An evaluation of the impact of a social inclusion programme on occupational functioning for forensic service users.
Abstract: Introduction: The rehabilitation of forensic service users with serious mental illness is an emerging specialism in occupational therapy. However, there is little evidence to support the development of this role. Government white papers and guidelines recommend a rehabilitation process that involves a social inclusion agenda and the literature supports the role of the occupational therapist in its provision. This study was designed to provide evidence for, and to guide, the practice of forensic occupational therapists working in a rehabilitation setting.

Method: The study compared Model of Human Occupation Screening Tool (MOHOST) scores of forensic service users who received treatment as usual and participated in a social inclusion programme (n = 24) with the scores of those who received treatment as usual (n = 19) only.

Results: Although no difference was found in MOHOST scores between the two groups before intervention (p>0.05 at 0.493), a significant difference in scores was found in the intervention group post-intervention (p<0.05 at 0.006). This difference is hypothesised to represent change in occupational functioning and evidence of successful treatment outcomes.

Conclusion: The study concluded that forensic service users could benefit from occupational therapy programmes that include activities to promote social inclusion.

Key words:

Social inclusion, forensic services, assessment.
Subject: Psychiatric services (Analysis)
Cognition disorders (Care and treatment)
Cognition disorders (Research)
Occupational therapy (Usage)
Practice guidelines (Medicine) (Usage)
Author: Fitzgerald, Martin
Pub Date: 10/01/2011
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Oct, 2011 Source Volume: 74 Source Issue: 10
Topic: Event Code: 310 Science & research
Product: Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 271053261
Full Text: Introduction

Social inclusion is a central principle of United Kingdom government policy and a dominant agenda for mental health services (Department of Health [DH] 2000, College of Occupational Therapists 2006, Harrison and Sellers 2008). The National Service Framework for Mental Health (DH 1999) and No Health without Mental Health (DH 2011) require health and social services to reduce discrimination and social exclusion among service users. Education, training and employment have been identified in these papers as key to meeting these objectives. When considering offenders with mental health problems, in particular schizophrenia, specific care is required to ensure the assessment of occupational status and potential. Forensic occupational therapy has been described as a new specialism in forensic care and has the potential to fulfil the social inclusion expectation of policy (DH 2002, Duncan et al 2003, O'Connell and Farnworth 2007). However, much of the evidence to support the role of occupational therapy in this new specialism has lacked currency and there is little evidence to guide the occupational therapist in his or her practice (O'Connell and Farnworth 2007).

In 2006, the occupational therapy team from the Forensic and High Support Directorate (FHSD) within Pennine Care NHS Foundation Trust developed a social inclusion programme (SIP). Its aims were to increase engagement in community-based activity; to introduce complex task performance and goal-orientated activity to treatment; to engage patients in normative learning environments; to improve literacy and numeracy skills; and to provide a stepping stone to further education and work. An additional aim was to evaluate the social inclusion work and to demonstrate evidence for occupational therapy interventions, consistent with the research priorities of Duncan et al (2003) to investigate treatment outcomes, to link research to practice and to address occupational deprivation.

Literature review

Mental illness is correlated with social exclusion (Fitzgibbon and Cameron 2007). Those experiencing serious mental illness (SMI) are one of the most excluded and disadvantaged groups in society (Social Exclusion Unit 2004) and those in forensic services are no exception (Lloyd 1987). The onset of SMI most commonly occurs during late adolescence or young adulthood, with a resulting interruption in secondary and tertiary education (McGorry 1992). This interruption can impair the development of essential social skills, such as problem solving, time management, motivation and the use of initiative (Bassett et al 2001). Social exclusion, experienced as stigma and the reduction of participation in relationships and mainstream social, cultural and economic activities, can often result from this impairment (Morgan and Bhugra 2010).

In addition to experiencing social exclusion, forensic service users are also prone to occupational deprivation. Occupational deprivation is a state in which an individual is unable to do what is necessary and meaningful in his or her life (Whiteford 2000, Mee and Sumsion 2001). Preece (1995) argued that in forensic services the medical model contributes to the experience of occupational deprivation because it shapes the types of professional intervention that lead to underachievement, low motivation and low self-esteem. Underachievement and low expectation can further decrease the service user's social networks and occupational opportunity which, in turn, increases the experience of social exclusion (Link et al 1989). Whiteford (2000) went further and stated that an occupational perspective is needed to support and develop treatment approaches, so as to provide alternative images and experiences of success to those of the medical model. Recent evidence supports the use of social inclusion interventions, such as education, vocational activity and work, to achieve this perspective in mental health services (Mowbray 2000, Bassett et al 2001, Becker et al 2002, Cheung et al 2006, Cook 2006).

People with SMI value work (Mowbray 2000) but lack the necessary skills, training and support to overcome functional deficits, social impairments and discrimination (Cook 2006, Corrigan 2006). Davis and Rinaldi (2004), in their study, successfully supported mental health service users back to employment through the development and implementation of a trust-wide vocational services strategy. It involved partnership working with service users, occupational therapists, mental health employment coordinators and care coordinators in the assessment, planning, placement and support of service users into work.

Supported education programmes are designed to foster self-confidence and self-esteem, to encourage skill acquisition and academic credentials and to normalise identity (Becker et al 2002, Westwood 2003). In Mowbray's (2000) study (n = 397), adults with SMI were supported for matriculation at a community college. Participants were randomly assigned to an active treatment group that involved small group exercises and experiential learning over two 14-week semesters, and a control group that did not participate in these structured and scheduled interventions. Participants in the active treatment group showed significant improvement in quality of life, self-esteem and social adjustment and a threefold increase in productive activity at 6 months follow-up. Westwood (2003) used semi-structured interviews to explore the benefits, barriers, drawbacks, enabling factors and impact on mental health for 12 individuals who attended college. The individuals found improvements in confidence, self-esteem, socialisation and motivation to have resulted from their attendance at college. Other authors have found reduced symptomatology, reduced relapses, increased ability to cope and increased daily structure to have resulted from supported education programmes (Dench and Regan 2000).

Work is an important step in the recovery process (Westwood 2003, Davis and Rinaldi 2004, National Social Inclusion Programme 2006) and supported education can serve as a stepping stone to work (Westwood 2003). Occupational therapy is a profession that promotes choice, participation and empowerment and provides a key role in coordinating, implementing and evaluating activity (Mee and Sumsion 2001, DH 2002, Dunn and Seymour 2008). By using activities that enable or support opportunities for social inclusion within a broader rehabilitation programme, the occupational therapist can meet service framework expectations, reduce occupational deprivation and provide the real possibility of enabling change in the lives of forensic service users (Whiteford 2000, Dunn and Seymour 2008).

The social inclusion programme (SIP)

The SIP (see Table 1) was made available to all 62 service users in four long-stay units in the FHSD, a low-secure, rehabilitation forensic service at Pennine Care NHS Foundation Trust. The programme entailed graded community engagement and one-to-one goal planning with a unit-based occupational therapist, in addition to normal treatment. As prerequisite referral criteria for admission to the FHSD, all service users had a history of poor insight and poor engagement; more than half had a history of violence, 46% had an index offence and all were subject to the Mental Health Act (1983).

Initially, the SIP was proposed to senior directorate managers. This was important because some of the programmes had financial implications and approval for this expenditure had to be agreed early on in the process. The unit-based occupational therapists worked collaboratively, sharing resources across all FHSD units. The SIP became an agenda item in the inpatient managers meeting, the service-wide occupational therapy meeting and the senior directorate managers meeting. This served to improve communication, review progress and identify good practice.

Service users were encouraged to attend activities that were assessed to be appropriate to their needs. However, there was a hierarchy of complexity, with leisure groups being the least and college work the most task demanding. As service user presentations stabilised, functional ability improved and risk reduced (as determined by the multidisciplinary team and monthly care planning meetings), they were encouraged to engage in more complex and task demanding activities until they were engaged in an individualised college/work-based programme.

Method

The purpose of the evaluation

The purpose of the evaluation was to test for a difference in occupational functioning between service users attending the SIP and those who did not. A pre-test and post-test, between-group comparison design was used (see Table 2). Occupational functioning was measured by the Model of Human Occupation Screening Tool (MOHOST). The activities that make up the SIP provided the opportunity for service users to experience social inclusion. The outcome measure, the MOHOST, was used to look at whether these activities improved occupational functioning.

All service users were offered the SIP and none were excluded from the programme once they had agreed to engage. Of those who consented to participate in the study, 24 agreed to engage in the SIP and therefore became the SIP group while 19 refused to engage in the SIP and thus became the treatment as usual (TAU) group. Group membership was, therefore, self-selecting. Due to this being an exploratory study, and for the ethical reason that random allocation would have denied treatment, participants were not allocated to groups. Both groups received TAU but only the intervention group engaged in the SIP. The SIP contained additional interventions to the TAU group and involved prescribed activity that was part of a clinical framework that connected the SIP to short-term and long-term treatment goals.

The SIP treatment goals were regularly reviewed and planned with the service user and his or her multidisciplinary team, but did not have a set number of sessions or a prescribed time period. Service user engagement was ongoing and progression was related to goal planning and its graded outcomes. The SIP was, therefore, a coherent set of interventions that only the SIP group received, and was above and beyond that which all service users received as usual. Details of age, race, gender, diagnosis (schizophrenia, schizophreniform, bipolar disorder), medication (typical or atypical, mood stabiliser, atypical with mood stabiliser) and whether an index offence was present or not were also collected.

Forty-three out of 62 service users consented to have their data used in the study, 14 refused to consent and five were discharged from the service. Ethical approval was sought through National Health Service (NHS) Central Ethics and approved by the North Manchester Research Ethics Committee (ref: 08/H1006/40). Pennine Care NHS Foundation Trust provided local approval (ref: SC/LSRA). Written and signed consent was obtained at least 24 hours after potential participants had been provided with a study information sheet.

Consent was given to allow the chief investigator to have access to and use of MOHOST scores for the data analysis. Because the SIP intervention was an established treatment, consent to receive the intervention was not required from participants. Anonymity of participants was guaranteed at all times.

Instrumentation

Occupational function was assessed using the MOHOST (version 2). The MOHOST is based on the concepts of the Model of Human Occupation (MOHO), which assesses motivation, performance and organisation of occupational behaviour (Parkinson et al 2006). It was developed by British occupational therapists in conjunction with the MOHO team in Chicago (Parkinson et al 2008). It contains 24 items, four for each of the six subsections of volition, habituation, communication, processing skills, motor skills and environment (Parkinson et al 2006). The first five sections assess the person's participation in occupation, while the last assesses how the environment supports that occupation (Parkinson et al 2006).

The MOHOST is designed to be scored from a variety of data sources (Parkinson et al 2008), is flexible and straightforward enough to be used in a range of settings and was designed to document progress towards occupational therapy goals (Parkinson et al 2006). It has been extensively pilot tested (Parkinson et al 2006) and a study of its psychometric properties is forthcoming (Parkinson et al 2008, Forsyth et al, in press).

Although there are other assessments that assess similar occupational areas, the MOHOST was chosen because it is specifically designed to assess and measure a person's overall occupational participation, regardless of symptoms, disorder and treatment stage (Parkinson et al 2006), and is considered to be well placed to evaluate the effectiveness of occupational therapy interventions (Parkinson et al 2008). Following discussion with the MOHOST authors, the nominal MOHOST scale of F (Facilitates), A (Allows), I (Inhibits) and R (Restricts) was changed to the ordinal scale of 4, 3, 2, 1 respectively, so as to facilitate statistical analysis.

Implementation

Participants were approached by their occupational therapist for consent. After this, demographic data (see Table 3) and MOHOST scores, which are routinely used for baseline care programme approach assessment, were collected from service users' files by the chief investigator. The chief investigator was not involved in providing any of the interventions.

The MOHOSTs used in this study were completed by occupational therapists, who also ran the SIP groups. Thus the potential for bias, the uncontrolled influence on outcomes, may have resulted. The SIP occupational therapists had caseloads of 12 service users, not all of whom would be engaged in the SIP at any one time. Although each therapist was involved in the running of the groups, they were not necessarily involved in the groups attended by their caseload. Most groups were run by other occupational therapists, unqualified staff or by outside agencies, such as education. In addition, none of the SIP occupational therapists were involved in the research (other than completing the MOHOST for those on their caseload), data collection or analysis. As a result of this, the risk of bias was reduced.

Data analysis

The data were analysed using SPSS Version 17.0 (SPSS 2009). All significance tests were two tailed, with p = 0.05. Descriptive statistics (see Table 4) were run on all variables but conditions for parametric testing were not met. Nonparametric, Mann-Whitney U Test (see Table 5 for rank scores and Table 6 for test statistics) was run for overall and subscale scores to answer the research questions:

1. Was there any difference in MOHOST scores between the two groups pre-intervention?

2. Was there any difference in MOHOST scores between the two groups post-intervention?

Results

There were 43 participants overall (SIP group n = 24, TAU group n = 19); 84% were male (SIP group n = 21, TAU group n = 15) and 16% female (SIP group n = 3, TAU group n = 4) (Table 3). Their ages ranged from 21 to 59 years, with an average age of 36.19 years. The TAU group was slightly older, at 39.53 years, than the SIP group, at 33.54 years.

Eighty-six per cent of participants had a diagnosis of schizophrenia (n = 37), 9% had a schizoaffective disorder (n = 4) and 5% a bipolar disorder (n = 2). Ninety-two per cent of participants in the SIP group had a diagnosis of schizophrenia (n = 22) as opposed to 79% of the TAU group (n = 15). More people with a mood component, 21%, were in the TAU group as opposed to 8% in the SIP group. Participants with bipolar disorder were represented in the TAU group only.

The majority of participants were white British, 86% (n = 37). The only minority ethnic groups were British Afro-Caribbean and British Pakistani-Asian, who were equally represented at 7% (n = 3). Ethnicity was evenly represented in both groups.

Seventy-two per cent of participants (n = 31) were on atypical medication, 21% (n = 9) on typical medication, 2% (n = 1) on mood stabilisers and 5% (n = 2) on atypical medication and mood stabilisers. Proportionally, more people, 37% (n = 7), were on typical medication in the TAU group as compared with 8% (n = 2) in the SIP group. More people were on atypical medication in the SIP group 87% (n = 21) than in the TAU group 53% (n = 10).

Almost half of participants, 46% (n = 20), had an index offence and represented 46% (n = 11) of the SIP group and 47% of the TAU group (n = 9). Just over half of participants, 53% (n = 23), did not have an index offence and represented 54% (n = 13) of the SIP group and 53% (n = 10) of the TAU group.

Because the mean age values indicate that the SIP group was younger than the TAU group, a post-hoc t-test was performed. The difference in age was not significant (t = -1.829, df = 36.468 p = 0.076).

The overall mean pre-intervention and post-intervention scores showed a mean increase for the SIP group (Table 4). The pre-intervention SIP group showed a mean of 66.29 and the pre-intervention TAU group showed a mean of 63.26. Post-intervention mean scores for the SIP group increased to 72.50, while the post-intervention TAU mean score decreased to 61.26. The SIP group scored higher at post-intervention as compared with pre-intervention and the TAU group had a lower post-intervention score as compared with their pre-intervention score. This pattern continued for the subscale scores of motivation for occupation, communication and interaction skills and process skills. Pattern of occupation and environment subscale scores improved for both groups, although the SIP group had the larger increase. Motor skills were the only subscale to show a decrease in mean scores for both groups, although the TAU group showed the greater decrease. The standard deviations show that both groups, at pre-intervention and post-intervention, had similar levels of variability. The data were normally distributed and there were no extreme scores.

Overall, the SIP group scored significantly better than the TAU group post-intervention, with a mean rank of 26.67, against the TAU group mean rank of 16.11, p<0.05 at 0.006 (Table 5). The two groups were not significantly different before the intervention, with SIP and TAU showing mean ranks of 23.17 and 20.53 respectively, p>0.05 at 0.493.

Further analysis of MOHOST subscale scores showed no significant difference in mean rank scores before intervention, but a significant difference post-intervention for four of the six subscales (Table 6). Motivation for occupation showed pre-intervention scores of 23.81 and 19.71 for SIP and TAU with p>0.05 at 0.284, and a significant difference in scores post-intervention with mean ranks of 27.25 and 15.37 for SIP and TAU with p<0.05 at 0.002. Pattern of occupation showed a significant difference in scores with SIP at 22.96 and TAU at 20.79 with p>0.05 at 0.571 for pre-intervention scores, and 27.13 and 15.53 for SIP and TAU with p< 0.05 at 0.002 for post-intervention scores.

There was no significant difference in communication and interaction skills, with pre-intervention scores of 22.17 and 21.79 respectively for SIP and TAU with p>0.05 at 0.922 and post-intervention scores of 24.44 and 18.92 with p>0.05 at 0.149. Process skills also showed no significant difference, with pre-intervention scores of 21.94 and TAU of 22.08 with p> 0.05 at 0.970 and post-intervention of 24.46 for SIP and 18.89 for TAU with p>0.05 at 0.146.

There was a significant difference in motor skills, with ranks pre-intervention scores showing 22.94 and 20.82 for SIP and TAU with p>0.05 at 0.577 and post-intervention scores of 25.48 and 17.61 for SIP and TAU with p<0.05 at 0.037. Environment subscale pre-intervention scores of 23.65 for SIP and 19.92 for TAU with p>0.05 at 0.326 and post-intervention scores of 25.56 for SIP and 17.50 for TAU with p< 0.05 at 0.033 also showed a significant difference in scores.

Discussion

This study found little difference in overall MOHOST scores between the SIP and the TAU groups before intervention and a significant difference in the scores of the SIP group following intervention. This difference continued to be evident in four of the six subscales scores, with motivation for occupation, pattern of occupation, motor skills and environment all showing significant difference.

These findings are consistent with the evidence in the literature and the expectation of this study. Those who experience SMI endure poor motivation, cognitive dysfunction and habitual deskilling, which can impair the rehabilitation process (McGorry 1992, Mee and Sumsion 2001, Gopal and Variend 2005). In addition, the rehabilitation process can itself prejudice skill acquisition through occupational deprivation (Preece 1995, Whiteford 2000). However, as the condition of occupational deprivation improves and the individual experiences skill-enhancing activities that positively redefine roles, habits and identity, a corresponding improvement in motivation and behaviour can be expected (Mowbray 2000, Westwood 2003). The SIP provided such an opportunity and those service users who engaged in the programme evidently improved in their occupational performance, as measured by their before-and-after MOHOST scores.

This study focused on the need to evidence an occupational therapy intervention within a forensic setting. The need to provide social inclusion within the framework of a mental health setting is well established (Davis and Rinaldi 2004, National Social Inclusion Programme 2006). Evidence already exists to support the use of social inclusion activities as interventions in forensic settings (Mowbray 2000, Becker et al 2002, Cheung et al 2006), but there is little evidence to support such an intervention in the remediation of established MOHO domains, as explored by the MOHOST. Improvements in these domains are hypothesised to represent improved occupational functioning, progress within an occupational therapy programme and evidence for prognostic change (Parkinson et al 2006). On the face of it, these findings suggest that a SIP that engages service users in the experience of social inclusion can be successful in improving the occupational performance of forensic service users.

Limitations and strengths of the study

Limitations

This was a small study, limited to four long-stay units at one NHS site, and participants were not randomly assigned to groups. Despite a 69% recruitment rate, the sample size was small and the ability to generalise limited. Reproduction of this study could benefit from a longer time scale and the use of multiple NHS sites so as to increase recruitment rate and sample size.

Statistically, there was no significant difference between the SIP and TAU groups before intervention. However, the SIP group had better before-intervention MOHOST scores and the TAU group had more people with a mood component to their illness. This may have affected results, and randomisation of participants in any future study would be useful in controlling for this. Another potential bias, the administration of MOHOSTs by occupational therapists who also run the SIP groups, is an issue. Reproduction of this study should therefore use independent MOHOST administrators.

No breakdown of SIP sessions into duration, frequency and numbers attending are available. The study is therefore unable to comment on the benefits or otherwise of particular SIP groups.

Strengths

This was the first study to use the MOHOST to assess the effectiveness of social inclusion interventions in a forensic occupational therapy programme. The results showed a significant difference in intervention scores against treatment as usual scores and, although the sample size was small, the degree of significance was encouraging. It was also encouraging to see that the intervention group was well represented with participants who experienced schizophrenia and who had index offences. Previous research has suggested that disengagement remains a significant problem for service users who experience schizophrenia (Lieberman et al 2005, Kreyenbuh et al 2009). This research provides evidence to suggest that this is not necessarily the case.

Further study

This study would merit follow up to assess the extent to which the changes, as measured on the MOHOST, endure over time. It also recommends reproduction at further sites with a larger sample size. Because self-selection was used to allocate group membership, the TAU group chose not to engage in the SIP. Further study could benefit from randomised allocation of participants to groups so as to eliminate potential bias.

This study did not assess mental state, risk profile, psychosis, self-esteem, self-worth or self-efficacy. Self-esteem, self-worth and self-efficacy have been found to benefit from social inclusion work (Mowbray 2000) and may provide insight into why some service users can be successfully engaged in social inclusion work while others remain reluctant.

Finally, this evaluation focused on measuring the impact of social inclusion activities on occupational functioning. It did not investigate whether it promoted service users' experience of social inclusion. Further investigation could therefore benefit from exploring service users' experience of social inclusion resulting from their engagement in activities described in this study.

Conclusion

As a growing specialism in the treatment and assessment of forensic service users, occupational therapy needs to evidence its practice. Forensic service users are prone to occupational deprivation, with resulting deficits in motivation and performance. Occupational therapy provides a key role in coordinating, implementing and evaluating activity that has been hypothesised to improve performance in these areas.

By comparing an intervention that promotes social inclusion with a non-intervention group that received treatment as usual, this study has provided some evidence to support the role of occupational therapy in forensic practice. No significant difference was found between these two groups pre-intervention but a significant difference was found post-intervention. The study concludes that social inclusion work can improve occupational performance for forensic service users and, therefore, recommends it as an occupational therapy intervention for forensic services.

Conflict of interest: None declared.

Key findings

* Occupational therapy, because of its key role in coordinating, implementing and evaluating activity, is well placed to support social inclusion in forensic services.

* The intervention group demonstrated improved occupational functioning as measured by MOHOST scores.

What the study has added

This study provides evidence to support the use of the MOHOST to measure occupational change in forensic service users engaged in social inclusion programmes.

References

Bassett J, Lloyd C, Bassett H (2001) Work issues for young people with psychosis: barriers to employment. British Journal of Occupational Therapy, 64(2), 66-72.

Becker M, Martin L, Wajeeh E, Ward J, Shem D (2002) Students with mental illness in a university setting: faculty and student attitudes, beliefs, knowledge and experiences. Psychiatric Rehabilitation Journal, 25(4), 359-68.

Cheung L, Tsang H, Tsui C (2006) A job-specific social skills training programme for people with severe mental illness: a case study for those who plan to be a security guard. Journal of Rehabilitation, 72(4), 14-23.

College of Occupational Therapists (2006) Recovering ordinary lives: the strategy for occupational therapy in mental health services 2007-2017, a vision for the next ten years. London: COT.

Cook J (2006) Employment barriers for persons with psychiatric disabilities: update of a report for the president's commission. American Psychiatric Association, 57(10), 1391-405

Corrigan PW (2006) Erase the stigma: make rehabilitation better fit people with disabilities. Rehabilitation Education, 20(4), 225-35.

Davis M, Rinaldi M (2004) Using an evidence-based approach to enable people with mental health problems to gain and retain employment, education and voluntary work. British Journal of Occupational Therapy, 67(7), 319-22.

Dench S, Regan J (2000) Learning in later life: motivation and impact. Research Report RP183. London: Department for Education and Employment.

Department of Health (1999) The National Service Framework for Mental Health. London: HMSO.

Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform. London: HMSO.

Department of Health (2002) Occupational therapy services--securing the future. London: HMSO.

Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages. London: Mental Health and Disability, Department of Health.

Duncan EA, Munro K, Nicol M (2003) Research priorities in forensic occupational therapy. British Journal of Occupational Therapy, 66(2), 55-64.

Dunn C, Seymour A (2008) Forensic psychiatry and rehabilitation: where are we at? British Journal of Occupational Therapy, 71(10), 448-51.

Fitzgibbon W, Cameron A (2007) Working with mentally disordered offenders: government policy, NOMS and inaction. British Journal of Forensic Practice, 9(1), 4-9.

Forsyth K, Parkinson S, Kielhofner G, Kramer J, Summerfield Mann L, Duncan E (in press) The measurement properties of the Model of Human Occupation Screening Tool and implications for practice. New Zealand Journal of Occupational Therapy.

Gopal YV, Variend H (2005) First-episode schizophrenia: review of cognitive deficits and cognitive remediation. Advances in Psychiatric Treatment, 11(1), 38-44.

Harrison D, Sellers A (2008) Occupation for mental health and social inclusion. British Journal of Occupational Therapy, 7(5), 216-18.

Kreyenbuhl J, Nossel IR, Dixon LB (2009) Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: a review of the literature. Schizophrenia Bulletin, 35(4), 696-703.

Lieberman JA, Stroup TS, McEvoy JP, Swartz M, Rosenheck R, Perkins D, Keefe D, Keefe RS, Davis S, Lebowitz B, Severe JB, Hsiao JK (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine, 353(12), 1209-23

Link B, Cullen F, Streuning E (1989) A modified labelling theory approach to mental disorders: an empirical assessment. American Sociological Review, 54(3), 400-23.

Lloyd C (1987) The role of occupational therapy in the treatment of the forensic psychiatric patient. American Journal of Occupational Therapy, 34(1), 20-25.

Mee J, Sumsion T (2001) Mental health clients confirm the motivating power of occupation. British Journal of Occupational Therapy, 64(3), 121-28.

McGorry PD (1992) The concept of recovery and secondary prevention in psychotic disorders. Australian and New Zealand Journal of Psychiatry, 26(1), 3-17.

Morgan C, Bhugra D, eds (2010) Principles of social psychiatry. 2nd ed. Oxford: Wiley-Blackwell.

Mowbray C (2000) The Michigan supported education program. American Psychiatric Association, 51(11), 1355-57.

National Social Inclusion Programme (2006) Vocational services for people with severe mentalhealth problems: commissioning guidance. London: COI.

O'Connell M, Farnworth L (2007) Occupational therapy in forensic psychiatry: a review of the literature and a call for a united and international response. British Journal of Occupational Therapy, 70(5), 184-91.

Parkinson S, Forsyth K, Kielhofner G (2006) Model of Human Occupation Screening Tool (MOHOST). Chicago: University of Illinois at Chicago.

Parkinson S, Chester A, Cratchley S, Rowbottom J (2008) Application of the Model of Human Occupation Screening Tool (MOHOST assessment) in an acute psychiatric setting. Occupational Therapy in Health Care, 22(2), 63-75.

Preece J (1995) Disability and adult education--the consumer view. Disability and Society, 10(1), 87-102.

Social Exclusion Unit (2004) Mental health and social exclusion. London: Office of the Deputy Prime Minister.

SPSS (2009) SPSS for Windows. Chicago, IL: SPSS Inc.

Westwood J (2003) The impact of adult education for mental health service users. British Journal of Occupational Therapy, 66(11), 505-10.

Whiteford G (2000) Occupational deprivation: global challenge in the new millennium. British Journal of Occupational Therapy, 63(5), 200-04.

Correspondence to: Martin Fitzgerald, Head Occupational Therapist, Forensic and High Support Services, Pennine Care NHS Foundation Trust, Heathfield House, Cale Green, Manchester SK2 6RA.

Emails: martin.fitzgerald@penninecare.nhs.uk/martin.fitzgerald@nhs.net

Reference: Fitzgerald M (2011) An evaluation of the impact of a social inclusion programme on occupational functioning for forensic service users. British Journal of Occupational Therapy, 74(10), 465-472.

DOI: 10.4276/030802211X13182481841903

Submitted: 23 June 2010.

Accepted: 14 July 2011.
Table I. The FHSD social inclusion programme

Intervention         Description                    Aims
type

Leisure        Sports, swimming, cinema,   1. Provide community-based
groups         women's group, snooker,        engagement
               summer holidays, weekly     2. Develop adaptive role,
               football tournaments,          identity and habits
               fishing, green gym and      3. Normalise social
               conservation activities        activities
                                           4. Develop wider social
                                              network
                                           5. Practise adaptive
                                              coping
                                           6. Provide graded
                                              exposure to complex
                                              task demands and
                                              goal-orientated
                                              activity

Literacy       Developing literacy         1. Provide communitygroup
skills and entry-level         based engagement
               qualifications, using       2. Provide an
               information technology         introduction to
               (IT) and accessing public      community education,
               libraries                      in particular
                                              numeracy,
Stepping       Supporting people back         literacy and IT
stone          into mainstream             3. Provide recognised
education      education/vocation             qualifications
                                           4. Identify individual
               Progressing from               education and
               prevocational training to      vocational based needs
               supported and unsupported      beyond the SIP
               education and employment
               via pathways to wider
               services

College        Foundation courses in IT,   1. Provide communitycreative
               writing,              based engagement
               cooking, music, drama and   2. Provide a broad range
               skills for life, and pre-      of educational and
               GCSE courses in literacy       vocational subjects
               and numeracy                   and activities to
                                              initiate community
                                              education
                                           3. Facilitate progress
                                              from prevocational
                                              training to supported
                                              and unsupported
                                              education and
                                              employment
                                           4. Enable the attainment
                                              of recognised
                                              qualifications
                                           5. Identify individual
                                              education and
                                              vocational based needs
                                              beyond the SIP

                                           1. Provide individual
                                              education and
                                              vocational engagement
                                              beyond the SIP
                                           2. Focus on community
                                              engagement and
                                              community living

Work           Paid, vocational and        1. Maintaining and
               voluntary                      developing roles,
                                              habits and identity
                                              that underpin
                                              normalised community
                                              living

Table 2. Study criteria

Study criteria   All FHSD service users in residence
                 from 2006 to 2008

SIP group (1)    Service users who had attended the SIP and received
                 treatment as usual from 2006 to 2008.

TAU group (2)    Service users who had received treatment as usual
                 only from 2006 to 2008.

SIP = Social inclusion programme; TAU = Treatment as usual.

Table 3. Demographic data for SIP and TAU groups

                               Sample overall   SIP group   TAU group
                                  (n = 43)      (n = 24)    (n = 19)

Age
Range (years)                      21-59          21-58       22-59
Mean                               36.19          33.54       39.53
Median                               34            30          40
SD                                 10.81          9.96         11

Gender
Male                               36 84%        21 85%      1 5 79%
Female                             7 16%          3 12%       4 21%

Diagnosis
Schizophrenia                      37 86%        22 92%      1 5 79%
Schizoaffective                     4 9%          2 8%        2 10%
Bipolar disorder                    2 5%            0         2 10%

Race
White British                      37 86%        21 85%      16 84%
British Afro-Caribbean              3 7%          1 4%        2 10%
British Pakistani-Asian             3 7%          2 8%        1 5%

Medication
Atypical                           31 72%        21 87%      10 53%
Typical                            9 21%          2 8%        7 37%
Mood stabiliser                     1 2%            0         1 5%
Atypical and mood stabiliser        2 5%          1 4%        1 5%

Index offence
Index offence                      20 46%        11 46%       9 47%
No index offence                   23 53%        13 54%      10 53%

SIP = Social inclusion programme; TAU = Treatment as usual.

Table 4. Descriptive data of pre-intervention and post-intervention
SIP and TAU groups (Group 1 = SIP and Group 2 = TAU)

                       Pre-SIP intervention

              n     Minimum   Maximum   Mean      SD

Overall

Group 1 SIP   24      49        95      66.29   12.192
      2 TAU   19      37        84      63.26   13.888

Motivation for occupation

Group 1 SIP   24       6        16      10.00    2.703
      2 TAU   19       5        13       8.89    2.424

Pattern of occupation

Group 1 SIP   24       5        16       9.00    2.859
      2 TAU   19       5        12       8.26    2.353

Communication and interaction skills

Group 1 SIP   24       7        16      11.08    2.948
      2 TAU   19       6        15      11 00    3.232

Process skills

Group 1 SIP   24       7        16      10.48    2.702
      2 TAU   19       5        16      10.53    3.438

Motor skills

Group 1 SIP   24       8        16      13.29     2.43
      2 TAU   19       8        16      12.89    2.644

Environment

Group 1 SIP   24       8        16      12.46    1.933
      2 TAU   19       6        16      11.68    2.382

                      Post-SIP intervention

               n    Minimum   Maximum   Mean      SD

Overall

Group 1 SIP   24      51        95      72.50   11.699
      2 TAU   19      32        79      61.26   12.036

Motivation for occupation

Group 1 SIP   24       7        16      11.21    2.797
      2 TAU   19       4        12       8.21    2.507

Pattern of occupation

Group 1 SIP   24       7        16      10.67    2.599
      2 TAU   19       4        16       9.12    2.645

Communication and interaction skills

Group 1 SIP   24       6        16      11.83    2.599
      2 TAU   19       4        14      10.42    3.254

Process skills

Group 1 SIP   24       7        16      11.33    2.823
      2 TAU   19       4        15       9.79    3.242

Motor skills

Group 1 SIP   24       7        16      13.24    2.483
      2 TAU   19       7        16      12.47    2.653

Environment

Group 1 SIP   24       9        16      13.37    1.929
      2 TAU   19       7        16      12.21    2.123

SIP = Social inclusion programme; TAU = Treatment as usual.

Table 5. Mann-Whitney U mean rank and sum of rank scores
for SIP and TAU groups

                                            Pr-SIP intervention

                                        Group   n    Mean    Sum of
                                                     rank    ranks

Overall                                 1 SIP   24   23.17   556.00
                                        2 TAU   19   20.53   390.00
Motivation for occupation               1 SIP   24   23.81   571.50
                                        2 TAU   19   19.71   374.50
Pattern of occupation                   1 SIP   24   22.96   551.00
                                        2 TAU   19   20.79   395.00
Communication and interaction skills    1 SIP   24   22.17   532.00
                                        2 TAU   19   21.79   414.00
Process skills                          1 SIP   24   21.94   526.50
                                        2 TAU   19   22.08   419.50
Motor skills                            1 SIP   24   22.94   550.50
                                        2 TAU   19   20.82   395.50
Environment                             1 SIP   24   23.65   567.50
                                        2 TAU   19   19.92   378.50

                                           Post-SIP intervention

                                        Group   n    Mean    Sum of
                                                     rank    ranks

Overall                                 1 SIP   24   26.67   640.00
                                        2 TAU   19   16.11   306.00
Motivation for occupation               1 SIP   24   27.25   654.00
                                        2 TAU   19   15.37   292.00
Pattern of occupation                   1 SIP   24   27.13   651.00
                                        2 TAU   19   15.53   295.00
Communication and interaction skills    1 SIP   24   24.44   586.50
                                        2 TAU   19   18.92   359.50
Process skills                          1 SIP   24   24.46   587.00
                                        2 TAU   19   18.89   359.00
Motor skills                            1 SIP   24   25.48   611.50
                                        2 TAU   19   17.61   334.50
Environment                             1 SIP   24   25.56   613.50
                                        2 TAU   19   17.5    332.50

SIP = Social inclusion programme; TAU = Treatment as usual.

Table 6. Mann-Whitney U overall and subscale MOHOST test statistics

                                  Test statistics

                        Overall   Overall      1         1
                          Pre      Post       Pre      Post

Mann-Whitney U          200.000   116.000   184.500   102.000
Asymp.sig. (2-tailed)     0.493     0.006     0.284     0.002

                                  Test statistics

                           2         2         3         3
                          Pre      Post       Pre      Post

Mann-Whitney U          205.000   105.000   224.000   169.500
Asymp.sig. (2-tailed)     0.571     0.002     0.922     0.149

                                  Test statistics

                           4         4         5         5
                          Pre      Post       Pre      Post

Mann-Whitney U          226.500   169.000   205.500   144.500
Asymp.sig. (2-tailed)     0.970     0.146     0.577     0.037

                         Test statistics

                           6         6
                          Pre      Post

Mann-Whitney U          188.500   142.500
Asymp.sig. (2-tailed)     0.326     0.033

1 = Motivation for occupation; 2 = Pattern of occupation;
3 = Communication and interaction skills; 4 = Process skills;
5 = Motor skills; 6 = Environment.
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.