Award Title: SCHEMA - Secure Care Hospital Evaluation of Manualised (interpersonal) Art-Psychotherapy: A Randomised Controlled Trial.
Funder: Health Education England

Abstract: SCHEMA - Secure Care Hospital Evaluation of Manualised (interpersonal) Art-psychotherapy: A Randomised Controlled Trial. Research questionDoes interpersonal art psychotherapy reduce (i) the frequency and severity of aggressive incidents and/or (ii) patient self-reported distress associated with psychiatric symptoms in adults within secure care who have intellectual disability (ID) or borderline intellectual functioning? AimsTo test the effectiveness, cost-effectiveness, and psychotherapeutic processes of interpersonal art psychotherapy in NHS adult secure care compared to usual care only. ObjectivesTo conduct an RCT of interpersonal art psychotherapy, compared to usual care, in secure care in England.To estimate the subsequent effectiveness and cost-effectiveness of interpersonal art psychotherapy.To report and disseminate outcomes and findings to a wide range of stakeholders.To brief/advise commissioning and policy/programmes as a result of the findings. Inpatient ID mental health and secure careThe presence of co-occurring mental illness can significantly increase the likelihood of people with intellectual disabilities (ID) having both victimisation and offending histories (24). People with ID who are inpatients in NHS services and/or residential care are more likely to have reported aggression compared with people living independently (10). In England, out of a population of 1.2M people with ID 3% are receiving treatment in psychiatric hospitals, with half treated in secure care. Expenditure is estimated at 300M pounds per annum (25). Patients with ID being treated in secure care are routinely in hospital for longer compared to patients on other types of secure mental health wards, >10 years in high secure, 5 years in medium secure or 15 years in a mix of high and medium secure settings (26). Patients in secure care are likely to be more violent than those in other types of psychiatric units (2). Psychological interventions in secure care The most recent systematic review (2019) of RCTs of psychological interventions in secure care (n=9 studies including 523 participants) reported that current practice is based on limited and inconsistent evidence (12). The study sample sizes were small ranging from 14 to 112. No economic evaluations were conducted in the studies. The review concluded that further studies within a standardised framework are needed to clarify the evidence base (29). Feasibility A RCT feasibility study of interpersonal art psychotherapy (n=20) carried out (by the applicant) indicated that a full trial is feasible and signalled moderate to strong effects upon aggressive behaviour and patient reported distress related to psychiatric symptoms (42). DesignThe RCT will utilise a parallel-group participant-randomised design with participants being allocated to interpersonal art psychotherapy and usual care (UC) or a UC delayed interpersonal art psychotherapy treatment control group after 38 weeks. Patient and Public Involvement and Engagement (PPIE) has informed the inclusion of a delayed treatment control group. Timelines for delivery Year 1: Trial development - protocol published, approvals, RCT set-up.Year 2 to 4: RCT effectiveness/cost-effectiveness/psychotherapy process analysis.Year 5: Stakeholder engagement and dissemination. Anticipated impact and disseminationRCT results will inform evidence-based practice/commissioning for the treatment of aggression and psychological distress for people with ID in secure care.

Lay Abstract: Key Points	Some people with learning disabilities who commit a crime and go to court can be sent to prison or to a hospital with secure care. 	People with learning disabilities in secure care are more likely to stay there longer than people without a learning disability. 	Records show that people in secure care hurt either themselves or others more often than in other mental health hospitals. 	People who struggle with reading information and communication can find creative approaches a helpful way to understand and manage their own mental health needs. 	Art psychotherapy is a psychological therapy where people work with a therapist and make artwork to help them to communicate about any difficulties they are having. It can be helpful for people who find it hard to talk about what they are thinking about, feeling, or struggling with.Who is doing this research? The research team is made up of art psychotherapists and researchers. People with learning disabilities have spoken to us about this research and helped us to design it, plan how to do it, and how we tell people about it when it is finished. Why is this research needed? In the past people who have a learning disability were often excluded from taking part in research. This means that knowing what works well for them is not always clear. Lots of psychotherapies available to help people with mental health difficulties are based on talking, which might not always be the best approach for people with learning disabilities. Doing artwork or creative things within art psychotherapy can be a helpful way for people to communicate about themselves. Interpersonal art psychotherapy has been designed to help people with learning disabilities in secure care. The art psychotherapist encourages people to use creative ways to express the things they are frustrated, angry, or distressed about. What are we aiming to find out? We want to find out if interpersonal art psychotherapy is helpful and value for money for people with learning disabilities who are in secure care. We will be testing if interpersonal art psychotherapy works better than the standard care that is being provided. To do this we will need to recruit 240 people and put them into groups by chance, with half having interpersonal art psychotherapy and half on a waiting list for it. This is called a randomised controlled trial (RCT). Everyone in the study will get a chance to have interpersonal art psychotherapy. How have we involved patients and the public in our research?People who have a learning disability have been advising us on how we should do this research. People helped us to design the study, suggesting using a waiting list. They thought it was important for everyone in the study to have a chance to do art psychotherapy. The therapy manual was developed by an art psychotherapist and people who have a learning disability looked at it and told us what they thought worked well and what could be improved. People with a learning disability will be advising us during the study. A theatre company, run by and for people who have a learning disability, will help share the results of our research through performances. How will people with learning disabilities and secure services benefit from the study?We will find out if interpersonal art psychotherapy can help people who are in secure care to improve their mood, become less distressed, and not hurt themselves or others. We think that this research will give people with a learning disability more choice about accessing psychotherapy in secure care.

Research Activity Codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health Categories: MENTAL HEALTH