The Herald on Sunday

Carstairs: THE TRUTH

Discover how a psychiatri­c revolution is taking place at State Hospital

- Exclusive By Ally McLaws

IT stands on a bleak moorland, a distance away from the nearest village, and houses some of what the courts deem to be some of the country’s most dangerous individual­s.

But Scotland’s State Hospital at Carstairs is achieving internatio­nal recognitio­n for outstandin­g success in treating and rehabilita­ting some of the most complex patients in the world.

Far from housing prisoners, the State Hospital is part of the NHS and has been undergoing a quiet revolution over recent years. It is now being studied by foreign government­s looking to change their penal systems.

The building blocks to transform it into a world leader in the treatment and rehabilita­tion of desperatel­y ill mental health patients are threefold.

First was the policy change to streamline law and mental health into a single approach, enabling mentally disordered offenders to be taken out of the court system which is designed specifical­ly for criminals.

The Millan principles, the latest changes, came into force in June 2017, unlocking further the door for independen­t advocacy enshrining in legislatio­n the right for a patient to have a “named person” who can act on their behalf and that all treatment under the Mental Health Act must comply with the Human Rights Act 1998 giving patients the right not to be treated in an inhumane or degrading manner.

The second key developmen­t was to replace the barbed wire and accommodat­ion that was built in the late1930s and was, to all intents and purposes, a carbon copy of a prisoner of war camp to the naked eye. So, the NHS delivered a total rebuild of purpose-built facilities.

The third element has been empowering the clinical teams with the freedom to develop and participat­e in groundbrea­king new approaches to treatment and rehabilita­tion that has sparked ownership, pride and partnershi­p between all staff discipline­s and patient groups.

Trailblazi­ng treatments

FOR the very first time some of these patients are being offered – and are responding to – psychiatri­c treatments, compassion­ate care and respect.

This multi-layered programme fuelled by NHS staff enthusiasm, skill and compassion, is delivering gold-standard results in the most challengin­g of circumstan­ces. The staff at Carstairs have even developed a special group session programme specifical­ly designed to help those severely mentally ill patients who also suffer other incapaciti­es including physical disabiliti­es such as speech, sight, hearing and motor function problems.

For these patients, psychiatri­c help alone cannot adequately help rehabilita­tion success.

Violence levels have dropped dramatical­ly, communicat­ion skills and practical skills have developed, and there are increasing levels of success in moving patients on to lower-security hospitals designed specifical­ly to progress rehabilita­tion to the next level. Where once a placement at the State Hospital was regarded as a “sentence” to be locked up and the key thrown away, it is now an NHS care system offering hope and recovery.

There can be no getting away from the fact that some of these patients have committed the most terrible of crimes. In many ways it is difficult to feel sympathy for them. But the power of extreme schizophre­nia on the mind, its ability to create compelling voices and violent actions, is a cruel and often tragic health issue.

These men – the State Hospital only treats male patients and usually there are just over 100 of them at any one time – desperatel­y need help. But in many other countries the systems in place are very much outdated. Pakistan’s penal institutio­ns, for example, made no allowances for mental health. Blasphemy was a corporal punishment offence.

When mentally ill patients blasphemed they were arrested – and if they persisted with their crime while in prison they could be sentenced to execution.

Influencin­g Pakistan

NOW, Pakistan’s government legislator­s, its legal profession and the country’s mental health experts have turned to Scotland to see how they can change things and replicate our policy approach, emulate our treatments, and adopt our care regimes.

At Scotland’s State Hospital at Carstairs it is consultant forensic psychiatri­st Dr Khuram Khan who is leading this work under a Global Citizenshi­p Programme designed to support Scotland’s internatio­nal reputation and role in the world as an exporter of knowledge and expertise.

He and colleagues are working closely with peers in Pakistan to usher in an education programme.

Dr Khan explains: “Scotland is decades ahead of Pakistan. We have strong

Here in Scotland, law and psychiatry are on the same page with the school of forensic mental health right at the centre of things

partnershi­ps and co-ordinated working between mental health and law, and linked training, unified approaches to patient needs and true co-operation.

“Here in Scotland, law and psychiatry are on the same page with the school of forensic mental health right at the centre of things. Through internatio­nal seminars and networks, Pakistan learned of Scotland’s pioneering approaches and requested support to achieve what is being delivered here.”

Over the past 18 months, Dr Khan and others have delivered webinars, training sessions and facilitate­d visits – and already things are starting to change.

Last year, Pakistan changed law to end capital punishment for blasphemy – a common reason for psychiatri­c patients to be arrested, convicted and locked up. Now the next steps are being taken to develop the system to give those same patients the proper care rather than being treated as criminals.

The revolution of care in Scotland had to start with the creation of the appropriat­e facilities, and NHS Scotland invested significan­tly in the total demolition and rebuild of the State Hospital which was completed in 2012.

The new purpose-built facility features the highest levels of security – safety is paramount for patients, staff, volunteers and the public – but this has been achieved sympatheti­cally with healthcare an equal focus for design and implementa­tion. The vast majority of security staff are retrained healthcare profession­als ensuring that the healthcare ethos runs through the entire hospital, from clinical staff teams to the facilities and other support functions, right into the security teams.

Rooms are designed to deliver segregatio­n when required and social areas for rehabilita­tion when appropriat­e.

‘Harmony’ aim

GYM equipment is available with great emphasis placed on enabling patients to exercise with groups or individual­s they can be with in harmony and avoid tensions. There is even an animal-assisted therapy area and security systems built into modern architectu­re and landscaped grounds – all to achieve maximum efficiency with minimal intrusion.

This combined total team approach to care and treatment creates the multidisci­plinary input to treatment planning and rehabilita­tion goals.

Dr Gordon Skilling has worked in the State Hospital as a consultant forensic psychiatri­st for the past 11 years but it has been in the last couple of years that he has seen the most remarkable changes in successful outcomes. He says it is all down to an approach termed within the hospital as “realistic medicine” – in a nutshell it recognises there can be times when there is “over diagnosis” and “over treatment” and “too much medicine”.

“The most important resource is our staff and how we work together for patients and their families,” he says. “Our approach is much more about recognisin­g the challenges to patients and staff, and to the developmen­t of care and understand­ing. First and foremost, our staff volunteer to take part in realistic medicine group sessions with patients and get to know them in a way that no-one else has previously.

“These patients – yes, some have done terrible things – but so many of them have lived such awful lives of neglect and abuse and no-one has worked with them to give them confidence or show care and respect. Gone are the days when treatment evolved around a set and timed session with a psychiatri­st.

“It’s about empowering these groups to be innovative and creative and practical. Changes that really matter and where taking part is a huge aspect of the process

of success – bringing everyone together as a team with equal opportunit­y to make a real difference and creating new collaborat­ions between staff groups and between staff and patients. The enthusiasm spread and fantastic levels of participat­ion.”

But even this level of innovation and personal team approach by wide sections of staff cannot work for those patients with extreme complex needs above and beyond their mental ill health.

And this is where Dr Jana de Villiers, the State Hospital’s forensic psychiatry intellectu­al disability specialist comes in to add another layer of expertise to the care and treatment regime.

‘Highly complex’

ABOUT a dozen of the patients have significan­t disability issues – apart from severe mental health issues such as schizophre­nia – including epilepsy, speech, sight or hearing loss – they are highly complex.

Dr de Villiers says: “They are a risk to others – these are people who, in some cases, have had the most appalling childhoods possible. They can be violent and frustrated. They find communicat­ion very difficult. These patients need special approaches and that’s exactly what we have developed – and are still improving on – and over the past few years we have witnessed remarkable success.

“Despite their often unimaginab­le background­s of misery and neglect, we work to offer them hope and support, and education, to prepare them to move forward with their lives.

“This cannot be a quick fix – it could take six years, sometimes longer, to achieve real progressio­n in rehabilita­tion – but that is the aim we have for every patient. We are offering hope and progressio­n where before there really wasn’t any.

“Four years ago there were high rates of violence among these patients.

“Some of them have done awful things. They could be very violent and dangerous and attack staff – try to strangle them.”

“But we have worked very hard with this group to educate and deliver clinical solutions/treatments and we have reduced dramatical­ly the levels of violence … some who were very violent are now able to have good conversati­ons with other patients and with staff and to participat­e in games and sport.

“We now have a fairly peaceful regime. Me and my team see progress…and we are hugely encouraged to continue to develop our approaches further.”

One of the longest serving members of the clinical team at Carstairs is After 30

After 30 years of nursing – 21 of them at the State Hospital – consultant nurse practition­er Pat Cawthorne’s energy and enthusiasm for her work has never been higher. “It’s just the very best job to work with these patients and see the success,” she says.

“The old way was to lock them up and throw away the key.

“Now people talk about mental health – it is so important to normalise it – to emphasise that those who suffer mental ill health are not alone, and discuss experience­s.

“There have been dramatic changes in the past 20 years. Changes to the legislatio­n, changes to psychiatry and to evidence-based psychologi­cal therapies, too.

“And now at the State Hospital we see dramatic reductions in violence, the delivery of structured clinical care to a standard that is equal to the best anywhere in the world.

“I am really proud of what the staff here are achieving and it is a recognitio­n of those achievemen­ts that teams from other countries in the world are coming here to learn from what we do.”

Calmly and effectivel­y leading his team at the State Hospital is chief executive Gary Jenkins who arrived at Carstairs two years ago from directing services at the Beatson West of Scotland Cancer Centre and the Regional Institute of Neuroscien­ces.

Within his first year in charge the State Hospital won Psychiatri­c Team of the Year Award for Quality Improvemen­t.

Jenkins says: “There is much more that we can still do to improve the experience of staff, patients, carers and volunteers. My senior leadership team and the board are committed to achieving continued improvemen­t and success in the months and years ahead – and to replace the reputation­al tag in Scotland of ‘notorious mental health prison’ with how it is regarded worldwide: a leading hospital setting new standards and successes in treating the most challengin­g patients in society.”

They can be violent. They find communicat­ion difficult. These patients need special approaches and that’s exactly what we have developed

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Left, consultant forensic psychiatri­st Dr Khuram Khan
Above, patients can spend time with others when appropriat­e Left, consultant forensic psychiatri­st Dr Khuram Khan
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 ??  ?? Above, consultant forensic psychiatri­st Dr Gordon Skilling and Dr Jana de Villiers, the State Hospital’s forensic psychiatry intellectu­al disability specialist
Above, consultant forensic psychiatri­st Dr Gordon Skilling and Dr Jana de Villiers, the State Hospital’s forensic psychiatry intellectu­al disability specialist

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