Howard League 25 June 2004 The National Centre for treatment of people with learning disability in conditions of high security at Rampton Hospital David

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

[email protected]@nottshc.nhs.uk

Catrin Morrissey, Forensic PsychologistCatrin Morrissey, Forensic [email protected]@nottshc.nhs.uk


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


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.


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


Tensions Security/TherapyTensions Security/Therapy

Relational, procedural & physical security

Difficulties in making therapy happen


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”


InformationInformation

Information needs to be presented in an understandable way

Rights, complaints, procedures etc

The ‘expert patient’

Involvement & empowerment


CLINICAL STRATEGYCLINICAL STRATEGY

Assessment & Treatment

MDT Working User/Carer

involvement Operational

structures & Systems

Workforce planning Training Clinical Governance


PathwaysPathways

ASSESSMENT & MOTIVATIONAL WORK

? Rx of mental illness1ST CPA

SKILLS ACQUISITIONOFFENCE-SPECIFIC TREATMENT

PSYCHOTHERAPY/PERSONALITY WORKEARLY DISCHARGE PLANNING

*REFERRAL &

ADMISSION


Pathways (continued)Pathways (continued)

CONSOLIDATIONRELAPSE PREVENTION

FINAL DISCHARGE PLANNING& DISCHARGEFOLLOW UP

*INTERIM CPAS


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


LD Directorate aims for: LD Directorate aims for:

High patient/staff involvement, with a creative tension

Nurturing relationshipsEffective treatmentsCreating an evidence baseFiscal realityReflective practice


Catrin MorrisseyCatrin Morrissey


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


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


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 ?


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


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


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


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


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


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


Thank you for your attention

Documents

Howard League 25 June 2004 The National Centre for treatment of people with learning disability in conditions of high security at Rampton Hospital David