Mission Statement

1. The National Centre for treatment of people with learning disability in conditions of high security at Rampton HospitalDavid Wilson, Consultant Psychiatristdavid.wilson2@nottshc.nhs.ukCatrin Morrissey, Forensic Psychologistcatrin.morrissey@nottshc.nhs.uk Howard League 25 June 2004

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

3. 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. Howard League 25 June 2004

4. 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 Howard League 25 June 2004

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

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

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

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

9. Pathways Howard League 25 June 2004

10. Pathways (continued) Howard League 25 June 2004

11. 20th 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 Howard League 25 June 2004

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

13. Catrin Morrissey Howard League 25 June 2004

14. 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 Howard League 25 June 2004

15. 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 Howard League 25 June 2004

16. 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 ? Howard League 25 June 2004

17. Treatment – Stage 2 • 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 Howard League 25 June 2004

18. 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 Howard League 25 June 2004

19. 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 Howard League 25 June 2004

20. 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 Howard League 25 June 2004

21. 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 Howard League 25 June 2004

22. 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 Howard League 25 June 2004

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