith, 2015).
b) The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004)
(Appendix 23) is a 36-item questionnaire in a 5-point Likert Scale format,
measuring components of emotional regulation. The scale has excellent internal
consistency (coefficient α = .93; Gratz & Roemer, 2004) and has been used in a
prison population (Walsh, DiLillo, & Scalora, 2011).
c) The Social Problem Solving Inventory-Revised (SPSI-R; D'Zurilla, Nezu, &
Maydeu-Olivares, 2002) (Appendix 24) is a 25-item scale assessing an
individual’s ability to generate solutions to problems. This scale has been
validated to use within a prison population and has good internal consistency
(coefficient α = .86) and excellent test-retest reliability (coefficient r = .94)
(Wakeling, 2007).
d) The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem,
Zimet, & Farley, 1988) (Appendix 25) is a 12-item scale in a 7-point Likert Scale
format, measuring perceived support from friends, family or significant others.
This measure has been widely used within a prison population (Staton-Tindall,
Royse, & Leukfeld, 2007; Brown & Day, 2008; Johnson & Zlotnick, 2008) with
excellent internal consistency (coefficient α = .92; Brown & Day, 2008).
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iv) Sessional Measures
The authors adapted brief sessional measures to capture a basic overview of the
main focus of each session, as used during a previous CBSP trial (Gooding et al.,
2017). Five questions were asked at each session which mapped onto standardised
outcome measures. Using a four point Likert format (i.e. not at all [0], a little [1],
mostly [2], completely [3]), participants were asked to rate, since the previous
session, how much they felt they had someone supportive to turn to (perceived
social support); had been struggling to manage emotions (emotional regulation);
had been able to deal with problems (problem solving); had felt like harming
themselves and had felt suicidal (Appendix 26). Therapists rated the same
questions, based upon how much of the session had been spent upon each of the
five issues (Appendix 27). Both forms had an ‘additional comments’ section to
capture additional contextual information.
v) Qualitative Interviews
Upon completion of the InSPire programme, all participants were offered the
opportunity to engage in a qualitative interview to investigate treatment
acceptability (Appendix 28). Analysis of these data are not the focus of the current
study and will be reported elsewhere (Killilea, 2019).
3.7 Intervention
All consenting participants were offered the InSPire programme alongside input
they received as part of their ACCT plan (i.e. regular observations, risk reviews).
Intervention for the current study was based upon the manualised therapy by
Tarrier et al. (2013) as amended by Pratt (2016). The CBSP intervention was a
cognitive behavioural therapy informed by the SAMS model (Johnson et al., 2008).
Intervention was tailored to each individual as guided by psychological assessment
and completion of a formulaic framework.
The manualised CBSP intervention was delivered in a tailored format to fit the
intensive nature required for this study. The original delivery of this intervention is
over 20 therapy sessions. For the current study, CBSP was condensed into a format
which allowed it to be delivered across five two-hour sessions. The original outline
of sessions, as specified by the developers of this intervention (Tarrier et al., 2014;
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Pratt, 2016), was amended to adjust for more intensive delivery. The outline
compromised of the following;
Sessions 1 – 2: Engagement and building the therapeutic relationship
Sessions 1 – 2: Risk assessment and increasing understanding of the function
of suicidal behaviours
Sessions 1 – 2: Socialisation to the CBSP model and development of the
SAMS formulation
Sessions 3 – 4: Intervention modules
Session 5: Developing the maintenance and well-being plan
Intervention consisted of three phases, including an initial engagement, assessment
and formulation phase, intervention (with a choice of up to five modules) and
maintenance and handover (Tarrier et al., 2013);
i. Engagement, Assessment and Formulation: Therapists focused upon
building engagement; engaging the client to talk about their concerns;
identifying how suicidal thoughts fit into concerns; establishing a shared
understanding/formulation and strengthening a commitment for change
(i.e. developing goals, using the SAMS model).
ii. Intervention
a) Attention broadening: Aiming to broaden participants’ control of their
attentional focus and overcome patterns of negative bias and becoming
stuck in a suicide schema cycle.
b) Cognitive restructuring: Supporting participants to identify unhelpful
thinking styles and develop helpful alternatives.
c) Mood management and behavioural activation: Supporting participants to
increase activities associated with pleasure and achievement and build them
into daily routines.
d) Problem-solving training: Supporting individuals to strengthen problem
solving skills and implement new problem solving techniques when
approaching interpersonal difficulties.
e) Improving self-esteem and positive schema: Aiming to reduce the cycle of
suicide schema by accessing positive self-schemas, positive ways of coping
and alternate approaches to problems.
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iii. Maintenance and Handover: This phase had two components: maintaining
well-being and working towards staying well and developing a handover
plan (involving prison staff).
Delivery of the InSPire programme consisted of up to five sessions, delivered within
a three week period. Each session lasted up to two hours. All participants began
with the initial engagement phase and received the maintenance phase upon
completion of the programme. It was not expected for all five intervention modules
to be delivered during the programme. Participants were made aware of the
modules available and collaboratively agreed with therapists as to which ones they
accessed during the programme (Appendix 29). This was informed by participant’s
formulation and therapy goals.
Treatment was provided by two therapists, with at least three years’ experience of
CBT training. Therapists received a two day training workshop with the Clinical
Supervisor (DP), to familiarise with CBSP intervention delivery. During this
workshop, existing CBSP manuals (Tarrier et al., 2013; Pratt, 2016) were adapted
into an intensive delivery format. Further training and practice experiences were
conducted with individuals from a Forensic Patient and Public Involvement (PPI)
Group at the University of Manchester. The group consisted of a number of ex-
prisoners who provided constructive opinion to the research team during the
treatment development phase to gauge any potential difficulties of implementing
the study within a prison. Two further sessions were conducted with one group
member, to rehearse therapeutic skills in the delivery of CBSP.
Clinical supervision was provided up to four times per week for 1-2 hours, by an
experienced qualified Clinical Psychologist (DP), to explore each therapy case and
address clinical issues arising. A Distress Protocol (Appendix 30) and Safe Working
Practices and Risk Management Protocol (Appendix 31) were adhered to when
responding to clinical risk and issues of safety.
3.8 Data Analysis
All data was entered into Microsoft Excel spreadsheets by an independent data
entry clerk, to limit bias. Data was checked by first author (LH) and minimal errors
78
had been made (error rate 0.44%). Data was exported to SPSS. To be included in
data analysis, participants were required to have attended at least one therapeutic
session.
i. Feasibility and Acceptability
Descriptive analyses were performed using Microsoft Excel to examine feasibility
data. Using the metric data, percentages were calculated to demonstrate
recruitment rates (i.e. proportion of participants eligible and interested in taking
part) and retention (i.e. level of attendance, rate of DNA/CNAs).
ii. Clinical Outcome Measures
Descriptive statistics and QQ plots were generated using SPSS and data were
checked for normality. Values of skewness and kurtosis were converted into z
scores and indicated normality for all variables at all time points (NB. values were
within the 1.96 criterion; Field, 2009).
Means, standards deviations and effect sizes were calculated. Baseline and follow
up assessment scores were taken into account when calculating effect sizes by
calculating Pearson’s correlations, as suggested by Morris and DeShon (2002).
Effect sizes assessed changes between baseline and follow up and were interpreted
using the pooled standard deviation Cohen’s d (Cohen, 1977). The method by
Cohen (1977) has been used in a number of other small scale case series (Searson,
Mansell, Lowens, & Tai, 2012; Watkins et al., 2007; Wells & Sembi, 2004). Cohen
(1977) interpreted effect sizes as small (d = 0.2), medium (d = 0.5) and large (d =
0.8).
Participant and therapist sessional data were examined using descriptive statistics
to review individual changes on a sessional basis.
3.9 Ethical Approval
The InSPire programme was registered as a Clinical Trial (ID: NCT03499548) and
received approval from the National Research Ethics Committee for Wales (IRAS ID:
238927); Her Majesty’s Prison and Probation Service National Research Committee
(ID: 2018-154) and the Governor of the host prison. Paper and electronic data were
held securely on the prison site, with access only available to the research team.
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Upon completion, all data were safely transported to the University of Manchester,
were securely stored and again made accessible only to the research team.
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4. Results
4.1 Demographic and Clinical Characteristics
Participants’ ages ranged from 21 to 52 years with a mean of 31.6 (SD = 9.3) years.
In terms of ethnicity, all 13 participants identified themselves as White
British/Other. Participants were serving a prison sentence of 38.5 (SD = 32) months,
on average. Sentences were categorised using the Home Office (2017) Offence
Classification Index. Participants reported index offences of violence against the
person (including sexual offences) (n = 8, 62%) and theft (including robbery,
burglary, fraud and forgery) (n = 5, 38%). Of the sample, three (23%) participants
had not previously served a sentence.
Two (15%) participants were on an ACCT at point of entry to the programme and a
further three had ACCT’s reopened during the programme. All participants had
made a suicide attempt at some point in their life, with seven (54%) participants
doing so within the previous year and five (38%) during the last month.
4.2 Feasibility Outcome Measures (Hypothesis One)
i) Recruitment and Retention
Thirteen participants were recruited to the study. The target was 16, with the view
that approximately 10 would go on to complete the InSPire programme.
Recruitment ceased when it became apparent that programme completion rates
were high (i.e. 12/13 participants completed the programme). Study retention was
high, with 100% of participants who completed baseline assessment also available
for follow up.
ii) Engagement and Programme Adherence
Of the 13 participants, 10 (77%) attended all five sessions of the programme. Two
(15%) participants were discharged from the programme, both after three sessions
due to non-attendance; although, one individual voluntarily opted for discharge.
One (8%) further participant was unable to engage in therapy as the programme
was not approved for delivery on the Care and Segregation Unit (CSU). The
individual was moved to this unit immediately after completing baseline
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assessment and was held on a wait list until return to the wing. This did not occur
during the programme and thus he never commenced therapy.
For the 12 individuals who did commence the programme, a total of 65 sessions
were offered and 56 (86%) sessions were attended. Therapy sessions lasted
between 15 to 135 minutes (M = 102.68 minutes; SD = 26.56), with an average of 8
hours of therapy delivered to each participant (M = 7.99 hours; SD = 2.52; range 2-
10 hours).
Across the programme, nine sessions were not attended. Four DNAs resulted in the
discharge of two participants from the programme and the remaining five were
CNAs which were rearranged. Reasons included: hospital appointment, forgot the
appointment, therapist unable to locate a suitable room, physically unwell, not
feeling up to talking and prison regime preventing attendance. Completion of
outcome measures were high at both baseline and follow up (99%) and sessional
measures (98%).
iii) Therapist Session Summary
Table 1 shows the proportion of therapy modules delivered across the programme
and the percentage of participants that accessed these modules. Therapists
reported all participants to use the engagement phase and for some (n = 3; 30%),
elements of this continued throughout the five therapy sessions. Across all sessions
delivered, a strong emphasis was placed upon initial engagement, assessment and
formulation activities with 57% of all sessions reported to include this phase.
Engagement was broken down further to capture five main areas (i.e. building
engagement; engaging client to talk about concerns; identifying where suicidal
thoughts/behaviours fit into concerns; establishing a formulation, strengthening a
commitment for change and eliciting goals). Each of the five components of
engagement were used. All individuals except one moved beyond the engagement
phase into intervention. The one individual who did not access the intervention
stage took voluntary withdrawal during the engagement phase, prior to developing
a SAMS formulation.
Eleven participants moved onto intervention work, which accounted for 39% of all
therapy sessions delivered. The most commonly delivered intervention module was
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cognitive restructuring, which was accessed by 10 (83%) participants. The two
individuals who did not access this module were the two discharged from the
programme. All other modules accounted for between 5-7% of sessions. Mood
management (n = 4) and attention broadening (n = 5) were accessed by more
participants than problem solving (n = 2) or schema work (n = 3). Finally, most
individuals (n = 10, 83%) completed the maintenance phase in the final two
sessions, the two who did not had previously disengaged. The maintenance phase
involved two components (i.e. developing a staying well plan; handover to staff).
Staff handover was only facilitated in cases of risk, which applied to one participant.
Table 1. An Overview of the Therapeutic Modules Delivered During the
Programme
Intervention Modules No. of participants who received the module
Total (%)
Engagement, Assessment and Formulation Phase:
12 (100%)
Intervention Modules:
11 (92%)
Attention broadening 5 (42%)
Cognitive restructuring 10 (83%)
Mood management and behavioural activation 4 (31%)
Problem-solving training 2 (17%)
Improving self-esteem and positive schema 3 (25%)
Maintenance Phase
10 (83%)
iv) Therapist Rating Scale
This measure was not completed for the individual who could not attend any
therapy sessions. Attendance (M = 4.50; SD = 0.80) and promptness (M = 4.67; SD =
0.65) were rated highly. Level of participation (M = 4.00; SD = 0.74) and completion
of homework (M = 4.00; SD = 1.21) were both reported to be reasonable. Mastery
of content (M = 3.42; SD = 0.90) and overall evaluation of therapy success (M =
3.42; SD = 1.24) were both rated to be reasonable. Level of disruptive behaviour
was a reverse item (higher scores denote less disruptive behaviour); therefore, this
reasonable score suggests limited disruptive behaviour during sessions (M = 3.42;
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SD = 0.67). Figure 2 presents a graphic demonstration of the therapist measure of
adherence.
Figure 2. A Box Plot to Demonstrate Therapists Rating of Adherence to Therapy
v) Client Satisfaction Questionnaire
Scores on the CSQ-8-R are presented in Table 2. All items scored above the mid-
point of the 1-4 point Likert rating scale (with a score of four denoting complete
satisfaction). Amongst higher scoring items, ‘recommending the service to a friend’
was rated 3.83 (SD = 0.39) and overall satisfaction of the service was rated 3.67 (SD
= 0.49). Amongst lower scoring items, the extent to which the InSPire programme
met participant’s needs was rated 2.67 (SD = 0.65) and the service helping
participants to deal more effectively with their problems was rated 3.25 (SD = 0.87).
Attendance Promptness Participation Mastery Disruptive Behaviour
Homework Overall Evaluation
Components of Therapy Adherence
T h
e ra
p is
ts R
a ti
n g
S
co re
Box Plot of the Therapist Rating Scale
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The mean score for overall satisfaction (from a range of 8 - 32) was 29.67 (SD =
3.28).
Table 2. CSQ Mean Scores and Overall Satisfaction Score
CSQ Questionnaire Items Mean (SD)
1. How would you rate the quality of the service you have received? 3.67 (0.49)
2. Did you get the kind of service you wanted? 3.42 (0.51)
3. To what extent has our program met your needs? 2.67 (0.65)
4. If a friend were in need of similar help, would you recommend our program to him or her? 3.83 (0.39)
5. How satisfied were you with the amount of help you received? 3.50 (0.67)
6. Have the service you received helped you to deal more effectively with your problems? 3.25 (0.87)
7. In an overall, general sense, how satisfied about you with the service you have received? 3.67 (0.49)
8. If you were to seek help again, would you come back to our program? 3.75 (0.45)
Total Scale Score
29.67 (3.28)
M = mean; SD = standard deviation
4.3 Clinical Outcome Measures (Hypothesis Two)
i) Baseline and Follow up
All participants completed four outcome measures at baseline and follow up (n =
13). One participant was unable to access the InSPire intervention and therefore
has been removed from this analysis for consistency. Repeated measures effect
sizes were calculated using the total mean change of all participants and the pooled
standard deviation of scores at baseline and follow up (see Table 3).
Table 3. Mean Scores and Effect Sizes at Baseline and Follow Up.
Measure Baseline (n = 12) M (SD)
Follow up (n = 12) M (SD)
Effect Size d
BSS (weekly rating) 10.00 (8.83) 8.42 (8.11) -0.29
BSS (monthly rating) 18.67 (7.51) 10.67 (7.07) -0.86 a
DERS 119.17 (30.14) 106.83 (23.81) -0.94
MSPSS 45.92 (24.62) 44.08 (24.84) -0.20
SPSI 47.08 (16.00) 49.50 (14.27) 0.18
BSS = Beck Suicide Scale; DERS = The Difficulties in Emotional Regulation Scale; MSPSS = Multidimensional Scale of Perceived Social Support; SPSI = Social Problem Solving Inventory.
a Data missing for one participant at follow up
A large effect size was found when measuring suicidal ideation across the previous
month; however, this effect was small when measuring suicidal ideation on a
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weekly basis. There was a large effect when comparing intervention scores for
emotional regulation. A small effect was found for perceived ability to solve
problems and for perceived social support when comparing baseline and follow up
scores.
ii) Sessional Measures
At the start of each therapy session, participant’s completed sessional measures
which captured change during therapy (i.e. problem solving, social support,
emotional regulation and thoughts of self-harm or suicide). Therapists captured the
proportion of time during each session that was spent discussing the mechanisms
(which mapped directly onto the sessional measure).
On the Therapist Rating Scale, emotional regulation appeared to be a leading focus
during sessions. Self-harm ideation was the lowest focus, perhaps mirrored by the
population and the lack of reported self-harm ideation during sessions. Suicidal
ideation was a common focus, which reduced during session three, but increased
again as sessions were coming to an end (see Figure 3). This could reflect the need
for increased risk management during the maintenance phase, but might reflect the
increase of some symptoms for some participants as sessions were ending (as
captured on sessional measures). On Figure 3, participant data suggests a relatively
stable suicidal ideation across sessions, with a slight increase in the final session.
Therapist data mirrors participant data, in that higher reporting of suicidal ideation
increased focus on that issue during sessions. This focus increased considerably in
final sessions.
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Figure 3. Suicidal Ideation as Rated by Participant and Therapist, across all Five
Sessions.
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5. Discussion
5.1 Acceptability and Feasibility
The InSPire programme was a feasibility pilot of an intensive CBSP intervention for
prisoners experiencing suicidal thoughts or behaviours in the past one month, with
some individuals continuing to actively engage in suicidal behaviours during the
delivery of the programme. Results suggest that delivering intensive CBSP within a
prison environment is feasible, with a large majority of participants completing the
CBSP intervention and all participants completing follow up assessments. For the
two individuals discharged from the programme, one was discharged solely based
upon the DNA rule (i.e. two DNAs before discharge). This participant was made
aware of the rule at each DNA, although did express an interest in continuing with
the programme upon point of discharge. The second participant opted to terminate
therapy after two DNAs and expressed that it was difficult for him to engage at this
current time. Prisoner samples have previously been shown to be less likely to
access help for suicidal thoughts, compared to other emotional difficulties (Deane,
Skogstad, & Williams, 1999). Therefore, perhaps traditional models of engagement
are a challenge in this population. Engagement difficulties are a reality in prison, as
there are increased barriers to accessing mental health services (Reingle-Gonzalez
& Connell, 2014), repeated discharges from services and a ‘revolving door’ pattern
of prison recall and reoffending (Padfield & Maruna, 2006; Nagin, Cullen, & Jonson,
2009). Perhaps a more flexible DNA rule could be considered for future studies of
this type, to facilitate engagement amongst those who find it more difficult to
access therapy, akin to an assertive outreach model of care (McIvor, Ek, & Carson,
2004). This could be suggestive of the need for pre-therapy work with individuals
with suicidal ideation, to strengthen motivation to change and to better facilitate
engagement into programmes such as InSPire (Britton, Patrick, Wenzel, & Williams,
2011). Research suggests there is an increased risk of suicide following discharge,
with a recommendation for increased follow up during this time (Shaw et al., 2004).
Overall participant satisfaction with the InSPire programme was high. The CSQ-8
has been used in a prison setting previously, to evaluate an alcohol recovery
programme, with a reported total scale score of 26.5 (SD = 3.4) (Johnson et al.,
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2014). Comparably, the total scale score measuring overall satisfaction was
marginally higher following the InSPire programme (M = 29.67; SD = 3.28). In a
further intervention of CBT to prevent suicide in the community, Britton et al.
(2011) reported individual mean scores of 3.45 (SD = 0.46), which was the same for
this current study (M = 3.4; SD = 0.4). In the InSPire programme, areas to improve
on included supporting individuals to better attend to their problems and
addressing a larger proportion of their needs. The nature of this feedback raises the
question of whether offering a longer duration of therapy might be helpful for
some individuals. Qualitative feedback on the CSQ-8 suggested that the InSPire
programme was too short, with participants stating that therapy ‘went too quickly’
and ‘did not last long enough’. Giving participants the option of a longer duration or
tailoring a package of treatment based upon individual need could be beneficial.
One option, in line with previous studies of intensive CBT, is to offer ‘booster’
sessions to maintain and increase the likelihood of change over time (Challacombe
& Salkovskis, 2011; Ehlers et al., 2010; Ehlers et al., 2014; Oldfield et al., 2011).
Alternatively, Bower and Gilbody (2005) propose a stepped care model of
intervention delivery, which offers some individuals additional sessions or longer-
term input based upon individual need.
Many studies have conducted intensive CBT in other settings, with hours of
treatment ranging from four hours (Paulik, Jones, & Hayward, 2018; distressing
voices); 7.5 hours (Bryant, Harvey, Dang, Sackville, & Basten, 1998; acute stress
disorder); 10 hours (Whiteside, Brown, & Abramowitz, 2008; OCD); and up to 18
hours (Ehlers et al., 2010; PTSD). Whilst there is no specific guidance for
psychological intervention in relation to suicide prevention, NICE guidelines
currently suggest between 3-12 sessions of psychological therapy with individuals
who self-harm (NICE, 2013). The InSPire programme delivered a compromise of 10
hours within a three week intensive window. Whilst for some this may have been
sufficient, many participants stated that they wanted therapy to be longer. Some
resolutions to this issue have been addressed above. It has been reported that
provision of mental health services in prison is not equivalent to that in the
community (Patel, Harvey, & Forrester, 2018). This was echoed by InSPire
therapists, who were regularly approached by inmates interested in the
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programme, but whom were not eligible. The widespread interest in the study,
alongside recruitment success and high level of programme completion, attaches
importance to the high level of unmet need for psychological support amongst
prisoners. Reingle-Gonzalez and Connell (2014) emphasised ongoing barriers to
mental health treatment in prison and the lack of continuity of treatment from the
community to prison. Psychological interventions to alleviate distress are essential
to mental health and well-being of the prison community. The participants within
this programme present at a much higher risk of suicide than the general
population (NICE, 2018).
Social complexity and increased risk of the population must be taken into
consideration when determining the most appropriate number of hours of
therapeutic input. The complex needs of this population ought to contribute to the
way services are shaped and delivered within prison. Andrews, Bonta and Wormith
(2006) presented an outline of major needs or risk factors that might present within
a prison context (i.e. antisocial factors [behaviour, associates, cognitions, and
personality], family or marital issues, unemployment, limited leisure activities and
use of substances). Interventions should be focussed upon dynamic need with
specific responsivity to individual factors (i.e. personality, motivation and individual
demographics) (Andrews et al., 2006).
Whilst therapists rating of programme participation was reasonable, considerations
could be given to improving homework completion, level of participation and
therapy mastery. For example, whilst specific figures on homework completion
were not obtained in this study, it could be hypothesised that completion of
homework between sessions could increase overall mastery of the intervention.
However, due to the intensive nature of the programme, sessions often fell on
consecutive days, leaving limited time or opportunity for homework completion.
Additionally, access to homework resources (i.e. writing tools) and privacy (i.e.
shared cell) in completing homework could have been a barrier.
The three phases of CBSP intervention included an engagement phase at the
beginning and a maintenance phase at the end. In between this, an intervention
phase with up to five therapeutic CBT skills based modules could be delivered, as
guided by the formulation. All of the five intervention modules were delivered to
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some extent across the 12 therapy completers, although this varied on an individual
level. Some participants remained longer in the engagement phase than others,
some accessed a number of different therapeutic modules during intervention,
whereas others accessed one module. There was a high proportion of investment in
the engagement phase and in the cognitive restructuring module. All other modules
were accessed although to a lesser extent. It raises the question of therapeutic
readiness to change. Individuals who remain in therapy tend to be at contemplation
stage or higher, whereas those who disengage are perhaps in a pre-contemplation
stage (Brogan, Prochaska, & Prochaska, 1999). This could have been a factor for the
individuals who remained mostly within the engagement phase and for those who
were discharged. Readiness to change was not assessed in this study, but may be
useful to consider in future studies of this type. Given what we know about the lack
of provision in prison, alongside the high proportion of engagement-focused
sessions, perhaps offering someone a confidential space to talk about and make
sense of suicide presents as much of a therapeutic benefit as a structured, skills-
based intervention. The Collaborative Assessment and Management of Suicidality
(CAMS) is an evidence based clinical intervention with a specific focus upon
assessment and treatment planning processes (Jobes, 2012). The CAMS does not fit
within a therapeutic modality and involves collaborative analysis of patients’
suicidal experiences through in depth assessment. Risk is continually considered
(i.e. access to means, suicide plans) and treatment and crisis plans are devised at
the end of each session. Whilst in this study there was a stronger emphasis on
cognitive restructuring interventions, the use of other modules was variable and a
leading focus appeared to be the engagement, assessment and formulation phase.
It could be efficacious to consider trialling other interventions, such as CAMS, using
an intensive delivery within the prison setting.
5.2 Clinical Outcome
A large treatment effect was found for suicidal ideation when assessed across one
month, compared to only a small effect when assessed for the past week. This
difference could be understood by considering the ACCT system. Participants were
recruited if they had experienced thoughts of suicide within the past one month,
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which meant for some that scores for the past week at baseline, were low
compared to scores across the month. This could have meant less of a change on a
week by week measure, but perhaps a more noticeable change when assessed
monthly.
There appeared to be less of an effect on problem solving and perceived social
support. Perhaps perceived social support was more challenging to address within
prison, due to practical difficulties and barriers in accessing social support. There
was a large effect on emotional regulation which is perhaps indicative of the time
spent on emotional regulation as captured on therapist sessional measures.
Effect sizes must be cautiously interpreted due to the small sample size and due to
Pearson’s correlation not taking into account the dependent groups. Effect sizes
could be overinflated due to these issues. What we can deduce, is that attendance
appears to be associated with beneficial change and is therefore worthy of further
investigation. In line with the Medical Research Council (MRC) Guidance (Craig et
al., 2013), effectively developing and evaluating complex interventions requires a
number of stages, the InSPire programme being an example of a preliminary pilot
feasibility stage. Feasibility results should be reviewed with caution and more work
is required on a larger scale in order to make more accurate assumptions about
intervention effects (Craig et al., 2013).
Another clinical issue, as captured on sessional measures, was the increase in
reported distress for some participants towards the end of therapy. Clinicians have
an ethical responsibility to manage therapeutic endings (Vasquez, Bingham, &
Barnett, 2008). Within this study, programme duration was made transparent from
the beginning, endings were discussed at every session, and were addressed within
the maintenance phase of the intervention, which was accessed by all those who
completed the CBSP intervention. Therapists noted that the programme delivery
and duration felt fast paced. Following feedback from participants, there was the
sense that ending therapy felt premature and difficult. In a previous study by
Bevan, Oldfield, and Salkovskis (2010), individuals completing weekly treatment
were disinclined to access intensive treatment because of anticipated
overwhelming pace and perceptions of having a more limited time to change.
However, those who attended intensive treatment described the pace as highly
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motivating. Perhaps this echoes the lack of provision of psychological interventions
for mental health difficulties in prison and that InSPire participants were motivated
to engage given the lack of provision otherwise. This could be suggestive of the type
of person that intensive interventions are more suited to, again tapping into issues
of readiness to change and motivation. Given the fast pace of intensive
interventions, Bevan et al. (2010) highlight the importance of follow up and longer-
term crisis intervention, particularly in intensive delivery. In the current study, the
therapist and researcher ensured effective risk assessment and management during
the ending transition, including handover to staff, attendance at ACCT reviews and
documentation of risk on healthcare systems.
5.3 Strengths and Limitations
There are a number of limitations to this study. This being a small-scale feasibility
study meant there was no control group to provide a comparator and no control of
variables. Having another person to talk to was often iterated by participants, which
could arguably account for some of the notable improvements. Effect sizes must be
interpreted with caution due to the small sample size. The sample from one prison
in the North of England was largely homogeneous, particularly with regards to
ethnicity and gender. A larger, more diverse, sample from a range of prisons with
varied levels of risk and security would give a broader understanding of the effects
of the intervention. Similarly, 20% of the pool were screened out due to risk.
Perhaps with more time, having both male and female therapists and increased
security support from the prison, this figure could have been lower. Kupers (2005)
explores the resistance to psychological therapy in prisons, which undoubtedly
contributed to some individuals declining participation. Future studies should
consider making the programme more accessible for all individuals. One further
limitation was the omission of both the formal recording and reporting of adverse
events during this study. In line with Trust Guidance on the recording and reporting
of non-clinical trials (Haddock, 2016), all adverse events should be formally
documented and reported in the study findings. This is recommended for future
studies of this nature.
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Working within a prison environment requires a considerable amount of flexibility.
Difficulties arose with limited access to an appropriate and safe therapeutic space
and in maintaining a reasonable level of privacy and confidentiality. Sessions were
occasionally disturbed by others and the level of noise was at times disruptive.
Occasionally sessions were cancelled (i.e. no room availability), began late, or were
terminated early (i.e. lock-down). Participants were generally resilient to many of
these issues, as it was considered the ‘norm’. However, a private home-like therapy
space correlates with increased social interaction and improvements in well-being
(Papoulias, Csipke, Rose, McKellar, & Wykes, 2014). Arguably, the prison
environment could serve as a barrier to engagement, as the absence of a
comfortable and safe environment could hinder participants’ ability to concentrate
entirely upon therapy material.
The 1:1 delivery of the programme was advantageous. Many individuals expressed
that they would have been reluctant to engage or would have declined a group-
based programme. As was the rationale for intensive delivery, no participants were
released or unexpectedly transferred during the programme. Some were due to be
released or transferred imminently and the programme felt timely in preparing for
transition to the community or to a new placement. Participants generally tolerated
longer sessions of up to two hours. This coupled with an intensive delivery meant
that ‘catch up’ time, as would happen with weekly/more intermittent sessions, was
not required as much, thus allowing for increased session time focusing upon
content. Many of these factors were addressed with participants directly, in the
follow up qualitative interviews exploring treatment acceptability of the InSPire
programme (Killilea, 2019).
5.4 Further Clinical and Research Considerations
Traditional psychological input in prison is most often focused upon risk
management and reoffending behaviour (Towl, 2002; Harvey & Smedley, 2012).
Harvey and Smedley (2012) highlight the importance of considering a combined
way of working, using a problem focussed approach and individualised
psychological formulations, alongside offending work. Arguably, supportive
interventions focusing upon psychological need in the short-term, may increase the
94
likelihood of individuals being better able to engage in offending behaviour
programmes, perhaps facilitating better long-term outcomes in terms of recovery
and criminality. To our knowledge, this is the first study to offer a non-offending
focussed intensive CBT intervention programme for suicide prevention within a
prison environment.
This was a single baseline and single follow up design. Having multiple baselines and
long-term follow ups would be useful to accurately attribute change to intervention
delivery and capture whether change effects have been maintained over time.
Whilst follow up data captured aspects of satisfaction and symptomology, further
consideration could be given to other outcome measures. As mentioned, readiness
to change could provide a useful insight into readiness for therapy, additionally
other contextual change information could be captured (i.e. changes in level of
ACCT observations, and increased participation in prison social roles [i.e. work,
education]).
Further adaptations to the InSPire programme could be considered on a systemic
level. Considerations could include staff liaison sessions; working alongside prison
staff to share psychological formulations and considering consultation or training
programmes to increase staff awareness and knowledge of how to respond to
individuals experiencing suicidal thoughts and behaviours. Increasing prison staffs
understanding and awareness of mental health is an important issue within a prison
environment (Leibling & Karup, 1993; Hansson & Markstron, 2014).
This feasibility study has demonstrated the potential for CBSP in an intensive
format within a prison setting. Whilst effect sizes were indicative of beneficial
change, this needs examining on a larger scale. As per MRC guidelines, this area
would now warrant further investigation with the design and implementation of a
feasibility trial (Craig et al., 2013).
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6. References
Andrews, D. A., Bonta, J., & Wormith, J. S. (2006). The recent past and near future
of risk and/or need assessment. Crime & Delinquency, 52(1), 7-27. https://doi.org/10.1177/0011128705281756
Attkisson, C. C., & Zwick, R. (1982). The Client Satisfaction Questionnaire: Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning, 5(3), 233-237. https://doi.org/10.1016/0149-7189(82)90074-X
Beck, A. T., & Steer, R. A. (1991). Beck scale for suicide ideation (BSS). San Antonio, TX: The Psychological Corporation.
Bevan, A., Oldfield, V. B., & Salkovskis, P. M. (2010). A qualitative study of the acceptability of an intensive format for the delivery of cognitive‐behavioural therapy for obsessive‐compulsive disorder. British Journal of Clinical Psychology, 49(2), 173-191. https://doi.org/10.1348/014466509X447055
Biggam, F. H., & Power, K. G. (1999). Suicidality and the state-trait debate on problem solving deficits: A re-examination with incarcerated young offenders. Archives of Suicide Research, 5(1), 27-42. https://doi.org/10.1080/13811119908258313
Britton, P. C., Patrick, H., Wenzel, A., & Williams, G. C. (2011). Integrating motivational interviewing and self-determination theory with cognitive behavioral therapy to prevent suicide. Cognitive and Behavioral Practice, 18(1), 16-27. https://doi.org/10.1016/j.cbpra.2009.06.004
Brogan, M. M., Prochaska, J. O., & Prochaska, J. M. (1999). Predicting termination and continuation status in psychotherapy using the transtheoretical model. Psychotherapy: Theory, Research, Practice, Training, 36(2), 105. http://dx.doi.org/10.1037/h0087773
Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Journal of the American Medical Association, 294(5), 563-570. doi:10.1001/jama.294.5.563
Brown, S., & Day, A. (2008). The role of loneliness in prison suicide prevention and management. Journal of Offender Rehabilitation, 47(4), 433-449. https://doi.org/10.1080/10509670801992459
Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., & Basten, C. (1998). Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66(5), 862. http://dx.doi.org/10.1037/0022-006X.66.5.862
Challacombe, F. L., & Salkovskis, P. M. (2011). Intensive cognitive-behavioural treatment for women with postnatal obsessive-compulsive disorder: a consecutive case series. Behaviour Research and Therapy, 49(6), 422-426. https://doi.org/10.1016/j.brat.2011.03.006
Cohen, J. (1977). Statistical power analysis for the behavioural sciences. New York: Academic Press.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2013). Developing and evaluating complex interventions: the new Medical
96
Research Council guidance. International Journal of Nursing Studies, 50(5), 587-592. https://doi.org/10.1136/bmj.a1655
D'Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002). Social problem-solving inventory-revised (SPSI-R): Technical manual. North Tonawanda, NY: Multi- Health Systems Incorporated.
Deane, F. P., Skogstad, P., & Williams, M. W. (1999). Impact of attitudes, ethnicity and quality of prior therapy on New Zealand male prisoners' intentions to seek professional psychological help. International Journal for the Advancement of Counselling, 21(1), 55-67. https://doi.org/10.1023/A:1005346703753
Ehlers, A., Clark, D. M., Hackmann, A., Grey, N., Liness, S., Wild, J., … McManus, F. (2010). Intensive cognitive therapy for PTSD: A feasibility study. Behavioural and Cognitive Psychotherapy, 38(4), 383-398. https://doi.org/10.1017/S1352465810000214
Ehlers. A., Hackmann, A., Grey, N., Wild, J., Liness, S., Albert, I., … Clark, D. (2014). A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry, 171(3), 294–304. https://doi.org/10.1176/appi.ajp.2013.13040552
Fazel, S., & Baillargeon, J. (2011). The health of prisoners. The Lancet, 377(9769), 956-965. https://doi.org/10.1016/S0140-6736(10)61053-7
Fazel, S., & Benning, R. (2009). Suicides in female prisoners in England and Wales, 1978–2004. The British Journal of Psychiatry, 194(2), 183-184. https://doi.org/10.1192/bjp.bp.107.046490
Fazel, S., Benning, R., & Danesh, J. (2005). Suicides in male prisoners in England and Wales, 1978–2003. The Lancet, 366(9493), 1301-1302. https://doi.org/10.1016/S0140-6736(05)67325-4
Field, A. (2009). Discovering statistics using SPSS. London: Sage publication. Fraser, A., Gatherer, A., & Hayton, P. (2009). Mental health in prisons: great
difficulties but are there opportunities? Public Health, 123(6), 410-414. https://doi.org/10.1016/j.puhe.2009.04.005
Georgiou, M., Coll, F., Stone, H., & Davies, S. (2017). Standards for 24 Hour Mental Healthcare in Prisons Quality Network for Prison Mental Health Services (Publication Number: CCQI268). Royal College of Psychiatrists. Retrieved from https://www.rcpsych.ac.uk/docs/default-source/improving- care/ccqi/quality-networks/prison-quality-network-prison/prison-qn- standards/prisons-24-hour-mental-healthcare-in-prison- standards.pdf?sfvrsn=bef29f20_2
Gooding, P., Pratt, D., Drake, R., Peters, S., Marriott, A., Awenat, Y., … Jones, S. (2017). A psychological intervention for suicide applied to patients with psychosis: the CARMS trial (Cognitive AppRoaches to coMbatting Suicidality). Retrieved from https://www.dev.fundingawards.nihr.ac.uk/award/13/161/25
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of
97
Psychopathology and Behavioral Assessment, 26(1), 41-54. http://dx.doi.org/10.1007/s10862-008-9102-4.
Haddock, G. (2016). RD SOP41 Recording and Reporting Adverse Events for non- CTIMPS. Retrieved from https://www.gmmh.nhs.uk/download.cfm?doc=docm93jijm4n2769.pdf&ve r=4503
Haddock, G., Davies, L., Evans, E., Emsley, R., Gooding, P., Heaney, L., … Awenat, Y. (2016). Investigating the feasibility and acceptability of a cognitive behavioural suicide prevention therapy for people in acute psychiatric wards (the ‘INSITE’ trial): study protocol for a randomised controlled trial. Trials, 17(1), 79. https://doi.org/10.1186/s13063-016-1192-9
Hansson, L. & Markstron, U. (2014). The effectiveness of an anti-stigma intervention in a basic police officer training programme: a controlled study. BioMed Central Psychiatry, 14, 55–57. https://doi.org/10.1186/1471-244X-14-55
Harvey, J., & Smedley, K. (Eds.). (2012). Psychological therapy in prisons and other settings. Oxon: Willan Publishing.
Home Office. (2017). Offence Classifcation Index. Retrieved from https://www.gov.uk/government/publications/counting-rules-for-recorded- crime
Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence‐based clinical approach to suicidal risk. Suicide and Life‐Threatening Behavior, 42(6), 640-653. https://doi.org/10.1111/j.1943-278X.2012.00119.x
Johnson, J., Gooding, P., & Tarrier, N. (2008). Suicide risk in schizophrenia: explanatory models and clinical implications, The Schematic Appraisal Model of Suicide (SAMS). Psychology and Psychotherapy: Theory, Research and Practice, 81(1), 55-77. https://doi.org/10.1348/147608307X244996
Johnson, J. E., Schonbrun, Y. C., & Stein, M. D. (2014). Pilot test of 12-step linkage for alcohol-abusing women in leaving jail. Substance Abuse, 35(1), 7-11. doi: 10.1080/08897077.2013.794760
Johnson, J. E., & Zlotnick, C. (2008). A pilot study of group interpersonal psychotherapy for depression in substance-abusing female prisoners. Journal of Substance Abuse Treatment, 34(4), 371-377. https://doi.org/10.1016/j.jsat.2007.05.010
Killilea, J. (2019). Exploring the Treatment Acceptability of Intensive Cognitive Behavioural Therapy for Male Prisoners with Suicidal Experiences (unpublished doctoral thesis). University of Manchester.
Kupers, T. A. (2005). Toxic masculinity as a barrier to mental health treatment in prison. Journal of Clinical Psychology, 61(6), 713-724. https://doi.org/10.1002/jclp.20105
Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: development of a general scale. Evaluation and Program Planning, 2(3), 197-207. https://doi.org/10.1016/0149- 7189(79)90094-6
Liebling, A. (2011). Moral performance, inhuman and degrading treatment and prison pain. Punishment & Society, 13(5), 530-550. https://doi.org/10.1177/1462474511422159
98
Liebling, A. & Karup, H. (1993). Suicide Attempts and Self-Injury in Male Prisons. London: Home Office.
Mandracchia, J. T., & Smith, P. N. (2015). The interpersonal theory of suicide applied to male prisoners. Suicide and Life‐Threatening Behavior, 45(3), 293- 301. doi: 10.1111/sltb.12132
McIvor, R., Ek, E., & Carson, J. (2004). Non-attendance rates among patients attending different grades of psychiatrist and a clinical psychologist within a community mental health clinic. Psychiatric Bulletin, 28(1), 5-7. https://doi.org/10.1192/pb.28.1.5
McManus, S., Hassiotis, A., Jenkins, R., Dennis, M., Aznar, C., & Appleby, L. (2014). Suicidal Thoughts, Suicide Attempts, and Self-harm. Adult Psychiatric Morbidity Survey: Chapter 12. Retrieved from https://files.digital.nhs.uk/publicationimport/pub21xxx/pub21748/apms- 2014-suicide.pdf
Merriam-Webster. (2019). Suicide. Retrieved from https://www.merriam- webster.com/dictionary/suicide
Ministry of Justice. (2013). National Offender Management Service (NOMS): Management of prisoners at risk of harm to self, to others and from others (Safer Custody). Retrieved from https://www.justice.gov.uk/offenders/psis/prison-service-instructions-2011
Morris, S. B., & DeShon, R. P. (2002). Combining effect size estimates in meta- analysis with repeated measures and independent-groups designs. Psychological Methods, 7(1), 105-125. https://doi.org/10.1037//1082-989X.7.1.105
Nagin, D. S., Cullen, F. T., & Jonson, C. L. (2009). Imprisonment and reoffending. Crime and Justice, 38(1), 115-200. https://doi.org/10.1086/599202
National Institute for Health and Care Excellence. (2011). Self-harm: longer-term management (NICE Quality Standard CG133). Retrieved from https://www.nice.org.uk/guidance/cg133/documents/selfharm-longer- term-management-nice-version-for-consultation2
National Institute for Health and Care Excellence. (2013). Self-harm (NICE Quality standard No. 34). Retrieved from https://www.nice.org.uk/guidance/qs34
National Institute for Health and Care Excellence. (2018). Preventing suicide in community and preventing suicide in community and custodial settings custodial settings (NICE Quality Standard NG105). Retrieved from https://www.nice.org.uk/guidance/ng105
Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015. Retrieved from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsand marriages/deaths/articles/suicidebyoccupation/england2011to2015
Office for National Statistics. (2018). Suicide in the UK: 2017 Registrants. Retrieved from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsand marriages/deaths/bulletins/suicidesintheunitedkingdom/2017registrations
Oldfield, V. B., Salkovskis, P. M., & Taylor, T. (2011). Time‐intensive cognitive behaviour therapy for obsessive‐compulsive disorder: A case series and
99
matched comparison group. British Journal of Clinical Psychology, 50(1), 7- 18. https://doi.org/10.1348/014466510X490073
Padfield, N., & Maruna, S. (2006). The revolving door at the prison gate: Exploring the dramatic increase in recalls to prison. Criminology & Criminal Justice, 6(3), 329-352. https://doi.org/10.1177/1748895806065534
Palmer, E. J., & Connelly, R. (2005). Depression, hopelessness and suicide ideation among vulnerable prisoners. Criminal Behaviour and Mental Health, 15(3), 164-170. https://doi.org/10.1002/cbm.4
Papoulias, C., Csipke, E., Rose, D., McKellar, S., & Wykes, T. (2014). The psychiatric ward as a therapeutic space: systematic review. The British Journal of Psychiatry, 205(3), 171-176. https://doi.org/10.1192/bjp.bp.114.144873
Patel, R., Harvey, J., & Forrester, A. (2018). Systemic limitations in the delivery of mental health care in prisons in England. International Journal of Law and Psychiatry, 60, 17-25. https://doi.org/10.1016/j.ijlp.2018.06.003
Paulik, G., Jones, A. M., & Hayward, M. (2018). Brief coping strategy enhancement for distressing voices: Predictors of engagement and outcome in routine clinical practice. Clinical Psychology & Psychotherapy, 25(5), 634-640. https://doi.org/10.1002/cpp.2299
Pratt, D. (2016). The prevention of suicide in prison: cognitive behavioural approaches. London, UK: Routledge.
Pratt, D., Gooding, P., Awenat, Y., Eccles, S., & Tarrier, N. (2016). Cognitive behavioral suicide prevention for male prisoners: case examples. Cognitive and Behavioral Practice, 23(4), 485-501. https://doi.org/10.1016/j.cbpra.2015.09.006
Pratt, D., Tarrier, N., Dunn, G., Awenat, Y., Shaw, J., Ulph, F., & Gooding, P. (2015). Cognitive–behavioural suicide prevention for male prisoners: a pilot randomized controlled trial. Psychological Medicine, 45(16), 3441-3451. https://doi.org/10.1017/S0033291715001348
Reingle-Gonzalez, J. M., & Connell, N. M. (2014). Mental health of prisoners: Identifying barriers to mental health treatment and medication continuity. American Journal of Public Health, 104(12), 2328-2333. doi:10.2105/AJPH.2014.302043
Rivlin, A., Hawton, K., Marzano, L., & Fazel, S. (2013). Psychosocial characteristics and social networks of suicidal prisoners: towards a model of suicidal behaviour in detention. Public Library of Science One, 8(7), e68944. https://doi.org/10.1371/journal.pone.0068944
Searson, R., Mansell, W., Lowens, I., & Tai, S. (2012). Think Effectively About Mood Swings (TEAMS): A case series of cognitive–behavioural therapy for bipolar disorders. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 770-779. https://doi.org/10.1016/j.jbtep.2011.10.001
Shaw, J., Baker, D., Hunt, I. M., Moloney, A., & Appleby, L. (2004). Suicide by prisoners: national clinical survey. The British Journal of Psychiatry, 184(3), 263-267. https://doi.org/10.1192/bjp.184.3.263
Stanley, B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry, J., … Hughes, J. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. Journal of the American
100
Academy of Child & Adolescent Psychiatry, 48(10), 1005-1013. doi:10.1097/CHI.0b013e3181b5dbfe
Staton-Tindall, M., Royse, D., & Leukfeld, C. (2007). Substance use criminality, and social support: An exploratory analysis with incarcerated women. The American Journal of Drug and Alcohol Abuse, 33(2), 237-243. doi:10.1080/00952990601174865
Tarrier, N., Gooding, P., Pratt, D., Kelly, J., Awenat, Y., & Maxwell, J. (2013). Cognitive behavioural prevention of suicide in psychosis: a treatment manual. East Sussex, UK: Routledge.
Tarrier, N., Taylor, K., & Gooding, P. (2008). Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Behavior Modification, 32(1), 77-108. https://doi.org/10.1177/0145445507304728
Towl, G. (2002). Psychological services in HM Prison Service and the National Probation Service: working towards an effective partnership. The British Journal of Forensic Practice, 4(3), 3-10. https://doi.org/10.1108/14636646200200016
Tucker, S., Hargreaves, C., Roberts, A., Anderson, I., Shaw, J., & Challis, D. (2017). Social Care in Prison: Emerging Practice Arrangements Consequent upon the Introduction of the 2014 Care Act. The British Journal of Social Work, 48(6), 1627-1644. https://doi.org/10.1093/bjsw/bcx115
Wakeling, H. C. (2007). The psychometric validation of the social problem-solving inventory—revised with UK incarcerated sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 19(3), 217-236. https://doi.org/10.1007/s11194-007-9038-3
Walsh, K., DiLillo, D., & Scalora, M. J. (2011). The cumulative impact of sexual revictimization on emotion regulation difficulties: An examination of female inmates. Violence against Women, 17(8), 1103-1118. https://doi.org/10.1177/1077801211414165
Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., … Malliaris, Y. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour Research and Therapy, 45(9), 2144- 2154. https://doi.org/10.1016/j.brat.2006.09.018
Way, B. B., Kaufman, A. R., Knoll, J. L., & Chlebowski, S. M. (2013). Suicidal ideation among inmate‐patients in state prison: Prevalence, reluctance to report, and treatment preferences. Behavioral Sciences and the Law, 31(2), 230-238. https://doi.org/10.1002/bsl.2055
Wells, A., & Sembi, S. (2004). Metacognitive therapy for PTSD: A core treatment manual. Cognitive and Behavioral Practice, 11(4), 365-377. https://doi.org/10.1016/S1077-7229(04)80053-1
Whiteside, S. P., Brown, A. M., & Abramowitz, J. S. (2008). Five-day intensive treatment for adolescent OCD: A case series. Journal of Anxiety Disorders, 22(3), 495-504. https://doi.org/10.1016/j.janxdis.2007.05.001
Williams, J.M.G. (1997). Cry of Pain. Harmondsworth, UK: Penguin. World Health Organisation. (2017). Suicide. Retrieved from
https://www.who.int/news-room/fact-sheets/detail/suicide
101
Vasquez, M. J., Bingham, R. P., & Barnett, J. E. (2008). Psychotherapy termination: Clinical and ethical responsibilities. Journal of Clinical Psychology, 64(5), 653- 665. https://doi.org/10.1002/jclp.20478
Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52(1), 30-41. https://doi.org/10.1207/s15327752jpa5201_2
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Introduction to Paper III
Paper III is a critical review which reflects upon the development and delivery of
Paper I and Paper II. This paper appraises the research processes and the
developmental decisions that were made as guided by theoretical, empirical and
professional contexts. Paper III considers decisions in more detail and offers
alternate options that were considered along the way. Strengths and limitations of
both will be considered. Recommendations for future research will be detailed.
Paper III begins with an introduction to both papers and leads on to discuss the
issues as mentioned above. In addition to this, the author’s reflective experiences
are integrated throughout, in reflecting upon the challenges of developing and
conducting both pieces of research and in the delivery of psychological therapy
within a prison. This links into a body of literature highlighting the challenges and
barriers clinicians face when integrating psychological services into such a
challenging environment.
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Paper 3: Critical Reflection Paper
Word count: 5966
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Overview
Paper III presents a critical reflection of the research conducted for this thesis. The
systematic review (Paper I) explored intensive Cognitive Behavioural Therapy (CBT)
conducted with clinical populations experiencing psychological distress. Findings
highlighted variations in the definition and the delivery of intensive CBT, with some
promise in the feasibility and efficacy of intensive CBT. Due to the heterogeneity of
the sample, small sample sizes and limited methodological quality of papers, it was
difficult to draw firm conclusions. It is recommended for future large scale studies
to use a more rigorous methodological design (i.e. randomised control trials [RCT]),
before future reviews take place. Future reviews could broaden inclusion criteria to
capture more studies, to facilitate more rigorous analysis (i.e. meta-analysis).
Paper II investigated the feasibility of intensive CBT in prison. The InSPire
programme used a case series design with single baseline and follow up. Intensive
CBT consisted of five sessions (up to two hours) of Cognitive Behavioural Suicide
Prevention (CBSP) (Tarrier et al., 2013) completed within a three week period.
Follow up measures assessed client satisfaction, suicidal ideation and three
psychological mechanisms associated with suicide (i.e. emotional regulation,
problem solving and perceived social support). Thirteen male prisoners were
recruited and retention was high. Effect sizes indicated a potential benefit of the
intervention for all outcomes measured. The intensive delivery of the programme
appeared feasible given the high attendance and programme completion and high
levels of client satisfaction, which holds promise in continuing larger-scale research
in this field. Throughout, the author reflects upon the experience of delivering
psychological therapy within a prison, and the professional and personal challenges
that occurred alongside.
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1. Paper I: Systematic Review
1.1 Rationale for the Review
Review topics were considered in areas of suicide prevention and work within
forensic settings, with a final decision to focus upon psychological intervention as
delivered in Paper II. Recent years have seen the emergence of alternate formats of
CBT delivery in line with streamlining NHS services and facilitating patient choice.
Compared to traditional weekly delivery, intensive CBT involves a reduction in the
duration of therapy (i.e. number of sessions) (Öst & Ollendick, 2017). Whilst there is
a comprehensive body of evidence for use of CBT across many clinical populations,
there appeared to be a gap in the literature for reviews of intensive CBT. Initial
scoping of key databases (i.e. PsychINFO) generated enough literature to justify
further exploration. A number of studies have investigated intensive CBT, including
family based intensive CBT with children with Obsessive Compulsive Disorder
(OCD), for 90 minute sessions, five days per week, for three weeks (Storch et al.,
2007). In an adult OCD population, 18 hours of CBT were equally as effective when
delivered over five days, compared with 18 weeks (Oldfield, Salkovskis, & Taylor,
2011). In an adult post-traumatic stress disorder (PTSD) population, intensive CBT
consisted of 18 therapy hours over five to seven working days (Ehlers et al., 2010).
Lastly, individuals with panic disorder were offered two longer sessions (i.e. up to
five hours per session) across two days (Deacon & Abramowitz, 2006). One review
investigated intensive CBT in a child population with anxiety (Öst & Ollendick,
2017), yet intensive delivery had not been reviewed with adults. Two unpublished
reviews were ongoing, in a child population (Clarkson, Allcott-Watson, Shafran, &
Bennett, 2018) and investigating adults with OCD (Millar, Bauer, Salkovskis,
Gregory, & Halligan, 2018). Reviews to date have focussed upon specific
populations defined by diagnostic criteria. For this current review, investigating a
population experiencing ‘psychological distress’ allowed a broader scope, as
opposed to investigating diagnoses. The review aimed to increase understanding on
the delivery of intensive CBT and its efficacy across clinical populations. The review
felt relevant alongside Paper II, which delivered intensive CBT within a prison, for
what was understood to be the first time.
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1.2 Scoping and Database Searching
Following preliminary scoping on the PsychINFO database, the terms ‘cognitive
behavioural therapy’ AND ‘intensive’ retrieved 70 articles. The search reduced to 60
when limited to English only. Twenty-one papers remained following a more in-
depth review and the author was aware of other relevant papers, which suggested
that enough literature existed to develop a systematic search. Development of the
review was guided by the ‘Preferred Reporting Items for Systematic review and
Meta-Analysis Protocols’ (PRISMA) systematic review protocol (Moher et al., 2015)
and a student practice guide (Boland, Cherry, & Dickson, 2017).
Given the varied definitions used to operationalise ‘intensive CBT’ there was
deliberation about defining search terms. There was debate about crossover
terminologies, such as ‘brief’ CBT (50% reduction of sessions compared to standard
delivery) and ‘concentrated’ CBT (the same number of sessions as standard delivery
but in less time) (Öst & Ollendick, 2017). One published review in this area
determined search terms using psychiatric diagnostic criteria, without reference to
intensive, brief or concentrated CBT delivery (Öst & Ollendick, 2017). Whilst the
current review focussed upon psychological distress, use of the term ‘psychological
distress’ alone generated many papers lacking a particular focus (n = >120, 000).
Broad search terms were trialled which included other terminologies for intensive
CBT (i.e. brief, concentrated) however this too yielded a large number of papers (n
= >19, 500) and was too broad for this scale of review given the time and resources
available. Development of search strategies is recognised as an iterative process
(Boland et al., 2017) and research supervision was used to consider the benefits
and drawbacks of including (or not including) particular terms. Supervision helped
to shape the ‘PICO’ inclusion criteria (i.e. Problem or Patient or
Population; Intervention or Indicator; Comparison; Outcome of interest) (Miller &
Forrest, 2001). It was a challenge to determine a comprehensive enough search
strategy which was inclusive enough to capture relevant studies but feasible for a
review of this scale. This is anticipated with a systematic review and there requires
a degree of intuition, practice and trial and error in determining search terms (Ecker
& Skelly, 2010). The author experienced a lack of confidence during this phase, yet
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the process fostered valuable learning in the development of systematic reviews.
Final search terms were justified using definitions from published studies
investigating intensive CBT (Storch et al., 2007; Oldfield et al., 2011; Ehlers et al.,
2010; Deacon & Abramowitz, 2006) and as guided by published and unpublished
reviews in this area (Öst & Ollendick, 2017; Millar et al., 2018; Clarkson et al., 2018).
Once databases searches were completed, title and abstract screening began.
Interrater reliability was conducted to ensure consistency with the PICO criteria.
1.3 Quality Appraisal
A number of quality tools were considered. The Critical Appraisal Skills Programme
(CASP) tool is known for its applicability across different methodological designs
(Voss & Rehfuess, 2013), which felt relevant for this review. After trialling the CASP
on a few papers the author wondered about the degree of subjectivity in questions
which asked for judgment upon the acceptability or appropriateness of certain
methodological components (i.e. appropriate method, acceptable recruitment).
Voss and Rehfuess (2013) note the importance of developing review tool questions
in a specific way, to avoid the likelihood of variability in responses. This is a criticism
of the CASP. The author reflected that a tool with more focused and specific
questions would be preferred. The Effective Public Health Practice Project (EPHPP;
1998) tool asks specific questions which require quantitative answers (i.e. attrition),
which increase the precision of the tool (Voss & Rehfuess, 2013). Whilst there were
limitations to EPHPP (i.e. heavy weighting of RCT’s renders other methodologies as
weak quality), it was considered the best option without designing a new tool.
Quality checking was a long process and the author lacked some confidence in the
possibility of increased subjectivity and unreliability of final ratings. In order to
combat this, a peer group was formed with two other doctoral trainees
(independent of this project). This group reviewed the EPHPP tool to determine
consistency in the interpretation of questions. Consistent approaches to each
question were justified during group discussion guided by the EPHPP quality
assessment dictionary (EPHPP, 2017) (Appendix 32). Additional input related to
uncertainties on specific queries (i.e. methodological design, calculating attrition) as
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well as quality rating a reasonable percentage of papers (29%). Interrater reliability
was almost perfect, which reassured the issues around subjectivity.
1.4 Synthesising Results
The sample was largely heterogeneous, restricting the author from conducting a
more rigorous synthesis of the results (i.e. meta-analysis). A meta-analysis offers
the advantage of statistically combining results which improves the reliability of
effect sizes, therefore being a more rigorous analysis than a systematic review
(Fagard, Staessen, & Thijs, 1996). This would have allowed increased confidence in
the assumptions and conclusions drawn from the effect sizes generated. The
variability of papers (i.e. design, sample size, target problems) required
consideration of how best to synthesise them within the analysis. Various methods
were considered in order to present sensible and succinct results (i.e. psychiatric
diagnostic criteria, intervention characteristics). As this review focussed upon
psychological distress, psychiatric diagnostic criteria was not used to categorise
results. This decision was driven by an intention to broaden the scope of clinical
populations reviewed and to avoid falling into the reliability and validity pitfalls of
psychiatric diagnoses (Timimi, 2014). This was a challenge given that a large
proportion of the papers determined their population using diagnostic criteria. For
the purposes of this review these papers were captured as ‘distress associated with
mental health’. Other categories included distress associated with chronic pain,
addiction and following a traumatic incident.
1.5 Limitations
The inclusion criterion required intervention completion within four weeks, yet four
papers offered booster sessions which surpassed this timeframe (Ehlers et al., 2010;
2014; Oldfield et al., 2011; Challacombe & Salkovskis, 2011). These papers
appeared important and pioneering and the authors appeared to have an interest
in the development of intensive CBT. Despite the potential added value of these
four papers, it felt important to adhere to the established PICO criteria in line with
the information published on prospero (ID: CRD42018086546) and to note this as a
recommendation for future larger scale reviews. Boland et al. (2017) note the
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potential for bias during the screening and inclusion phase. This decision
maintained reliability and consistency with the eligibility criteria and limited bias
generated by the author including supplement papers.
The review excluded grey literature, non-English papers, conference titles and
abstracts. Whilst this may have increased publication bias, the omission of grey
literature was deemed appropriate given the challenges in its inclusion and given
the relatively small scope of the review (Boland et al., 2017). Additionally some
papers (n = 10) were not accessible through the University of Manchester library
without incurring a fee. Whilst the final decision was to exclude these papers, there
was debate during supervision as the omission was likely to introduce further
publication bias. There is recognition that studies with non-significant results often
remain unpublished and difficult to access, thus leaving published literature to be
an inaccurate representation (Balshem et al., 2013). For this review the search
results were deemed to be sufficiently inclusive to proceed.
1.6 Clinical Implications and Future Directions
This review felt clinically important during an era of increased emphasis on
streamlining NHS services. The review found promise in the feasibility and efficacy
of intensive CBT in clinical populations experiencing psychological distress.
Development of this intervention could have an important role in service
development. The Care Quality Commission’s (CQC; 2015) objective to facilitate the
delivery of efficient NHS services is continually hampered by increasing pressures,
lack of resources and significant funding gaps. Government initiatives (i.e. ‘No
health without mental health’) (Department of Health [DoH], 2011), emphasise the
importance of improving mental health well-being, given the significant impact
mental health has upon physical health. Poor mental health has a number of
societal and socio-economic costs, therefore earlier investment into treatment
could have profound impacts upon individuals, reducing their reliance upon
services and increasing their ability to engage in society (DoH, 2011). Access to
psychological interventions is important in supporting government initiatives.
Effectiveness of services is influenced by severity of need, presenting difficulties,
patient preference and their ability to engage in interventions. The National
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Institute for Health and Care Excellence (NICE) offers specific guidelines for
psychiatric conditions which outline recommendations for therapy delivery (i.e.
number of sessions). However, Stiles, Barkham, Connell, and Mellor-Clark (2008)
place less emphasis upon the number of sessions, reporting that some individuals
experience as much of a benefit after one to two sessions compared to the
recommended 16. This steered the development of the response regulation model,
which determines therapy dose based upon need (Stiles et al., 2008). This model
fosters efficient services which respond to patient need. Patient choice is another
key mediator in the acceptability and efficacy of services. Bevan, Oldfield, &
Salkovskis (2010) interviewed patients following intensive or weekly CBT for OCD.
Both groups determined benefits and drawbacks to each delivery. Benefits of
weekly included the advantage of having increased time to consolidate therapy
material and this group held the assumption that intensive delivery would be too
stressful. Whereas, the intensive group reported an increased motivation and
momentum and preferred the shorter-term commitment. Further studies
investigated intensive CBT for childhood OCD, highlighting a number of barriers in
committing to weekly therapy (i.e. geography, access to appropriate specialist
services, severity of difficulties) (Storch et al., 2008; Whiteside, Brown, &
Abramowitz, 2008; Lewin et al., 2005). All of the above, including the current
systematic review, challenge the assumption that therapy can only be delivered in a
traditional weekly format, and propose that intensive deliveries are as effective.
1.7 Conclusions
The review provided an overview into populations that intensive CBT has been
explored with, as well as understanding more about feasibility and effectiveness.
Although this review had limitations, much was done to combat criticism and to
shape the review into a manageable size. This was a learning curve for the author,
having never conducted a systematic review before. Whilst the author questioned
their competence at times, this led to more investment in quality appraisal,
interrater reliability and adhering to systematic practice and guidelines, thus, one
hopes, creating a more ‘systematic’ review.
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2. Paper II: Empirical Study
2.1 Study Aims and Rationale
The InSPire programme was developed following previous research delivering CBT
in a prison (The PROSPeR Study; Pratt et al., 2015). The aim was to address attrition
rates during psychological therapy in prison with barriers preventing long-term
engagement and therapy completion (i.e. sudden transfer or release). In response,
the InSPire programme delivered an intensive programme of cognitive behavioural
suicide prevention (CBSP) (Tarrier et al., 2013), across five two-hourly sessions
within three weeks. Baseline and follow up measures investigated effects on
suicidality, emotional regulation, problem solving and perceived social support.
The issue of suicide poses a worldwide concern, requiring investment of time,
resources and research. In the UK, suicide rates are high, which is further
heightened within forensic settings (Georgiou et al., 2017). Prison outcomes are
more concerning than ever, with the highest ever prisoner population experiencing
increasing rates of suicidality and reconviction (Leibling, 2006). Given the high
suicide risk in prison, there is an ever increasing importance in providing
psychological therapy with the aim of reducing self-inflicted deaths (Pratt, Gooding,
Awenat, Eccles, & Tarrier, 2016). This was evident within the host prison, whereby
two suicide incidents had taken place, days before commencement of the InSPire
programme and during it. The recent deaths in custody unsettled staff and
prisoners, and led to a spike in Assessment, Care in Custody and Teamwork (ACCT)
documents being opened upon commencement of the InSPire programme.
2.2 Development Stage
Trainees approached all the North West prisons to establish a site for the InSPire
programme. The Governor of the hosting prison expressed initial interest and was
welcoming of hosting the research. The Governor linked the research team with
healthcare and the safer custody team and various communications and meetings
were coordinated. There was some negotiation regarding who would oversee (and
ultimately hold responsibility) for the programme, which took time due to some
hesitancy. Although study participants were identified through safer custody,
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healthcare oversaw the programme, which required written consent from head of
healthcare. Whilst healthcare oversaw the programme, there was not the capacity
(i.e. rooms) to deliver the programme from this department. Finding a research
base and therapy space became a logistical challenge. Other requirements included
locked facilities for data, access to ACCT data and risk information, access to
healthcare computers (for clinical notes) and generally ensuring the InSPire
programme could run safely. Delays to research commencement felt like a likely
reality and continual liaison and problem solving ensured that this was avoided.
Safer custody staff supported the research team to embed within the prison and
distribute study information to prison staff on every wing. Prison staff became
increasingly more aware of the InSPire programme and were active in receiving risk
feedback and supporting therapists to find safe and appropriate therapeutic spaces
on the wings. Whilst the programme was completed with few setbacks, this was
likely due to the effective planning and coordination between the research team
and prison staff. This highlights aspects of research development which were a
challenge specifically related to conducting research within the criminal justice
system, which may not require the same degree of consideration in the community.
2.3 Recruitment Considerations
The research period was pre-defined by the doctoral programme and a lot of
consideration went into tailoring the project to fit within the allotted timeframe.
Whilst previous case studies helped to shape the recruitment target (Challacombe
& Salkovskis, 2011; Ehlers et al., 2010), the target was also shaped by what was
feasible during the research period. Öst and Ollendick (2017) define ‘intensive’ CBT
as being a reduction in both the number and duration of sessions compared to
standard treatment. ‘Standard delivery’ in this instance was that delivered as part
of The PROSPeR Trial (i.e. 20-24 one hour sessions; Pratt et al., 2015). The 10 hours
of therapy in this trial fits with the definition of intensive CBT alongside the
standard delivery to date.
A common recruitment challenge is engaging enough participants to successfully
recruit to time and target, particularly in prison research (Apa et al., 2012). This
study raised other recruitment challenges. A high interest meant that some eligible,
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although mostly ineligible, individuals were unable to take part. Therapists accessed
the wings daily to deliver InSPire programme sessions. During this time therapists
were regularly approached from other prisoners requesting to take part. This raised
issues of maintaining the confidentiality of those involved in the programme and
was an ongoing reminder of the level of need. Managing confidentiality was
discussed in supervision in the interests of adhering to the Code of Ethics and
Conduct (BPS, 2018). Therapists did not disclose details of the programme when
approached by others. Many individuals who approached therapists were not on an
ACCT list and therefore ineligible for the programme. This felt like a rejection given
the high level of need, motivation and willingness to engage expressed by these
individuals. Conversations regarding non-eligibility were managed sensitively and
individuals were encouraged to liaise with staff regarding a healthcare referral. This
highlights a difficulty in limiting eligibility only to those on an ACCT document, as
there could be individuals outside of this system who experience suicidal thoughts
and behaviours. This maps onto many service-related issues in the NHS currently, in
only having resources to respond to risk when it reaches a level of severity deemed
to be ‘priority’ (St John-Smith et al., 2009), determined by lack of resources rather
than level of need. It raises the question of whether earlier investment into mental
health treatment would be an effective preventative strategy in reducing suicidality
(Aleman & Denys, 2014). Other barriers which determined ineligibility included use
of substances and specific risk presentations (i.e. risk of hostage, risk to females -
both researchers were female). For reasons of safety, sessions could not be
facilitated in prison cells, therefore ‘self-isolative’ individuals (i.e. who declined
leaving their cell) were unable to take part. One self-isolative individual expressed
an interest and agreed to leave his cell only to access InSPire sessions in facilities
which he felt safe (i.e. staff office, education). This challenged staff assumptions
that he truly met the perceived criteria as self-isolative, which resulted in some
judgement to both the prisoner and therapist. Jolliffe and Haque (2017) note how
many individuals experiencing mental health difficulties in prison are considered
‘manipulative’ or ‘challenging’. This opinion is heightened towards those
experiencing suicidal ideation and raises the likelihood of their difficulties, risks and
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vulnerabilities being overlooked by staff and evoking less care than needed (Joliffe
& Haque, 2017).
The care and segregation unit (CSU) was deemed by staff to be an inappropriate
place to deliver therapy. Firstly because of practical issues (i.e. rooms, staffing) but
additionally because individuals may be of increased risk of harm to themselves,
others, or from others. This raised several ethical questions about obstructing
access to support during increased times of need. Contrary to its purpose, the CSU
can increase a person’s isolation and negatively impact mental well-being (Browne,
Cambier, & Agha, 2011). Proactive engagement, access to meaningful activities,
support during transitions (i.e. transfer, relationships, sentencing) were all
identified as important factors in minimising ‘near miss’ incidents within a female
prison (Borrill, Snow, Medlicott, Teers, & Paton, 2005). During the InSPire
programme, one participant was moved to the CSU immediately following baseline
assessment. This individual was motivated to engage and the level of need
appeared to be high, yet he was prevented from taking part. The individual was
held on a waitlist in case he was reintegrated onto the wings, but this did not
happen. He was approached to complete follow up measures and reflected that the
programme could have been the help he required. This individual’s personal
circumstances and mental health, as captured on outcome measures, deteriorated
at follow up. Given that completion of the InSPire programme was indicative of
beneficial change for all completing participants across all measures, this
participant could have similarly benefitted from the intervention. Involvement
could have reduced isolation and supported him to cope with ongoing prison
stressors maintaining his suicide schema.
2.4 Conducting Research in Prison
i) Logistical Considerations
Lack of availability of psychological interventions in prison, beyond offending-
focused work, has been a growing concern (Towl, 2002; Harvey & Smedley, 2012).
This current study highlighted complexities in the suitability of the prison
environment when delivering psychological interventions. The level of noise and
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disruption is unlikely to be encountered to the same degree in the community and
finding a therapeutic space for sessions was challenging. Recruitment sessions were
conducted in various spaces, including a chemicals room, bike locker and corridor
amidst broken furniture. It felt important to facilitate a more therapeutic space for
intervention sessions, although this was not always feasible. At times, lack of
appropriate rooms and low staffing levels raised lone working concerns. Therapists
managed their personal safety and adhered to the InSPire Safe Working Practices
Protocol whilst making appropriate use of clinical supervision.
Timing of sessions was a logistical issue complicated by the prison regime. Sessions
were facilitated in between morning and afternoon movement schedules (i.e.
between 9am – 11.30am and 2pm – 4.30pm). Therapists adhered to movement
times due to being unable to independently escort prisoners if sessions overran.
Early/late movement times and lock-downs (i.e. where prisoners are confined to
their cell for an undetermined period of time) further complicated this picture and
occasionally sessions began late or were terminated prematurely. Therapists were
required to attend to frustrations expressed by prisoners when sessions abruptly
ended. The prison environment could be unpredictable, which challenges the
foundation of stability, predictability and consistency required during therapy.
‘Stability’ has been captured as an integral human need (Flanagan, 2010). During
the programme, issues of stability, predictability and consistency were managed by
booking appointments directly with participants (including provision of reminder
slips), or otherwise posting appointments in the prison mail (appendix 33).
Therapists always attended at the agreed time. In the event that the therapist could
not attend, a contingency was in place for the researcher to inform the participant.
Participants were aware of the location, timing and anticipated content of therapy
sessions. The therapist and participant collaboratively agreed an agenda at the start
of sessions and bridging between sessions was used to reflect upon the previous
session and plan for the next (The Association for Behavioural and Cognitive
Therapies [ABCT], 2019). A metaphorical ‘stop button’ was introduced to offer an
opportunity to pause at any point and to foster a sense of control.
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ii) Personal Safety
Issues of personal safety, of therapists and participants, were a daily consideration
in peer supervision, clinical supervision and prison staff conversations. The author
experienced situations which challenged their sense of safety, including witnessing
physical altercations, low staffing levels and experiencing unsuitable therapy
facilities (i.e. rooms without functional panic alarms). Feeling overwhelmed and a
lack of safety is a difficult reality amongst prison staff (Liebling, 2011). This reality
often evoked emotional reactions which mirrored that of the participant (i.e.
frustration, overwhelmed, ‘stuckness’). Self-care and use of supervision were
invaluable.
iii) Role Dilemmas
Alternate roles were required from the research team interchangeably for a
number of months. The author alternated between ‘researcher’ and ‘therapist’,
whilst all the while being a doctoral student with a vested interest in the success of
the project. The principle investigator alternated between roles of research
supervisor, clinical supervisor and teacher/lecturer. Participants were receivers of
therapy and research participants. Each competing role had different expectations,
requiring a level of continual flexibility.
Being a research participant required involvement in research processes (i.e.
informed consent, outcome measures, therapy engagement). If participants did not
attend (DNA) two sessions they were discharged from the programme. Given the
level of complexity and barriers to trust and engagement, the presence of the DNA
‘rule’ felt difficult. Future studies could consider increased DNAs prior to automatic
discharge (i.e. more than two) or consider discharge on a case by case basis.
Involving the participant in conversation about discharge could be useful, given that
one discharged individual had wanted to continue.
Response to risk was regularly required from the therapist and researcher as they
were often the primary clinician assessing or working with the individual at the
time. During times of increased risk, the therapist/researcher attended emergency
ACCT reviews and supported the participant in an advocacy type capacity (i.e.
advocate for a wing move in the interests of personal safety). Most attendance at
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ACCT reviews were valued by prison staff, in the interests of sharing risk. However,
it was sometimes perceived that opening an ACCT or calling for an emergency ACCT
review was problematic. Staff work tirelessly under constant pressures of
understaffing and compromised personal safety (Steiner & Wooldredge, 2017). The
ACCT system generates a number of ‘tasks’ and requirements, and arguably
another level of pressure. Jolliffe and Haque (2017) reflect upon the ACCT system
being a litigation process, as opposed to eliciting individualised care. An ACCT
requires a judgement on risk severity, which triages the individual according to the
level of risk they are perceived to require.
2.5 The Role of Clinical Psychology in Prison
Aside to direct involvement in clinical risk, the therapist and researcher adhered
strictly to the research protocol. Whilst important for research consistency, rigour
and replicability, it is important to consider the therapist’s role beyond the therapy
manual. The role of a clinical psychologist involves advocating for individuals and
supporting with difficult transitions (i.e. wing moves, transfer, release), including
working alongside staff teams (The British Psychological Society [BPS], 2008). In a
community setting, a clinical psychologist might work with the staff team and
individual to prepare for and facilitate transitions (BPS, 2008). In prison, transitions
were unpredictable and without knowledge or preparation of the individual, often
leading to escalations in behaviours that challenged staff (i.e. threats and actual
harm to self and others). There is a high level of uncertainty involved in a prison
sentence, which leads to a high level of psychological distress (Harvey, 2011).
‘Control’ was a central issue in therapy, as prisoners expressed that they had little
or no control. It seemed that escalating behaviours (i.e. self-harm, assault, suicide
attempts, self-isolating) were an attempt at maintaining control. Whilst there is the
perception that some behaviours (i.e. self-harm) are ‘manipulative’ (Dear,
Thomson, & Hills, 2000) it feels important to reflect that these behaviours can be
interpreted as a call for help, an expression of distress, or limited skills in effective
communication and problem solving. Working psychologically within an
environment geared towards punishment can ultimately feel challenging (Harvey,
2011), and being a psychologist bound by the same prison regime creates barriers
118
in developing a trusting therapeutic relationship. The regime itself strengthened
schemas of distrust, unsafety and lack of control and power, with many of these
factors central to individuals’ suicide formulation (Tarrier et al., 2013). Limiting
psychological distress during such transitions was not a primary focus. Being
unaware of transitions discounted the therapist’s ability to prepare for them during
sessions and instead required a responsive approach to escalating behaviour and
risk disclosures (i.e. imminent intentions to harm self or others). Realistically it begs
the question of how 1:1 psychological interventions can work in a prison without
making changes on a systemic level.
2.6 Delivering Psychological Intervention in Prison
i) Engagement and the ‘Prison Mask’
Encouraging control and autonomy was part of the InSPire intervention, yet issues
of control and power were a dynamic within therapy itself. The prison creates a
dynamic of compliance and therapy requires a shift towards collaboration, which
was difficult for some. Harvey (2011) reflects upon how prisoners struggle to
determine therapeutic goals as their level of autonomy is challenged and a lack of
trust and power can make it difficult to deliver effective therapy. Haney (2012)
highlights the perception of vulnerability or weakness as intolerable for prisoners,
often generating interpersonal distance. Adoption of the ‘prison mask’ prevents
anyone from getting close, both emotionally and behaviourally (Haney, 2012).
Whilst hypervigilance is an important survival strategy in prison (Haney. 2012), the
adaptive quality appears useful only to particular situations. The mask has negative
consequences in being able to engage socially and develop healthy and useful
relationships, as well as being a barrier to therapy. There is a widely recognised
reluctance to accept help within prison for the fear of being perceived as weak and
the repercussions this could trigger (i.e. bullying) (Cobb & Farrants, 2014). Therapy
raised questions about individuals’ readiness to change and motivational
interviewing techniques, such as ‘rolling with resistance’, were commonly used
(Rollnick & Miller, 1995). Outside the parameters of a research protocol, it is
unlikely that therapy would end with such instability and risk ongoing and perhaps
119
more would be done to facilitate transitions and stabilise issues. This felt like a
drawback to the intensive delivery and questions whether more sessions would be
beneficial. NICE (2013) quality standard for self-harm recommend up to 12 one
hour sessions, which could be trialled in future studies (i.e. 12 hours compared to
10). Alternatively, studies of intensive CBT have offered booster sessions to
increase long-term effects (Ehlers et al., 2010; 2014; Oldfield et al., 2011;
Challacombe & Salkovskis, 2011). Further models of intervention delivery have
considered offering additional sessions based upon need (Stiles et al., 2008; Bower
& Gilbody, 2005).
ii) CBSP Intervention
The intensive intervention was developed from the CBSP manual (Tarrier et al.,
2013). Research steering meetings adapted the CBSP manual into an intensive
format and ensured it was compatible with the prison regime. Delivering sessions
on consecutive days became routine and appeared to facilitate an element of
momentum (Bevan et al., 2010). Longer durations between sessions (i.e. across a
weekend) began to feel infrequent and as with the nature of the environment,
could mean that a lot had changed between sessions. The intensive delivery meant
that less time was spent ‘catching up’ and participants were able to develop case
conceptualisations more readily. This momentary focus allowed cognitive (i.e.
thought challenging) and behavioural (i.e. exposure) components of CBT to be
trialled day by day.
iii) Endings
The intensive intervention started and finished within a matter of weeks. Endings
were managed throughout sessions and were not unexpected, yet for some
prisoners there was a shift in interpersonal dynamics in final sessions (i.e.
resistance, dis-engagement). Arguably, therapy endings within prison could be
more difficult given the nature of the environment and the population (i.e.
increased prevalence of historical abuse, rejection, abandonment and unstable
attachments) (Rogers & Law, 2010). Disengagement could be interpreted as a
protective factor, as it is safer to put the ‘prison mask’ back on before facing prison
life independently again (Harvey, 2011).
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iv) Clinical Supervision
There is an emphasis on the importance of good clinical supervision when working
with complex risk presentations, particularly within a prison (NICE, 2013; Marzano,
Ciclitira, & Adler, 2012). Clinical supervision was joint between the author and
fellow doctoral trainee. Supervision took place early morning prior to prison
movement and occurred most days as sessions were delivered on consecutive days.
In weekly delivery of therapy, participants reflected upon the benefit of time
between sessions to consolidate the material (Bevan et al., 2010). This too felt
relevant for the therapist as intensive delivery allowed limited reflection time
between sessions and supervisions. Supervision mirrored the quick pace and
intense nature of therapy. This intensity was likely heightened by the trainee’s lack
of experience in delivering this model. During the early stages of the InSPire
programme, supervision required a directive approach, as opposed to way-finding
and experiential learning. Over time, supervision began to feel akin to what
qualified supervision might look like, yet this conflicted with the current role as a
trainee psychologist and the challenge of holding more clinical risk than ever
before. The process generated a lot of learning and development, particularly in
autonomy and initiative in managing clinical risk. Some of these issues could be
lessened by having more practice sessions to improve competence (i.e. role play
and feedback) and by increasing the gap between intensive CBT sessions (i.e. every
other day compared to everyday).
2.7 System-level Considerations
A prisoner’s experience of psychological distress and suicidality is mediated by
relationships with others (Liebling, Durie, Stiles, & Tait, 2005). Leibling (2006)
emphasises how prisoners seek ‘fairness’, ‘respect’, ‘trust’, ‘humanity’ and ‘safety’,
which when undermined leads to anger, tension, depression and rage. Issues of
authority and injustice lead to isolation, increased distress and lack of self-worth
(Leibling, 2006). Prisoners struggle to find meaning, particularly when serving an
indeterminate sentence (Liebling, 2011). The above issues were commonly
considered during therapy and issues (i.e. powerlessness) were central to some
121
individuals’ suicide schema. The author sought support during supervision for these
therapy dilemmas and was directed to literary works which emphasised a human’s
ability to survive in the most extreme situations: by finding a reason to live,
choosing the way to ‘be’ in each moment and by holding on to moments already
lived (Frankl, 1985). One strategy delivered during the CBSP intervention was the
broad minded affective coping procedure (BMAC), a CBT strategy for eliciting
positive emotions (Tarrier, 2010). Furthermore, problem solving techniques
supported individuals to effectively communicate needs and address current
problems.
A focus on increasing staffs understanding and awareness of mental health is
important (Leibling & Karup, 1993; Hansson & Markstron, 2014). Future research
considerations could include increased staff liaison, consultation and teaching.
Wider presentation of the InSPire programme could have increased understanding
and recognition of suicidality in prison, alongside modelling helpful responses to
suicidality.
2.8 Final Considerations
The InSPire programme offered the author an opportunity to deliver a clinical
intervention in a prison, with previous prison experience being solely research
based. This opportunity led to considerable professional development and learning
experiences in the delivery of the research and in managing clinical risk whilst
delivering therapy with such a complex population. This study was the first to
deliver intensive CBT in prison and future research considerations and
recommendations have evolved following the InSPire programme. Feasibility
studies offer an advantage by highlighting successes and pitfalls in the feasibility
stage which is an important mediator in increasing the likelihood of success in
larger trials (Van Teijlingen & Hundley, 2002). The InSPire programme was
successful in recruitment and retention and given the promising results in this
study, intensive CBSP holds some promise in supporting prisoners with issues of
suicidality.
Whilst the results were promising, the sample size was small and therefore not
generalisable. Further analysis was considered in terms of efficacy (i.e. Reliable
122
Change Index; Jacobson & Truax, 1991), however, the same sample size issue would
apply. Whilst a limited sample size might be expected within a feasibility study
(Arain, Campbell, Cooper, & Lancaster, 2010), other factors affected
generalisability. The sample was largely homogenous (i.e. ethnicity, gender, same
host prison) and prisoners were motivated to engage, as reflected in the high
retention rate. As both therapists were female, some individuals were excluded due
to specific risk towards females. Future studies could include male and female
therapists and increase collaboration with the host prison to facilitate wider
engagement (i.e. self-isolative individuals). Reaching harder to engage individuals
could improve generalisability and strengthen the conclusions made regarding
feasibility.
Dissemination will include submission to a peer reviewed journal, alongside
presentation of the findings at the University of Manchester and the host prison.
Where opted for, prisoners will receive a short summary of the findings. Personally,
application of the CBSP model will influence future ways of working, by applying the
clinical formulation within community settings when working with individuals
experiencing suicidality.
123
3. References
Aleman, A., & Denys, D. (2014). Mental health: a road map for suicide research and
prevention. Nature News, 509(7501), 421. doi:10.1038/509421a Apa, Z. L., Bai, R., Mukherejee, D. V., Herzig, C. T., Koenigsmann, C., Lowy, F. D., &
Larson, E. L. (2012). Challenges and strategies for research in prisons. Public Health Nursing, 29(5), 467-472. https://doi.org/10.1111/j.1525- 1446.2012.01027.x
Arain, M., Campbell, M. J., Cooper, C. L., & Lancaster, G. A. (2010). What is a pilot or feasibility study? A review of current practice and editorial policy. BioMed Central Medical Research Methodology, 10(1), 67. https://doi.org/10.1186/1471-2288-10-67
Association for Behavioural and Cognitive Therapies. (2019). Cognitive Behavioural Therapy. Retrieved from http://www.abct.org/Resources/?m=mResources&fa=Syllabi
Balshem, H., Stevens, A., Ansari, M., Norris, S., Kansagara, D., Shamliyan, T., … Dickersin, K. (2013). Finding grey literature evidence and assessing for outcome and analysis reporting biases when comparing medical interventions: AHRQ and the effective health care program. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from www.effectivehealthcare.ahrq.gov/reports/final.cfm
Bevan, A., Oldfield, V. B., & Salkovskis, P. M. (2010). A qualitative study of the acceptability of an intensive format for the delivery of cognitive‐behavioural therapy for obsessive‐compulsive disorder. British Journal of Clinical Psychology, 49(2), 173-191. https://doi.org/10.1348/014466509X447055
Boland, A., Cherry, G., & Dickson, R. (Eds.). (2017). Doing a systematic review: A student's guide. London: Sage.
Borrill, J., Snow, L., Medlicott, D., Teers, R., & Paton, J. (2005). Learning from ‘Near Misses’: Interviews with Women who Survived an Incident of Severe Self‐ Harm in Prison. The Howard Journal of Criminal Justice, 44(1), 57-69. https://doi.org/10.1111/j.1468-2311.2005.00355.x
Bower, P., & Gilbody, S. (2005). Stepped care in psychological therapies: access, effectiveness and efficiency: narrative literature review. The British Journal of Psychiatry, 186(1), 11-17. https://doi.org/10.1192/bjp.186.1.11
British Psychology Society. (2008). Briefing Paper No 30: The role of psychologists working in Crisis Resolution Home Treatment (CRHT) Teams. Leicester: The British Psychological Society. Retrieved from https://www.bps.org.uk/sites/bps.org.uk/files/Member%20Networks/Divisi ons/DCP/The%20role%20of%20psychologists%20in%20Crisis%20Resolution %20Home%20Treatment%20%28CRHT%29%20Teams.pdf
British Psychological Society. (2018). Code of Ethics and Conduct. Leicester: The British Psychological Society. Retrieved from https://www.bps.org.uk/sites/bps.org.uk/files/Policy/Policy%20- %20Files/BPS%20Code%20of%20Ethics%20and%20Conduct%20%28Update d%20July%202018%29.pdf
124
Browne, A., Cambier, A., & Agha, S. (2011). Prisons within prisons: The use of segregation in the United States. Federal Sentencing Reporter, 24(1), 46- 49. doi:10.1525/fsr.2011.24.1.46
Care Quality Commission. (2015). Delivering cost effective care in the NHS. Retrieved from https://www.cqc.org.uk/sites/default/files/20151028_delivering_cost_effec tive_care_in_the_NHS.pdf
Challacombe, F. L., & Salkovskis, P. M. (2011). Intensive cognitive-behavioural treatment for women with postnatal obsessive-compulsive disorder: a consecutive case series. Behaviour Research and Therapy, 49(6), 422-426. https://doi.org/10.1016/j.brat.2011.03.006
Clarkson, H., Allcott-Watson, H., Shafran, R., & Bennett., S. (2018). The effectiveness of intensive CBT for anxiety disorders, OCD and PTSD in children and adolescents: a systematic review. PROSPERO 2016 CRD42016038783 Retrieved from http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD4201603 8783
Cobb, S., & Farrants, J. (2014). Male prisoners’ constructions of help- seeking. Journal of Forensic Practice, 16(1), 46-57. https://doi.org/10.1108/JFP-01-2013-0005
Deacon, B. J., & Abramowitz, J. S. (2005). The Yale-Brown Obsessive Compulsive Scale: factor analysis, construct validity, and suggestions for refinement. Journal of Anxiety Disorders, 19(5), 573-585. https://doi.org/10.1016/j.janxdis.2004.04.009
Dear, G. E., Thomson, D. M., & Hills, A. M. (2000). Self-harm in prison: Manipulators can also be suicide attempters. Criminal Justice and Behavior, 27(2), 160- 175. https://doi.org/10.1177/0093854800027002002
Department of Health. (2011). No health without mental health. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploa ds/attachment_data/file/215811/dh_124057.pdf
Ecker, E. D., & Skelly, A. C. (2010). Conducting a winning literature search. Evidence- based Spine-care Journal, 1(01), 9-14. doi:10.1055/s-0028-1100887
Ehlers, A., Clark, D. M., Hackmann, A., Grey, N., Liness, S., Wild, J., … McManus, F. (2010). Intensive cognitive therapy for PTSD: A feasibility study. Behavioural and Cognitive Psychotherapy, 38(4), 383-398. https://doi.org/10.1017/S1352465810000214
Ehlers, A., Hackmann, A., Grey, N., Wild, J., Liness, S., Albert, I., … Clark, D. M. (2014). A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry, 171(3), 294-304. https://doi.org/10.1176/appi.ajp.2013.13040552
Effective Public Health Practice Project. (1998). Quality Assessment Tool For Quantitative Studies. Hamilton, ON: Effective Public Health Practice Project. Retrieved from: https://merst.ca/ephpp/
Effective Public Health Practice Project. (2017). Quality Assessment Tool For Quantitative Studies Dictionary. Retrieved from: https://merst.ca/wp- content/uploads/2018/02/qualilty-assessment-dictionary_2017.pdf
125
Fagard, R. H., Staessen, J. A., & Thijs, L. (1996). Advantages and disadvantages of the meta-analysis approach. Journal of hypertension. Supplement: Official Journal of the International Society of Hypertension, 14(2), S9-12.
Flanagan, C. M. (2010). The case for needs in psychotherapy. Journal of Psychotherapy Integration, 20(1), 1. http://dx.doi.org/10.1037/a0018815
Frankl, V. E. (1985). Man's search for meaning. New York: Simon and Schuster. Georgiou, M., Coll, F., Stone, H., & Davies, S. (2017). Standards for 24 Hour Mental
Healthcare in Prisons Quality Network for Prison Mental Health Services (Publication Number: CCQI268). Royal College of Psychiatrists. Retrieved from https://www.rcpsych.ac.uk/docs/default-source/improving- care/ccqi/quality-networks/prison-quality-network-prison/prison-qn- standards/prisons-24-hour-mental-healthcare-in-prison- standards.pdf?sfvrsn=bef29f20_2
Haney, C. (2012). Prison effects in the era of mass incarceration. The Prison Journal, 1-24. https://doi.org/10.1177/0032885512448604
Hansson, L. & Markstron, U. (2014). The effectiveness of an anti-stigma intervention in a basic police officer training programme: a controlled study. BioMed Central Psychiatry, 14, 55–57. https://doi.org/10.1186/1471-244X-14-55
Harvey, J. (2011). Acknowledging and understanding complexity when providing therapy in prisons. European Journal of Psychotherapy & Counselling, 13(4), 303-315. doi:10.1080/13642537.2011.625204
Harvey, J., & Smedley, K. (Eds.). (2012). Psychological therapy in prisons and other settings. Oxon: Willan Publishing.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12. doi=10.1037%2F0022- 006X.59.1.12
Jolliffe, D., & Haque, Z. (2017). Have prisons become a dangerous place? Disproportionality, safety and mental health in British Prisons. Project Report. The Runnymede Trust. Retrieved from https://gala.gre.ac.uk/id/eprint/20107/
Lewin, A. B., Storch, E. A., Merlo, L. J., Adkins, J. W., Murphy, T., & Geffken, G. A. (2005). Intensive Cognitive Behavioral Therapy for Pediatric Obsessive Compulsive Disorder: A Treatment Protocol for Mental Health Providers. Psychological Services, 2(2), 91. http://dx.doi.org/10.1037/1541- 1559.2.2.91
Liebling, A. (2006). Prisons in transition. International Journal of Law and Psychiatry, 29(5), 422-430. https://doi.org/10.1016/j.ijlp.2006.03.002
Liebling, A. (2011). Moral performance, inhuman and degrading treatment and prison pain. Punishment & Society, 13(5), 530-550. https://doi.org/10.1177/1462474511422159
Liebling, A., Durie, L., Stiles, A., & Tait, S. (2005). Revisiting prison suicide: the role of fairness and distress. In A. Liebling & S. Maruna (Eds.), The effects of imprisonment. Oxon: Willan Publishing.
Liebling, A. & Karup, H. (1993). Suicide Attempts and Self-Injury in Male Prisons. London: Home Office.
126
Marzano, L., Ciclitira, K., & Adler, J. (2012). The impact of prison staff responses on self‐harming behaviours: Prisoners’ perspectives. British Journal of Clinical Psychology, 51(1), 4-18. https://doi.org/10.1111/j.2044-8260.2010.02007.x
Millar, J., Bauer, A., Salkovskis, P., Gregory, J., & Halligan, S. (2018). Is intensive CBT an effective treatment format for adults with OCD? A systematic review. PROSPERO 2018 CRD42018106840 Retrieved from: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD4201810 6840
Miller, S.A., & Forrest, J.L. (2001). Enhancing your practice through evidence-based decision making: PICO, learning how to ask good questions. Journal of Evidence-Based Dental Practice, 1(2):136–41. https://dx.doi.org/10.1016/S1532- 3382(01)70024-3.
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … Stewart, L.A. (2015). Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Systematic Review, 4(1):1. doi: 10.1186/2046-4053-4-1
National Institute for Health and Care Excellence. (2013). Self-harm (NICE Quality standard No. 34). Retrieved from https://www.nice.org.uk/guidance/qs34
Oldfield, V. B., Salkovskis, P. M., & Taylor, T. (2011). Time‐intensive cognitive behaviour therapy for obsessive‐compulsive disorder: A case series and matched comparison group. British Journal of Clinical Psychology, 50(1), 7- 18. https://doi.org/10.1348/014466510X490073
Öst, L. G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 97, 134-145. https://doi.org/10.1016/j.brat.2017.07.008
Pratt, D., Gooding, P., Awenat, Y., Eccles, S., & Tarrier, N. (2016). Cognitive behavioral suicide prevention for male prisoners: case examples. Cognitive and Behavioral Practice, 23(4), 485-501. https://doi.org/10.1016/j.cbpra.2015.09.006
Pratt, D., Tarrier, N., Dunn, G., Awenat, Y., Shaw, J., Ulph, F., & Gooding, P. (2015). Cognitive–behavioural suicide prevention for male prisoners: a pilot randomized controlled trial. Psychological Medicine, 45(16), 3441-3451. https://doi.org/10.1017/S0033291715001348
Rogers, H., & Law, H. (2010). Working with Trauma in a Prison Setting. In J. Harvey & K. Smedley (Eds.), Psychological therapy in prisons and other settings. Oxon: Willan Publishing.
Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325-334. https://doi.org/10.1017/S135246580001643X
St John-Smith, P., McQueen, D., Michael, A., Ikkos, G., Denman, C., Maier, M., … Rao, R. (2009). The trouble with NHS psychiatry in England. Psychiatric Bulletin, 33(6), 219-225. https://doi.org/10.1192/pb.bp.108.023184
Steiner, B., & Wooldredge, J. (2017). Individual and environmental influences on prison officer safety. Justice Quarterly, 34(2), 324-349. https://doi.org/10.1080/07418825.2016.1164883
127
Stiles, W. B., Barkham, M., Connell, J., & Mellor-Clark, J. (2008). Responsive regulation of treatment duration in routine practice in United Kingdom primary care settings: Replication in a larger sample. Journal of Consulting and Clinical Psychology, 76(2), 298. doi:b>10.1037/0022-006X.76.2.298
Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., … Goodman, W. K. (2007). Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child & Adolescent Psychiatry, 46(4), 469-478. https://doi.org/10.1097/chi.0b013e31803062e7
Storch, E. A., Merlo, L. J., Lehmkuhl, H., Geffken, G. R., Jacob, M., Ricketts, E., … Goodman, W. K. (2008). Cognitive-behavioral therapy for obsessive– compulsive disorder: A non-randomized comparison of intensive and weekly approaches. Journal of Anxiety Disorders, 22(7), 1146-1158. https://doi.org/10.1016/j.janxdis.2007.12.001
Tarrier, N. (2010). Broad minded affective coping (BMAC): A “positive” CBT approach to facilitating positive emotions. International Journal of Cognitive Therapy, 3(1), 64-76. https://doi.org/10.1521/ijct.2010.3.1.64
Tarrier, N., Gooding, P., Pratt, D., Kelly, J., Awenat, Y., & Maxwell, J. (2013). Cognitive behavioural prevention of suicide in psychosis: a treatment manual. East Sussex, UK: Routledge.
The British Psychological Society. (2008). Briefing Paper: The role of psychologists working in Crisis Resolution Home Treatment (CRHT) Teams. Leicester: The British Psychological Society. Retrieved from https://www.bps.org.uk/sites/bps.org.uk/files/Member%20Networks/Divisi ons/DCP/The%20role%20of%20psychologists%20in%20Crisis%20Resolution %20Home%20Treatment%20%28CRHT%29%20Teams.pdf
Timimi, S. (2014). No more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished. International Journal of Clinical and Health Psychology, 14(3), 208-215. https://doi.org/10.1016/j.ijchp.2014.03.004
Towl, G. (2002). Psychological services in HM Prison Service and the National Probation Service: working towards an effective partnership. The British Journal of Forensic Practice, 4(3), 3-10. https://doi.org/10.1108/14636646200200016
Van Teijlingen, E., & Hundley, V. (2002). The importance of pilot studies. Nursing Standard, 16(40), 33. doi:10.7748/ns.16.40.33.s1
Voss, P. H., & Rehfuess, E. A. (2013). Quality appraisal in systematic reviews of public health interventions: an empirical study on the impact of choice of tool on meta-analysis. Journal of Epidemiological Community Health, 67(1), 98-104. http://dx.doi.org/10.1136/jech-2011-200940
Whiteside, S. P., Brown, A. M., & Abramowitz, J. S. (2008). Five-day intensive treatment for adolescent OCD: A case series. Journal of Anxiety Disorders, 22(3), 495-504. https://doi.org/10.1016/j.janxdis.2007.05.001
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Appendices
1. Paper I: Systematic Review
129
Appendix 1 Clinical Psychology Review
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AUDIENCE
Psychologists and Clinicians in Psychopathy
IMPACT FACTOR
2017: 9.577 © Clarivate Analytics Journal Citation Reports 2018
ABSTRACTING AND INDEXING
PsycINFO
Current Contents/Social & Behavioral Sciences
BIOSIS
EMBASE
Scopus
Google Scholar
MEDLINE®
EDITORIAL BOARD
Editor-in-Chief Gordon J. G. Asmundson, University of Regina, Regina, Saskatchewan, Canada Associate Editors Ernst H. W. Koster, Universiteit Gent, Gent, Belgium Christine Purdon, University of Waterloo, Waterloo, Ontario, Canada Annemieke van Straten, Vrije Universiteit Amsterdam, Amsterdam, Netherlands Michael J. Zvolensky, University of Houston, Houston, Texas, USA Editorial Board Ruth A. Baer, University of Kentucky, Lexington, Kentucky, USA Daniel Bagner, Florida International University, Miami, Florida, USA
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Anna M. Bardone-Cone, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Linda Booij, Concordia University, Montréal, Quebec, Canada Andrew M. Busch, The Miriam Hospital, Centers for Behavioral and Preventive Medicine, Providence, Rhode Island, USA John E. Calamari, Rosalind Franklin University of Med. and Science, North Chicago, Illinois, USA Michael S. Christopher, Pacific University, Forest Grove, Oregon, USA Pim Cuijpers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands Melissa Cyders, Indiana University-Purdue University at Indianapolis (IUPUI), Idianapolis, Indiana, USA Joanne Davis, University of Tulsa, Tulsa, Oklahoma, USA Jon D. Elhai, University of Toledo, Toledo, Ohio, USA Brandon A. Gaudiano, Brown University, Providence, Rhode Island, USA David A. F. Haaga, The American University (AU), Washington, District of Columbia, USA Gretchen Haas, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Gerald Haeffel, University of Notre Dame, Notre Dame, Indiana, USA Richard Hallam, London, UK Martin Harrow, University of Illinois College of Medicine, Chicago, Illinois, USA Holly Hazlett-Stevens, University of Nevada at Reno, Reno, Nevada, USA Eli R. Lebowitz, Yale University School of Medicine, New Haven, Connecticut, USA Ellen W. Leen-Feldner, University of Arkansas, Fayetteville, Arkansas, USA Carl Lejuez, University of Kansas, Lawrence, Kansas, USA Richard Moulding, Deakin University, Melbourne, Victoria, Australia Kim T. Mueser, Boston University, Boston, Massachusetts, USA Jeremy Pettit, Florida International University, Miami, Florida, USA Suzanne Pineles, National Center for PTSD, Boston, Massachusetts, USA Mark D. Rapport, University of Central Florida, Orlando, Florida, USA Karen Rowa, McMaster University, Hamilton, Ontario, Canada Kristalyn Salters-Pedneault, Eastern Connecticut State University, Willimantic, Connecticut, USA Donald Sharpe, University of Regina, Regina, Saskatchewan, Canada Eric A. Storch, Baylor College of Medicine, Houston, Texas, USA Bruce E. Wampold, University of Wisconsin at Madison, Madison, Wisconsin, USA Carl F. Weems, Iowa State University, Ames, Iowa, USA Aviv Weinstein, Ariel University, Ariel, Israel Thomas A. Widiger, University of Kentucky, Lexington, Kentucky, USA Sabine Wilhelm, Harvard Medical School, Boston, Massachusetts,
USA
GUIDE FOR AUTHORS
Submission checklist
You can use this list to carry out a final check of your submission before you send it to the journal for review.
Please check the relevant section in this Guide for Authors for more details.
Ensure that the following items are present:
One author has been designated as the corresponding author with contact details:
E-mail address
Full postal address
All necessary files have been uploaded:
Manuscript:
Include keywords
All figures (include relevant captions)
All tables (including titles, description, footnotes)
Ensure all figure and table citations in the text match the files provided
Indicate clearly if color should be used for any figures in print
Graphical Abstracts / Highlights files (where applicable)
Supplemental files (where applicable)
Further considerations
Manuscript has been 'spell checked' and 'grammar checked'
All references mentioned in the Reference List are cited in the text, and vice versa
Permission has been obtained for use of copyrighted material from other sources (including theInternet)
A competing interests statement is provided, even if the authors have no competing interests todeclare
Journal policies detailed in this guide have been reviewed
Referee suggestions and contact details provided, based on journal requirements
For further information, visit our Support Center.
BEFORE YOU BEGIN
Ethics in publishing
Please see our information pages on Ethics in publishing and Ethical guidelines for journal publication.
Declaration of interest
All authors must disclose any financial and personal relationships with other people or organizations that could
inappropriately influence (bias) their work. Examples of potential competing interests include employment,
.
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consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or
other funding. Authors must disclose any interests in two places: 1. A summary declaration of interest statement
in the title page file (if double-blind) or the manuscript file (if single-blind). If there are no interests to declare
then please state this: 'Declarations of interest: none'. This summary statement will be ultimately published if the
article is accepted. 2. Detailed disclosures as part of a separate Declaration of Interest form, which forms part of
the journal's official records. It is important for potential interests to be declared in both places and that the
information matches. More information.
Submission declaration and verification
Submission of an article implies that the work described has not been published previously (except in the form of
an abstract, a published lecture or academic thesis, see 'Multiple, redundant or concurrent publication' for more
information), that it is not under consideration for publication elsewhere, that its publication is approved by all
authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if
accepted, it will not be published elsewhere in the same form, in English or in any other language, including
electronically without the written consent of the copyrightholder. To verify originality, your article may be
checked by the originality detection service Crossref Similarity Check.
Preprints
Please note that preprints can be shared anywhere at any time, in line with Elsevier's sharing policy. Sharing your
preprints e.g. on a preprint server will not count as prior publication (see 'Multiple, redundant or concurrent
publication' for more information).
Use of inclusive language
Inclusive language acknowledges diversity, conveys respect to all people, is sensitive to differences, and
promotes equal opportunities. Articles should make no assumptions about the beliefs or commitments of any
reader, should contain nothing which might imply that one individual is superior to another on the grounds of
race, sex, culture or any other characteristic, and should use inclusive language throughout. Authors should
ensure that writing is free from bias, for instance by using 'he or she', 'his/her' instead of 'he' or 'his', and by
making use of job titles that are free of stereotyping (e.g. 'chairperson' instead of 'chairman' and 'flight attendant'
instead of 'stewardess').
Changes to authorship
Authors are expected to consider carefully the list and order of authors before submitting their manuscript and
provide the definitive list of authors at the time of the original submission. Any addition, deletion or
rearrangement of author names in the authorship list should be made only before the manuscript has been
accepted and only if approved by the journal Editor. To request such a change, the Editor must receive the
following from the corresponding author: (a) the reason for the change in author list and (b) written confirmation
(e-mail, letter) from all authors that they agree with the addition, removal or rearrangement. In the case of
addition or removal of authors, this includes confirmation from the author being added or removed.
Only in exceptional circumstances will the Editor consider the addition, deletion or rearrangement of authors
after the manuscript has been accepted. While the Editor considers the request, publication of the manuscript will
be suspended. If the manuscript has already been published in an online issue, any requests approved by the
Editor will result in a corrigendum.
Author Disclosure Policy
Authors must provide three mandatory and one optional author disclosure statements. These statements should be
submitted as one separate document and not included as part of the manuscript. Author disclosures will be
automatically incorporated into the PDF builder of the online submission system. They will appear in the journal
article if the manuscript is accepted.
The four statements of the author disclosure document are described below. Statements should not be numbered.
Headings (i.e., Role of Funding Sources, Contributors, Conflict of Interest, Acknowledgements) should be in
bold with no white space between the heading and the text. Font size should be the same as that used for
references.
Statement 1: Role of Funding Sources
Authors must identify who provided financial support for the conduct of the research and/or preparation of the
manuscript and to briefly describe the role (if any) of the funding sponsor in study design, collection, analysis, or
interpretation of data, writing the manuscript, and the decision to submit the manuscript for publication. If the
funding source had no such involvement, the authors should so state.
Example: Funding for this study was provided by NIAAA Grant R01-AA123456. NIAAA had no role in the
study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit
the paper for publication.
Statement 2: Contributors
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Authors must declare their individual contributions to the manuscript. All authors must have materially
participated in the research and/or the manuscript preparation. Roles for each author should be described. The
disclosure must also clearly state and verify that all authors have approved the final manuscript.
Example: Authors A and B designed the study and wrote the protocol. Author C conducted literature searches
and provided summaries of previous research studies. Author D conducted the statistical analysis. Author B
wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Statement 3: Conflict of Interest
All authors must disclose any actual or potential conflict of interest. Conflict of interest is defined as any
financial or personal relationships with individuals or organizations, occurring within three (3) years of beginning
the submitted work, which could inappropriately influence, or be perceived to have influenced the submitted
research manuscript. Potential conflict of interest would include employment, consultancies, stock ownership
(except personal investments equal to the lesser of one percent (1%) of total personal investments or USD$5000),
honoraria, paid expert testimony, patent applications, registrations, and grants. If there are no conflicts of interest
by any author, it should state that there are none.
Example: Author B is a paid consultant for XYZ pharmaceutical company. All other authors declare that they
have no conflicts of interest.
Statement 4: Acknowledgements (optional)
Authors may provide Acknowledgments which will be published in a separate section along with the manuscript.
If there are no Acknowledgements, there should be no heading or acknowledgement statement.
Example: The authors wish to thank Ms. A who assisted in the proof-reading of the manuscript.
Copyright
Upon acceptance of an article, authors will be asked to complete a 'Journal Publishing Agreement' (see more
information on this). An e-mail will be sent to the corresponding author confirming receipt of the manuscript
together with a 'Journal Publishing Agreement' form or a link to the online version of this agreement.
Subscribers may reproduce tables of contents or prepare lists of articles including abstracts for internal
circulation within their institutions. Permission of the Publisher is required for resale or distribution outside the
institution and for all other derivative works, including compilations and translations. If excerpts from other
copyrighted works are included, the author(s) must obtain written permission from the copyright owners and
credit the source(s) in the article. Elsevier has preprinted forms for use by authors in these cases.
For gold open access articles: Upon acceptance of an article, authors will be asked to complete an 'Exclusive
License Agreement' (more information). Permitted third party reuse of gold open access articles is determined by
the author's choice of user license.
Author rights
As an author you (or your employer or institution) have certain rights to reuse your work. More information.
Elsevier supports responsible sharing
Find out how you can share your research published in Elsevier journals.
Role of the funding source
You are requested to identify who provided financial support for the conduct of the research and/or preparation
of the article and to briefly describe the role of the sponsor(s), if any, in study design; in the collection, analysis
and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. If
the funding source(s) had no such involvement then this should be stated.
Funding body agreements and policies
Elsevier has established a number of agreements with funding bodies which allow authors to comply with their
funder's open access policies. Some funding bodies will reimburse the author for the gold open access publication
fee. Details of existing agreements are available online.
Open access
This journal offers authors a choice in publishing their research:
Subscription
Articles are made available to subscribers as well as developing countries and patient groups throughour
universal access programs.
No open access publication fee payable by authors.
The Author is entitled to post the accepted manuscript in their institution's repository and make this public after
an embargo period (known as green Open Access). The published journal article cannot be shared publicly, for
example on ResearchGate or Academia.edu, to ensure the sustainability of peerreviewed research in journal
publications. The embargo period for this journal can be found below.
Gold open access
Articles are freely available to both subscribers and the wider public with permitted reuse.
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A gold open access publication fee is payable by authors or on their behalf, e.g. by their researchfunder or
institution.
Regardless of how you choose to publish your article, the journal will apply the same peer review criteria and
acceptance standards.
For gold open access articles, permitted third party (re)use is defined by the following Creative Commons user
licenses:
Creative Commons Attribution (CC BY)
Lets others distribute and copy the article, create extracts, abstracts, and other revised versions, adaptations or
derivative works of or from an article (such as a translation), include in a collective work (such as an anthology),
text or data mine the article, even for commercial purposes, as long as they credit the author(s), do not represent
the author as endorsing their adaptation of the article, and do not modify the article in such a way as to damage
the author's honor or reputation.
Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)
For non-commercial purposes, lets others distribute and copy the article, and to include in a collective work (such
as an anthology), as long as they credit the author(s) and provided they do not alter or modify the article.
The gold open access publication fee for this journal is USD 1950, excluding taxes. Learn more about Elsevier's
pricing policy: https://www.elsevier.com/openaccesspricing.
Green open access
Authors can share their research in a variety of different ways and Elsevier has a number of green open access
options available. We recommend authors see our green open access page for further information. Authors can
also self-archive their manuscripts immediately and enable public access from their institution's repository after
an embargo period. This is the version that has been accepted for publication and which typically includes
author-incorporated changes suggested during submission, peer review and in editor-author communications.
Embargo period: For subscription articles, an appropriate amount of time is needed for journals to deliver value
to subscribing customers before an article becomes freely available to the public. This is the embargo period and
it begins from the date the article is formally published online in its final and fully citable form. Find out more.
This journal has an embargo period of 24 months.
Elsevier Researcher Academy
Researcher Academy is a free e-learning platform designed to support early and mid-career researchers
throughout their research journey. The "Learn" environment at Researcher Academy offers several interactive
modules, webinars, downloadable guides and resources to guide you through the process of writing for research
and going through peer review. Feel free to use these free resources to improve your submission and navigate the
publication process with ease.
Language (usage and editing services)
Please write your text in good English (American or British usage is accepted, but not a mixture of these).
Authors who feel their English language manuscript may require editing to eliminate possible grammatical or
spelling errors and to conform to correct scientific English may wish to use the English Language Editing service
available from Elsevier's WebShop.
Submission
Our online submission system guides you stepwise through the process of entering your article details and
uploading your files. The system converts your article files to a single PDF file used in the peer-review process.
Editable files (e.g., Word, LaTeX) are required to typeset your article for final publication. All correspondence,
including notification of the Editor's decision and requests for revision, is sent by e-mail.
PREPARATION
Peer review
This journal operates a single blind review process. All contributions will be initially assessed by the editor for
suitability for the journal. Papers deemed suitable are then typically sent to a minimum of two independent expert
reviewers to assess the scientific quality of the paper. The Editor is responsible for the final decision regarding
acceptance or rejection of articles. The Editor's decision is final. More information on types of peer review.
Use of word processing software
It is important that the file be saved in the native format of the word processor used. The text should be in single-
column format. Keep the layout of the text as simple as possible. Most formatting codes will be removed and
replaced on processing the article. In particular, do not use the word processor's options to justify text or to
hyphenate words. However, do use bold face, italics, subscripts, superscripts etc. When preparing tables, if you
are using a table grid, use only one grid for each individual table and not a grid for each row. If no grid is used,
use tabs, not spaces, to align columns. The electronic text should be prepared in a way very similar to that of
conventional manuscripts (see also the Guide to Publishing with Elsevier). Note that source files of figures,
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tables and text graphics will be required whether or not you embed your figures in the text. See also the section
on Electronic artwork.
To avoid unnecessary errors you are strongly advised to use the 'spell-check' and 'grammar-check' functions of
your word processor.
Article structure
Manuscripts should be prepared according to the guidelines set forth in the Publication Manual of the American
Psychological Association (6th ed., 2009). Of note, section headings should not be numbered.
Manuscripts should ordinarily not exceed 50 pages, including references and tabular material. Exceptions may be
made with prior approval of the Editor in Chief. Manuscript length can often be managed through the judicious
use of appendices. In general the References section should be limited to citations actually discussed in the text.
References to articles solely included in meta-analyses should be included in an appendix, which will appear in
the on line version of the paper but not in the print copy. Similarly, extensive Tables describing study
characteristics, containing material published elsewhere, or presenting formulas and other technical material
should also be included in an appendix. Authors can direct readers to the appendices in appropriate places in the
text.
It is authors' responsibility to ensure their reviews are comprehensive and as up to date as possible (at least
through the prior calendar year) so the data are still current at the time of publication. Authors are referred to the
PRISMA Guidelines (http://www.prisma-statement.org/statement.htm) for guidance in conducting reviews and
preparing manuscripts. Adherence to the Guidelines is not required, but is recommended to enhance quality of
submissions and impact of published papers on the field.
Appendices
If there is more than one appendix, they should be identified as A, B, etc. Formulae and equations in appendices
should be given separate numbering: Eq. (A.1), Eq. (A.2), etc.; in a subsequent appendix, Eq. (B.1) and so on.
Similarly for tables and figures: Table A.1; Fig. A.1, etc.
Essential title page information
Title. Concise and informative. Titles are often used in information-retrieval systems. Avoid abbreviations and
formulae where possible. Note: The title page should be the first page of the manuscript document indicating the
author's names and affiliations and the corresponding author's complete contact information.
Author names and affiliations. Where the family name may be ambiguous (e.g., a double name), please indicate
this clearly. Present the authors' affiliation addresses (where the actual work was done) below the names. Indicate
all affiliations with a lower-case superscript letter immediately after the author's name and in front of the
appropriate address. Provide the full postal address of each affiliation, including the country name, and, if
available, the e-mail address of each author within the cover letter.
Corresponding author. Clearly indicate who is willing to handle correspondence at all stages of refereeing and
publication, also post-publication. Ensure that telephone and fax numbers (with country and area code) are
provided in addition to the e-mail address and the complete postal address.
Present/permanent address. If an author has moved since the work described in the article was done, or was
visiting at the time, a "Present address"' (or "Permanent address") may be indicated as a footnote to that author's
name. The address at which the author actually did the work must be retained as the main, affiliation address.
Superscript Arabic numerals are used for such footnotes.
Abstract
A concise and factual abstract is required (not exceeding 200 words). This should be typed on a separate page
following the title page. The abstract should state briefly the purpose of the research, the principal results and
major conclusions. An abstract is often presented separate from the article, so it must be able to stand alone.
References should therefore be avoided, but if essential, they must be cited in full, without reference to the
reference list.
Graphical abstract
Although a graphical abstract is optional, its use is encouraged as it draws more attention to the online article.
The graphical abstract should summarize the contents of the article in a concise, pictorial form designed to
capture the attention of a wide readership. Graphical abstracts should be submitted as a separate file in the online
submission system. Image size: Please provide an image with a minimum of 531 × 1328 pixels (h × w) or
proportionally more. The image should be readable at a size of 5 × 13 cm using a regular screen resolution of 96
dpi. Preferred file types: TIFF, EPS, PDF or MS Office files. You can view Example Graphical Abstracts on our
information site.
Authors can make use of Elsevier's Illustration Services to ensure the best presentation of their images and in
accordance with all technical requirements.
Highlights
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Highlights are mandatory for this journal. They consist of a short collection of bullet points that convey the core
findings of the article and should be submitted in a separate editable file in the online submission system. Please
use 'Highlights' in the file name and include 3 to 5 bullet points (maximum 85 characters, including spaces, per
bullet point). You can view example Highlights on our information site.
Keywords
Immediately after the abstract, provide a maximum of 6 keywords, using American spelling and avoiding general
and plural terms and multiple concepts (avoid, for example, 'and', 'of'). Be sparing with abbreviations: only
abbreviations firmly established in the field may be eligible. These keywords will be used for indexing purposes.
Abbreviations
Define abbreviations that are not standard in this field in a footnote to be placed on the first page of the article.
Such abbreviations that are unavoidable in the abstract must be defined at their first mention there, as well as in
the footnote. Ensure consistency of abbreviations throughout the article.
Acknowledgements
Collate acknowledgements in a separate section at the end of the article before the references and do not,
therefore, include them on the title page, as a footnote to the title or otherwise. List here those individuals who
provided help during the research (e.g., providing language help, writing assistance or proof reading the article,
etc.).
Formatting of funding sources
List funding sources in this standard way to facilitate compliance to funder's requirements:
Funding: This work was supported by the National Institutes of Health [grant numbers xxxx, yyyy]; the Bill &
Melinda Gates Foundation, Seattle, WA [grant number zzzz]; and the United States Institutes of Peace [grant
number aaaa].
It is not necessary to include detailed descriptions on the program or type of grants and awards. When funding is
from a block grant or other resources available to a university, college, or other research institution, submit the
name of the institute or organization that provided the funding.
If no funding has been provided for the research, please include the following sentence:
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit
sectors.
Footnotes
Footnotes should be used sparingly. Number them consecutively throughout the article. Many word processors
can build footnotes into the text, and this feature may be used. Otherwise, please indicate the position of
footnotes in the text and list the footnotes themselves separately at the end of the article. Do not include footnotes
in the Reference list.
Electronic artwork General points
Make sure you use uniform lettering and sizing of your original artwork.
Embed the used fonts if the application provides that option.
Aim to use the following fonts in your illustrations: Arial, Courier, Times New Roman, Symbol, oruse fonts that
look similar.
Number the illustrations according to their sequence in the text.
Use a logical naming convention for your artwork files.
Provide captions to illustrations separately.
Size the illustrations close to the desired dimensions of the published version.
Submit each illustration as a separate file.
A detailed guide on electronic artwork is available.
You are urged to visit this site; some excerpts from the detailed information are given here. Formats
If your electronic artwork is created in a Microsoft Office application (Word, PowerPoint, Excel) then please
supply 'as is' in the native document format.
Regardless of the application used other than Microsoft Office, when your electronic artwork is finalized, please
'Save as' or convert the images to one of the following formats (note the resolution requirements for line
drawings, halftones, and line/halftone combinations given below):
EPS (or PDF): Vector drawings, embed all used fonts.
TIFF (or JPEG): Color or grayscale photographs (halftones), keep to a minimum of 300 dpi.
TIFF (or JPEG): Bitmapped (pure black & white pixels) line drawings, keep to a minimum of 1000 dpi. TIFF (or
JPEG): Combinations bitmapped line/half-tone (color or grayscale), keep to a minimum of 500 dpi.
Please do not:
Supply files that are optimized for screen use (e.g., GIF, BMP, PICT, WPG); these typically have alow number
of pixels and limited set of colors;
Supply files that are too low in resolution;
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Submit graphics that are disproportionately large for the content.
Color artwork
Please make sure that artwork files are in an acceptable format (TIFF (or JPEG), EPS (or PDF), or MS Office
files) and with the correct resolution. If, together with your accepted article, you submit usable color figures then
Elsevier will ensure, at no additional charge, that these figures will appear in color online (e.g., ScienceDirect and
other sites) regardless of whether or not these illustrations are reproduced in color in the printed version. For
color reproduction in print, you will receive information regarding the costs from Elsevier after receipt of your
accepted article. Please indicate your preference for color: in print or online only. Further information on the
preparation of electronic artwork.
Figure captions
Ensure that each illustration has a caption. Supply captions separately, not attached to the figure. A caption
should comprise a brief title (not on the figure itself) and a description of the illustration. Keep text in the
illustrations themselves to a minimum but explain all symbols and abbreviations used.
Tables
Please submit tables as editable text and not as images. Tables can be placed either next to the relevant text in the
article, or on separate page(s) at the end. Number tables consecutively in accordance with their appearance in the
text and place any table notes below the table body. Be sparing in the use of tables and ensure that the data
presented in them do not duplicate results described elsewhere in the article. Please avoid using vertical rules and
shading in table cells.
References
Citations in the text should follow the referencing style used by the American Psychological Association. You
are referred to the Publication Manual of the American Psychological Association, Sixth Edition, ISBN 1-4338-
0559-6, copies of which may be ordered from http://books.apa.org/ books.cfm?id=4200067 or APA Order Dept.,
P.O.B. 2710, Hyattsville, MD 20784, USA or APA, 3 Henrietta Street, London, WC3E 8LU, UK. Details
concerning this referencing style can also be found at
http://humanities.byu.edu/linguistics/Henrichsen/APA/APA01.html
Citation in text
Please ensure that every reference cited in the text is also present in the reference list (and vice versa). Any
references cited in the abstract must be given in full. Unpublished results and personal communications are not
recommended in the reference list, but may be mentioned in the text. If these references are included in the
reference list they should follow the standard reference style of the journal and should include a substitution of
the publication date with either 'Unpublished results' or 'Personal communication'. Citation of a reference as 'in
press' implies that the item has been accepted for publication.
Web references
As a minimum, the full URL should be given and the date when the reference was last accessed. Any further
information, if known (DOI, author names, dates, reference to a source publication, etc.), should also be given.
Web references can be listed separately (e.g., after the reference list) under a different heading if desired, or can
be included in the reference list.
Data references
This journal encourages you to cite underlying or relevant datasets in your manuscript by citing them in your text
and including a data reference in your Reference List. Data references should include the following elements:
author name(s), dataset title, data repository, version (where available), year, and global persistent identifier. Add
[dataset] immediately before the reference so we can properly identify it as a data reference. The [dataset]
identifier will not appear in your published article.
References in a special issue
Please ensure that the words 'this issue' are added to any references in the list (and any citations in the text) to
other articles in the same Special Issue.
Reference management software
Most Elsevier journals have their reference template available in many of the most popular reference
management software products. These include all products that support Citation Style Language styles, such as
Mendeley and Zotero, as well as EndNote. Using the word processor plug-ins from these products, authors only
need to select the appropriate journal template when preparing their article, after which citations and
bibliographies will be automatically formatted in the journal's style. If no template is yet available for this
journal, please follow the format of the sample references and citations as shown in this Guide. If you use
reference management software, please ensure that you remove all field codes before submitting the electronic
manuscript. More information on how to remove field codes.
Users of Mendeley Desktop can easily install the reference style for this journal by clicking the following link:
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http://open.mendeley.com/use-citation-style/clinical-psychology-review
When preparing your manuscript, you will then be able to select this style using the Mendeley plugins for
Microsoft Word or LibreOffice. Reference style
References should be arranged first alphabetically and then further sorted chronologically if necessary. More than
one reference from the same author(s) in the same year must be identified by the letters "a", "b", "c", etc., placed
after the year of publication. References should be formatted with a hanging indent (i.e., the first line of each
reference is flush left while the subsequent lines are indented).
Examples: Reference to a journal publication: Van der Geer, J., Hanraads, J. A. J., & Lupton R. A. (2000). The
art of writing a scientific article. Journal of Scientific Communications, 163, 51-59.
Reference to a book: Strunk, W., Jr., &White, E. B. (1979). The elements of style. (3rd ed.). New York:
Macmillan, (Chapter 4).
Reference to a chapter in an edited book: Mettam, G. R., & Adams, L. B. (1994). How to prepare an electronic
version of your article. In B.S. Jones, & R. Z. Smith (Eds.), Introduction to the electronic age (pp. 281-304).
New York: E-Publishing Inc.
[dataset] Oguro, M., Imahiro, S., Saito, S., Nakashizuka, T. (2015). Mortality data for Japanese oak wilt disease
and surrounding forest compositions. Mendeley Data, v1. http://dx.doi.org/10.17632/ xwj98nb39r.1
Video
Elsevier accepts video material and animation sequences to support and enhance your scientific research. Authors
who have video or animation files that they wish to submit with their article are strongly encouraged to include
links to these within the body of the article. This can be done in the same way as a figure or table by referring to
the video or animation content and noting in the body text where it should be placed. All submitted files should
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139
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140
Appendix 2
The Effect Public Health Practice
Project (EPHPP) Quality Tool
141
Appendix A: Effective Public Health Practice
Project (EPHPP) Quality Assessment Tool for
Quantitative Studies
© The Author(s) 2015 45 N. Evans et al., A Systematic Review of Rural Development Research, SpringerBriefs in Public Health, DOI 10.1007/978-3-319-17284-2
46Appendix A: Effective Public Health Practice Project (EPHPP) Quality Assessment
Tool...
142
143
144
Appendices
2. Paper II: Empirical Study
145
Appendix 3
Archives of Suicide Research
Guidance for Authors
146
Instructions to Authors Archives of Suicide Research, the official journal of the International Academy for Suicide Research, is an
international journal in the field devoted to suicide research. The contributions in Archives represent the breadth
of suicide erudition in the scientific community featuring original research from diverse disciplines including
biology, psychiatry, psychology and sociology. The journal has become renowned for reporting on the most
current and relevant aspects of suicide research, as well as defining the foundations of the field.
Submission of Manuscripts: Please send questions and/or electronic manuscripts in English to the Editor-in-
Chief: Barbara Stanley, Ph.D. E-mail: [email protected]. Manuscripts, including tables,
figures, and references, should be prepared in accordance with the American Psychological Association 5th
Edition. All manuscripts must be typed, double-spaced, on 8.5 x 11 inch paper with a 1-inch margin all around.
Articles should be limited to 6000 words. For any other inquiries please contact Abbie Kwitel, Editorial
Assistant at (country code: 001) 212-543-2913.
Review Process. The Journal Editor and Editorial Staff determine whether the subject matter and content of the
manuscripts submitted are pertinent to ASR. The manuscript will be sent out for peer review if it is found to be
relevant and important. The author may expect to receive the reviewers’ responses within 4 to 6 weeks from the
date the manuscript was originally sent to ASR. All reviewers remain anonymous. Authors will be informed of
the Editor’s decision regarding their manuscript’s status of publication when the review process ends.
Manuscript Organization. Cover Letter: A cover letter must be included indicating that the material is intended
for publication and that all the authors have agreed to the content and submission of the manuscript.
Title page: The title page should include the following:
·Title of the manuscript: Authors should also supply a shortened version of the title suitable for the running head,
not exceeding 50 characters and spaces.
·Total word count
·Up to 6 keywords
·Complete contact information: this includes the corresponding author’s full name, title, telephone number, fax
number, and e-mail address.
Disclosures and Acknowledgments: authors are required to disclose of all forms of support, including financial
support or involvement in their cover letter. Pharmaceutical company and grant support, as well as any other
supportive agency, grant number or contract, and acknowledgments of individuals should all be included here.
Abstract: Each article should be summarized in an abstract of no more that 120 words. Abstract should be
separated into Objectives, Methods, Results, Conclusion. Avoid abbreviations, diagrams, and reference to the
text.
Text: The contents of the text should adhere to the general structure of scientific papers: introduction, method,
results, and discussion. If applicable, it should be made clear in the methods section that informed consent was
obtained from subjects who participated in the study.
Illustrations: Illustrations submitted (line drawings, halftones, photos, photomicrographs, etc.) should be clean
originals or digital files. Digital files are recommended for highest quality reproduction and should follow
these guidelines: 300 dpi or higher; sized to fit on journal page; EPS, TIFF, or PSD format only; submitted as
separate files, not embedded in text files.
Color illustrations will be considered for publication; however, the author will be required to bear the full cost
involved in their printing and publication. The charge for the first page with color is $900.00. The next three
pages with color are $450.00 each. A custom quote will be provided for color art totaling more than 4 journal
pages. Good-quality color prints or files should be provided in their final size. The publisher has the right to
refuse publication of color prints deemed unacceptable.
Tables and Figures. Tables and figures should be numbered and included as separate sheets or files. Tables and
figures should not be embedded in the text. A short descriptive title should appear above each table with a clear
legend and any footnotes suitably identified below. All units must be included. Figures should be completely
labeled, taking into account necessary size reduction. Captions should be typed, double-spaced, on a separate
sheet.
References. References should be listed on separate pages following the text. They should be listed
alphabetically by first author and should not be numbered. Be sure all references have been cited in the text.
Provide the last names and first initials of maximum three authors; “et al.” should be used for articles containing
more than three authors. Journal names should not be abbreviated. Italicize journal names and book titles. Article
references should include the author names, year of publication, title of the article, complete name of the journal,
the volume and the page numbers in which the article appears.
Proofs. One set of page proofs is sent to the designated author. Proofs should be checked and returned within 48
hours.
Off prints and Complimentary Copies. The corresponding author of each article will receive up to 3
complimentary issues. Off prints of the article and additional issues may be ordered from Taylor & Francis by
using the link to the order form included with the page proofs.
Permissions. Authors are responsible for obtaining permission to reproduce copyrighted material from other
sources.
147
Appendix 4
University of Manchester Ethical Approval
148
Faculty of Biology, Medicine & Health The University of Manchester
Oxford Road Manchester M13 9PT
www.manchester.ac.uk
5 April 2018 To whom it may concern Sponsor Reference: NHS001347
Role of the Research Sponsor under the UK Policy Framework for Health and Social Care (2017) and the Medicines for Human Use (Clinical Trials) Regulations 2004 (SI2004/1031)
I hereby confirm that the University of Manchester would be prepared to accept the role of research sponsor as currently defined in the UK Policy Framework for Health and Social Care (2017) and the Medicines for Human Use (Clinical Trials) Regulations 2004 (SI2004/1031), in relation to the study:
The INSPiRe Programme: Developing an Intensive Suicide Prevention Therapy for suicidal prisoners
I have been informed that this study will be led by Dr Daniel Pratt of The University of Manchester. Sponsorship is subject to the following conditions: The lead investigator for the study must be an employee of the University of Manchester. For student research the academic supervisor is considered to be the lead investigator. An appropriate contract must be agreed between the University and the funding body. The research must be reviewed and approved by appropriate ethics, NHS and regulatory bodies and registered in accordance with University insurance requirements. To enable the sponsor to meet their responsibilities as listed in section 9.10 of the UK Policy Framework for Health and Social Care (2017), Chief Investigators are asked to adhere to the responsibilities as outlined in section 9.2 of the UK Policy Framework for Health and Social Care (2017) (available at: https://www.hra.nhs.uk/documents/1068/uk-policy-framework-health- social-care-research.pdf). In line with this requirement Dr Daniel Pratt must ensure that all involved in the research project understand and discharge their responsibilities in accordance with the agreed protocol and any relevant management, ethical and regulatory approvals. If you have any queries about sponsorship of this project then please address them to Ms Lynne MacRae, Faculty Research Practice Coordinator, University of Manchester, Simon Building, Brunswick Street, Manchester M13 9PL, or email [email protected]. Yours Faithfully,
Lynne MacRae Dated: 5
th April 2018
Research Practice Governance Coordinator Faculty of Biology, Medicine and Health The University of Manchester, Oxford Road, Manchester M13 9PL Royal Charter Number: RC000797
149
Appendix 5
Health Research Authority Ethical Approval
150
Dr Daniel Pratt Clinical Psychologist Email: [email protected] University of Manchester [email protected] 2nd Floor Zochonis Building Brunswick Street University of Manchester M13 9PL
04 June 2018
Dear Dr Pratt
HRA and Health and Care
Research Wale(HCRW) Approval Letter
Study title: The INSPiRe Programme: Developing an Intensive Suicide
Prevention Therapy for suicidal prisoners.
IRAS project ID: 238927
Protocol number: 7923
REC reference: 18/NE/0158
Sponsor University of Manchester
I am pleased to confirm that HRA and Health and Care Research Wales (HCRW) Approval has been given for the above referenced study, on the basis described in the application form,
protocol, supporting documentation and any clarifications received. You should not expect to receive
anything further relating to this application.
How should I continue to work with participating NHS organisations in England and Wales? You should now provide a copy of this letter to all participating NHS organisations in England and Wales*, as well as any documentation that has been updated as a result of the
assessment. *‘In flight studies’ which have already started an SSI (Site Specific Information) application for NHS
organisations in Wales will continue to use this route. Until 10 June 2018, applications on either
documentation will be accepted in Wales, but after this date all local information packs should be
shared with NHS organisations in Wales using the Statement of Activities/Schedule of Events for
non-commercial studies and template agreement/ Industry costing template for commercial studies.
Following the arranging of capacity and capability, participating NHS organisations should formally confirm their capacity and capability to undertake the study. How this will be confirmed is detailed in the “summary of assessment” section towards the end of this letter. Page 1 of 8
You should provide, if you have not already done so, detailed instructions to each organisation as to
how you will notify them that research activities may commence at site following their confirmation
of capacity and capability (e.g. provision by you of a ‘green light’ email, formal notification
151
following a site initiation visit, activities may commence immediately following confirmation by
participating organisation, etc.).
It is important that you involve both the research management function (e.g. R&D office) supporting
each organisation and the local research team (where there is one) in setting up your study. Contact
details of the research management function for each organisation can be accessed here.
How should I work with participating NHS/HSC organisations in Northern Ireland and
Scotland?
HRA and HCRW Approval does not apply to NHS/HSC organisations within the devolved
administrations of Northern Ireland and Scotland.
If you indicated in your IRAS form that you do have participating organisations in either of these
devolved administrations, the final document set and the study wide governance report (including this
letter) has been sent to the coordinating centre of each participating nation. You should work with the
relevant national coordinating functions to ensure any nation specific checks are complete, and with
each site so that they are able to give management permission for the study to begin.
Please see IRAS Help for information on working with NHS/HSC organisations in Northern Ireland
and Scotland.
How should I work with participating non-NHS organisations?
HRA and HCRW Approval does not apply to non-NHS organisations. You should work with your
nonNHS organisations to obtain local agreement in accordance with their procedures.
What are my notification responsibilities during the study?
The document “After Ethical Review – guidance for sponsors and investigators”, issued with your REC favourable opinion, gives detailed guidance on reporting expectations for studies,
including: Registration of research
• Notifying amendments
• Notifying the end of the study
The HRA website also provides guidance on these topics, and is updated in the light of changes in
reporting expectations or procedures.
I am a participating NHS organisation in England or Wales. What should I do once I
receive this letter?
You should work with the applicant and sponsor to complete any outstanding arrangements so you
are able to confirm capacity and capability in line with the information provided in this letter.
The sponsor contact for this application is as follows: Name: Lynne Macrae (University of Manchester) Tel: 0161 275 5436 Email: [email protected] Who should I contact for further information?
Please do not hesitate to contact me for assistance with this application. My contact details are below.
Your IRAS project ID is 238927. Please quote this on all correspondence.
Yours sincerely
Andrea Bell
Assessor
Email: [email protected]
Copy to: Ms Lynne Macrae – Sponsor contact
Ms Rachel Rosenhead, Greater Manchester Mental Health NHS
Foundation Trust – Lead NHS R&D contact
152
Appendix 6
Favourable Research and Ethics Committee Letter
153
North East - York Research Ethics Committee
NHSBT Newcastle Blood Donor Centre Holland Drive
Newcastle upon Tyne NE2 4NQ
Telephone: 0207 1048091 Please note: This is the favourable opinion of the REC only and does not allow you to start your study at NHS sites in England until you receive HRA Approval
29 May 2018
Dr Daniel Pratt Clinical Psychologist University of Manchester 2nd Floor Zochonis Building Brunswick Street University of Manchester M13 9PL
Dear Dr Pratt
Study title: The INSPiRe Programme: Developing an Intensive
Suicide Prevention Therapy for suicidal prisoners.
REC reference: 18/NE/0158
Protocol number: 7923
IRAS project ID: 238927
Thank you for your letter of 23 May 2018, responding to the Committee’s request for further
information on the above research [and submitting revised documentation].
The further information has been considered on behalf of the Committee by the Chair.
We plan to publish your research summary wording for the above study on the HRA website,
together with your contact details. Publication will be no earlier than three months from the
date of this opinion letter. Should you wish to provide a substitute contact point, require
further information, or wish to make a request to postpone publication, please contact
[email protected] outlining the reasons for your request.
Confirmation of ethical opinion
On behalf of the Committee, I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the application form, protocol and supporting documentation [as
revised], subject to the conditions specified below.
Conditions of the favourable opinion
The REC favourable opinion is subject to the following conditions being met prior to the start of the
study.
154
Management permission must be obtained from each host organisation prior to the start of the
study at the site concerned.
Management permission should be sought from all NHS organisations involved in the study in accordance with NHS research governance arrangements. Each NHS organisation must confirm through the signing of agreements and/or other documents that it has given permission for the research to proceed (except where explicitly specified otherwise).
Guidance on applying for HRA and HCRW Approval (England and Wales)/ NHS permission for research is available in the Integrated Research Application System, at www.hra.nhs.uk or at http://www.rdforum.nhs.uk.
Where a NHS organisation’s role in the study is limited to identifying and referring potential participants to research sites ("participant identification centre"), guidance should be sought from the R&D office on the information it requires to give permission for this activity.
For non-NHS sites, site management permission should be obtained in accordance with the procedures of the relevant host organisation.
Sponsors are not required to notify the Committee of management permissions from host organisations
Registration of Clinical Trials
All clinical trials (defined as the first four categories on the IRAS filter page) must be
registered on a publically accessible database within 6 weeks of recruitment of the first
participant (for medical device studies, within the timeline determined by the current
registration and publication trees).
There is no requirement to separately notify the REC but you should do so at the earliest
opportunity e.g. when submitting an amendment. We will audit the registration details as part
of the annual progress reporting process.
To ensure transparency in research, we strongly recommend that all research is registered but
for non-clinical trials this is not currently mandatory.
If a sponsor wishes to request a deferral for study registration within the required timeframe,
they should contact [email protected]. The expectation is that all clinical trials
will be registered, however, in exceptional circumstances non registration may be permissible
with prior agreement from the HRA. Guidance on where to register is provided on the HRA
website. It is the responsibility of the sponsor to ensure that all the conditions are complied
with before the start of the study or its initiation at a particular site (as applicable).
Ethical review of research sites
NHS sites
The favourable opinion applies to all NHS sites taking part in the study, subject to management
permission being obtained from the NHS/HSC R&D office prior to the start of the study (see
"Conditions of the favourable opinion" below).
Non-NHS sites
The Committee has not yet completed any site-specific assessment (SSA) for the non-NHS research
site(s) taking part in this study. The favourable opinion does not therefore apply to any non-NHS site
at present. We will write to you again as soon as an SSA application(s) has been reviewed. In the
meantime no study procedures should be initiated at non-NHS sites.
Approved documents
155
The final list of documents reviewed and approved by the Committee is as follows:
Document Version Date
Covering letter on headed paper [Response Letter to Prov Opin] 23 May 2018
Evidence of Sponsor insurance or indemnity (non NHS Sponsors only) [Insurance] 05 April 2018
GP/consultant information sheets or letters [GP Letter] 1 04 January 2018
Interview schedules or topic guides for participants [Topic Guide] 2 17 April 2018
IRAS Application Form [IRAS_Form_23052018] 23 May 2018
IRAS Checklist XML [Checklist_23052018] 23 May 2018
Letter from sponsor [Letter from Sponsor] 05 April 2018
Other [Student CV - Lauren Hampson] 1 18 December 2017
Other [MDSPS] 1 06 April 2018
Other [DERS] 1 06 April 2018
Other [Liability Confirmation Letter] 25 May 2017
Other [Distress Protocol] 2 13 March 2018
Other [Employers Liability] 31 May 2017
Other [Insurance Confirmation] 01 June 2017
Other [Participant Debriefing Sheet] 2 13 March 2018
Other [Public Liability]
Other [UoM Risk Assessment] 01 April 2018
Other [Safe Working Practices and Risk Management Protocol] 2 13 March 2018
Other [Social Problem Solving Inventory - Revised]
Other [Beck Suicide Scale]
Other [Participant Sessional Measure] 2 21 May 2018
Other [Demographics Form] 2 21 May 2018
Other [Additional Metrics] 19 April 2018
Other [CV Yvonne Awenat] 19 April 2018
Other [Demographics Form] 19 April 2018
Other [Discharge Summary] 19 April 2018
Other [Session Summary Sheet] 19 April 2018
Other [The Client Satisfaction Questionnaire] 19 April 2018
Other [The Multidimensionla Scale of Percieved Social Support ] 19 April 2018
Other [Therapist Sessional measure] 19 April 2018
Other [Therapy Rating Form] 19 April 2018
Other [Summary Participant Information Sheet] 2 21 May 2018
Participant consent form [Consent Form] 3 21 May 2018
Participant information sheet (PIS) [Participant Information Sheet] 4 21 May 2018
Research protocol or project proposal [The INPRiRe Programme Protocol] 2 13 March 2018
Summary CV for Chief Investigator (CI) [CI Summary CV] 01 December 2017
Summary CV for student [Student CV - Jessica Killilea] 18 December 2017
Summary CV for supervisor (student research) [Supervisor CV] 01 December 2017
156
Statement of compliance
The Committee is constituted in accordance with the Governance Arrangements for Research Ethics
Committees and complies fully with the Standard Operating Procedures for Research Ethics
Committees in the UK.
After ethical review
Reporting requirements
The attached document “After ethical review – guidance for researchers” gives detailed guidance on reporting requirements for studies with a favourable opinion, including:
• Notifying substantial amendments
• Adding new sites and investigators
• Notification of serious breaches of the protocol
• Progress and safety reports
• Notifying the end of the study
The HRA website also provides guidance on these topics, which is updated in the light of
changes in reporting requirements or procedures.
User Feedback
The Health Research Authority is continually striving to provide a high quality service to all
applicants and sponsors. You are invited to give your view of the service you have received and the
application procedure. If you wish to make your views known please use the feedback form available
on the HRA website:
http://www.hra.nhs.uk/about-the-hra/governance/quality-assurance/
HRA Training
We are pleased to welcome researchers and R&D staff at our training days – see details at
http://www.hra.nhs.uk/hra-training/
18/NE/0158 Please quote this number on all correspondence
With the Committee’s best wishes for the success of this project.
Yours sincerely
pp
Mr Chris Turnock Chair
Email: [email protected]
Enclosures: “After ethical review – guidance for researchers” Copy to: Ms Lynne Macrae
Ms Rachel Rosenhead, Greater Manchester Mental Health NHS
Foundation Trust
157
Appendix 7
HMPSS Ethical Approval Letter
158
19 July, 2018
Lauren Hampson Trainee Clinical Psychologist Division of Psychology and Mental Health Faculty of Biology, Medicine and Health 2.01, 2
nd Floor Zochonis Building 1
Brunswick Street Manchester M13 9PL
Dear Lauren
Re: NRC Research Application 2018-154: The INSPiRe Programme : Developing an
Intensive Suicide Prevention Therapy for Suicidal Prisoners
Your research application above has been approved by NW Psychological Services and the
Governor of HMP Risley.
Please note should you wish to publish or present any of the findings from your research you
will need to obtain permission. The procedure is:
An email should be sent to:
Lynne Carter (email [email protected]) with:
A brief synopsis of the purpose and conclusions of the research
A copy of the research paper/presentation
An indication of anything contentious within the paper/presentation
Yours sincerely
Sue Thomas
Dr. Sue Thomas, AFBPsS Chartered and Registered Forensic Psychologist Cluster Manager: Training, Research & Consultancy Service (TRaC) North West Psychological Services 0177244 (VPN7236) 2472
159
Appendix 8
Clinical Trial Registration
160
ClinicalTrials.gov Protocol Registration and Results System (PRS) Receipt
Release Date: April 4, 2018
ClinicalTrials.gov ID: [Not yet assigned]
Study Identification Unique Protocol ID: 238927 Brief Title: The INSPiRe Programme Official Title: The INSPiRe Programme: Intensive Suicide
Prevention Therapy in Prison Secondary IDs:
Study Status Record Verification: April 2018 Overall Status: Not yet recruiting Study Start: June 1, 2018 [Anticipated] Primary Completion: July 31, 2019 [Anticipated] Study Completion: September 30, 2019 [Anticipated]
Sponsor/Collaborators Sponsor: University of Manchester Responsible Party: Principal Investigator Investigator: Jessica Killilea [jkillilea] Official
Title: University of Manchester Affiliation: University of Manchester Collaborators:
Oversight U.S. FDA-regulated Drug: No U.S. FDA-regulated Device: No U.S. FDA IND/IDE: No Human Subjects Review: Board
Status: Exempt Data Monitoring: Yes FDA Regulated Intervention: No
Study Description Brief Summary: This study aims to assess the acceptability and feasibility of a short-term, intensive Cognitive Behavioural
Therapy (CBT) delivered to male prisoners who have thoughts of ending their lives. Detailed Description: 10 hours of an
adapted CBT therapy for suicide will be delivered across 2 weeks in 5 2 hour sessions to male prisoners. They will initially be assessed on several measures of mood, social support and suicidality. They will then undergo therapy. Following this they will
be asked to re-completed the initial measures and a post-therapy interview to ascertain their thoughts on their experience of the
therapy.
Conditions Conditions: Suicide Keywords: Intensive Cognitive Behavioral Therapy Male prisoners
Study Design Study Type: Interventional Primary Purpose: Treatment Study Phase: N/A Interventional Study Model: Single Group Assignment Number of Arms: 1 Masking: None (Open Label) Allocation: N/A Enrollment: 16 [Anticipated]
Arms and Interventions Arms: Experimental: Intervention 10 hours of intensive CBT for suicide will be delivered to male prisoners who are havin g
thoughts of ending their lives. This will be delivered in 2 hours sessions, 5 times across 2 weeks. Assigned Interventions: INSPiRe Programme Intensive CBT for suicide
Outcome Measures Primary Outcome Measure:
1. The Client Satisfaction Questionnaire (CSQ-8) A measure of participant satisfaction with therapy [Time Frame: 20 minutes]
2. Therapist Session Summary Measuring levels of adherence and engagement [Time Frame: 5 minutes] 3. Discharge summary sheet Capturing individuals’ adherence to the programme or discharge from it [Time Frame: 15
minutes] 4. Therapist Rating Form Giving an overall picture of each individual’s engagement and progress during the study.
[Time Frame: 20 minutes] 5. Post-intervention interview Qualitative interview to explore the participant's experience of therapy [Time Frame: 1 hour]
Eligibility Minimum Age: 21 Years Maximum Age: Sex: Male Gender Based: Yes All participants will be recruited from a prison site that
houses males. Accepts Healthy Volunteers: No Criteria: Inclusion Criteria: Aged over 21 years old. Has been managed under
the Assessment, Care in Custody, and Teamwork (ACCT) system within the last 1 month (including current ACCT review). Sufficient English language proficiency, as judged by the researcher, in order to complete psychometric questionnaires (i.e.
adequate reading comprehension) and engage in intensive CBT programme (i.e. adequate verbal communication). Adult is able
to provide informed consent as established during baseline clinical interview (BPS, 2006; MCA, 2005). Currently residing in HM Prison (and expected to remain there for at least six weeks; determined through staff and prisoner report). Exclusion
Criteria: A primary organic disorder (indicated by prison medical staff report or records). Any current risk behaviour which
would compromise the safety of others, as identified by prison staff.
Contacts/Locations Central Contact Person: Jessica Killilea Telephone: 0161 306 0401 Email: [email protected]
Central Contact Backup: Lauren Hampson Telephone: 0161 306 0401 Email: [email protected]
Study Officials: Daniel Pratt Study Principal Investigator University of Manchester; Yvonne Awenat Study Chair University of Manchester; Charlotte Lennox Study Chair University of Manchester
Locations:
IPDSharing Plan to Share IPD: No
References Citations: Links: Available IPD/Information:
U.S. National Library of Medicine | U.S. National Institutes of Health | U.S. Department of Health & Human Services
161
Appendix 9
Participant Information Sheet
162
Participant Information Sheet
The INSPiRe Programme Intensive Suicide Prevention
Therapy in Prison
Study Invitation
You are being invited to take part in The INSPiRE Programme. Before you decide
whether or not you wish to take part, it is important for you to understand why the
research is being done and what it will involve. Please take time to read the
following information sheet carefully and discuss it with others if you wish. Please
ask us if there is anything that is not clear or if you would like more information.
Thank you for taking the time to read this.
What is the purpose of the study?
The INSPiRe Programme is a new programme of Cognitive Behavioural Therapy
(CBT) for suicide within a prison population. The INSPiRe Programme will be
delivered ‘intensively’, meaning that individuals will receive up to 10 hours of
therapy across a two week period. The study aims to find out how practical and
suitable it is to deliver therapy in a quicker format.
Why have I been asked to take part?
We are interested in talking to prisoners who in the past one month may have had
suicidal thoughts and/or behaviours.
Do I have to take part?
No, you do not have to take part. If you would prefer not to take part then you do not
have to give a reason and you will not be pressured to change your mind. This will
not affect the normal support you receive.
If you decide to take part you will be asked to sign a consent form. You are able to
leave the study at any time, without giving a reason. If you do decide to leave we
may ask you to discuss your reasons for leaving. However you will not have to do
this if you do not wish. Information you have already given will remain part of the
163
research. Should you lose capacity to consent (for example, because of drug use) your role
in the study may stop, but any data collected up to that point will still be used.
What does taking part involve?
First Meeting:
We shall contact you to talk to you about the programme and to see whether you
might be interested in taking part. We will give you some time to consider this (no
less than 24 hours). If you would like to take part we shall support you to complete a
consent form and then we would like to ask you further questions about how you
have been feeling recently. This should take about 30 minutes and can be arranged at
a time suitable for you. It may be the case that during this meeting that the INSPiRE
Programme is not suitable for you. If the Programme is not suitable for you then we
will not need to see you again and that will be the end of your part in the study. This
does not mean that your problems are more or less important than anyone else’s
problems; it just means that our Programme is not suitable for you.
INSPiRE Programme:
The INSPiRE Programme will last for two weeks. This will involve the Intensive
CBT Programme. Each of the ten sessions will last for up to two hours and will take
place on weekdays from Monday to Friday. Sessions will be on a one to one basis
with a member of the research team. Participant’s involvement in the programme
may be stopped should they miss two sessions without giving a reason (NB:
However, incidents outside of the participants’ control i.e. lock-down, would not be
grounds to end participation).
Final Meetings:
Once the programme has been completed, we would like to hear about how you
found the INSPiRe programme. We would like to complete the questionnaires with
you once more, which again should take about 20 minutes. We would also like to
hear your thoughts within an ‘interview’ format. We would like to hear about how
you found the Intensive CBT and how you think this could be improved in the
future. This interview will be audio tape recorded so that we can explore your
experiences at a later stage. If you wish to do the interview without recording it then
this will be possible however there will be another member of the research team
present to take notes during the interview.
164
What are the possible benefits of taking part?
We hope that the Intensive CBT Programme will be helpful for you in managing
your difficult experiences. However, this may not be the case. Findings from the
research may be helpful in making CBT in prisons better in the future.
What are the possible risks or cons of taking part?
We do not see any serious risks in taking part in the study. You will be asked to give
up some of your time to take part. It would not be unusual for people to feel some
emotional distress when they are asked to think about difficult events from their past.
If you are upset you will be able to talk to the researcher about it. If you feel you
require further support they will be able to tell you about other sources of help or
advice.
What if there is a problem?
If you have concerns about how you have been treated during this study, you can ask
to speak to a member of the research team, who will do their best to answer your
questions. You can also direct any complaints, concerns, requests for information
and queries through the prison. In the event that something goes wrong and you are
harmed during the research, and whereby someone is at fault, then you may have
grounds for a legal action for compensation but you may have to pay your own legal
costs.
Will my taking part in the study be kept confidential?
Yes. Information collected about you will be kept strictly confidential and will not
be shared with anyone outside the research team without your consent. Any personal
information that we collect about you, and any consent forms will be stored securely
and will only be used for research purposes. If you take part, prison staff or those
responsible for your care will be informed of your involvement in the study, but they
will not have access to information collected during the study.
Audio tape recordings will only be transcribed by members of the research team.
Any quotes from research participants used in the project report will be anonymised
and no real names will be used.
You have the right to check the data held about you and to correct any errors.
Procedures for the handling, processing, storage and destruction of your data will be
in line with the Data Protection Act 1998. Some parts of the data collected for the
study may be looked at by individuals working with the research team at the
University of Manchester or within the Sponsoring NHS Trust. Records also may be
165
reviewed by persons authorised to do so within regulatory authorities to check that
the study is being correctly carried out, but this information will remain anonymous.
All such individuals have a duty of confidentiality to you as a research participant.
The data will be securely disposed of by 5 years. During the study, data will be held
securely at the University of Manchester.
Are there any circumstances in which confidentiality would be broken?
Yes. You should be aware that the researcher has a duty to inform an appropriate
person should you disclose any of the following:
a) Behaviour that is against prison rules and can be prosecuted for
b) Information that suggests a risk of harm to yourself or another person, or refers
to a new crime or plans to commit a new crime
c) Undisclosed illegal acts
d) Information that raises concerns about terrorism, radicalisations, or security
issues.
What will happen to the results of the study?
The results of this study may be available in a report or criminal justice or medical
journal. If you would like a copy of any report or a summary of the results, please let
the researcher know. You will not be identified in any report following this study.
This study is being completed as part of a Clinical Psychology Doctoral Thesis by
Trainee Clinical Psychologists within the University of Manchester.
Who has reviewed this study?
The research has been reviewed by an independent group of people, called a
Research Ethics Committee (REC) to protect your safety, rights, wellbeing and
dignity. This study has been reviewed and given a favourable opinion by North East
– York REC (Ref: 18/NE/0158). The research has been reviewed and approved by
the Health Research Authority (ID: 238927) and HMPPS (Ref: 2018-154).
Thank you for reading this.
If you need further information, please speak with a member of the research team:
Lauren Hampson and Jessica Killilea (Trainee Clinical Psychologists).
We will give you this information sheet to keep as well as a signed consent form if
you agree to take part. Should you require support during your participation in The INSPiRE Programme, you are
able to access the following services: Samaritans Helpline; Prisoner Listener/Buddy/Peer
Service; Personal Officer; Prison GP
Mental Health Team; Chaplaincy.
166
Appendix 10
Summary Participant Information Sheet
167
The INSPiRe Programme: Intensive Suicide Prevention Therapy in Prison
Do you experience difficult thoughts about
ending your life? Do you find yourself feeling hopeless, or feel
that there is no point going on?
If you feel this way, you may be interested in taking part in the INSPiRe Programme. This is
a new programme for people experiencing
thoughts about ending their life.
Why? We want to learn more about how best to offer help and treatments to suicidal prisoners.
Who? We are looking for English speaking adults who have
experienced suicidal thoughts in the past month.
What? The study will require you to attend the INSPiRe Programme for up to 10 hours over a course of 2 weeks with a psychologist. You will be asked to fill in some questionnaires and attend a researcher meeting to find
out about your experiences of the therapy.
If you would like some more information or are interested in taking part please contact your Personal Officer or Member
of the Prison Staff Team.
168
Appendix 11
Informed Consent Form
169
The INSPiRe Programme: Intensive Suicide Prevention Therapy in Prison
CONSENT FORM Please initial
1. I confirm that I have read and understood the Participant Information Sheet,
version 4 (16/05/2018), and have been given the opportunity to ask
questions.
2.
I understand that my participation is voluntary and that I am free to
withdraw at any time, without giving any reason and without my legal rights
being affected.
3. I understand that if I withdraw from the study I will stop receiving the
intervention, but this will not affect any other aspects of my medical care.
4. I understand that if I withdraw from the study data collected up to this point
will still be used and I will still be contacted to discuss my reasons for
withdrawing, but that this is also voluntary and that I can refuse without
penalty.
5. I understand that if I lose capacity to consent (e.g. because of drug use) I
will stop receiving the intervention but any data collected up to that point
will still be used.
6. I understand that whilst I participate in the study, the researcher has a duty to
inform prison staff should I disclose:
e) Behaviour that is against prison rules and can be adjudicated against
f) Information that either indicates a risk or harm to yourself or others or
refers to a new crime committed or plans to commit a new crime
g) Undisclosed illegal acts
h) Information that raises concerns about terrorist, radicalisations, or
security issues.
7. I give permission for the research team to look at my criminal justice and
health records for the purpose of informing the research.
8. I give permission for the research team to inform the prison GP and
healthcare team about my participation in this research study.
9. I agree to the interview part of the study to be audio-recorded. I understand
that the audio-recording will be written out in full (transcribed) by the
research team.
10. OPTIONAL: I agree for quotes to be used when writing up and publishing
the study. I understand that any identifiable data will be removed so that no-
170
one will be able to identify me from the quotes.
11. I understand that data collected during the study may be looked at by
individuals from the University of Manchester, from regulatory authorities
or from the NHS Trust, where it is relevant to my taking part in this
research. I give permission for these individuals to access my data.
12. I agree to take part in the above study.
13. OPTIONAL: I would like to receive a summary of the findings of this study
once it has been completed.
Sign below for participant completed consent form
Name of participant Date Signature
Name of researcher Date Signature
Sign below for researcher completed consent form
“I [researcher name] have read this form of consent to [participant name]
because [participant name] is not able to read this informed consent document.
I have asked [participant name] to make his mark to confirm that he has understood the informed consent document”
Name of participant Date Signature
Name of researcher Date Signature
*1 copy for participant: 1 copy for researcher Principal Investigator: Dr Dan Pratt, University of Manchester
171
Appendix 12
Prison GP Letter
172
Division of Psychology and Mental Health School of Health Sciences
Faculty of Biology, Medicine and Health University of Manchester
2nd Floor Zochonis Building Brunswick Street
Manchester M13 9PL
Private and Confidential <GP Name> Healthcare Centre HMP Risley Warrington Rd Risley Croft Warrington WA3 6BP
<Date> Dear Doctor ……… Re: <Participant’s name> Prison Identification Number: <number> DoB: <date of birth> PARTICIPATION IN RESEARCH STUDY: I am writing to you because the above patient has consented to take part in the INSPiRe: Intensive Suicide Prevention Therapy in Prison study at HMP Risley. The study aims to explore participants’ experiences of a short-term, intensive CBT intervention for people experiencing suicidal thoughts. The research involves taking part in 10 hours of CBT delivered across 2 weeks (5 x 2 hour sessions), then completing a series of questionnaire measures and discussing their experience of the intervention within a post-therapy interview. Attached is the information sheet your patient received about the study before they consented to take part. If you have any questions, please do not hesitate in contacting us. Yours sincerely Jessica Killilea Email: [email protected] Lauren Hampson Email: [email protected] Under the Supervision of Dr. Daniel Pratt, Clinical Psychologist
173
Appendix 13
The InSPire Programme: What to Expect
174
Thank you for agreeing to take part in the Intensive CBT for Suicide in Prison (INSPiRE)
Programme. You have been allocated to the treatment list, which means you have the
chance to meet with one of the INSPiRE team (Lauren or Jess) over the next few months.
This leaflet will tell you a little more about what kind of work you might want to do with
Lauren or Jess.
What is the INSPiRE Programme?
CBT, or Cognitive Behavioural Therapy, is a psychological treatment that was developed
through scientific research. All of the parts of CBT have been tested by researchers to
determine whether they help and that they do what they are intended to do. The INSPiRE
programme is a new type of CBT designed to be helpful to prisoners who are currently, or
have previously, been suicidal.
What does the INSPiRE Programme involve?
The sessions:
You will meet with Lauren or Jess, the INSPiRE therapists, for up to 5 sessions.
These will run across a two week period, and will last up to 2 hours each.
In the first session(s), the therapist will check that you can use this sort of
treatment and you will check that you feel comfortable with it.
The therapist will also ask you questions about your past life and background.
Although the INSPiRE Programme concentrates more on the ‘here and now’, at
times you may need to talk about the past to understand how it is affecting you
now.
With your therapist, you will learn to understand more about problems you may
have struggled with and why you may have thoughts about suicide or feeling
worthless.
You decide which of these problems you want to deal with in the sessions.
You and the therapist will usually start by agreeing on what to talk about that day.
The work:
With the therapist, you break each problem down into its separate parts. To help
with this, your therapist may ask you to keep a diary. This will help you to identify
your individual patterns of thoughts, emotions, bodily feelings and actions.
Together you will look at your thoughts, feelings and behaviours to work out:
o If they are unhelpful
o How they affect each other, and you
The therapist will then help you to work out how to change unhelpful thoughts and
behaviours
175
It’s easy to talk about something, but much harder to actually do it. So, after you
have worked out what you can change, your therapist will suggest “homework” –
you practice these changes in your everyday life. Depending on the situation, you
might start to:
o Question a self-critical or upsetting thought and replace it with a more
helpful (and more realistic) one that you have developed in session with
your therapist
o Recognise that you are about to do something that will make you feel
worse and, instead, do something more helpful.
At each session, you will talk about how you’ve got on since the last session. Your
therapist can help with suggestions if any of the tasks seem too hard or don’t seem
to be helping.
They will NOT ask you to do things you don’t want to do – you decide the pace of
the programme and what you will and won’t try. The strength of CBT is that you
can continue to practise and develop your skills even after the sessions have
finished. This makes it less likely that your problems will return.
What are the problems with the INSPiRE Programme?
The programme is not a quick fix. A therapist is like a personal trainer at the gym –
they can advise and encourage you, but they cannot ‘do’ it for you.
If you are feeling low, it can be difficult to concentrate and get motivated.
To overcome problems with feeling nervous or worried, you need to face it head
on. This may lead you to feel more anxious for a short time.
A good therapist will pace your sessions. You decide what you do together, so you
stay in control.
How long does the INSPiRE Programme last?
The INSPiRE Programme can last up 2 weeks. How long you spend working with your
therapist will depend on the type of problem and how the programme is working for you.
Once we have completed the five sessions, we would like to talk to you once more to find
out how you found being involved in the INSPiRE Programme.
What if my problems come back?
There is always a risk that the problems related to feeling suicidal might return. If they do,
your new skills developed in the INSPiRE Programme should make it easier for you to
manage these problems. So, it is important to keep practising your new skills, even after
you are feeling better.
So what impact would the INSPiRE Programme have on my life?
Problems related to feeling suicidal can be very unpleasant. The INSPiRE Programme may
help you to manage these problems better. It is unlikely to have a negative effect on your
life, apart from the time and effort you need to put into the sessions with your therapist.
176
Appendix 14
Participant Debriefing Sheet
177
The InSPire Programme Intensive Suicide Prevention Therapy in Prison
PARTICIPANT DEBRIEFING SHEET
Thank you for taking the time to participate in this research. We hope that you
have found it interesting and have not been upset by any of the topics in the
questionnaires or interview
However, if you have found any part of this experience to be distressing there
are a number of people and organisations that you can contact for support: If you feel as though you are struggling to cope or feeling low in mood it is
important that you tell a member of the prison staff.
If you have been upset by anything discussed as part of this research you should
tell a member of the research team.
You can also talk to the Samaritans Listener on your wing.
Giving Feedback
People react differently after being in studies like this one. Please let us know
any thoughts or feelings you have about the study. Honest feedback from you
will help us learn. It also gives us a chance to explain parts of the study that
may still be confusing.
Purpose of the Study
This study involved investigating the experiences of people who had a short
course of intensive therapy for suicidal thoughts. The study focused on 2 key
questions: 1. Whether people liked the therapy.
2. Whether it was possible to deliver such an intensive therapy in a prison
environment.
You will have been asked to fill out several questionnaires before starting
therapy and after finishing therapy. You will also have been asked to discuss
your experiences of therapy in an interview. The data collected during the
interview and with the questionnaires will be analysed to answer these two
questions.
Once all the data is collected and analysed, a summary of the findings will be
made available to you on request. If you wish to receive a summary of results
please indicate this below and provide contact details. Please note the summary
may take up to 18 months to complete.
I wish to receive a summary of the results of this study:
Contact address: _____________________________________________
___________________________________________________________
If you have any further questions feel free to ask now.
Thank you for taking part in this study.
178
Appendix 15
Certificate of Completion
179
180
Appendix 16
Demographics Questionnaire
181
Participant ID: __ __ __ Researcher Initials: __ __ Assessment date: _ _/ _ _ /_ _ _ _
The INSPiRE Programme
DEMOGRAPHICS QUESTIONNAIRE
1. Establishment:
Prison Name: ____________________
2. Age and DOB: …………………………….…
3. Ethnicity:
White British (1)
White Irish (2)
Other, White (3)
White & Black Caribbean (4)
White & Black African (5)
White & Asian (6)
Other, Mixed (7)
Black Caribbean (8)
Black African (9)
Other, Black (10)
Indian (11)
Pakistani (12)
Bangladeshi (13)
Other, Asian (14)
Chinese (15)
Other, specify (16) ………….…………
Prefer not to answer (17)
Unknown (18)
4. Marital status: (immediately prior to prison entry)
Single (1)
Married/Civil Partner/Co-habiting with Partner (2)
Divorced (3)
Widowed (4)
Separated (5)
Other, specify (6) …………………..……
Prefer not to answer (7)
Unknown (8)
5. Employment status: (immediately prior to prison entry)
Employed full time (1)
182
Employed part time (2)
Unemployed (but casual work) (3)
Unemployed (4)
Long term sick (on benefits) (5)
Long term sick (employed) (6)
Not seeking work & not receiving benefits (7)
Retired (8)
Other, specify (9) .……………………….
Prefer not to answer (10)
Unknown (11)
6. Religious Status:
Christian (Catholic) (1)
Christian (Protestant) (2)
Christian (other) (3)
Muslim (4)
Hindu (5)
Buddhist (6)
Agnostic (7)
Other (8)
7. Living circumstances: (immediately prior to prison entry)
Alone (1)
With spouse/partner (with children) (2)
With spouse/partner (without children) (3)
With children only (4)
With parents (5)
Other, specify (6) ………………………….
Prefer not to answer (7)
Unknown (8)
8. Accommodation type: (immediately prior to prison entry)
Homeless / No fixed abode (sleeping rough) (1)
Temporary accommodation (sleeping on friends/family sofa) (2)
Supervised hostel (3)
Unsupervised hostel (4)
House or flat (renting) (5)
House or flat (own) (6)
Other, specify (7)…………………………
Prefer not to answer (8)
Unknown (9)
9. Date arrived in this prison: __/____ (MM/YY)
183
10. Main (index) offence you are charged with/convicted of:
Violence against another person (1)
Robbery / burglary (2)
Theft & handling (3)
Motoring (4)
Arson (5)
Criminal damage (6)
Fraud & forgery (7)
Drugs (8)
Sexual (9)
Other, specify (10)…………….…………
Unknown (11)
Prefer not to answer (12)
11. Prisoner status:
Remand (1)
Convicted – un-sentenced (2)
Convicted – sentenced, if so please specify:
o sentence length (mths) …...…… or NK
o date of sentence ___/_____ (MM/YY) or NK (3)
12. Have you been to prison before this sentence/charge?
Yes, if so how many times ….... (not including this occasion, but including remands) or NK (1)
No (2)
Unknown (3)
13. What type of wing are you currently located in?
Remand/induction (1)
Convicted (2)
Vulnerable Prisoner Unit (3)
Healthcare (4)
Cat A /Closed Secure Unit (5)
Segregation Unit (6)
Detox (7)
Drug free (8)
Older person (9)
Other, please specify (10) …….………………...
14. What regime are you currently on?
Basic (1)
Standard (2)
Enhanced (3)
Other, please specify (4) ………………….
184
15. Cell type
Single occupancy (1)
Shared cell (2)
16. Previous Talking Therapy for Suicide prevention/ideation?
Yes (1)
No (2)
17. Currently on an ACCT?
Yes (1), if so since what date ……..…..
No (2) When did ACCT end ………..…
18. Previously been on an ACCT?
Yes (1) How many times …………..…..
When was the last time? ...…..…
No (2)
19. Previous suicide attempts?
In Prison: ………………………………..
In community: …………………………..
Date of more recent attempt: …………….……
FURTHER NOTES:
185
Appendix 17
Additional Study Metrics
186
Additional Study Metrics
To be recorded during Recruitment, Intervention and Follow Up
Number of referrals to the study
Proportion of referrals attending the first appointment
Number of pre- and post- outcome measures
completed (as a measure of acceptability)
Total number of DNAs
Total number of sessions attended
Number of participants completing the treatment
187
Appendix 18
Therapist Session Summary Sheet
188
Session summary sheet Therapist to complete at the end of every session
Participant ID: Session no: Date & Time of session:
Duration of session: Location: S/U DNA/CNA:
ENGAGEMENT, ASSESSMENT & FORMULATION PHASE:
1. Building Engagement 2. Engaging client to talk about concerns, values and life satisfaction 3. Identifying how suicidal thoughts / suicide attempts fit into concerns 4. Establishing a shared understanding / formulation 5. Strengthening a commitment for change & eliciting goals for therapy
INTERVENTION PHASE:
6. Intervention: Information biases and attention (e.g. Attention Training, BMAC) 7. Intervention: Cognitive (e.g. appraisal restructuring, thought challenging) 8. Intervention: Behaviour (e.g. activity scheduling & behavioural activation) 9. Intervention: Affective (e.g. emotional regulation training, distress tolerance) 10. Intervention: Schema change
MAINTENANCE & HANDOVER PHASE:
11. Plan for maintaining wellbeing / staying well 12. Develop a ‘handover plan’ (inc. involving care team in handover session)
Stage of Therapy: _____________________ (indicate all stages above that apply to current
session)
Level of Formulation: 1 2 3 4 5 (rate conservatively if falls between two
levels)
189
Planned agenda:
Actual agenda:
Notes (continue overleaf):
Therapist Name: _________________________________________________
Therapist Signature: _______________________________________________
Date: ___________________________________________________________
2. Shared agreement between client and therapist about key problems but no summary or formulation
around how these relate to each other and to how they relate to other salient issues for the client.
3. Therapist attempted to negotiate a collaborative formulation or proposed a formulation around
main problem areas, however, client not fully engaged in this and formulation not collaboratively
agreed.
4. Shared and agreed formulation of key problem/s that highlight maintaining factors in
terms of thoughts, feelings, and behaviours. Suicidal ideation and/or behaviour is
incorporated into the formulation appropriately. Development of problems not included
and the formulation may not be fully comprehensive and cover all issues.
5. Comprehensive, shared and agreed formulation of key problem/s highlighting
development factors (including onset, schema etc) and maintenance factors in
terms of thoughts, feelings, and behaviour. Suicide ideation and behaviour and
other salient issues are incorporated appropriately.
1. The therapist has endeavoured to explore client concerns, however, there has been little shared enlightenment
about key concerns, an absence of key concerns, or it has been impossible to facilitate the client to discuss any
concerns with the therapist.
190
Appendix 19
Therapist Rating Scale
191
Therapist Rating Form
Participant ID Number: ………………………… Therapist Name: …………………………
Date of Commencement: …………………………
Date of Completion /
Termination: …………………………
1. Did the offender complete the program? Yes No
2. Did the offender drop-out of the program? Yes No
If YES, number of sessions attended prior to
drop-out? ………………………………………
Please rate the following items on the scale provided to the right of the question, regardless of
whether or not the offender completed the program. Circle the number on each scale that best
suits the offender behaviour in each question.
3. Attendance. Poor
1
2 Moderate
3
4 Excellent
5
4. Promptness. Never
prompt
1
2
Moderately
prompt
3
4
Always
prompt
5
5. Offender’s level of participation during
programme.
Never
participated
1
2
Moderate
participation
3
4
Always
participated
5
6. Mastery of programme content. Poor
1
2 Moderate
3
4
Excellent
5
7. Disruptive behaviour. Never
disruptive
1
2
Moderately
disruptive
3
4
Always
disruptive
5
8. Completion of homework or assignments. Never
completed
1
2
Completed
half of the
time
3
4
Always
completed
5
9. Overall evaluation of offender programme
success. Poor
1
2 Moderate
3
4
Excellent
5
Additional comments or Notes:
___________________________________________________________________________
___________________________________________________________________________
192
Appendix 20
Client Satisfaction Questionnaire
193
The Client Satisfaction Questionnaire (CSQ-8)
CLIENT SATISFACTION QUESTIONNAIRE (CSQ-8) Purpose: To assess client satisfaction with treatment. Scoring: The CSQ-8 is easily scored by summing the individual item scores to produce a range of 8 to 32, with high scores indicating greater satisfaction. Description: The CSQ-8 is an 8-item, easily scored and administered measurement that is designed to measure client satisfaction with services. The items for the CSQ- 8 were selected on the basis of ratings by mental health professionals of a number of items that could be related to client satisfaction and by subsequent factor analysis. The CSQ-8 is unidimensional, yielding a homogeneous estimate of general satisfaction with services. The CSQ-8 has been extensively studied, and while it is not necessarily a measure of a client’s perceptions of gain from treatment, or outcome, it does elicit the client’s perspective on the value of services received. The CSQ-8 seems to operate about the same across all ethnic groups. This also is true for a version of the CSQ-8 that was translated into Spanish. Primary Reference: Larsen, D.L., Attkisson, C.C., Hargreaves, W.A., and Nguyen, T.D. (1979). Assessment of client/patient satisfaction: Development of a general scale, Evaluation and Program Planning, 2, 197-207. Instrument reproduced with permission of C. Clifford Attkisson. Availability: Dr. C. Clifford Attkisson, Professor of Medical Psychology, Department of Psychiatry, Box 33-c, University of California, San Francisco, CA 94143.
194
CLIENT SATISFACTION QUESTIONNAIRE Please help us improve our program by answering some questions about the services you have received. We are interested in your honest opinions, whether they are positive or negative. Please answer all of the questions. We also welcome your comments and suggestions. Thank you very much; we really appreciate your help. Circle your answer:
195
196
Appendix 21
Discharge Summary Sheet
197
Discharge Summary Sheet
Participant No:
Prisoner Number:
Sentence Status (Remand / Sentenced):
Therapist Initials:
Date of Baseline Assessment:
Date of Discharge / Termination:
Number of sessions attended:
Reason for discharge:
Successful completion of therapy:
If yes, please complete aspects of therapy completed:
Yes / No
Unexpected termination of therapy: If yes, please tick all reasons for termination:
Yes / No
Transfer / release from prison
Lost motivation to continue with therapy
Unwillingness to engage in therapy
Participant reports therapy not to be beneficial
Participant reports therapy not to be relevant
Lack of available time to dedicate to sessions
Lack of available room / space for sessions Withdrawn from study due to risk concerns of staff Did not attend sessions (how many DNAs:________) Other, please state: __________________________ ___________________________________________ ___________________________________________
Comments on discharge:
Date form completed: _______________
198
Appendix 22
Beck Suicide Scale
199
BSS ID number Assessor Date
Please carefully read each group of statements below. Circle the one statement in each group that best describes
how you have been feeling for the past week, including today. Be sure to read all of the statements in each
group before making a choice.
1. Do you have strong, moderate or weak wish to live?
0. I have a moderate to strong will to live 1. I have a weak wish to live 2. I have no wish to live
2. Do you have strong, moderate or weak wish to die?
0. I have no wish to die 1. I have a weak wish to die. 2. I have a moderate to strong wish to die.
3. Do your reasons for living outweigh your reasons for dying?
0. My reasons for living outweigh my reasons for dying. 1. My reasons for living and dying are about equal 2. My reasons for dying outweigh my reasons for living.
4. Do you ever have the desire to kill yourself?
0. I have no desire to kill myself 1. I have a weak desire to kill myself. 2. I have a moderate to strong desire to kill myself.
5. Would you try to save yourself if you found yourself in a life threatening situation?
0. I would try to save my life if I found myself in a non-threatening situation.
1. I would take a chance on life or death if I found myself in a life threatening situation.
2. I would not take the steps necessary to avoid death if I found myself in a life-threatening
situation.
If you have ticked 0 statements for questions 4 and 5 above the skip to question 20.
If you have ticked 1 or 2 on either question 4 or 5 then go to question 6.
6. If you do think about killing yourself, how long do you think about it for?
0. I have brief periods of thinking about killing myself which pass quickly
1. I have periods of thinking about killing myself which last for moderate amounts of time.
2. I have long periods of thinking about killing myself
7. If you do think about killing yourself, how often do you think about it?
0. I rarely or only occasionally think about killing myself.
1. I have frequent thoughts about killing myself.
2. I continuously think about killing myself.
8. Do you accept this idea of killing yourself?
0. I do not accept the idea of killing myself
1. I neither accept nor reject the idea of killing myself.
2. I accept the idea of killing myself
9. Can you keep yourself from committing suicide?
0. I can keep myself from committing suicide.
1. I am unsure that I can keep myself from committing
suicide.
2. I cannot keep myself from committing suicide.
10. Do concerns about friends and family, religion or possible injury from an unsuccessful attempt
stop you?
0. I would not kill myself because of my family, friends, religion, possible injury from
unsuccessful attempts etc.
1. I am somewhat concerned about killing myself because of my family, friends, religion,
possible injury from unsuccessful attempt etc.
2. I am not or only a little concerned about killing myself because of my family, friends,
religion, possible injury from unsuccessful attempts etc.
11. Are your reasons for wanting to commit suicide aimed at influencing other people i.e. getting
even with someone or to make people happy?
0. My reasons for wanting to commit suicide are primarily aimed at influencing other people
such as getting even with people, making people happier, making people pay attention to me,
etc.
200
1. My reasons for wanting to commit suicide are not only aimed at influencing other people, but
also represent a way of solving my problem.
2. My reasons for wanting to commit suicide are primarily based upon escaping from my
problems.
12. Do you have a plan?
0. I have no specific plan about how to kill myself.
1. I have considered ways of killing myself but have not worked out the details.
2. I have a specific plan for killing myself.
13. Do you have access to a method or an opportunity?
0. I do not have access to a method or an opportunity to kill myself.
1. The method I would use for committing suicide takes time, and I really do not have an
opportunity to use this method.
2. I have access or anticipate having access to the method that I would choose for killing myself
and also have or shall have the opportunity to use it.
14. Do you have the courage or ability?
0. I do not have the courage or ability to commit suicide.
1. I am unsure that I have the courage or ability to commit suicide.
2. I have the courage and the ability to commit suicide.
15. Do you expect to make an attempt?
0. I do not expect to make a suicide attempt.
1. I am unsure that I shall make a suicide attempt.
2. I am sure that I shall make a suicide attempt.
16. Have you made preparations?
0. I have made no preparations for committing suicide.
1. I have made some preparations for committing suicide.
2. I have almost finished or completed my preparations for committing suicide.
17. Have you written a suicide note?
0. I have not written a suicide note.
1. I thought about writing a suicide note or have started to write one, but not completed it.
2. I have completed a suicide note
18. Have you made arrangements for what will happen after?
0. I have made no arrangements for what will happen after I have committed suicide.
1. I have thought about making arrangements for what will happen after I have committed suicide.
2. I have definite arrangements for what will happen after I have committed suicide.
19. Do you try and hide these thoughts etc from others?
0. I have not hidden my desire to kill myself from people.
1. I have held back telling people about wanting to kill myself.
2. I have attempted to hide, conceal, or lie about wanting to commit suicide.
20. Have you attempted suicide before?
0. I have never attempted suicide.
1. I have attempted suicide once.
2. I have attempted suicide two or more times.
If you have previously attempted suicide please continue with the next question.
21. Was your wish to die strong, moderate or weak before?
0. My wish to die during the last suicide attempt was low.
1. My wish to die during the last suicide attempt was moderate.
2. My wish to die during the last suicide attempt was high.
201
Appendix 23
The Difficulties in Regulating Emotions Scale
202
The Difficulties in Emotion Regulation Scale (DERS)
203
204
205
206
207
Appendix 24
Social Problem Solving Inventory
208
209
Appendix 25
Multi-dimensional Scale of Perceived Social Support
210
The Multidimensional Scale of Perceived Social Support (MSPSS)
Canty-Mitchell, J. & Zimet, G.D. (2000). Psychometric properties of the Multidimensional Scale of
Perceived Social Support in urban adolescents. American Journal of Community Psychology, 28, 391-400.
Zimet, G.D., Dahlem, N.W., Zimet, S.G. & Farley, G.K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52, 30-41.
Zimet, G.D., Powell, S.S., Farley, G.K., Werkman, S. & Berkoff, K.A. (1990). Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 55, 610-17.
211
Appendix 26
Participant Sessional Measure
212
Participant Sessional Measure
(to be completed at the start of each therapy session)
Session Number: ______________________
Please rate how much you agree with each of the following
statements:
Since the previous session
Please circle one option…
Not at all
A little
Mostly
Completely
I felt that I had someone
supportive to turn to
0 1 2 3
I have been struggling to manage
my emotions
0 1 2 3
I have been able to deal with my
problems
0 1 2 3
I have felt like harming myself
0 1 2 3
I have felt suicidal
0 1 2 3
Additional Comments (feel free to write any notes below):
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
213
Appendix 27
Therapist Sessional Measure
214
Therapist Sessional Measure
(to be completed after every therapy session)
Session Number: ______________
Please rate how much of this session was focussed upon the following mechanisms:
None
at all
A
little
Mostly
Completely
Social Support
(appraisals of having someone supportive to turn
to)
0 1 2 3
Emotional Regulation
(ability to manage emotions / emotional reactions)
0 1 2 3
Interpersonal problem solving
(ability to deal with relationship problems)
0 1 2 3
Self-harm Ideation (thoughts, feelings, urges,
behaviours relating to self-harm)
0 1 2 3
Suicide Ideation (thoughts, feelings, urges,
behaviours relating to suicide)
0 1 2 3
Additional Comments (feel free to write any notes below):
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
215
Appendix 28
Qualitative Interview Topic Guide
216
INSPiRe Programme Post-Intervention Feedback Interview Topic Guide
This is a guide for the areas and topics to be explored during the interview however specific
questions will be determined by the context of the participant’s individual experience of
the programme:
We are really interested in hearing about your personal experiences of engaging in the
INSPiRe psychological programme.
I would like to ask you to think back to when you were going through the programme and
tell me about your feelings and views of your psychological treatment. Anything and
everything that you want to tell me will be helpful so that we can get a better
understanding of how it was for you.
Sometimes this involves people talking about positive things about the programme,
sometimes negative things about the programme and sometimes a mixture of the two.
Through this feedback and that of other people we will hopefully be able to adapt what we
do and improve it. It is important that we learn about your experience and other individual’s
experiences who also participated in the INSPiRe programme.
Before we start can I check that you would still like to participate and that it is okay for me
to record this conversation? We do this because we don’t want to miss anything that you
say which could happen if we had to just rely on writing notes.
If you want a break at any point just let me know.
Start recording
The areas to be explored are in bold font:
Topic: Participants’ past experience of suicidality & psychological therapy programmes
Q. Can you tell me how things were for you before you started the INSPiRe programme?
Prompts: How were you feeling at that time?
Can you tell me about the difficulties were you experiencing?
How bad were things for you at that time?
Topic: What interested the participant in taking part in the study
Q. What made you want to take part in this research?
Prompts: What were your expectations of the INSPiRe programme?
Topic: The participant’s experience of the INSPiRe programme
Q. How would you describe your experience of the programme?
Prompts: In what way did it make a difference to you?
What do you think was helpful about the programme?
What do you think was beneficial about doing the programme?
Have you learned any skills or coping strategies that you think you would keep
using in the future?
Topic: Differences in how the participant manages thoughts of suicide and self-harm prior
to the programme compared to after the programme
217
Q. Can you tell me about your experience of thoughts of self-harm or suicide in the past?
Q. Can you tell me about your experience of thoughts of self-harm or suicide currently?
Prompts: Has going through the INSPiRe programme influenced these experiences?
If so, how?
If not, why do you think it did not influence you?
Topic: Areas that could be improved on when delivering the INSPiRe programme
Q.Could you tell me about your experience of the INSPiRe programme??
Q.What did you think the positives and negatives of the INSPiRe programme were??
Prompts: What did you think was the most beneficial about it?
What do you think was the least helpful thing about it?
How could this/What do you think could be improved on?
What do you think did not make a difference for you?
Topic: How the participant find the therapeutic experience
Q. How did you find talking to [name of therapist] about your experiences?
Prompts: Did they do anything that was helpful? What was that?
Could you tell me how you found talking to them?
Q. How did you find the timing of the sessions?
Prompts: how did you find the time of day when the session were delivered?
How did you find the length of sessions?
How did you find the length time between sessions?
Topic: What are the reasons for a participant disengaging from the INSPiRe
programme
Q. (If DNA) Could you tell me the reason why you didn’t attend the sessions?
Q. (If DNA) Could you tell me what prevented you from attending the sessions?
Prompts:
What do you think could have been done to support you to attend the session?
What additional supports could have been put in place to help you attend?
Do you think changing the way the programme was carried out would reduce these
difficulties?
Q. (If dropped out) Could you tell me the reasons why you did not attend your sessions?
Q. (If dropped out) What do you think could have been done to prevent this?
Prompts: what made it hard to attend the sessions?
What additional supports could have been put in place?
Do you think changing the delivery format would reduce these difficulties?
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OPTIONAL; ONLY USE IF PARTICIPANT DISENGAGED
What are the reasons for a participant disengaging from the INSPiRe programme
Q. (If DNA) Could you tell me the reason why you didn’t attend the session?
Q. (If DNA) What do you think could have been done to support you to attend the session?
Prompts: What made it hard to attend the sessions?
What additional supports could have been put in place?
Do you think changing the way the programme was carried out would reduce these
difficulties?
Q. (If dropped out) Could you tell me the reasons why you did not attend your sessions?
Q. (If dropped out) What do you think could have been done to prevent this?
Prompts: what made it hard to attend the sessions?
What additional supports could have been put in place?
Do you think changing the delivery format would reduce these difficulties?
Topic: Did the prison environment influence the participants’ experiences of the
programme
Q. Could you tell me about your experience of engaging in a therapy programme in
prison?
Q. Was there anything about the prison environment that made it difficult to go to the
sessions?
Prompt: How did the sessions fit with other prison services and systems/by the ACCT
process?
Topic: Further feedback on the INSPiRe programme
Q. Do you have any other comments or suggestions about how we deliver this programme
to other prisoners?
Topic: General feedback on interview
Q. Finally may I ask how you have found being involved in this interview today?
Prompts: How might we improve the experience for other participants?
I would really like to thank you for spending your time talking to me today. The things we
have discussed will be very helpful in improving treatments in the future.
Explain what will happen to the information discussed and offer to provide summary of
study findings when available.
End interview
Implement Debrief protocol
Notes:
Topic guide structure:
1. Background of their experiences prior to inspire programme; 2. Expectations of inspire;
3. Actual experience of inspire; 4. What could be improved upon?; 4. Thoughts
surrounding self-harm and suicide; 5. Therapeutic relationship; 10. Why disengagement if
they did?; 11. Influence of prison environment on experiencing the programme.
219
Appendix 29
Cognitive Behavioural Suicide Prevention (CBSP) Therapy Modules
220
Part 1. Are you in control of your thoughts or are your thoughts in control of you?
Do you ever get stuck thinking about your problems? Do you struggle to think about other
things when this happens? Depressing thoughts can often be hard to ignore. This module
helps you learn how to become more in control of what you focus your mind on. You will
learn how to pay attention to more positive thoughts and find out if helps you cope better
when negative thoughts happen
Part 2. Changing our thoughts by challenging our thoughts
Do your think about your current situation and what it’s like to be in prison? Do these
thoughts stress you out? Do they make you feel bad about yourself and put you “on a
downer”? Do you spend a lot of time thinking about your past and the mistakes you’ve
made? Do you think about your future and worry about what this may hold for you? This
module will help you to look at your thoughts and understand more about where they have
come from and why you think in the way that you do. You will learn about unhelpful ways
of thinking and try to learn new ways of thinking that may be more helpful to you.
Part 3. Managing your mood
How’s your mood right now? Do you ever get depressed or stuck in a low mood? This
module will teach you how to manage your mood by doing things that lift your spirits.
When people are depressed they tend to be less active than normal and stop doing things
they used to enjoy doing. This can be a vicious circle and make you feel even worse. It can
help hugely to do things which you get pleasure from, or things which give you a sense of
achievement.
Part 4. Improve how to solve problems
Do you have problems in your life? Can these problems sometimes be difficult to solve? Do
you ever feel stuck with a problem and can’t seem to find a way round it? You might find it
more difficult to cope if you have lots of problems that you can't seem to get on top of. This
can have a clear impact on our mood and stress levels. Struggling with unresolved problems
can often make us feel worse. We can end up worrying about our problems without finding
a way to resolve them. This module will help you to develop a structured way of working
through a problem. Beginning to overcome some of your problems might help you to feel
better. You can improve your problem solving skills by learning to apply the steps outlined in
this module.
Part 5. Improving your self-esteem
From time to time, we can all feel bad about ourselves. How we were treated when we
were younger can affect how we feel about ourselves now. If we have been criticised by
other people or if bad stuff has happened to us in the past, we are more likely to have low
self-esteem. This module will help you to see when you are being too critical of yourself.
You can then try to develop more helpful ways of thinking about yourself and what you can
do.
221
Appendix 30
Distress Protocol
222
The INSPiRe Programme Intensive Suicide Prevention Therapy in
Prison
DISTRESS PROTOCOL
1. If a participant is identified as being distressed during therapy or data collection, the researcher will invite them to take time out and have a break. Participants will be allowed to take as many
breaks as they wish without any detriment to their participation. The researcher will offer to accompany them.
2. If the researcher judges that participation is causing undue
distress to the participant, they will sensitively terminate the
session/interview prematurely. Depending on the instance, the researcher will either assure the participant that therapy will
continue as planned. Otherwise, their participation in the study may cease, in the interest of safety. Participants will be assured that their contribution is valuable and unless they ask to withdraw
their data, this will be retained for analysis. Each individual case such as this, will be discussed within Clinical Supervision prior to
any decision making.
3. Following the completion of the battery of questionnaires, all
participants will be debriefed by the researcher to ensure that no- one leaves the room in a distressed state.
4. The debrief sheet given to participants will detail avenues of support that participants can access should they feel the need.
5. The Researchers will also inform a member of Prison staff should
any participant display distress either during a therapy session or during data collection so that any increase in risk will be managed appropriately.
6. The Researchers will make every effort to support the participant should they become distressed however if the participant becomes
so distressed that their safety is at risk the ‘Safe Working Practices and Risk Assessment’ Protocol will supersede the Distress Protocol.
223
Appendix 31
Safe Working Practices and Risk Management Protocol
224
The INSPiRe Programme
Intensive Suicide Prevention
Therapy in Prison
Safe Working Practices and Risk
Management Protocol
Contents
Page:
1. Introduction 3 1.1 Foreword 3 1.2 Study Roles 3 2. Study Procedures and Safety Considerations 4 2.1 Screening and Baseline Period 4 2.2 Intervention Period 4 3. Staff Safety Procedures 4-5 3.1 Participant Factors 4 3.2 Environmental Factors 5 3.3 Specific Safety Procedures 5 4. Indications of Intent to Harm Self or Others 6-7 4.1 Disclosures of Harm to Self or Others 6-7
Appendices
Page:
1. List Of Useful Study Contacts 9 2. Risk Assessment: History Checklist And Prompts 10-12 3. Child Protection Service Contact Details 13 4. Flowchart Of Actions For Participants With Identified Imminent
Suicidal Intent
5. Procedures for Serious Adverse Events
14
15
6. Supportive Resources For Participants 16 7. Disclosure Of Risk During A Session 17-18 8. Safe Working Practices - Declaration 19
225
1. INTRODUCTION
1.1) Foreword
This document outlines the Safe Working Practices for The INSPiRE Programme:
Intensive Suicide Prevention Therapy in Prison
It describes the general procedures and specific safe working practices.
Throughout The INSPiRE Programme, the Safe Working guidelines will be reviewed regularly
and will also incorporate any necessary changes to procedure, which may become apparent
during the general running of the study
All Safe Working guidelines will work alongside HMP Risley Prison Safe working protocols and
safe practice guidelines. Prison mandatory training must be completed by all study staff and must
be adhered to at all times.
The procedures outlined here have been modified from previous trials, as prior referenced. Such
guidelines were developed from existing Safe Working guidelines from the Department of
Clinical Psychology, University of Manchester and from the Mental Health Trusts of
Manchester; Bolton, Salford and Trafford; Pennine Care and Lancashire Care NHS Foundation
Trust Lone Working Policy and the Lone Worker Procedure for the Lancashire Early
Intervention Service.
1.2) Study Roles
Dr Dan Pratt Clinical Supervisor
Chief Investigator
Dr Charlotte Lennox Supervisor
Ms Yvonne Awenat Supervisor
Lauren Hampson Researcher
Jessica Killilea Researcher
Prison Staff
Wing Staff
Governor
Safer Custody Manager
Healthcare Staff
For appropriate contact details, see Appendix 1.
2. STUDY PROCEDURES AND SAFETY CONSIDERATIONS
2.1) Screening and Baseline Assessment 1. The Researcher contacts the Safer Custody Manager prior to recruitment. 2. A Risk Assessment Checklist (See Appendix 2) is completed prior to initial contact with
each participant.
3. All risk information must be recorded and placed into the participant file. 4. The Researcher should contact prison staff prior to each contact with the individual
participant, for an update on any current risk concerns.
5. Safety procedures are followed for each contact with the participant. 6. All Lone Worker Practices and Prison Protocols are adhered to.
2.2) Intervention Period 1. All risk information from baseline assessment is passed on to the Researcher delivering the
intervention.
2. The Researcher should contact prison staff prior to each contact with the individual participant, for an update on any current risk concerns.
3. All Lone Working Practices and Prison Protocols are adhered to. 4. Any new risk information should be discussed within Clinical Supervision and responded to
accordingly, in the interests of safety.
226
5. At the earliest opportunity, all new risk pertinent information should be communicated to prison staff, in the interests of risk and protecting a person’s safety.
3. STAFF SAFETY PROCEDURES
Prior to recruitment, Researchers should complete a Risk Assessment Checklist to identify any
current concerns (Appendix 2). Researchers must do this by liaison with the Prison Staff. Risk must
be considered thereon prior to every session, by liaison with Prison Staff. If there are any doubts
about personal safety then the session must be rearranged and the case discussed in supervision.
3.1) Participant Factors
Information concerning historical/current violent or aggressive behaviour must be recorded.
Prison Staff should be asked about the participant’s current mental state, their current level of distress and any known risk factors or potential problems. They should also be asked whether it is
safe for the participant to be visited by a lone female.
If there are any concerns about visiting the participant, their participation in the The INSPiRE Programme must be considered by the study team and within supervision.
All parties in contact with the participant must be informed of any identified risk factors that
might place someone visiting the participant in danger.
If the Researcher feels uncomfortable or unsafe for any reason, they should make their apologies
and leave. They should not be under pressure to carry on.
3.2) Environmental Factors
Sessions will take place within the prison, either in Healthcare or on the Prison Wings. The Prison Staff in that area should be informed of who the Researchers are seeing and the expected
duration of the session, so that they can be mindful of their safety.
Other factors of risk within the environment, such as other prisoners, prison movement hours, periods of lockdown should be considered.
Each Researcher should be aware of what security systems are in place for the area that they are in and how to use them.
The Researchers should be aware of how to summon help as quickly as possible i.e. use of a panic alarm, if there is anyone in a room nearby who can be called upon for assistance.
Researchers should avoid carrying out sessions on Friday afternoons, to allow for adequate time to respond to risk, if required.
3.3) Specific Safety Procedures The following Safety Procedures must be adhered to for all lone visits.
(1) Name of the person being seen and their prison location (i.e. wing). (2) Names of researchers who will be making the visit. (3) Time and location of appointment.
On the day of sessions, both Researchers should meet prior to participant contact. Both Researchers
should know the three details as above, and the expected time to reconvene in a staff area of the
prison. Whilst sessions are in place, staff in the close vicinity should be made aware of the
researcher’s presence and the intended duration of the session. Researchers must be away of the local
safety protocols and the best way to signal for help if required. Researchers can terminate a session at
any time if required, in the interests of safety, for both themselves and the participant.
4. INDICATION OF INTENT TO HARM SELF OR OTHERS
During a session a participant may indicate intent to harm themselves or others. Alternatively they
may provide information to the effect that a child or other vulnerable person may be in danger. Any
information of this nature must be acted upon.
At the beginning of each session the participant should be informed that what is discussed
during the session is confidential. However, the participant should also be made aware that
227
confidentiality cannot be guaranteed if they indicate any current intention to harm themselves
or others, or if they provide information to the effect that a child or other vulnerable person
may be in danger. In such situations the staff member has a legal duty to break confidentiality.
Other incidents in which confidentiality can be broken include:
i) Behaviour that is against prison rules and can be adjudicated against j) Undisclosed illegal acts k) Information that raises concerns about terrorism, radicalisations, or security issues.
The Researchers will discuss any risk issues they have encountered during supervision. There will be
a set agenda item for this at each supervision session. If the Researchers are in any doubt as to
whether to raise a risk issue they will follow best practice guidelines and raise it.
If the Researchers have any concerns regarding a child’s welfare they will contact the child
protection team (Appendix 3) and inform the Chief Investigator.
4.1) Disclosure of Harm to Self or Others
In the case that the individual indicates current intention to harm themselves or others the action taken
is to remind the participant of the staff member’s Duty of Care to break confidentiality where risk is
identified (as previously outlined at the commencement of the session) and contact the appropriate
member of staff within the prison to verbally report the situation. This must be documented in both
the Study Participant File and within the Prison’s Clinical Records System (SystemOne) as soon as
possible but always before the staff member leaves for the day.
The following is an agreed standard format:
“During the course of a study session on (date & time) (specify as appropriate) XX (participant’s full
name) disclosed information indicating risk of harm to him/herself / and / or others (specify as
appropriate). This has been verbally reported to XX (Prison staff full name)”
In situations where the researcher is uncertain of whether information disclosed by a participant
constitutes a risk, contact should be made with Dr Daniel Pratt (Clinical Supervisor) by phone or
during supervision the same day, for advice on the appropriate action. If it is not possible to make
contact with Dr Daniel Pratt, the situation should be reported to the appropriate member of prison
staff (as above) and recorded similarly.
It is advisable for Researchers to record details of the situation within study specific records for
evaluation, training and supervision purposes. Identifying and managing disclosure of risk should
always feature within supervision sessions.
Research staff should not carry out full Risk Assessments and must ensure prison staff understand that
a formal Risk Assessment has not been done as this is their responsibility. The specific details of any
risk disclosed will determine decisions of whether to stop the session at that point or continue to the
natural conclusion of the session. Generally this will be influenced by the participant’s demeanour
and level of distress and / or the researcher’s level of perceived threat in situations where there is a
risk of harm to others.
In a situation where a participant expresses intent to harm the researcher, or if the researcher feels that
their personal safety is threatened, they must signal for support from prison staff and remove
themselves to a place of safety. Incidents such as this must be discussed with the Chief Investigator,
and during Clinical Supervision. The individual’s participation must be reviewed and may be
terminated, if it considered that the researcher’s safety will continue to be compromised.
In a situation where a participant begins to engage in self-harm behaviour, or express immediate
suicidal intent, during a session (e.g. ligaturing, cutting, taking medications etc.) the researcher should
immediately signal for support from Prison Staff, commence first-aid or resuscitative interventions if
necessary and not leave the participant until prison staff have taken over (Appendix 4). Such
situations should be reported to Dr Daniel Pratt (Clinical Supervisor) at the earliest opportunity.
Document recordings should be made in line with HMPPS and NHS Trust policies, (i.e. DATIX,
Serious Adverse Events) (Appendix 5). Additional reports may need to be completed if it is
determined to be a Serious Incident Requiring Investigation (SIRI). For such incidents research staff
should participate in Trust procedures including Debriefing sessions and other staff support
228
mechanisms. Relevant supportive contact details can be provided to individuals during the study
(Appendix 6).
The Researchers should ensure they record all information and actions taken, including telephone
calls and discussions with the project lead/clinical supervisor, in the participant’s study file.
Researchers must follow this Protocol at all times (see Appendix 8).
NB. Appendices for the Safe Working Practices and Risk Management Protocol have not been
included in this thesis due to the large scale of the document.
Please see APPENDIX 7 for further guidelines and examples of managing
disclosure of risk during an interview with a patient in a prison setting.
229
Appendices
3. Paper III: Critical Review Paper
230
Appendix 32
EPHPP Dictionary
231
Quality Assessment Tool
for
Quantitative Studies Dictionary
The purpose of this dictionary is to describe items in the tool thereby
assisting raters to score study quality. Due to under-reporting or lack
of clarity in the primary study, raters will need to make judgements
about the extent that bias may be present. When making judgements about each component, raters should form
their opinion based upon information contained in the study rather than making inferences about what the
authors intended. Mixed methods studies can be quality assessed using this tool with the quantitative component of the study.
A) SELECTION BIAS
(Q1) Participants are more likely to be representative of the target population if they are randomly selected from a comprehensive list of individuals in the target population (score very likely). They may
not be representative if they are referred from a source (e.g. clinic) in a systematic manner (score
somewhat likely) or self-referred (score not likely).
(Q2) Refers to the % of subjects in the control and intervention groups that agreed to participate in the study before they were assigned to intervention or control groups.
B) STUDY DESIGN In this section, raters assess the likelihood of bias due to the allocation process in an experimental
study. For observational studies, raters assess the extent that assessments of exposure and outcome are
likely to be independent. Generally, the type of design is a good indicator of the extent of bias. In stronger designs, an equivalent control group is present and the allocation process is such that the
investigators are unable to predict the sequence.
Randomized Controlled Trial (RCT)
An experimental design where investigators randomly allocate eligible people to an intervention or
control group. A rater should describe a study as an RCT if the randomization sequence allows each
study participant to have the same chance of receiving each intervention and the investigators could
not predict which intervention was next. If the investigators do not describe the allocation process and
only use the words ‘random’ or ‘randomly’, the study is described as a controlled clinical trial.
See below for more details.
Was the study described as randomized?
Score YES, if the authors used words such as random allocation, randomly assigned, and random
assignment.
Score NO, if no mention of randomization is made.
Was the method of randomization described?
Score YES, if the authors describe any method used to generate a random allocation sequence.
Score NO, if the authors do not describe the allocation method or describe methods of allocation
such as alternation, case record numbers, dates of birth, day of the week, and any allocation
procedure that is entirely transparent before assignment, such as an open list of random numbers of
assignments.
If NO is scored, then the study is a controlled clinical trial.
Was the method appropriate?
Score YES, if the randomization sequence allowed each study participant to have the same chance of
receiving each intervention and the investigators could not predict which intervention was next.
Examples of appropriate approaches include assignment of subjects by a central office unaware of
subject characteristics, or sequentially numbered, sealed, opaque envelopes.
Score NO, if the randomization sequence is open to the individuals responsible for recruiting and
allocating participants or providing the intervention, since those individuals can influence the
allocation process, either knowingly or unknowingly.
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If NO is scored, then the study is a controlled clinical trial.
Controlled Clinical Trial (CCT)
An experimental study design where the method of allocating study subjects to intervention or control
groups is open to individuals responsible for recruiting subjects or providing the intervention. The
method of allocation is transparent before assignment, e.g. an open list of random numbers or
allocation by date of birth, etc.
Cohort analytic (two group pre and post)
An observational study design where groups are assembled according to whether or not exposure to the
intervention has occurred. Exposure to the intervention is not under the control of the investigators.
Study groups might be nonequivalent or not comparable on some feature that affects outcome.
Case control study
A retrospective study design where the investigators gather ‘cases’ of people who already have the
outcome of interest and ‘controls’ who do not. Both groups are then questioned or their records
examined about whether they received the intervention exposure of interest.
Cohort (one group pre + post (before and after)
The same group is pretested, given an intervention, and tested immediately after the intervention. The
intervention group, by means of the pretest, act as their own control group.
Interrupted time series
A study that uses observations at multiple time points before and after an intervention (the
‘interruption’). The design attempts to detect whether the intervention has had an effect significantly
greater than any underlying trend over time. Exclusion: Studies that do not have a clearly defined
point in time when the intervention occurred and at least three data points before and three after the
intervention Other:
One time surveys or interviews
C) CONFOUNDERS
By definition, a confounder is a variable that is associated with the intervention or exposure and
causally related to the outcome of interest. Even in a robust study design, groups may not be balanced with respect to important variables prior to the intervention. The authors should indicate if
confounders were controlled in the design (by stratification or matching) or in the analysis. If the
allocation to intervention and control groups is randomized, the authors must report that the groups
were balanced at baseline with respect to confounders (either in the text or a table).
D) BLINDING
(Q1) Assessors should be described as blinded to which participants were in the control and
intervention groups. The purpose of blinding the outcome assessors (who might also be the care
providers) is to protect against detection bias.
(Q2) Study participants should not be aware of (i.e. blinded to) the research question. The purpose of
blinding the participants is to protect against reporting bias.
E) DATA COLLECTION METHODS
Tools for primary outcome measures must be described as reliable and valid. If ‘face’ validity or
‘content’ validity has been demonstrated, this is acceptable. Some sources from which data may be
collected are described below:
Self reported data includes data that is collected from participants in the study (e.g. completing a
questionnaire, survey, answering questions during an interview, etc.).
Assessment/Screening includes objective data that is retrieved by the researchers. (e.g. observations by investigators).
Medical Records/Vital Statistics refers to the types of formal records used for the extraction of the
data.
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Reliability and validity can be reported in the study or in a separate study. For example, some
standard assessment tools have known reliability and validity.
F) WITHDRAWALS AND DROP-OUTS
Score YES if the authors describe BOTH the numbers and reasons for withdrawals and drop-outs. Score NO if either the numbers or reasons for withdrawals and drop-outs are not reported. Score NOT APPLICABLE if the study was a one-time interview or survey where there was not follow-up data reported. The percentage of participants completing the study refers to the % of subjects remaining in the study
at the final data collection period in all groups (i.e. control and intervention groups).
G) INTERVENTION INTEGRITY
The number of participants receiving the intended intervention should be noted (consider both
frequency and intensity). For example, the authors may have reported that at least 80 percent of the
participants received the complete intervention. The authors should describe a method of measuring if
the intervention was provided to all participants the same way. As well, the authors should indicate if
subjects received an unintended intervention that may have influenced the outcomes. For example, co-
intervention occurs when the study group receives an additional intervention (other than that intended).
In this case, it is possible that the effect of the intervention may be overestimated. Contamination
refers to situations where the control group accidentally receives the study intervention. This could
result in an under-estimation of the impact of the intervention.
H) ANALYSIS APPROPRIATE TO QUESTION
Was the quantitative analysis appropriate to the research question being asked?
An intention-to-treat analysis is one in which all the participants in a trial are analyzed according to the
intervention to which they were allocated, whether they received it or not. Intention-to-treat analyses
are favoured in assessments of effectiveness as they mirror the noncompliance and treatment changes
that are likely to occur when the intervention is used in practice, and because of the risk of attrition
bias when participants are excluded from the analysis.
Component Ratings of Study:
For each of the six components A – F, use the following descriptions as a roadmap.
A) SELECTION BIAS
Good: The selected individuals are very likely to be representative of the target population (Q1 is 1) and there is greater than 80% participation (Q2 is 1). Fair: The selected individuals are at least somewhat likely to be representative of the target population (Q1 is 1 or 2); and there is 60 - 79% participation (Q2 is 2). ‘Moderate’ may also be assigned if Q1 is 1 or 2 and Q2 is 5 (can’t tell).
Poor: The selected individuals are not likely to be representative of the target population (Q1 is 3); or there is less than
60% participation (Q2 is 3) or selection is not described (Q1 is 4); and the level of participation is not described (Q2 is 5).
B) DESIGN Good: will be assigned to those articles that described RCTs and CCTs. Fair: will be assigned to those that described a cohort analytic study, a case control study, a cohort design, or an interrupted time series.
Weak: will be assigned to those that used any other method or did not state the method used.
C) CONFOUNDERS
Good: will be assigned to those articles that controlled for at least 80% of relevant confounders (Q1 is 2); or (Q2 is 1).
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Fair: will be given to those studies that controlled for 60 – 79% of relevant confounders (Q1 is 1) and (Q2 is 2). Poor: will be assigned when less than 60% of relevant confounders were controlled (Q1 is 1) and (Q2 is 3) or control of confounders was not described (Q1 is 3) and (Q2 is 4).
D) BLINDING
Good: The outcome assessor is not aware of the intervention status of participants (Q1 is 2); and the study participants are not aware of the research question (Q2 is 2).
Fair: The outcome assessor is not aware of the intervention status of participants (Q1 is 2); or the study participants are not aware of the research question (Q2 is 2). Poor: The outcome assessor is aware of the intervention status of participants (Q1 is 1); and the study participants are aware of the research question (Q2 is 1); or blinding is not described (Q1 is 3 and Q2 is 3).
E) DATA COLLECTION METHODS
Good: The data collection tools have been shown to be valid (Q1 is 1); and the data collection tools have been shown to be reliable (Q2 is 1).
Fair: The data collection tools have been shown to be valid (Q1 is 1); and the data collection tools have not been shown to be reliable (Q2 is 2) or reliability is not described (Q2 is 3). Poor: The data collection tools have not been shown to be valid (Q1 is 2) or both reliability and validity are not described (Q1 is 3 and Q2 is 3).
F) WITHDRAWALS AND DROP-OUTS - a rating of:
Good: will be assigned when the follow-up rate is 80% or greater (Q1 is 1 and Q2 is 1). Fair: will be assigned when the follow-up rate is 60 – 79% (Q2 is 2) OR Q1 is 4 or Q2 is 5. Poor: will be assigned when a follow-up rate is less than 60% (Q2 is 3) or if the withdrawals and drop-outs were not described (Q1 is No or Q2 is 4).
Not Applicable: if Q1 is 4 or Q2 is 5.
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Appendix 33
InSPire Appointment Slips
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HMP Risley
The InSPire Programme
Prison Number …………………. Name ……………………………………
Location …………………….
On (Day) ……………………………. Date ………………………………. Time
………………………………………
Please speak to wing staff if you are unable to attend.
Reasons as to why you cannot attend your appointment
………………………………………
HMP Risley
The InSPire Programme
Prison Number …………………. Name ……………………………………
Location …………………….
On (Day) ……………………………. Date ………………………………. Time
………………………………………
Please speak to wing staff if you are unable to attend.
Reasons as to why you cannot attend your appointment
………………………………………
HMP Risley
The InSPire Programme
Prison Number …………………. Name ……………………………………
Location …………………….
On (Day) ……………………………. Date ………………………………. Time
………………………………………
Please speak to wing staff if you are unable to attend.
Reasons as to why you cannot attend your appointment
………………………………………
