Title: Art psychotherapy for adult offenders with intellectual and developmental disabilities: a randomised, multiple-baseline single-case study.
Funder: Health Education England

Abstract: Background An international literature review of inpatient violence and aggression (Bowers et al., 2011) reported that patients treated in forensic settings are likely to be more violent than those from other settings such as psychiatric units. The UK has one of the highest rates of aggression reported in inpatient settings including relatively high levels of staff being victims of violence (Bowers et al., 2011). The National Audit of Violence in the UK found that a third of inpatients had been threatened or made to feel unsafe while in care (Royal College of Psychiatrists, 2007). The majority of admissions to forensic services in England are because of violent behaviour (Coid et al., 2001). Meekums and Daniel's (2011) meta-synthesis of the role of arts in therapeutic goals for offenders identified associations with improvements in emotional literacy, quality of life, and lower levels of arousal linked with feelings of anger. Improving trend in reduced levels of aggression in adult offenders with intellectual and developmental disabilities have been measured in art psychotherapy single-case studies (Hackett, 2012). A systematic review of the literature will be carried out within the CAT CL. Aims The aim of this research is to investigate art psychotherapy as a novel treatment for aggression in adult offenders with mild intellectual and developmental disabilities within secure NHS services in England. Questions 1.Are treatment effects measurable and repeated in multiple single-case studies? 2.Are adjustments required in order to deliver the therapy in different categories of low, medium, and high security? 3.Can a RCT full trial be conducted post-award? Research Plan A randomised, multiple-baseline single-case study will be carried out to provide an estimate of the overall effect of art psychotherapy as a complex intervention with adult offenders who exhibit aggressive behaviour. Multiple baseline designs have extended pre-treatment baseline measurement of the target behaviour which is used as the control condition (Kazdin, 2011). Treatment effects on the target behaviour can be measured during and following the introduction of therapy through analysis of within and between person variability. Treatment delivery by different therapists in three different NHS forensic high, medium, and low secure services will be tested contributing to an assessment of feasibility for a full trial. The investigation will focus on identifying the change processes associated with outcomes, specific components of therapy, and factors associated with the delivery of the treatment including therapist factors. The active components of treatment described as in therapy events' will be identified. The analysis will also include assessment of the potential influence of extra-therapy events' in order to isolate active components of the intervention.A Feasibility Study The outputs of this study will lay the foundations necessary for conducting a full trial following the CAT CL award. A feasibility report will be produced identifying the following, sample size estimates willingness of participants to be randomised to waiting times willingness of clinicians to recruit participants number of eligible patients or other appropriate participants performance of outcome measures follow-up rates, response rates to questionnaires, adherence/compliance rates data collection and analysis procedures To develop capacity for future forensic art psychotherapy studies in the NHS a research consortium will be formed. The dissemination strategy will be carried out in order to maximise the opportunity to recruit NHS Trusts to a research consortium capable of supporting a full trial with an internal pilot following the CAT CL award. Potential benefits to patients Within the NHS physical and verbal aggression can cause significant management difficulties within specialist forensic services. There will be direct benefits to patients who are treated within specialist forensic services and the staff who manage violence and aggression within these settings.

Lay abstract: Art therapy is a psychological therapy that uses art making to help people communicate about themselves to a therapist. A small art therapy research study with men with mild learning disabilities in a hospital showed that their levels of aggression towards others reduced during and following art psychotherapy. This research will build upon these findings and test the treatment in a larger number of patients in three different NHS sites in England. The results of this research will show if the treatment works by seeing if outcomes can be replicated. This will inform the design of a randomised control trial.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH