1. 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.netgordon.ritchie@nhs.net Tel: 01738 562390 (Rohallion CSS) 07718203202 (Mobile)

2. 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.

3. 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

4. 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.

5. 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.

6. 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

7. 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.

8. 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

9. 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?

10. C-BIT Aims  Address Beliefs  Awareness of Substance Use/Mental Health Relationship  Skills Development

11. 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.

12. 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.

13. 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

14. 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.

15. 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.