The Assessment and Treatment of Substance Misuse in a Low Secure Psychiatric Hospital

Michele Gilluley

Jillian McGinty

• 34 Bed Low Secure In-Patient Facility • 1 Female ward,1 Male ward,1 Rehabilitation

ward• Patient demographics: 17 to 65

• Major Mental Illness, Personality Disorders, Learning Disability, and Acquired Brain Injury.

• Referrals • Prisons, Courts, NHS (IPCU, HSU, MSU, LSU)

• Clinical Team: Forensic Psychiatrists and Psychologists, Nursing, Occupational Therapists and Health Care Workers.

The Ayr Clinic

Comorbidity of substance misuse and mental health

• The prevalence of co-existing mental health and substance use problems ‘dual diagnosis’ may affect between 30 and 70% of those presenting to health and social care settings (Research Briefing 30 (2009) Social Care Institute for Excellence).

• There is growing awareness of the serious social, psychological and physical complications of the combined use of substances and mental health problems.

• Given the multiplicity of social, familial and economic problems associated with dual diagnosis, there is a distinctive role for multi-agency work.

Prevalence – Ayr Clinic

Primary Diagnosis Prevalence of Substance Misuse

Substance Misuse and Mental Health problems

• Increased suicide risk

• More severe mental health problems

• Homelessness/unstable housing

• Increased risk of being violent

• Increased risk of victimisation

• Poorer general health

• More contact with criminal justice system

• Family and relationship problems

• History of childhood abuse (physical and sexual)

• More likely to fall through the net of care

• Less likely to be compliant with medication and other treatment

(Department of Health 2009)

•When compared with a mental health problem alone, people with dual diagnosis are more likely to have

Assessment and Case Formulation

• All Patients in Ayr Clinic are subject to Care Programme Approach (CPA)

• 6 monthly meetings attended by patient, clinical team, named persons, advocacy, and family/friends

• Care and Treatment plan developed • Treatment plan objectives set with cognisance

to appropriate risks and a sequencing approach to addressing patient needs.

Dual Diagnosis/Sequencing of interventions

• OR

What Works in Forensic settings?

• ‘What works’ = introduction of ‘manualised’, group-based offender programmes.

• ‘One size fits all approach’• Application of cognitive behavioural

approaches to address particular problem behaviours e.g. sexual offending, domestic violence, anger, substance-misuse etc.

What works in Forensic Mental Health?

• Smaller and heterogeneous populations• Patient’s have highly individual presentations• Their needs must be considered alongside the

risks they present. • Patients often undertake numerous

interventions (medical, social, psychological and occupational).

• Generally one-to-one delivery of complex, be-spoke, eclectic treatments are the most appropriate in settings of small populations.

Assessment

• Comprehensive Case Formulation• Full Structured Professional Judgement Risk

Assessment • Battery of Baseline psychometric

assessments depending on individual RNR

Key Ingredients of Treatment

• Person-centred care • Therapeutic Relationship • Therapeutic Milieu • Motivational Interviewing

Treatment Approaches: • Cognitive Behaviour Therapy• Cognitive Therapy• Good Lives Model • Dialectical Behaviour Therapy

Motivational Interviewing

How we get patients to treatment •Explore ambivalence about drug use and possible treatment.•Aim: increasing motivation to change behaviour.•Provide non-judgemental feedback.•Four general principles: -expressing empathy, -developing discrepancy, -rolling with resistance-supporting self-efficacy.

Therapies

Cognitive Behaviour Therapy

• Critical Components: Functional Analysis & Skills Training

• Integrated elements include (not limited to): psychoeducation, problem solving, anxiety management, coping skills, emotion regulation, insight work, skills training, self-esteem, relapse prevention

Dialectical Behaviour Therapy

• Delivered by DBT Team

• Includes five essential functions:

- Improving patient motivation to change

- Enhancing patient capabilities

- Generalizing new behaviours

- Structuring the environment

- Enhancing therapist capability and motivation

Good Lives Model

• GLM – is a strength based rehabilitative approach with dual focus on Risk Management & Psychological Well Being

• Used for Forensic Population • Model considers the individuals risk to

themselves and others• GLM – is about learning new skills and more

life opportunities.

Evaluation

• Pre & Post Treatment measures• Single case study methodology• Patient feedback • Feedback from clinical team

Future Directions at the Ayr Clinic

• Across PiC there is a national and regional review of all available substance misuse programmes for Scotland, England and Wales intended during 2013

Future Developments at Ayr

Please Check Back With Us Soon

References

• National Education for Scotland; Scottish Government. A Guide to Delivering Evidence Based Psychological Therapies in Scotland – The Matrix. 2009.

• Mental Health (Care and Treatment) (Scotland) Act 2003

• Scottish Government Mental Health Division. Memorandum of Procedure for Restricted Patients. 2010.

• Case Formulation in Cognitive-Behaviour Therapy. The Treatment of Challenging and Complex Cases. s.1.: Routledge, 2006

• Yin.R.K.,(2003) Case Study Research, Design and Methods. Sage Publications. United States of America

• Research Briefing 30 (2009):The relationship between dual diagnosis: substance misuse and dealing with mental health issues. Crome, I., Chambers, P., Frisher ,M., Bloor, R,. & Roberts, D. Social Care Institute for Excellence).

• Department of Health (2009) Mental Health Policy Implementation Guide Dual Diagnosis Good Practice Guide

• Andrews, D. A., & Bonta, J. (2003). The psychology of criminal conduct (3rd ed.). Cincinnati, OH: Anderson Publishing.