1 THE STATE HOSPITAL THE FORENSIC ADDICTION FORUM FRIDAY 15 TH MARCH 2013 Current Status & Future Direction

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 on- suite 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, (AUDIT-appendix 4).

Drug Name- Indicate 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 DiconalTemazepam√++ 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.