Michele Gilluley Jillian McGinty The Assessment and Treatment of Substance Misuse in a Low Secure Psychiatric Hospital Michele Gilluley Jillian McGinty

The Ayr Clinic 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.

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 Dr Gary Tanner Prevalence – Ayr Clinic Primary Diagnosis Prevalence of Substance Misuse 4

Substance Misuse and Mental Health problems Dr Gary Tanner Substance Misuse and Mental Health problems When compared with a mental health problem alone, people with dual diagnosis are more likely to have 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) 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 5

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 Dialectical 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 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.