Psychiatric Intensive Care

Cover......Page 1
Half-title......Page 3
Title......Page 5
Copyright......Page 6
Contents......Page 7
Contributors......Page 9
Preface to second edition......Page 13
Preface to first edition......Page 15
Foreword......Page 17
Part I Therapeutic interventions......Page 19
Secure provision in the 1970s in the UK......Page 21
Development of psychiatric intensive care units world-wide......Page 22
Secure provision in the  UK  in the 1980s and 1990s......Page 23
Aims of  NAPICU......Page 24
Definition of psychiatric intensive care......Page 27
REFERENCES......Page 28
2 Management of acutely disturbed behaviour......Page 30
Nursing observations......Page 31
Staff safety......Page 32
Related factors and considerations......Page 33
Mental State Examination......Page 34
Management of acutely disturbed behaviour......Page 35
Management after an aggressive incident/debriefing......Page 37
Advantages of charges being pressed include......Page 39
REFERENCES......Page 40
Recommended further reading......Page 41
3 De-escalation......Page 42
Situation......Page 43
Component 2 : communication......Page 44
Component 3- : de-escalation and negotiation --UnicodeCharacterx2013  the tactics......Page 45
The win--lose equation......Page 46
Conclusion......Page 47
REFERENCES......Page 48
Introduction......Page 50
Restraint......Page 51
Choice of medication......Page 53
Following RT......Page 57
Dangers of rapid tranquillisation......Page 58
Current use of RT......Page 60
Alternatives to RT......Page 61
Legal considerations and advanced directives......Page 62
REFERENCES......Page 64
Use of neuroleptics......Page 68
Tranquillisation......Page 69
Maintenance treatment in psychosis......Page 70
Alleviation of symptoms in personality disorders......Page 71
Extrapyramidal syndromes......Page 72
Other    side-effects of antipsychotics......Page 73
Use of 'high' dose' antipsychotics......Page 74
Atypical antipsychotics......Page 75
Treatment resistance......Page 78
Propranolol......Page 79
Management......Page 80
Drug treatments......Page 81
Mood stabilisers......Page 82
Electroconvulsive therapy......Page 84
Mode of action......Page 85
Conclusion......Page 86
REFERENCES......Page 87
Introduction......Page 92
Case history......Page 93
The experience of the admission to hospital for the patient’s family......Page 94
The provision of psychotherapy for patients......Page 95
Some further considerations......Page 96
The violent patient......Page 97
Addressing hopelessness and reasons for living......Page 98
Suicide-harm management and staff containment......Page 99
Reasons for living......Page 100
Coming to terms with admission and illness......Page 101
Philosophy......Page 102
Difficulties......Page 103
References......Page 104
Introduction......Page 107
Some possible reasons for challenging behaviour......Page 108
Faulty cognitive styles......Page 109
Problems of internal control......Page 110
Concepts from attachment theory......Page 111
Case history......Page 112
Problems in engagement......Page 113
Pressures on the treating teams......Page 114
Treating challenging behaviours in ward settings......Page 116
Approaches to the problem of engagement......Page 117
Case history......Page 118
Constructive institutional responses......Page 119
Integrative treatment approaches......Page 120
Functional analysis......Page 121
References......Page 122
History of seclusion......Page 124
Patient behaviour......Page 127
Patient characteristics......Page 128
The moral argument......Page 129
Verbal de-escalation......Page 130
The extra care area (  ECA  )......Page 131
The treatment argument......Page 132
Mental Health Act    1983......Page 133
Conclusion......Page 134
References......Page 137
Restraint and physical intervention: the questions......Page 141
History and development of interpersonal systematised restraint in UK mental health services......Page 142
Mental Health Act......Page 143
Evidence and efficacy for methods of interpersonal restraint......Page 144
Safety factors innate to the person being restrained......Page 145
Factors that affect safety during the restraint process......Page 146
Leadership and restraint......Page 147
References......Page 148
Definition of  'complex needs patient'......Page 150
Background and characteristics of the complex needs patient......Page 151
Management......Page 160
Assessing the complex need areas......Page 161
Psycho-education......Page 162
References......Page 163
History of therapeutic activity......Page 167
Activity and aggression......Page 168
The patient group and the environment......Page 169
Physical activity and exercise......Page 170
Establishing a ward therapeutic programme......Page 171
Case history......Page 172
Implementation of therapeutic activities......Page 173
Case history......Page 174
References......Page 176
Introduction*5pt......Page 179
Some questions to assist a risk assessment framework......Page 182
Approaches to violence risk assessment......Page 183
Events that indicate imminent violence in psychiatric settings......Page 184
Some factors leading to violence in PICU......Page 185
Risk management......Page 186
A framework for risk management......Page 190
Introduction......Page 191
Evaluation and management of short-term suicide risk......Page 193
Summary......Page 194
References......Page 195
Part II Interface issues......Page 199
13 Provision of intensive care in forensic psychiatry......Page 201
REFERENCES......Page 206
INTRODUCTION......Page 209
Care pathways for violence in mental illness......Page 210
The medium secure unit -- forensic psychiatric services at the interface with general psychiatry......Page 211
Guidelines on access to inpatient forensic care......Page 213
Conclusion......Page 214
Secure care admission criteria (from Eastman and Bellamy 1998)......Page 215
How to make a referral......Page 217
REFERENCES......Page 218
Defining learning disability......Page 220
Communication......Page 222
The clinical interview......Page 223
Psychiatric disorder or 'challenging behaviour'
?......Page 224
Case Study......Page 225
Case Study......Page 226
Autistic spectrum disorders......Page 227
Pharmacological treatments......Page 229
Psychological treatments......Page 231
Mental health and mental capacity legislation......Page 232
Generic or specialist inpatient services?......Page 234
Conclusion......Page 235
REFERENCES......Page 236
Introduction......Page 238
Interface issues......Page 239
Protocols and guidelines......Page 241
PICU and special problems (rehabilitation, personality disorder and substance misuse)......Page 242
Personality disorder......Page 243
Acute wards and PICUs......Page 244
Conclusions......Page 245
REFERENCES......Page 246
Inpatient provision......Page 247
Prevalence......Page 248
Multi-axial classification of child and adolescent psychiatric disorders......Page 249
Substance abuse......Page 250
Deliberate self-harm and suicide......Page 251
Major psychotic disorders......Page 252
Case study......Page 254
Community-based outreach adolescent teams......Page 255
Early intervention in psychosis units......Page 256
Case study......Page 257
Procedures on admission......Page 258
Tier 2......Page 261
References......Page 262
Introduction......Page 265
Substance use amongst first-onset psychosis patients......Page 266
Substance use and risk of violence......Page 267
Nicotine......Page 268
Cannabis......Page 269
Benzodiazepines......Page 271
Assessment......Page 272
Psycho-education on the effects of substances......Page 273
Specially designed services for severe mental illness and substance misuse or use......Page 274
Psychological interventions......Page 275
Pharmacotherapy of severe mental illness and substance abuse......Page 277
Summary......Page 278
References......Page 279
Definition of social work......Page 283
Social work in a multidisciplinary team......Page 284
The social work model......Page 285
Anti-discriminatory practice......Page 286
The ‘appropriate adult’ role......Page 287
Case history B......Page 288
Case history C......Page 289
Case history A (continued)......Page 290
References......Page 291
Supporting staff......Page 293
The role of user representatives/consultants......Page 295
The role of advocates......Page 296
Carer involvement on PICUs......Page 297
References......Page 299
Part III Management of the Psychiatric Intensive Care Unit/Low Secure Unit......Page 301
Introduction......Page 303
Definition of psychiatric intensive care......Page 304
Proposed service description......Page 305
The project manager or management team......Page 306
Staffing issues......Page 307
The operational policy......Page 308
Appendix 21.1 Example of PICU operational policy......Page 309
Philosophy of care......Page 310
REFERENCES......Page 311
General philosophy of Psychiatric Intensive Care Low Secure Unit design......Page 312
Security levels......Page 313
Fire exits......Page 314
Aggression and access through doors......Page 315
Observation......Page 316
Facilities for managing the most acutely disturbed patient......Page 317
Recreation and occupational therapy......Page 318
Staff and patient safety......Page 319
Standard operational procedure......Page 320
References......Page 321
Key principles......Page 324
Guidelines for care......Page 325
Working practice manual......Page 326
The ward environment......Page 329
Therapeutic programme......Page 330
Education and training plan......Page 331
Breakaway techniques/control and restraint/care and responsibility......Page 332
Mental Health Act......Page 333
Evidence-based interventions......Page 334
Induction and mentoring......Page 335
Post-incidents debrief and support......Page 336
Staff--patient ratios......Page 337
References......Page 338
Definition of a multidisciplinary team......Page 340
History......Page 341
Criticism......Page 342
Can it work?......Page 343
Developing a team approach within PICU/LSU......Page 344
Professional-specific responsibilities......Page 345
Team roles......Page 346
Team morale......Page 351
Disagreements and resolution......Page 352
Staying effective......Page 354
Acknowledgements......Page 355
References......Page 356
National Association and need for Standards......Page 358
Format of National Minimum Standards (NMS)......Page 359
Admission criteria and legal status of patients......Page 360
Summary and Conclusions......Page 365
References......Page 367
Index......Page 369