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Howard League 25 June 2004
The National Centre for treatment The National Centre for treatment of people with learning disability in of people with learning disability in
conditions of high security conditions of high security at Rampton Hospitalat Rampton Hospital
David Wilson, Consultant PsychiatristDavid Wilson, Consultant Psychiatrist
david.wilson2@nottshc.nhs.ukdavid.wilson2@nottshc.nhs.uk
Catrin Morrissey, Forensic PsychologistCatrin Morrissey, Forensic Psychologistcatrin.morrissey@nottshc.nhs.ukcatrin.morrissey@nottshc.nhs.uk
Howard League 25 June 2004
Thank you for your tenacity!Thank you for your tenacity!
“I thought you would have all “I thought you would have allgone home by now to weep and gone home by now to weep and
grieve about the footballgrieve about the football
Howard League 25 June 2004
Mission StatementMission Statement
To lower risk by evidence based treatment interventions in a hospital environment. Treatment should take place in an atmosphere where relationships are respectful, therapeutic enduring and paramount.
Howard League 25 June 2004
Patient ProfilesPatient Profiles
73 patients Mean IQ 66.61 All detained 67% restricted Admitted from 12.3% High Security, 30.1%
Secure units, 28.8% Prison, 26% courts Grade 1 & 2 offences Mean PCLR score 18.25. 17% above 24 23.3% meet at least one criteria for DSPD
Howard League 25 June 2004
Tensions Security/TherapyTensions Security/Therapy
Relational, procedural & physical security
Difficulties in making therapy happen
Howard League 25 June 2004
Prime importance of Prime importance of milieu/relationshipsmilieu/relationships
Appropriate living environmentTo be treated with dignity and respectRelationships paramountDamaged and abused“I trust no one”
Howard League 25 June 2004
InformationInformation
Information needs to be presented in an understandable way
Rights, complaints, procedures etc
The ‘expert patient’
Involvement & empowerment
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CLINICAL STRATEGYCLINICAL STRATEGY
Assessment & Treatment
MDT Working User/Carer
involvement Operational
structures & Systems
Workforce planning Training Clinical Governance
Howard League 25 June 2004
PathwaysPathways
ASSESSMENT & MOTIVATIONAL WORK
? Rx of mental illness1ST CPA
SKILLS ACQUISITIONOFFENCE-SPECIFIC TREATMENT
PSYCHOTHERAPY/PERSONALITY WORKEARLY DISCHARGE PLANNING
*REFERRAL &
ADMISSION
Howard League 25 June 2004
Pathways (continued)Pathways (continued)
CONSOLIDATIONRELAPSE PREVENTION
FINAL DISCHARGE PLANNING& DISCHARGEFOLLOW UP
*INTERIM CPAS
Howard League 25 June 2004
2020thth Century to the new Century to the new MillenniumMillennium
Abusive institutional regimes
The era of inquiries
Kind paternalistic custodial care
Holistic, MDT risk lowering treatment
AIMING FOR :
Clear treatment pathways
Evidence based treatment
Reduce average stay from 8 to 5 years
Howard League 25 June 2004
LD Directorate aims for: LD Directorate aims for:
High patient/staff involvement, with a creative tension
Nurturing relationshipsEffective treatmentsCreating an evidence baseFiscal realityReflective practice
Howard League 25 June 2004
Assessment and Treatment Assessment and Treatment
Complex patients, multiple problemsSevere PD and MI compounded by LDGoal of assessment : individualised
formulation of patient needs/goalsGoal of treatment: to reduce level of risk, to
a point where medium security is appropriate
Howard League 25 June 2004
AssessmentAssessment
Multidisciplinary task Assess whole person and their needs Assessments which will allow change to be
measured- behavioural ( eg Behavioural Status Index ), attitudinal, clinical
To include actuarial and clinical assessments of risk – in process of validating these in LD
Re-assessment – tie in to CPA
Howard League 25 June 2004
Treatment – Stage 1Treatment – Stage 1
Stabilise Mental Illness and Contain Extreme Behaviour
Motivational work
Why am I here ?
Do I want to change?
What do I get out of changing ?
Howard League 25 June 2004
Treatment – Stage 2Treatment – Stage 2 1. Foundation Treatments and Skills Acquisition SALT – communication skills; OT - practical and social skills; Thinking Skills – planning, reasoning, problem solving Emotional Regulation and Distress Tolerance – emotion
recognition, techniques for emotion control ; ‘mindfulness’; reducing self harm and externally directed aggression
Substance Abuse awareness Sex education and relationship skills Abuse Counselling
Howard League 25 June 2004
Treatment : Stage 3 Treatment : Stage 3
Offence Focussed TreatmentsOffence Focussed Treatments Three core areas : Sexual offending Violent offending Arson Aim: to obtain detailed understanding of the individual
risk factors; to increase motivation to control offending; to provide skills and practice skills to recognise and reduce own risk
Adapted to apply to people with mild learning disability
+/- Individual psychotherapy to address deeper issues
Howard League 25 June 2004
Adaptation of TreatmentsAdaptation of Treatments
Evolving evidence base of “what works” in forensic learning disability
Principle of informed consent to psychological treatment – advantages and disadvantages of treatment
We have achieved delivering treatment with very low drop out rates
Ongoing evaluation and research
Howard League 25 June 2004
Typical AdaptationsTypical Adaptations
Slower pace Increased frequency of sessions Individual session back up Creativity – Variety – practical games and exercises Simplification of language Communication – symbols and pictures Ensuring commonality of language between programmes Reward, praise , encouragement, increase self efficacy Clear feedback and link to ward and clinical teams Revision, repetition and focus on relapse prevention
Howard League 25 June 2004
Stage 4 – Relapse preventionStage 4 – Relapse prevention
Reducing external controls – ground privilege, escorted leave of absence
Specific RP programmes e.g.
Safe Steps - Keeping SafeConsolidation , reinforcement , and
generalisation of skills
Howard League 25 June 2004
Throughout all stages :
creative therapies, recreation, education, work/vocational training, ward based therapy groups, skills reinforcement by staff
Working towards a new, smaller unit in 2007
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