The recent government Concordat (Transforming Care) described specialist learning disability hospitals as “an outdated model of institutional care” and set out a commitment to move anyone with a learning disability and challenging behaviour that was felt not to need inpatient care into the community. However, the expected reduction in specialist inpatient beds for people with learning disabilities has not happened and there has been an acknowledgement that as detailed data on learning disabled inpatients is poor, the task is more complex than was originally laid out in the government papers.

There is however, some idea of prevalence of specialist learning disability hospital placements, and recent figures suggest that of the 900,000 adults in England with a learning disability, less than 1% of them receive treatment at specialist psychiatric inpatient units.

However, despite the small number of individuals who need treatment in these specialist units, they are a group of individuals who have very complex needs and require specialist and skilled support.

The Royal College of Psychiatrists (RCP) also helped to address this issue around poverty of good data on this subject by releasing a specialist report on inpatient forensic and mental health care for adults with learning disabilities. This report was commissioned by the College’s Faculty of Psychiatry of Intellectual Disabilities as part of the response to Winterbourne View. (See the Elf’s summary here)

The RCP examined the reasons for admission and treatment, and concluded that it “is a mistake to label all inpatient services as assessment and treatment units for challenging behaviour”. They also set about classifying the different unit types that may see adults with learning disabilities seeking treatment. Of the six they describe, the two that the authors felt most important to examine further were Category 1 beds (forensic hospitals in conditions of either high, medium or low security) and Category 4 beds (forensic rehabilitation units for people who continue to have enduring risk issues but have been stepped down from Category 1).

In the current paper, the authors examine the argument that since learning disability is not a mental illness, psychiatry and psychiatric hospitals should not have a role in the care and treatment of these individuals. They suggest that this argument would lead some to believe that admitting someone with a learning disability to a psychiatric unit is a mere throwback to institutionalisation. The authors clearly state that they believe this position to be wrong, and that holding this position will lead to individuals with learning disabilities and mental health or challenging behaviour not having equitable treatment outcomes.

Their aim in this article is to discuss the complex interaction and implications of clinical and legal practice surrounding learning disabled individuals placed in these forensic beds, and to highlight why moving them to the community may not be as simple as originally thought in the government concordat.

Methods

The authors used two illustrative case studies and examined them both using three key questions: 1) containment vs treatment; 2) hospital care vs conditional discharge; and 3) hospital treatment vs using deprivation of liberty safeguards (DOLS) in the community.

The first case study is a man (Mr. A.) with mild learning disability and “challenging behaviour” including physical and sexual aggression. He is also thought to have recurrent depressive disorder and disorder of sexual preference. He received a Section 37/41 (hospital order given by the crown court) order under the Mental Health Act (MHA) and has spent a total of 7 years in a Category 1 bed with a 10 point treatment plan. He was then transferred to a Category 4 bed as it was felt that he could be in a less restrictive setting and continue with his treatment plan, however, unescorted leave remains problematic. Mr. A. has been at a Category 4 bed for six years and is still detained under the MHA. He has not offended in this time but still shows inappropriate sexual interests despite treatment.

Case 2 is a man named Mr. B. who has the same clinical history as Mr. A. but is detained under a Section 3 (compulsory admission to hospital) due to him already being treated in hospital at the time of the offence. It was not felt in the public interest to charge him.

Results

Question 1: containment vs treatment

The Code of Practice within the MHA suggests that treatment consisting only of “nursing and specialist day-to-day care under the clinical supervision of an approved clinician, in a safe and secure therapeutic environment with a structured regime may constitute appropriate medical treatment”. According to this, the authors suggest that both the case studies show individuals being treated rather than merely contained in hospital.

Further to this the authors also suggest that saying that there is no treatment or that treatment has not been effective would be an accurate statement if we measured success of treatment as an individual’s ability to be out in the community unsupervised. This then raises lots of questions about how we measure the success of treatment and what outcomes are appropriate to expect in cases such as those described above.

To further this, the authors report that under the MHA there is no requirement that appropriate treatment reduce the risk of an individual: it is simply enough if that treatment prevents any further deterioration of symptoms. For many this may lead to large questions around the utility of treatment. Should treatment be about risk reduction in these individuals, and if not, should treatment be more concerned with the quality of life that an individual experiences?

If appropriate treatment is sufficient to just keep the individual in stasis, without deterioration of symptoms, but without the need to show recovery, or even reduction of risk, how do we create treatment plans that include future step-down progression for some individuals?

Question 2: hospital care vs conditional discharge

The authors conclude that presently both men satisfy the criteria for detention under the MHA, as both gentlemen have a “mental disorder that is of a nature and degree that it makes it appropriate for them to receive treatment in hospital”. The mental disorder includes learning disability that is associated with abnormally aggressive or irresponsible behaviour. The authors conclude that the risk posed to the community by these two individuals is such that it would be inappropriate to consider a conditional discharge without high levels of supervision. It is not explicit whether the authors are arguing for such a discharge to happen, and they do not comment on why the need high levels of supervision maybe a barrier to discharge for these individuals.

Question 3: hospital treatment vs using deprivation of liberty safeguards (DOLS) in the community

The authors conclude that despite both men having a learning disability, they have capacity to decide where and how they wish to live. Since they have this capacity the issue of DOLS should not arise. Both question 2 and question 3 bring up the idea of step-down. It is acknowledged that step-down needs to be appropriate, with consideration given to potential risk and quality of life of the individual. However, given the questions that arise from question 1, it may be important for the authors to think about how the step-down process can be thought about within the treatment plan, and how clinicians working with such individuals can begin to think about the future of their clients.

Arguably, clinicians need to be concerned with ensuring that each case is guided by treatment aims, risk assessment and appropriate discharge strategies which need to be reviewed, modified and managed on a regular basis, from the point of admission to exit.

Conclusion

The authors conclude that individuals who have a learning disability and mental health problems as well as offending behaviours often have long stays if they are treated in a forensic inpatient unit.

Quite often this is due to the risk that they pose to themselves and to others. They also conclude that clinicians need to be cautious when making decisions when it comes to treatment planning, risk assessment and discharge plans for these individuals, and where these decisions lie with regards to the law.

Strengths and Limitations

In this article, the authors present an interesting thought experiment that draws out some really big ideas around the purpose of treatment and how we should care for individuals with learning disabilities who also have mental health problems and offending behaviour. It also allows us to think as devil’s advocates and explore ideas, as these are not real cases but are fictional accounts considered typical. However, no matter how realistic the cases are, some may argue that the ideas generated through this discussion are purely theoretical and will need application to real world data.

There are also the issues highlighted by the authors around the lack of good data about inpatients who have learning disabilities. Discussions presented in this article give the reader some idea where data needs to be collected and analysed to help answer the difficult questions presented above.

From this article and the discussions presented by the authors, several big questions arose which were discussed above. No doubt there are many more that could be explored. The main questions raised are about the use of treatment and the need to have clear aims and review for treatment. This will also impact on an individual’s discharge strategy. Whilst some of the authors’ views were implicit in the paper, their examples used did not give explicit attention to these issues.

Understandably, it was not possible to cover these issues in this article, but they do give some potential future direction for this important discussion around psychiatric forensic placement of individuals with learning disabilities, including more exploration of how to effectively plan and review treatment and discharge strategies for these individuals.

 

 

Links

Primary paper

Alexander, R., Devapriam, J., Michael, D., McCarthy, J., Chester, V., Rai, R., Naseem, A., & Roy, A., (2015). “Why can’t they be in the community?” A policy and practice analysis of transforming care for offenders with intellectual disability. Advances in Mental Health and Intellectual Disabilities, 9(3), 139-148 [abstract]

Other references

Health and Social Care Information Centre, (2013). Learning Disabilities Census Report, Health and Social Care Information Centre.

Mental Health Act. (2007). Retrieved from http://www.legislation.gov.uk/ukpga/2007/12/contents

National Audit Office, (2015). Care Services For People With Learning Disabilities and Challenging Behaviour, National Audit Office, London.

Royal College of Psychiatrists’ Faculty of Psychiatry of Intellectual Disability, (2013). People with Learning Disability and Mental Health, Behavioural or Forensic Problems: the Role of In-patient Services, Royal College of Psychiatrists, London