Carstairs: The truth behind psychiatric revolution at Scotland's State Hospital

Far from housing prisoners, the State Hospital is part of the NHS and has been undergoing a quiet revolution over recent years and is now being studied by foreign Government's 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 late 1930s and was, to all intents and purposes, a carbon copy of a prison of war camp to the naked eye and 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 fueled 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 including 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.

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 Citizen 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 very closely with peers in Pakistan to usher in an education programme. Dr Khan explains: “Scotland is decades ahead of Pakistan. We have strong 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 re-trained healthcare professionals ensuring that the healthcare ethos runs through the entire hospital from clinical staff teams through the facilities and other support functions and 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 is 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 and visibility.

This combined total “team” approach to care and treatment creates the multi-disciplinary 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 – and 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. Our approach is much more about recognising the challenges to patients and to 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. Many small changes bringing about a notable transformation in approach and treatment and care and respect and experience.

“Facilitating improved menus, access to gym equipment, quality improvement across the entire hospital regime – getting involved in plastic free canteens delivered opportunity and responsibility out with health but hugely rewarding for everyone involved to achieve – patients themselves entrusted and participating in areas that are not directly to do with treatment but have direct spin-off effects from being involved in decisions and influencing change.

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 as 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 vulnerable and HDHD.   – they are highly complex.

Dr De Villiers: “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 un-imaginable backgrounds of misery and neglect we work to offer them hope and support and education and 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 amongst 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 Consultant Nurse Practitioner Pat Cawthorne. After 30 years of nursing – 21 of them at the State Hospital – her 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.

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. The biggest change has been in last 21 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 the 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.  Gary adds: “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”.