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THE STATE HOSPITAL
THE FORENSIC ADDICTION FORUM
FRIDAY 15TH MARCH 2013
Current Status
&
Future Direction
1
THE STATE HOSPITAL
The State Hospital is a custom built facility providing high
secure mental health care for patients from across Scotland
and Northern Ireland. It occupies a single site with 140 beds
and approximately 700 staff.
THE STATE HOSPITAL
• NHS Forensic restructure: The developments at Rowanbank,
The Orchard Clinic and the new Murray Royal now provide
regional medium secure mental Health facilities.
• TSH purpose built specialist high secure facility, including onsuite accommodation. Therapeutic activities are built around a
central Atrium, which offers a full range of facilities, including a
shop, bank, library, café, gardens, craft & design, woodwork,
sports dept, group therapy areas, advocacy service, offices.
• There is now external carer’s facilities, security buildings and
estates buildings.
TSH Psychology Service.
• In line with the NHS(S) MATRIX-2011 Report (a guide to
delivering evidence based psychological therapies in
Scotland). Service provision has developed to promote joint
working within the Psychological services across the Forensic
Network.
• Includes a staff competency based framework of low intensity
psychological group work provision increasing to complex
needs, using a common language across the network to
reduce duplication, standardise staff training and patient
treatment.
• The Substance Misuse Service has modified group protocols
in line with the Forensic Network, offering a more streamlined
efficient service, cutting out duplication.
Matched Stepped Care in
Forensic Services
• The matched stepped model has a tiered approach that
matches the level of treatment with the complexity of the
patients problems.
• “High volume low intensity interventions are provided to
service users to meet underlying needs. Subsequent “steps”
are usually defined by increasing levels of complexity of
treatment, provided by appropriately trained staff.
• For patients with substance misuse this means formulating the
reasons the individual misuses substances and addressing
the underlying needs in a systematic way. (Example of
underlying needs: trauma, abuse, poor problem solving, poor
impulse control etc)
Matched Stepped Care in
Forensic Services
TSH Substance Misuse
Treatment Provision.
•
Underlying mental health needs and coping skills in substance misuse are
delivered through Road to Recovery modules (low intensity).
•
Underlying needs to develop self awareness and self management are
addressed through “Tune in” (emotion regulation intervention),
relationships and social skills, problem solving and thinking skills. (high
intensity)
•
Problem specific education in substance misuse addressed through the
Drug and Alcohol education intervention (high intensity)
•
Relapse prevention is discussed in terms of all potentially relapsing
behaviours – offending, substance misuse and mental illness. Saying ‘No’
Relapse Prevention and Recovery after Psychosis help individuals coping
with personal Cues & Triggers. (high intensity – specialist)
•
Highly specialist individual work offered to those with complex needs (e.g.
drug use in the context of severe sexual or violent offending, precipitating
psychotic breakdown or poor motivation. Highly specialist 1:1 Pre transfer
work.
Specific changes
• The Psychology Dept delivers a full Substance Misuse
Assessment, which is combined into the patients global
Psychological Admission Assessment.
• All referrals remain formulation and risk driven via HCR-20 &
MDT review.
• Substance Misuse treatments are based on a recent 2012
literature review. Scottish Intercollegiate Guidelines Network
(NICE) and National Institute for Health & Clinical Excellence
(SIGN), best practice guidelines.
• Protocols, documentation, treatments, group content and
psychometric measures were reviewed to meet quality
assurance and research criteria.
Assessment Stage.
• All TSH admissions undertake a comprehensive
Substance Misuse Assessment. A file review is carried
out as part of the global Psychology Assessment,
including a standardised assessment protocol and a
Substance Misuse Check List (appendix 1 & 2). Tests
include:
• The Drug Use Disorders Identification Test,
(DUDIT-appendix 3).
• The Alcohol Use Disorders Identification Test, (AUDITappendix 4).
Drug NameIndicate frequency
Drug Name
Indicate Frequency
Alcohol
√
++
Magic Mushrooms Psilocybin
√
++
Amphetamines speed
√
++++
Methadone
√
+++
Cannabis Marijuana, hashish
√
++++
Mephedrone
Caffeine tea, coffee, red bull,
√
+
Meta-amphetamines
Cocaine
√
+
MST (opiate)
√
+
Codeine
√
+
Poppers GBH, Liquid Gold
√
+
Crack Cocaine
√
+
Solvents (gas / glue)
√
+++
Diazepam
√
++++
Steroids
Temazepam
√
++
Diconal
Dihydrocodeine
√
++
Temgesic
√
+
Ecstasy (MDMA)
√
+
Tobacco
√
+
Heroin Skag, brown
√
++++
‘Legal’ Highs-Below
Ketamine (special K)
√
+
“Annihilation”
Khat
√
+
“Ivory Wave”
LSD
√
+
Subutex
√
+
Education & Awareness 1:1
Group Programme.
• Less didactic learning methods.
• Increased debate and encouragement of
individual involvement in group discussion.
• Increased group exercises (e.g. detailed
Cost/benefit analysis).
• Involvement of Doctors, Pharmacists, Infection
Control Nurse to inform ).
• Using Socratic questions and motivational
Interviewing enhancement techniques
Psychometric Measures
• Locally developed 20 question Drug & Alcohol,
Multiple Choice (4 option) questionnaires based
on general knowledge & specific group content
are completed Pre & Post group to measure
substance misuse awareness.
• The University of Rhode Island Change
Assessment (URICA) questionnaire is used to
monitor any shifts in Stages of Change, with an
aim of promoting self referral to the Saying No
Relapse Prevention group.
Saying No Relapse
Prevention Group work.
• In line with Forensic Network guidelines,
excessive duplication reduced-The Road to
Recovery & Tune In Modules use common
language across specific topics such as:
• Mental health awareness, Good Lives Model,
recovery, understanding and managing
emotions, problem solving, social skills,
assertive techniques.
Saying ‘No’ Relapse
Prevention (RP) Group work.
• The overall programme is streamlined to
concentrate specifically on identifying personal
Cues & Triggers and High Risk Situations
(HRS). The participants then develop a unique
personal staying well plan (appendix 5).
• Booster work is available to all patients to
revise the RP work Pre-transfer.
Fin.