Contact Information Gordon Ritchie Consultant Nurse/Lecturer North of Scotland Forensic Services Rohallion CSS/University of the West of Scotland e-mail: [email protected] Tel: 01738 562390 (Rohallion CSS) 07718203202 (Mobile) Rohallion Clinic Secure Services (Perth) & North of Scotland Forensic Services. RCSS, currently 2, soon to be 3 Medium secure wards for the North of Scotland region (32 Male beds in total when fully open) 3 Low secure wards with 35 Male available beds (currently near full occupancy) Forensic community team, currently approx 50 patients engaged by the team. Inverness (New Craigs Hospital) 20 beds M & F although not all dedicated to forensic patients & small forensic community team Aberdeen (Blair Unit) 24 Male & 2 Female beds, Community team with 50-60 patients engaged. Prevalence of Substance Misuse Histories in Forensic Populations Various estimates but generally accepted that a large proportion of people with SMH problems will have some history of substance misuse problems Reiger et al(1990) found lifetime rates of 47% in those with a diagnosis of schizophrenia and 61% in those with a diagnosis of bi-polar disorder. Higher rates are found in clients who are male, young, poorly educated and single. Highest rates are found in mentally disordered offender populations, some studies have reported rates of up to 90% where patients had significant histories of substance misuse. Similar high rates are found within the NOS region Types of substances used Varies widely but alcohol, cannabis & stimulants most used. Appears that availability is the primary determinant of substance use Important not to overlook tobacco use, high use in SMH. Scotland has higher use of opiates & benzo’s than the rest of the UK and this is reflected in MDO populations. The Ongoing Development of Assessment & Intervention Processes across the North of Scotland Standardised Assessment Tool developed. Initially 15 staff from the 3 area’s in the NOS region trained (5 days in formal assessment methods using the Standardised tool, & introduction to treatment methods, broadly following adapted C-BIT principles) A further 16 staff trained in assessment and formulation methods at RCSS to meet needs within the new service. Consultant Psychiatrist for the Community Team (Dr Friel) leading on integrated treatments in conjunction with SMS and S/W Drug & Alcohol Teams Some initial treatments delivered on an individual basis (no current group treatments). Treatments include Educational Interventions, Relapse Prevention and limited Controlled Drinking interventions for community based patients. Small number of community patients on Methadone managed by SMS. The Standardised Assessment Tool Designed to be as user friendly as possible Should take less than 1 hour to administer (excluding file review) and could be done over several sessions Reports from the separate sections should be short & concise Final report should bring all the sections together (cut & paste) and include the Preliminary Formulation The Standardised Assessment Tool (Sections) Assessment from available file information Current functioning (To initially engage with client, build rapport and assess current functioning) Alcohol use & Consequences, Possible Relationship to Mental Health, Possible Relationship to Offending Behaviour Drug use & Consequences, Possible Relationship to Mental Health, Possible Relationship to Offending Behaviour Beliefs about Alcohol & Drug use Child Protection (statutory obligation) Formal initial assessment tools (Dast-20,ADS) Continues to be evaluated and if necessary modified to meet local needs. Working Towards a Preliminary Formulation Is the substance use causal in mental health problems (rare, drug induced psychosis a very specific diagnosis) ? Alcohol & Organic Problems Is substance use exacerbating pre-existing conditions/problems Are substances being used to alleviate distressing positive and/or negative symptoms of mental illness (deliberate or otherwise) Are substances being used to increase social inclusion Are substances being used in an attempt to overcome social skills deficits e.g. assertiveness, self-esteem, anger management etc Substance use and Offending Behaviour Was the client intoxicated when displaying offending behaviours including increased levels of aggression and violence (is dangerousness increased when using substances?) Are offences being committed to support continuing substance use (how is the client financing their use & how much are they spending?) Are there patterns of offending behaviour? Do they offend on their own or with others? Who is effected by the offending behaviours? C-BIT Aims Address Beliefs Awareness of Substance Use/Mental Health Relationship Skills Development C-BIT, 3 Main Aims To collaboratively identify, challenge and undermine unrealistic beliefs about alcohol/drugs that maintain problematic use and replace them with more adaptive beliefs. To facilitate an understanding of the relationship between substance use and mental health problems (adapted to include offending behaviours). To teach specific skills for controlling substance use and recognising early signs of psychosis, and for developing social support for an alternative lifestyle. Structure of the C-BIT programme (Core Components) Screening and Assessment & Formulation Four treatment phases; Engagement & building motivation to change Negotiating some behaviour change Early Relapse Prevention Relapse Prevention and Relapse Management 2 additional components (To address skills deficits); Management of moods, communication, self-esteem and lifestyle balance. Examine lifestyle changes & alternative social networks. C-BIT, Treatment Planning (factors in deciding appropriate interventions) The SOC the client is in The clients stage of engagement The clients self-identified goals and concerns Short & long term treatment needs The clients overall needs as identified in the care plan Summary C-BIT offers a structured, evidence based way forward in developing & implementing integrated treatment programmes for Dual-Diagnosis clients. Follows all current best practices guidelines and service recommendations. Unfortunately not specifically intended for use with Mentally Disordered Offenders, obviously does not contain specific offending behaviour elements. Continuing Developments All existing patients and new admissions will have a full SU assessment & report completed Continue to deliver and develop interventions to meet identified need Continue to develop links and working relationships with SMS’S and S/W Drug & Alcohol Teams Currently some discussion taking place led by the Consultant Psychiatrist, Consultant Psychologist & Consultant Nurse for the Medium Secure service in relation to developing a sustainable substance misuse strategy that integrates with services throughout the patients journey.