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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.