Background: We aimed to establish what core elements were required in a group therapy programme f... more Background: We aimed to establish what core elements were required in a group therapy programme for men who disclose perpetrating intimate partner abuse in a substance use setting and develop, and test the feasibility of delivering an intervention in this setting. Methods: We describe the theoretical development and feasibility testing of an integrated substance use and intimate partner abuse intervention("ADVANCE") for delivery in substance use services. We employed a comprehensive eight stage process to guide this development applying the 'COM-B' model for intervention design which speci es: 1) de ne the problem, 2) select the target behaviour, 3) specify the target behaviour, 4) identify what needs to change, 5) identify intervention functions, 6) identify policy categories, 7) select behaviour change techniques, and 8) design a mode of delivery. The development was informed by primary research conducted by the authors, consulting with organisation steering groups and by those with personal experiences. A feasibility study (ISRCTN 79435190) involving 104 men, 27 female partners and 30 staff at three different locations across the UK was conducted to assess the feasibility and acceptability of the intervention and to re ne the content and approach to delivery. Results: Our nal intervention, the ADVANCE intervention consisted of a group intervention comprising of up to four pregroup individual interviews, followed by 12 x 2-hour group sessions supported by integrated safety work for victim/survivors, and risk and safety support and integrity support for the professionals. The main targets for change were personal goal planning, self-regulation and attitudes and beliefs supporting intimate partner abuse. The intervention was regarded as very acceptable to both staff and clients in substance use services, with group attendees reported positive behavior changes and development of new skills, that facilitators noted were 'life-changing' for some. Conclusion: We have demonstrated the ability to employ a structured eight-step process to develop an integrated intervention to address substance use related intimate partner abuse that is acceptable to staff and clients in substance use services. However, there has been general consensus that motivational interviewing has had some positive impact on engagement and short term recidivism rates (Stephens-Lewis et al., 2019). Research indicates that IPA risks can be attributable to individual characteristics, including long-term traits such as personality and transient states such as depression (McKinney et al., 2009; Weldon & Gilchrist, 2012), cultural (Schnurr & Lohman, 2008) and relationship factors (Cui et al., 2010), such as the status of the relationship, martial or not, cohabiting or not and transient features such as relationship con ict, parenting disagreements and general stressors linked to features such as money, housing and employment. Furthermore, historical risk factors experienced in childhood, such as witnessing violence between parents or experiencing physical violence from parents (Cafferky et al., 2018), are associated with adult IPA perpetration (Holtzworth-Munroe & Stuart, 1994; Ward & Beech, 2006). Historically, IPA has been viewed as gendered violence, perpetuated by systems of patriarchal power (Dobash & Dobash, 2004; Morgan & Björkert, 2006) and, within this, substance use was largely viewed by perpetrators, victims and some professionals and academics as an excuse for IPA perpetration (Galvani, 2006). Recently, however, there has been increasing acknowledgement of the role of substance use as an aggravating factor (Lessard et al., 2020) or a risk factor for IPA (McMurran & Gilchrist, 2008). Meta-analyses have shown signi cant reductions in violence for men in substance use treatment services (Karakurt et al., 2019; Miller et al., 2013) and subgroup analysis has indicated that treating substance use and trauma in perpetrator programmes potentially enhances outcomes (Karakurt et al., 2019). Recent research has increased the awareness of the association between substance use and the risk of IPA incidence and level of injury (
A summary of key features from a systematic review protocol registered in PROSPERO International ... more A summary of key features from a systematic review protocol registered in PROSPERO International prospective register of systematic reviews.
Background Substance use is a risk factor for intimate partner abuse (IPA) perpetration. Deliveri... more Background Substance use is a risk factor for intimate partner abuse (IPA) perpetration. Delivering perpetrator interventions concurrently with substance use treatment shows promise. Methods The feasibility of conducting an efficacy and cost-effectiveness trial of the ADVANCE 16-week intervention to reduce IPA by men in substance use treatment was explored. A multicentre, parallel group individually randomised controlled feasibility trial and formative evaluation was conducted. Over three temporal cycles, 104 men who had perpetrated IPA towards a female (ex) partner in the past year were randomly allocated to receive the ADVANCE intervention + substance use treatment as usual (TAU) (n = 54) or TAU only (n = 50) and assessed 16-weeks post-randomisation. Participants’ (ex) partners were offered support and 27 provided outcome data. Thirty-one staff and 12 men who attended the intervention participated in focus groups or interviews that were analysed using the framework approach. Pre-s...
Background Strong evidence exists that substance use is a contributory risk factor for intimate p... more Background Strong evidence exists that substance use is a contributory risk factor for intimate partner abuse (IPA) perpetration. Men in substance use treatment are more likely to perpetrate IPA than men from the general population. Despite this, referral pathways are lacking for this group. This trial will assess the feasibility of conducting an evaluation trial of a tailored integrated intervention to address substance use and IPA perpetration to men in substance use treatment. Methods/design ADVANCE is a multicentre, parallel-group individually randomised controlled feasibility trial, with a nested formative evaluation, comparing an integrated intervention to reduce IPA + substance use treatment as usual (TAU) to TAU only. One hundred and eight men who have perpetrated IPA in the past 12 months from community substance use treatment in London, the West Midlands, and the South West will be recruited. ADVANCE is a manualised intervention comprising 2–4 individual sessions (2 compul...
BackgroundThe children of parents with severe personality difficulties have greater risk of signi... more BackgroundThe children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs.ObjectivesTo develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial.DesignA pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation.SettingTwo NHS mental health trusts and concom...
Bergin first published evidence that some individuals become significantly worse after psychother... more Bergin first published evidence that some individuals become significantly worse after psychotherapy (Bergin, 1966). Now, more than five decades later, there is wider acceptance that, as with any powerful treatment, psychological therapies may have negative as well as positive effects. Beneficently intended treatments may prove to be inherently harmful; grief counseling for normal bereavement is one such example (Lilienfeld, 2007). It is important to know this as early as possible and stop such interventions in such circumstances. Most adverse
Introduction Employment is a key goal for many people with long-term mental health issues. Eviden... more Introduction Employment is a key goal for many people with long-term mental health issues. Evidence-based individual placement and support is a widely advocated approach. This study explored whether individual placement and support outcomes could be enhanced with work-focused counselling. Method The study was designed as a pragmatic randomised controlled trial comparing the cost-effectiveness, in severe mental illness, of work-focused intervention (intervention) as an adjunct to individual placement and support compared to individual placement and support alone (control). Results The original sample (330) proved impossible to attain so the design was revised to a pilot study from which information on feasibility of a full trial could be drawn. Twenty-five individuals out of 74 found paid work but no difference was found in the mean number of hours in paid employment between the intervention and control groups. Conclusion Results demonstrate that delivering work-focused counselling i...
Background Antisocial personality disorder (ASPD), although associated with very significant heal... more Background Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD. Methods Three hundred and two participants r...
BackgroundSpecialist parenting intervention could improve coexistent parenting and child mental h... more BackgroundSpecialist parenting intervention could improve coexistent parenting and child mental health difficulties of parents affected by severe personality difficulties.ObjectiveConduct a feasibility trial of Helping Families Programme-Modified (HFP-M), a specialist parenting intervention.DesignPragmatic, mixed-methods trial, 1:1 random allocation, assessing feasibility, intervention acceptability and outcome estimates.SettingsTwo National Health Service health trusts and local authority children’s social care.ParticipantsParents: (i) primary caregiver, (ii) 18 to 65 years, (iii) severe personality difficulties, (iv) proficient English and (v) capacity for consent. Child: (i) 3 to 11 years, (ii) living with index parent and (iii) significant emotional/behavioural difficulties.InterventionHFP-M: 16-session home-based intervention using parenting and therapeutic engagement strategies. Usual care: standard care augmented by single psychoeducational parenting session.OutcomesPrimary f...
Background: There is a concern in the literature that harm from interventions is insufficiently d... more Background: There is a concern in the literature that harm from interventions is insufficiently documented in clinical trials in general, and in those assessing psychological treatments in particular. A recent decision by a trial steering committee to stop recruitment into a randomized controlled trial (RCT) of a psychological intervention for personality disorder led to an investigation of the recording of harm in trials funded by the National Institute for Health Research (NIHR). Methods: The protocols and final reports of all 82 NIHR trials funded between 1995 and 2013 were examined for the reporting of adverse events. These were subdivided by category of intervention. Results: None of the psychological intervention trials mentioned the occurrence of an adverse event in their final report. Trials of drug treatments were more likely to mention adverse events in their protocols compared with those using psychological treatments. When adverse events were mentioned, the protocols of psychological interventions relied heavily on severe adverse events guidelines from the National Research Ethics Service (NRES), which were developed for drug rather than psychological interventions and so may not be appropriate for the latter. Conclusions: This survey supported the belief that the reporting of adverse events in psychological treatments is weak and the criteria used may not be appropriate. Recommendations are made as to how current practice might be improved.
The purpose of this study was to investigate a clinical observation in referrals to a forensic cl... more The purpose of this study was to investigate a clinical observation in referrals to a forensic clinical psychology outpatient service: that anger was related to obsessional-compulsive behaviours, possibly as a substitute means of controlling situations. A secondary ...
The social and economic cost of intimate partner violence (IPV) is exorbitant and highlights the ... more The social and economic cost of intimate partner violence (IPV) is exorbitant and highlights the need for policy reform as it pertains to IPV interventions at a global level. There are multiple variables associated with the aetiology of IPV and, hence, multiple treatment needs must be considered. Substance use is one of several factors likely to influence the occurrence of IPV, but often goes unaddressed in standard treatment approaches. This review will discuss several treatment models for substance using offenders of IPV, including Psycho-educational Models, Cognitive Behavioural Therapy, Couples' Treatments, Parenting Programmes, Integration of Care Models, and Pharmacotherapies. Clinical recommendations will be discussed. Treatment outcomes among substance using offenders of IPV may be improved by implementing changes in protocol that increase diagnostic evaluations, integrate care with evidence-based models, require limits to the number of offenders in a group, and require qualifications for clinicians who treat offenders (licensed and trained psychologists, social workers, and/or psychiatrists).
Previous research has demonstrated the clinical effectiveness of long-term psychological treatmen... more Previous research has demonstrated the clinical effectiveness of long-term psychological treatment for people with some types of personality disorder. However, the high intensity and cost of these interventions limit their availability. Lower-intensity interventions are increasingly being offered to people with personality disorder, but their clinical and cost effectiveness have not been properly tested in experimental studies. We therefore set out to develop a low intensity intervention for people with personality disorder and to test the feasibility of conducting a randomized controlled trial to compare the clinical effectiveness of this intervention with that of treatment as usual (TAU). A two-arm, parallel-group, single-blind, randomized controlled trial of Psychological Support for Personality (PSP) versus TAU for people aged over 18 years, who are using secondary care mental health services and have personality disorder. We will exclude people with co-existing organic or psych...
Background: We aimed to establish what core elements were required in a group therapy programme f... more Background: We aimed to establish what core elements were required in a group therapy programme for men who disclose perpetrating intimate partner abuse in a substance use setting and develop, and test the feasibility of delivering an intervention in this setting. Methods: We describe the theoretical development and feasibility testing of an integrated substance use and intimate partner abuse intervention("ADVANCE") for delivery in substance use services. We employed a comprehensive eight stage process to guide this development applying the 'COM-B' model for intervention design which speci es: 1) de ne the problem, 2) select the target behaviour, 3) specify the target behaviour, 4) identify what needs to change, 5) identify intervention functions, 6) identify policy categories, 7) select behaviour change techniques, and 8) design a mode of delivery. The development was informed by primary research conducted by the authors, consulting with organisation steering groups and by those with personal experiences. A feasibility study (ISRCTN 79435190) involving 104 men, 27 female partners and 30 staff at three different locations across the UK was conducted to assess the feasibility and acceptability of the intervention and to re ne the content and approach to delivery. Results: Our nal intervention, the ADVANCE intervention consisted of a group intervention comprising of up to four pregroup individual interviews, followed by 12 x 2-hour group sessions supported by integrated safety work for victim/survivors, and risk and safety support and integrity support for the professionals. The main targets for change were personal goal planning, self-regulation and attitudes and beliefs supporting intimate partner abuse. The intervention was regarded as very acceptable to both staff and clients in substance use services, with group attendees reported positive behavior changes and development of new skills, that facilitators noted were 'life-changing' for some. Conclusion: We have demonstrated the ability to employ a structured eight-step process to develop an integrated intervention to address substance use related intimate partner abuse that is acceptable to staff and clients in substance use services. However, there has been general consensus that motivational interviewing has had some positive impact on engagement and short term recidivism rates (Stephens-Lewis et al., 2019). Research indicates that IPA risks can be attributable to individual characteristics, including long-term traits such as personality and transient states such as depression (McKinney et al., 2009; Weldon & Gilchrist, 2012), cultural (Schnurr & Lohman, 2008) and relationship factors (Cui et al., 2010), such as the status of the relationship, martial or not, cohabiting or not and transient features such as relationship con ict, parenting disagreements and general stressors linked to features such as money, housing and employment. Furthermore, historical risk factors experienced in childhood, such as witnessing violence between parents or experiencing physical violence from parents (Cafferky et al., 2018), are associated with adult IPA perpetration (Holtzworth-Munroe & Stuart, 1994; Ward & Beech, 2006). Historically, IPA has been viewed as gendered violence, perpetuated by systems of patriarchal power (Dobash & Dobash, 2004; Morgan & Björkert, 2006) and, within this, substance use was largely viewed by perpetrators, victims and some professionals and academics as an excuse for IPA perpetration (Galvani, 2006). Recently, however, there has been increasing acknowledgement of the role of substance use as an aggravating factor (Lessard et al., 2020) or a risk factor for IPA (McMurran & Gilchrist, 2008). Meta-analyses have shown signi cant reductions in violence for men in substance use treatment services (Karakurt et al., 2019; Miller et al., 2013) and subgroup analysis has indicated that treating substance use and trauma in perpetrator programmes potentially enhances outcomes (Karakurt et al., 2019). Recent research has increased the awareness of the association between substance use and the risk of IPA incidence and level of injury (
A summary of key features from a systematic review protocol registered in PROSPERO International ... more A summary of key features from a systematic review protocol registered in PROSPERO International prospective register of systematic reviews.
Background Substance use is a risk factor for intimate partner abuse (IPA) perpetration. Deliveri... more Background Substance use is a risk factor for intimate partner abuse (IPA) perpetration. Delivering perpetrator interventions concurrently with substance use treatment shows promise. Methods The feasibility of conducting an efficacy and cost-effectiveness trial of the ADVANCE 16-week intervention to reduce IPA by men in substance use treatment was explored. A multicentre, parallel group individually randomised controlled feasibility trial and formative evaluation was conducted. Over three temporal cycles, 104 men who had perpetrated IPA towards a female (ex) partner in the past year were randomly allocated to receive the ADVANCE intervention + substance use treatment as usual (TAU) (n = 54) or TAU only (n = 50) and assessed 16-weeks post-randomisation. Participants’ (ex) partners were offered support and 27 provided outcome data. Thirty-one staff and 12 men who attended the intervention participated in focus groups or interviews that were analysed using the framework approach. Pre-s...
Background Strong evidence exists that substance use is a contributory risk factor for intimate p... more Background Strong evidence exists that substance use is a contributory risk factor for intimate partner abuse (IPA) perpetration. Men in substance use treatment are more likely to perpetrate IPA than men from the general population. Despite this, referral pathways are lacking for this group. This trial will assess the feasibility of conducting an evaluation trial of a tailored integrated intervention to address substance use and IPA perpetration to men in substance use treatment. Methods/design ADVANCE is a multicentre, parallel-group individually randomised controlled feasibility trial, with a nested formative evaluation, comparing an integrated intervention to reduce IPA + substance use treatment as usual (TAU) to TAU only. One hundred and eight men who have perpetrated IPA in the past 12 months from community substance use treatment in London, the West Midlands, and the South West will be recruited. ADVANCE is a manualised intervention comprising 2–4 individual sessions (2 compul...
BackgroundThe children of parents with severe personality difficulties have greater risk of signi... more BackgroundThe children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs.ObjectivesTo develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial.DesignA pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation.SettingTwo NHS mental health trusts and concom...
Bergin first published evidence that some individuals become significantly worse after psychother... more Bergin first published evidence that some individuals become significantly worse after psychotherapy (Bergin, 1966). Now, more than five decades later, there is wider acceptance that, as with any powerful treatment, psychological therapies may have negative as well as positive effects. Beneficently intended treatments may prove to be inherently harmful; grief counseling for normal bereavement is one such example (Lilienfeld, 2007). It is important to know this as early as possible and stop such interventions in such circumstances. Most adverse
Introduction Employment is a key goal for many people with long-term mental health issues. Eviden... more Introduction Employment is a key goal for many people with long-term mental health issues. Evidence-based individual placement and support is a widely advocated approach. This study explored whether individual placement and support outcomes could be enhanced with work-focused counselling. Method The study was designed as a pragmatic randomised controlled trial comparing the cost-effectiveness, in severe mental illness, of work-focused intervention (intervention) as an adjunct to individual placement and support compared to individual placement and support alone (control). Results The original sample (330) proved impossible to attain so the design was revised to a pilot study from which information on feasibility of a full trial could be drawn. Twenty-five individuals out of 74 found paid work but no difference was found in the mean number of hours in paid employment between the intervention and control groups. Conclusion Results demonstrate that delivering work-focused counselling i...
Background Antisocial personality disorder (ASPD), although associated with very significant heal... more Background Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD. Methods Three hundred and two participants r...
BackgroundSpecialist parenting intervention could improve coexistent parenting and child mental h... more BackgroundSpecialist parenting intervention could improve coexistent parenting and child mental health difficulties of parents affected by severe personality difficulties.ObjectiveConduct a feasibility trial of Helping Families Programme-Modified (HFP-M), a specialist parenting intervention.DesignPragmatic, mixed-methods trial, 1:1 random allocation, assessing feasibility, intervention acceptability and outcome estimates.SettingsTwo National Health Service health trusts and local authority children’s social care.ParticipantsParents: (i) primary caregiver, (ii) 18 to 65 years, (iii) severe personality difficulties, (iv) proficient English and (v) capacity for consent. Child: (i) 3 to 11 years, (ii) living with index parent and (iii) significant emotional/behavioural difficulties.InterventionHFP-M: 16-session home-based intervention using parenting and therapeutic engagement strategies. Usual care: standard care augmented by single psychoeducational parenting session.OutcomesPrimary f...
Background: There is a concern in the literature that harm from interventions is insufficiently d... more Background: There is a concern in the literature that harm from interventions is insufficiently documented in clinical trials in general, and in those assessing psychological treatments in particular. A recent decision by a trial steering committee to stop recruitment into a randomized controlled trial (RCT) of a psychological intervention for personality disorder led to an investigation of the recording of harm in trials funded by the National Institute for Health Research (NIHR). Methods: The protocols and final reports of all 82 NIHR trials funded between 1995 and 2013 were examined for the reporting of adverse events. These were subdivided by category of intervention. Results: None of the psychological intervention trials mentioned the occurrence of an adverse event in their final report. Trials of drug treatments were more likely to mention adverse events in their protocols compared with those using psychological treatments. When adverse events were mentioned, the protocols of psychological interventions relied heavily on severe adverse events guidelines from the National Research Ethics Service (NRES), which were developed for drug rather than psychological interventions and so may not be appropriate for the latter. Conclusions: This survey supported the belief that the reporting of adverse events in psychological treatments is weak and the criteria used may not be appropriate. Recommendations are made as to how current practice might be improved.
The purpose of this study was to investigate a clinical observation in referrals to a forensic cl... more The purpose of this study was to investigate a clinical observation in referrals to a forensic clinical psychology outpatient service: that anger was related to obsessional-compulsive behaviours, possibly as a substitute means of controlling situations. A secondary ...
The social and economic cost of intimate partner violence (IPV) is exorbitant and highlights the ... more The social and economic cost of intimate partner violence (IPV) is exorbitant and highlights the need for policy reform as it pertains to IPV interventions at a global level. There are multiple variables associated with the aetiology of IPV and, hence, multiple treatment needs must be considered. Substance use is one of several factors likely to influence the occurrence of IPV, but often goes unaddressed in standard treatment approaches. This review will discuss several treatment models for substance using offenders of IPV, including Psycho-educational Models, Cognitive Behavioural Therapy, Couples' Treatments, Parenting Programmes, Integration of Care Models, and Pharmacotherapies. Clinical recommendations will be discussed. Treatment outcomes among substance using offenders of IPV may be improved by implementing changes in protocol that increase diagnostic evaluations, integrate care with evidence-based models, require limits to the number of offenders in a group, and require qualifications for clinicians who treat offenders (licensed and trained psychologists, social workers, and/or psychiatrists).
Previous research has demonstrated the clinical effectiveness of long-term psychological treatmen... more Previous research has demonstrated the clinical effectiveness of long-term psychological treatment for people with some types of personality disorder. However, the high intensity and cost of these interventions limit their availability. Lower-intensity interventions are increasingly being offered to people with personality disorder, but their clinical and cost effectiveness have not been properly tested in experimental studies. We therefore set out to develop a low intensity intervention for people with personality disorder and to test the feasibility of conducting a randomized controlled trial to compare the clinical effectiveness of this intervention with that of treatment as usual (TAU). A two-arm, parallel-group, single-blind, randomized controlled trial of Psychological Support for Personality (PSP) versus TAU for people aged over 18 years, who are using secondary care mental health services and have personality disorder. We will exclude people with co-existing organic or psych...
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Papers by Mary McMurran