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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
17
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!