Transcript powerpoint presentation - London

Improving the Assessment and Treatment
of Drug and Alcohol-Impaired Parents in
Custody Proceedings
Dr. Mike McPhillips
Consultant Psychiatrist
Knightsbridge Psychiatry
The Chelsea Consulting Rooms, London
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.
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.
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
4
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
5
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
6
Divorce: Causes
Amato& 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%
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
8
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)
Hair analysis
Urine analysis
 Simple and hygienic
 Needs supervision
 Easy to store/transport
 Processed quickly
 Single test covers
 Serial testing needed
weeks/months
 Retrospective ++
 Days-weeks only
 Repeat testing possible
 Not possible
Hair analysis: Phases of hair growth
Hair analysis: sampling
Gas chromatography/mass
spectroscopy
Gas chromatography/mass spectroscopy
Mass spectrum of cocaine
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
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
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Components of Treatment
 Education
 Counselling
 Group
 Individual
 Family
 AA and other 12-Step groups
 Vocational rehabilitation
 Pharmacotherapy
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)
“Treatment as usual” vs. Impaired
Physician Programmes
TAU
IPP’s
 No legal compulsion
 Explicit compulsion (loss of licence)
 No mandatory follow-up,
 Mandatory treatment and follow-up,
treatment is usually a matter
of weeks, and voluntary
for many years
 No testing at follow-up
 Detailed supervision and testing
 Poor recovery rates (<30%
 Recovery rate: 85% sober at 5 years
sober at 5 years)
(monthly visits plus urine, blood and
hair testing)
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
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
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
”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
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%

♂>♀
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
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!