WORKING IN A MEDIUM SECURE SETTING WITH DUAL DIAGNOSIS

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WORKING IN A MEDIUM SECURE SETTING WITH DUAL
DIAGNOSIS

• Learning Disability and Personality Disorder

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DEFINITIONS I.C.D. 10

• F 70.1 Mild Mental Retardation
• Delayed speech but able to conduct everyday
  conversation.
• Full independence in self care.
• Slow rate of development.
• Difficulties in academic work, particularly
  reading/writing.
• Emotional/social immaturity.

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DEFINITIONS I.C.D. 10

• F 70.1 Diagnostic Guidelines
• I.Q. test 50 69 is mild mental retardation.
• Patients understanding and use of language is
  delayed observation and reporting.
• Associated conditions may coexist, e.g. autism,
  epilepsy or other conduct disorders.

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DEFINITIONS I.C.D. 10

• F60.3/F60.31 Emotionally Unstable
• Personality Disorder (including Borderline)
• Tendency to act on impulse without consideration
  of consequence.
• Affective instability.
• Minimal ability to plan ahead.
• Outbursts of extreme anger leading to violence
  and behavioural explosions.

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DEFINITIONS I.C.D. 10

• Impulsive type (F 60.3)
• Characteristics of emotional instability, lack of
  impulse control and outbursts of violence and
  threatening behaviour
• Borderline type (F60.31)
• Characteristics of confused self image and
  internal preferences (including sexual), chronic
  feelings of emptiness, and intense unstable
  relationships resulting in expressive attempts to
  avoid abandonment .

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SECURE SERVICES

• There is little doubt that, in secure services
  generally there are a small number of patients
  who generate an inordinate amount of anxiety for
  clinical teams and organisations alike!
• The combination of a mild learning disability
  with emotional/borderline personality with
  additional offending behaviour can be extremely
  clinically and organisationally challenging.

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KEY THEMES

• Difficulties in assessment and diagnosis
• Particular difficulties exist when patients
  primary diagnosis is learning disability.
• Often overlap occurs between behaviours presented
  by learning disability and personality which
  cloud clear diagnosis an offending history,
  such as sexual offending, may further complicate
  diagnosis.

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KEY THEMES

• Relationships
• Both previous and current relationships often
  have influenced the diagnosis of personality
  disorder which will then influence care
  provision.
• An understanding of early and current attachment
  in relationships are essential for all those
  involved in a patients care and treatment with
  this dual diagnosis.

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KEY THEMES

• Treatment and treatability
• There is a general debate about the treatability
  of personality disorder.
• With an emotionally unstable/borderline
  personality disorder and learning disability
  diagnosis in secure settings often treatment is
  aimed at the management of the extremes of
  behaviour and impulsivity rather than
  understanding of psychological motivational
  factors.

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KEY THEMES

• Ethical issues
• The presentation and subsequent of some very
  extreme behaviours (which often have contributed
  to an offending history or a degree of
  unmanageability in the community) throw up
  challenging ethical issues for clinicians and for
  organisations when caring for someone in secure
  setting against the backdrop of the MHA and
  Mental Capacity/Human Rights legislation.

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POTENTIAL CHALLENGING BEHAVIOURS

• Extreme aggression
• Unpredictable and intense aggression toward self
  or those caring for the patient.
• Aggression against environment.
• Lack of discrimination in who may assault
  relationships dont seem to matter!
• Calm and apologetic after incidents.

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CONVENTIONAL RESPONSES

• Seclusion often for long periods.
• Physical Intervention.
• Medication rapid tranquilisation and long term
  prescribed.
• Increased observation.
• Nurse in isolation.
• Thorough risk assessment of environment.
• Referral to High Secure Hospital.

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POTENTIAL CHALLENGING BEHAVIOURS

• Self injurious behaviour
• Food/fluid refusal.
• Explosive, unpredictable and intense in
  severity.
• Punching self, head banging, gouging eyes, trying
  to break limbs or neck by trapping in doors,
  removing finger/toe nails and serious cutting of
  body (sometimes through to artery or veins).

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CONVENTIONAL RESPONSES

• Limit access to objects or situations that give
  opportunity to self harm.
• Increase supervision and support.
• Nurse away from other patients with high level of
  staff support.
• Extremes of self harm may require use of
  mechanical restraint, as seclusion not an option.
• Forced hydration or feeding.

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DILEMMA !

• When a client presents with extremes of
  aggression and of self harming behaviours, the
  situation needs to be managed from the
  perspective of Health and Safety of client and
  staff. However, clinically many of our previously
  identified responses re enforce feelings of
  rejection and exacerbate the behaviours
  presented.

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RELATIONSHIPS

• Patient viewed negatively by staff.
• Seen to be manipulative and good at splitting
  teams, both on ward and within multi
  disciplinary setting.
• Lack of constructive engagement by patient can
  lead to staff burnout and patient being passed
  around service.

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DILEMMA!

• Behaviours lead to difficulties in relationships,
  especially with staff/peers if they have been
  assaulted or dealt with serious self harm
  episode. Relationship difficulties re enforce
  patients feelings of isolation and abandonment.
  Where to care for also becomes an issue usually
  on admission areas for long periods due to staff
  ratios, seclusion facilities e.t.c. not the
  best place re stimulation and building
  relationships!

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TREATMENT ISSUES

• Explanation
• Staff at all levels need to understand why these
  patients are behaving in the ways they do and
  avoid reactive and authoritarian responses
• Understanding the concept of therapeutic
  alliance with the patient
• Look at pro active rather than reactive
  therapeutic environment

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TREATMENT ISSUES

• The value of one to one therapeutic engagement
  cannot be underestimated as it gives opportunity
  for self reporting and reconstruction of early
  life relationships which help give insight and
  control to the patient.
• Need for a robust, practical therapeutic model
  for staff to work with e.g. Dialectical Behaviour
  therapy

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ETHICAL CHALLENGES

• Managing extremes of behaviour when life
  threatening-
• Food refusal human rights v duty of care.
• Self harm use of mechanical restraints.
• Management of extreme aggression seclusion,
  physical intervention and rapid
  tranquilisation .

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CONCLUSIONS

• Excellent work can be done by focusing on
  consistency in the team approach at all levels.
• A robust clinical model is essential.
• Therapeutic alliance and understanding of
  attachment theory is important for all staff.
• Good staff supervision and support is essential.
• Be prepared for set backs and remain optimistic.