The National High Secure Services for Women Rampton Hospital

1. The National High Secure Services for WomenRampton Hospital Dr Sue Elcock Consultant Forensic Psychiatrist

2. Positive about integrated healthcare

4. Rampton Hospital Clinical Directorates Directorate 1 -Mental Health Services -National Learning Disability -National Deaf Service Directorate 2 -Personality Disorder Services -National High Secure Healthcare Service for Women -Dangerous & Severe Personality Disorder Directorate (The Peaks) Support Services • Security Department • Therapies and Education Department • Social Care Services • Facilities Department • Corporate Services

5. Therapies & Education Department • 4 Departments – 135 staff / 18 patient areas • Occupational Therapy Team • Education (including Patients Library) • Art Therapies • Speech and Language Therapy • Operations Support: • Chaplaincy • Technical Instructors • Relief Pool • Administration

8. One National Service • Women’s Mental Health : Into the Mainstream Implementation Guidance 2003: one national service • 1991 345 women in high security -Female beds at Ashworth closed in 2003 -Female beds at Broadmoor closed mid 2007 -Female bed at Carstairs Hospital 2008 • NHSHSW new build (50 beds) opened January 2007 • 3 Women’s Enhanced Medium Secure Services (46beds) 2007 • 1993 - 2000 the average women’s population in prison increased by 111.5% compared to a 42% increase for men

11. NHSHSW 50 beds • Emerald A 6 Beds -Learning Disability Unit • Emerald B 6 Beds -Intensive Care Unit • Topaz 12 Beds -PD Admission/Treatment Ward • Ruby 14 Beds -PD Treatment Ward • Jade 12 Beds -Mental Health Ward • Diamond Resource Centre -Day care services for women

12. De-escalation Quiet Rooms Low Stimulus Seclusion

13. Referral and Assessment Process • Existence of Mental Disorder requiring detention and treatment in hospital. • Availability of Appropriate Treatment. • Presenting a Grave and Immediate Risk to others. Referral Assessment by Senior Clinicians from NHSHSW Reports submitted to Admission Panel Panel Decision *Secretary of State Direction to Admit can bypass the above process and direct an admission

14. Referrals

15. Admissions

16. Conversion Rates • 2008 5 admitted from 13 referrals 38.5% • 2009 8 admitted from 23 referrals 35% • 2010 7 admitted from 17 referrals 41% • 2011 9 admitted from 20 referrals 45% • 2012 7 admitted from 14 referrals 50% • 2013 9 admitted from 20 referrals 45%

17. Discharges

18. The Population

19. MHA (2012)

20. Length of Stay (2012)

21. Challenges

22. Co-existing self injury and violence • Balancing the risks to patient and staff • Managing superficial and life threatening self injury • Use of seclusion and mechanical restraint in exceptional circumstances • Recognising and supporting impact on staff

23. 2009 : 25% of all forensic services incidents (2376 of 9323) per month 173 – 246 staff sickness 5-12% • Oct-Dec 2009: 574 incidents: 30% self injury (173) 48% violence (277) of 277 violent incidents: 95% to staff 5% injury during restraint 9% physical assaults 49% threats/verbal abuse • Jan – June 2009: 230 seclusion episodes (32-45 per month) 27 episodes of continuous obs (1-11per month)

24. Seclusion and segregation: balance violence and self injury risks • Safe and Exceptional Use of Mechanical Restraint Policy • Trauma and Self Injury Programme: adapted risk reduction approach to self injury • Specialist supervision • Post Incident Defusing and Debriefing (NICE) • Promote staff well being: OH, physio, sickness policy

25. Integrated Care Pathway

30. Women’s experiences of self injury and trauma

31. The Background • Audit 2007 • Approx 80% of patients had experienced abuse • Most had experienced complex trauma with residual symptoms • Often linked to their index offence • 76% of women employ self injurious behaviour as a coping strategy • Many engaging in life threatening self injury • On average over 50 incidents per month across the ward areas • Staff injuries due to intervening to prevent self injury

32. NICE Guidance Self-Harm: longer-term management (133) Nov 2011 The key priorities for implementation when working with people who self-harm include: Trusting supportive relationships Awareness of stigma and discrimination Non judgemental approach Involvement in decision making about treatment and care Foster autonomy and independence where ever possible Continuity of therapeutic relationships Information communicated sensitively

33. The National High Secure Healthcare Service for Women Trauma and Self Injury Programme

34. Positive Risk Reduction Through Systemic Change 3 levels: • Proactive Approaches educating patients and staff about living and working with self injury and the impact of trauma • Interactive Approaches to create positive ward atmospheres which focus on managing and minimising self injury in a way which is helpful to all who live and work there • Enhance Resources in CAT, DBT, CBT and trauma therapies (e.g. EMDR) to support women to use different ways of coping

35. Level 1: Proactive Approaches

36. Level 2: Interactive Approaches

37. Level 3: Therapy Interventions

40. ‘opportunity to look at what helps reduce distress It is what I should be doing as a nurse, this aids recovery’ ‘It gives me a framework as a nurse to gain understanding of what the woman is experiencing from her own view” ‘The most helpful thing was learning about the vicious cycles I didn’t realise that avoidance doesn’t help.’ ‘It has helped me trust my named nurse and the team, they get where I am coming from, I can now ask them when things get bad in my head’ ‘I now understand the difference between when I am impulsive and when I am spontaneous’ ‘It gives me something that’s just about me , not what I’ve done’ ‘I don’t feel so ashamed to talk about how it feels inside when everything builds up. Stops me hitting someone or cutting my arms’ ‘I would like to share what I have learnt with my mum I think she will understand me better.’

42. Dialectical Behavioural Therapy • Focus on regulating emotions, mindfulness, distress tolerance and acceptance • Recommended by NICE for BPD where recurrent self harm is a priority • Foundation treatment to women with personality disorders • Expanded provision to two DBT groups running continuously including an adapted group • Preparatory work before full engagement • More responsive to needs of women • Weekly therapy group and individual session

43. Cognitive Analytic Therapy • Focus: patterns of relating to self and others and the therapeutic relationship • Integrative approaches recommended in NICE BPD guidelines • Expanded provision by: • supervision of CAT Trainees (Practitioner and Psychotherapist) • specialist placements for final year Clinical Psychology and Forensic Psychology Trainees • supervised clinical practice for qualified staff • Weekly sessions via 16 or 24 sessions • Therapy tools

44. Cognitive Behavioural Therapy • Focus on thinking, behaving, and feeling • Recommended in NICE Guidelines on PTSD • Provided by TASI Programme Co-Leads • Programme support for CBT training • Weekly therapy sessions

45. Eye Movement Desensitisation and Reprocessing • Combines elements of exposure therapy, cognitive therapy, and body work • Also recommended in NICE Guidance on Post-Traumatic Stress Disorder (PTSD) • Pilot project started April 2010 • Challenges implementing

46. The Future • Develop physical healthcare provision - physical healthcare suite • Truly national service working with Scotland and N Ireland • CIPs • National Women's Personality Disorder Strategy • National debate about number of high secure beds needed • WEMMS evaluation • Need to establish seamless pathways for women through the different tiers of secure services with seamless entry/exit criteria

47. Contact details: susan.elcock@nottshc.nhs.uk