2. Howard League 25 June 2004 The National Centre for treatment of people with learning disability in conditions of high security at Rampton Hospital David Wilson, Consultant Psychiatrist david.wilson2@nottshc.nhs.uk Catrin Morrissey, Forensic Psychologist catrin.morrissey@nottshc.nhs.uk

3. Howard League 25 June 2004 Thank you for your tenacity! “I thought you would have all gone home by now to weep and grieve about the football Thank you for your tenacity! “I thought you would have all gone home by now to weep and grieve about the football

4. Howard League 25 June 2004 Mission 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.

5. Howard League 25 June 2004 Patient 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

6. Howard League 25 June 2004 Tensions Security/Therapy Relational, procedural & physical security Difficulties in making therapy happen

7. Howard League 25 June 2004 Prime importance of milieu/relationships Appropriate living environment To be treated with dignity and respect Relationships paramount Damaged and abused “I trust no one”

8. Howard League 25 June 2004 Information Information needs to be presented in an understandable way Rights, complaints, procedures etc The ‘expert patient’ Involvement & empowerment

9. Howard League 25 June 2004 CLINICAL STRATEGY Assessment & Treatment MDT Working User/Carer involvement Operational structures & Systems Workforce planning Training Clinical Governance

10. Howard League 25 June 2004 Pathways ASSESSMENT & MOTIVATIONAL WORK ? Rx of mental illness 1 ST CPA SKILLS ACQUISITION OFFENCE-SPECIFIC TREATMENT PSYCHOTHERAPY/PERSONALITY WORK EARLY DISCHARGE PLANNING *REFERRAL & ADMISSION

11. Howard League 25 June 2004 Pathways (continued) CONSOLIDATION RELAPSE PREVENTION FINAL DISCHARGE PLANNING & DISCHARGE FOLLOW UP *INTERIM CPAS

12. Howard League 25 June 2004 20 th Century to the new Millennium 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

13. Howard League 25 June 2004 LD Directorate aims for: High patient/staff involvement, with a creative tension Nurturing relationships Effective treatments Creating an evidence base Fiscal reality Reflective practice

14. Howard League 25 June 2004 Catrin Morrissey

15. Howard League 25 June 2004 Assessment and Treatment Complex patients, multiple problems Severe PD and MI compounded by LD Goal of assessment : individualised formulation of patient needs/goals Goal of treatment: to reduce level of risk, to a point where medium security is appropriate

16. Howard League 25 June 2004 Assessment 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

17. Howard League 25 June 2004 Treatment – 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 ?

18. Howard League 25 June 2004 Treatment – 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

19. Howard League 25 June 2004 Treatment : Stage 3 Offence 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

20. Howard League 25 June 2004 Adaptation 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

21. Howard League 25 June 2004 Typical 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

22. Howard League 25 June 2004 Stage 4 – Relapse prevention Reducing external controls – ground privilege, escorted leave of absence Specific RP programmes e.g. Safe Steps - Keeping Safe Consolidation, reinforcement, and generalisation of skills

23. 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

24. Howard League 25 June 2004 Thank you for your attention