Contact Information
Gordon Ritchie
Consultant Nurse/Lecturer
North of Scotland Forensic Services
Rohallion CSS/University of the West of Scotland
e-mail: gordon.ritchie@nhs.net
Tel: 01738 562390 (Rohallion CSS)
07718203202 (Mobile)
Rohallion Clinic Secure Services (Perth)
& North of Scotland Forensic Services.
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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
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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
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Varies widely but alcohol, cannabis & stimulants most
used.
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Appears that availability is the primary determinant of
substance use
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Important not to overlook tobacco use, high use in SMH.
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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
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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
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Designed to be as user friendly as possible
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Should take less than 1 hour to administer (excluding
file review) and could be done over several sessions
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Reports from the separate sections should be short &
concise
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Final report should bring all the sections together (cut &
paste) and include the Preliminary Formulation
The Standardised Assessment Tool
(Sections)
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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
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Is the substance use causal in mental health problems (rare, drug
induced psychosis a very specific diagnosis) ? Alcohol & Organic
Problems
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Is substance use exacerbating pre-existing conditions/problems
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Are substances being used to alleviate distressing positive and/or
negative symptoms of mental illness (deliberate or otherwise)
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Are substances being used to increase social inclusion
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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
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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?
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Do they offend on their own or with others?
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Who is effected by the offending behaviours?
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C-BIT Aims
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Address Beliefs
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Awareness of Substance
Use/Mental Health
Relationship
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Skills Development
C-BIT, 3 Main Aims
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To collaboratively identify, challenge and
undermine unrealistic beliefs about alcohol/drugs
that maintain problematic use and replace them
with more adaptive beliefs.
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To facilitate an understanding of the relationship
between substance use and mental health problems
(adapted to include offending behaviours).
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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)
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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)
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The SOC the client is in
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The clients stage of engagement
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The clients self-identified goals and concerns
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Short & long term treatment needs
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The clients overall needs as identified in the care plan
Summary
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C-BIT offers a structured, evidence based way
forward in developing & implementing integrated
treatment programmes for Dual-Diagnosis clients.
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Follows all current best practices guidelines and
service recommendations.
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Unfortunately not specifically intended for use with
Mentally Disordered Offenders, obviously does not
contain specific offending behaviour elements.
Continuing Developments
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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.