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
Primary Diagnosis
Prevalence of
Substance Misuse
Substance Misuse and Mental Health
problems
• When compared with a mental health problem alone, people with dual
diagnosis are more likely to have
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Increased suicide risk
•
Family and relationship problems
•
More severe mental health
problems
•
History of childhood abuse (physical
and sexual)
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Homelessness/unstable housing
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Increased risk of being violent
More likely to fall through the net of
care
•
Increased risk of victimisation
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Poorer general health
Less likely to be compliant with
medication and other treatment
•
More contact with criminal justice
system
(Department of Health 2009)
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, bespoke, 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
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•
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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, selfesteem, 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
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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
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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.