1. ComQuol: Users Focused Outcomes
Dr Janet Parrott, Consultant Forensic Psychiatrist
Principal Investigator (ComQuol)
Oxleas NHS Foundation Trust

2. Service User Focused Outcome Measures
Primary Outcome
Quality of Life (MANSA)
Secondary Outcomes
Recovery (Process of Recovery Questionnaire)
Therapeutic Relationship (Helping Alliance Scale)

3. Outcome Assessments Time Point 1 – Baseline – Before intervention
Time Point 2 – 6-Months – Following completion of intervention
Time Point 3 – 12-Months
The primary endpoint will be measured at three time points. To ensure results are not affected by a secular trend, each intervention group will be paired with a control unit group.
Time Point 1 – baseline assessment of patients for the intervention group this will be prior to their first structured communication session while for the control group this will be at the same time as when the intervention group are assessed.
Time Point 2 – within the two weeks following the intervention; the last DIALOG approach meeting (after six months from Time Point 1 assessment).
Time Point 3 – six months post intervention (twelve months after time point 1 assessment).

4. Definition of Quality of Life (QoL)
Broad agreement about characteristics:
Subjective experience
Multidimensional nature (physical, psychological, social, environmental)
Positive and negative aspects
(WHOQOL, 1998)
WHOQOL = World Health Organisation Quality of Life Group

5. Quality of Life and Forensic Mental Health
Fitzpatrick et al (2010) - Rated 17th out of 21 variables regarding importance of outcome.
QoL has not been extensively employed in forensic mental health research but is a relevant and important issue.
Research shows that quality of life is important although a systematic review by Fitzpatrick et al (2010) found the quality of life was rated 17th out of 21 regarding important of outcomes placing violence, disturbance, and reoffending has been seen as more important to focus on.

6. (1 = couldn’t be worse to 7 = couldn’t be better)
Outcome Assessments
Primary outcome = Quality of Life
Assessed using Manchester Short Assessment of Quality of Life scale (MANSA) (Priebe et al, 1999)
Short form of the Lancashire Quality of Life Profile (Oliver et al 1996)
Twelve questions rated on 7-point Likert scale
(1 = couldn’t be worse to 7 = couldn’t be better)
Generates overall summary mean score (from 1 to 7)

7. Comparison of Mean Quality of Life Scores
Domain Mean
(range 1-7) (SD)
Baseline
6-Months
12-Months
Control
(N = 52)
4.2 (0.2)
4.3 (0.1)
4.3 (0.3)
Intervention
(N = 53)
4.4 (0.3)
4.5 (0.4)
4.7 (0.2)
Put in ICC and confidence interval

8. Comparison of Treatment Effect Quality of Life Scores
Treatment Effect (intervention – control) and Confidence Interval
6-Month
12-Month
0.2 (-0.4 to 0.8)
0.4 (-0.3 to 1.1)
ICC (CI)
0.04 (0.00 to 0.17)
0.05 (0.00 to 0.18)
ICC = Intracluster Correlation Coefficient

9. Recovery in Forensic Settings
Definition of Recovery
“A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony, 1993)

10. Recovery in Forensic Settings
Other important aspects of recovery include spirituality, peer support, self-management, creativity, housing, finances, work and hobbies (Roberts & Hollins, 2007)
Forensic services definition must acknowledge the challenge of dual recovery from mental illness and offending behaviour, and recognise that risk management is equally necessary and can happen alongside restoration of a meaningful and satisfying life (Aldred & Drennan, 2010)

11. (0 = disagree strongly to 4 = agree strongly)
Outcome Assessment
Recovery Measure
Assessed using Process of Recovery Questionnaire (QPR) (Neil et al, 2007)
22-item measure rated on 5-point Likert scale
(0 = disagree strongly to 4 = agree strongly)
Score generated:
Intrapersonal mean score (from 0 to 51)
Relating to intrapersonal tasks that an individual is responsible for carrying out and that they complete in order to rebuild their life
Interpersonal mean score (from 0 to 15)
Relating to interpersonal ability to reflect on their value in the external world and how recovery is facilitated by external processes in interpersonal relationships with others
The Process of Recovery Questionnaire (QPR) will be used, which is a 22-item measure that asks about aspects of recovery that are meaningful to patients

12. Comparison of Mean Recovery Scores
Domain Mean
(range 0-51)(SD)
Baseline
6-Months
12-Months
Control (N = 52)
Intrapersonal
45.6 (4.1)
47.1 (2.0)
46.9 (1.1)
Interpersonal
13.9 (0.8)
14.0 (0.7)
14.7 (0.9)
(range 0-15) (SD)
Intervention (N = 53)
48.4 (1.7)
49.4 (2.0)
48.6 (1.0)
14.1 (0.3)
13.9 (0.4)
13.9 (0.7)
Subtract 17 from intra and 5 from inter

13. Comparison of Treatment Effect Recovery Scores
Treatment Effect (intervention – control)
and Confidence Interval
6-Months
12-Months
Intrapersonal
2.2 (-2.3 to 6.7)
1.7 (-0.7 to 4.1)
Interpersonal
-0.1 (-1.3 to 1.2)
-0.9 (-2.7 to 1.0)

14. Therapeutic Relationship in Forensic Settings
Best Practice Guidelines in Medium Secure Units
Therapeutic alliance between staff and patients is at the centre of high-quality care and treatment
Research in Mental Health Setting:
Influential in predicting positive outcomes such as reducing hospitalisation, symptomatology and social disability, increasing engagement with services, medication, adherence and global functioning. (Priebe & Gruyters, 1993; Tatten & Tarrier, 2000)
Relational Security:
described as therapeutic alliance between staff and patient in continuing risk assessment ad detailed knowledge of patient (Diamond & Chiweda, 2011)

15. (0 = not at all to 10 = entirely)
Outcome Assessment
Therapeutic Relationship
Assessed using the Helping Alliance Scale
3-item questionnaire rated on a 11-point Likert scale
(0 = not at all to 10 = entirely)
Three domain scores generated (from 0 to 10) and total score
Feeling clinician understands you and is engaged in your treatment
Belief about getting right treatment
Feeling respected
Item 1: Feeling understood by clinicial staff (Clinican understanding and engaged in treatment)
Item 2: Belirefs about receving right treatment (Belief about treatment)
Item 3: Respected and well regarded (Respect and Regard)
Overall: Total sum score

16. Comparison of Mean Therapeutic Relationship Scores
Domain Mean
(range 0-10) (SD)
Baseline
6-Months
12-Month
Control
N = 52
N = 41
Understanding/Engaged
6.9 (0.2) †
6.4 (0.3)
7.1 (0.3)
Belief
5.6 (0.8)
6.2 (0.3)
6.2 (0.6)
Respected
6.0 (0.9)
6.0 (0.2)
6.7 (0.6)
Total Score
6.2 (0.2) †
6.3 (0.5)
6.7 (0.2)
Intervention
N = 46
N = 47
6.4 (0.4)
6.9 (0.5)
7.0 (0.4)
6.1 (0.8)
6.2 (1.0)
6.9 (1.3)
6.1 (0.5)
6.4 (0.6)
7.1 (0.7)
6.6 (0.6)
7.0 (0.8)
† N = 51

17. Comparison of Treatment Effect Therapeutic Relationship Scores
Treatment Effect (intervention – control)
and Confidence Interval
6-Month
12-Months
Understanding/Engaged
0.4 (-0.5 to 1.4)
-0.1 (-0.9 to 0.7)
Belief
0.1 (-1.6 to 1.7)
0.8 (-1.6 to 3.1)
Respected
0.5 (-0.6 to 1.5)
0.3 (-1.1 to 1.8)
Total Score
0.3 (-0.9 to 1.6)
0.3 (-1.0 to 1.7)

18. Concluding Remarks
Outcome assessments understood by participants and gave relevant information outcomes
QoL treatment effect is viewed as clinically important
A difference of 0.2 equates to a increase in 1 point on the MANSA for 2-3 items
A difference of 0.4 equates to a 1 point difference in 5 items
Recovery indicates estimated treatments effect increase intrapersonal scores a 6- and 12-months, and decrease in interpersonal scores at 12- months
In line with non-forensic scores
Therapeutic Relationship
Overall score shows good improvements
Equates to approx 1-point increase in one of the domains
‘Understanding’ has improvement at 6-monts but not at 12-months (Reduction in feeling of being cared for after completing of intervention)
‘Belief’ most improved
Consistent improvement in ‘Respect and Regard’