Reflections on working with women with Intellectual Disability and Autism (ID/A) in Generic Secure Wards

by Dr Paul Simon Williams, Consultant Forensic Psychiatrist, North London Forensic Service

This article appears in our latest newsletter which can be downloaded here.

Having been asked to reflect on my experiences as a consultant forensic psychiatrist working with female ID/A patients in a generic medium secure unit for the past 12 months, I would describe the experience with the time tested adage of ‘challenging and rewarding’. In preparing our ward for this, the staff received training from ID/A specialists which continues, on an intermittent basis. I attended a services forum highlighting good practice. Challenging aspects of working with ID/A patients include responding and meeting the requirements of greater scrutiny for this group, such as wellbeing and Care and Treatment reviews. Service relationships with families can be complex and occasionally adversarial, influenced in part by families’ frustration at the historical (and current) lack of available resources for their relative.

As a generic medium secure inpatient team, there was criticism of our lack of specialism in ID/A though this improved over time as we were able to include specialists from within our service more into regular and CPA reviews. Further challenges presented at Manager’s Hearings and Tribunals where detention for ID/A diagnoses was questioned even when we could show that the patient was not ready for discharge – both on received policy grounds and because our credentials for making clinical judgements about this group were regarded as questionable despite our supplementary training and liaison work. A considerable challenge has been managing the mix of generic and ID/A patients on the ward, in particular when risk has presented to others and also in relation to the extra time needed in the clinical approach to ID/A patients, leading other patients to feel excluded. There can be a further challenge of the ID/A patients being vulnerable to bullying.

In terms of rewards, the ward and MDT team have built up many skills, in the course of a year, in meeting the needs of ID/A patients. This has included use of Positive Behavioural Support Plans and Sensory Inventory. We have learnt much about the need to modify environment and how to maximise patient involved in their care (e.g. making use of written communication in addition to verbal). In a relatively short time, the team have become much more confident in meeting the needs of this group.

In summary, it has been an eventful year working with ID/A patients on a generic medium secure ward. To make it as successful as possible, resource including time and training is required along with regular input from ID/A trained staff. Good outcomes for patients can be obtained though this would require objective measurement for comparison with specific ID/A secure wards, not that these presently exist for women.

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