Credentials

1. Improving the Assessment and Treatment of Drug and Alcohol-Impaired Parents in Custody ProceedingsDr. Mike McPhillipsConsultant PsychiatristKnightsbridge PsychiatryThe Chelsea Consulting Rooms, London

2. Credentials • Full –time Consultant psychiatrist in private practice in Central London. • BA in Medical Sciences (Cantab). • MBBS (London). • MRCP (UK). • FRCPsych (UK). • Accredited specialist in Adult Psychiatry and Addictions Psychiatry.

3. Relevant Experience • Lecturer in Psychiatry, Imperial College Medical School, London, 1994-1997 • NHS Consultant, Borough of Kensington and Chelsea, London, 1997-2002, Substance Misuse. • Head of Addictions Treatment Programme, Priory Hospital Roehampton, London, 2003-2007 • Medical Director, The Causeway Retreat, Essex, 2007-2009 • Consultant, The Nightingale Hospital, Marylebone, London, 2009-present date • Experience of being a professional witness and an expert witness in many matrimonial and custody proceedings.

4. Why this particular work? • Many years of seeing poor outcomes affecting my patients and their families • Losing custody usually leads to a poor outcome for the patient and their family • Physical illness, mental illness and even premature death in the affected parent • Emotional and behavioural problems in their children and the former spouse

5. Why this particular work? My belief that a solely adversarial approach to the care of the patient was directly harmful to their chances of recovery

6. Outline of Presentation • Drug, alcohol and divorce • Drug and alcohol testing within the Justice System • Treatment options and the structure of recommended detoxification/rehabilitation programmes • Impaired professional programmes • Impaired parent programme • Outcomes, case examples and discussion

7. Divorce: CausesAmato& Previti,2003, n=208 • Infidelity: 22% • Incompatibility 19% • Drug and Alcohol abuse 11%* • Growing Apart 9% • Personality clash 8% • Physical/Mental abuse 6% • Loss of love 5% • Other < <5%

8. Role of Psychiatrist in Matrimonial Proceedings • Assesses both substance misuse and other compulsive behaviour; • Diagnoses and treats physical and psychiatric comorbidity; • Prescribes and oversees treatment; • Provides reports for the Courts

9. Assessing Substance Dependence • Patients often conceal, minimise or deny SUD’s • Past Medical Records often inadequate • Use of operational criteria may be lacking • Blood/urine/hair tests often not done systematically • Neither diagnosis nor test results are proof of risk to others • Expert opinion required (often = psychiatrist)

10. Simple and hygienic Easy to store/transport Single test covers weeks/months Retrospective ++ Repeat testing possible Needs supervision Processed quickly Serial testing needed Days-weeks only Not possible Hair analysis Urine analysis

11. Hair analysis: Phases of hair growth

12. Hair analysis: sampling

13. Gas chromatography/mass spectroscopy

14. Gas chromatography/mass spectroscopy

15. Mass spectrum of cocaine

16. Proving Fitness to Parent • Accept and understood the full consequences of their addiction for them their family and their children • Motivated and able to have effective treatment • *Proof that they have undergone and are continuing with such treatment • Presently abstinent • Able to remain abstinent under the pressures of daily life and parenting over a period of months and years

17. What is treatment? • Comprehensive approach to a chronic disease • Four main goals • Enhance function • Optimize motivation toward abstinence • Restructure life without substances • Relapse prevention (and where possible) • Reunite families

18. Components of Treatment • Education • Counselling • Group • Individual • Family • AA and other 12-Step groups • Vocational rehabilitation • Pharmacotherapy

19. Programme Factors Predictive of Better Outcomes •  Range, frequency, intensity of services • Flexible, individualized treatment •  Length of time in treatment (months and years, not days) • Adequate supervision and aftercare (testing)

20. “Treatment as usual” vs. Impaired Physician Programmes TAU IPP’s Explicit compulsion (loss of licence) Mandatory treatment and follow-up, for many years Detailed supervision and testing (monthly visits plus urine, blood and hair testing) Recovery rate: 85% sober at 5 years • No legal compulsion • No mandatory follow-up, treatment is usually a matter of weeks, and voluntary • No testing at follow-up • Poor recovery rates (<30% sober at 5 years)

21. Setting up treatment for Impaired Parents • Explain, sympathise, seek collaboration • Encourage a voluntary, negotiated package of care • Ask for cessation of proceedings, where possible, as long as the parent is in treatment • Ask the parent to volunteer for treatment, backed by at least one year of regular testing as proof of abstinence

22. The Programme • Detoxification/rehabilitation -Typically 4-6 weeks of inpatient care and over 100 hours of individual, family* and group psychotherapy Alternatives: Evening Programme Day Programme • Frequent testing( may include daily breathalyser, weekly urines, monthly blood, three monthly hair sample) x 1 year • Independent expert with medicolegal experience treats patient/ collates the reports of the team and regular reports to both legal teams and to the Court

23. Problematic cases • Complex comorbity • Patient sober > 9 months, lost custody over personality factors and attitude • Patient presents very late • Alcoholic mother presents 1/12 before a scheduled final hearing • Patient tests positive on hair but not serial urine tests • The same GC/MS technology giving different answers • The reporting of positives on antibody kit tests only • Kit tests are inherently less accurate, false +ves up to 1:20 times • New technologies • Ketamine and alcohol tests are newer and less well-evidenced than cocaine and heroin tests

24. ”Non-Chemical Dependency” Legal proceedings are now involving allegations of addiction to: - Gambling - Food - Work - Exercise - Sex and love - Internet and Computer games - Shopping/compulsive spending Features: Intense preoccupation (thinking of the activity all the time). Many hours spent doing/reading/preparing Neglect of self and others: emotional/occupational/childcare Loss of control: it carries on despite the problems is causes Pleasure or excitement outweighs guilt or remorse Sense of strong compulsion

25. Non-chemical Dependency:Prevalence • Eating Disorders: 3% • Bulimia 1-3%, Anorexia 1%, • 10♀>1♂. • Compulsive shopping: 1.4% • ♀>♂ • Pathological Gambling: 0.6% • ♂>♀ • Sexual addiction: 3% • ♂>♀

26. Non-chemical dependencies in DSM V and ICD 10 • Most NCD’s are not recognised as addictions in either system of classification • Instead, they are scattered through the classifications under disparate subheadings: Sex Addiction = Satyriasis or Nymphomania Food Addiction = Bulimia or Binge Eating Disorder Shopping Addiction = Habit and Impulse Disorder

27. Non-chemical dependencies:Current Legal standing • Disagreement about validity of diagnosis • Disagreement about the best treatment • Lack of good research on outcomes • A medico-legal minefield!