The development of a training programme for C-BIT Alcohol Misuse: A Training Route for Staff in Specialist and General Services The development of a training programme for C-BIT

Working with Alcohol Use and Mental Health Together Comorbidity: An Expectation instead of an Exception Schizophrenia and Bipolar Disorder and Substance Use Disorders – around 50% About 1/3 of those with mood and anxiety disorders with comorbid substance abuse Of those with substance misuse, often around 50% have comorbid mental health problems

Models of Treatment Sequential Parallel Integrated

Cognitive-Behavioural Integrated Treatment (C-BIT) A framework for integrated treatment Working with mental health and substance use together in an integrated package Three aims: Collaboratively identify, undermine and replace unrealistic beliefs Explore the relationship between substance use and mental health Develop coping skills to prevent relapse

Cognitive-Behavioural Integrated Treatment (C-BIT) Three areas of therapeutic focus Assessment and Formulation Engagement and Enhancing Motivation Supporting a Journey of Behavioural Change

Development of a Training Programme in C-BIT National Policy Road to Recovery Changing our Relationship with Alcohol Delivering for Mental Health Effective Interventions HTBS cost and clinically effective interventions for alcohol NICE recommended interventions for drug treatment Local Policy Goals and priorities of treatment Continuum of services available Levels of service and integration Staffing levels and skill base Local Challenges Benzodiazepine use Alcohol related brain damage Cognitive impairment Level of violence Complex comorbidity

National Policy Drivers Road to Recovery Changing Scotland’s Relationship with Alcohol Delivering for Mental Health Commitment 4 Commitment 13 Increasing the Availability of Evidence-Based Psychological Therapies in Scotland Applied Psychologists and Psychology in NHS Scotland (Draft)

Local Policy What are the goals and desired outcomes of interventions? Where are the resources focused Chronic “life challenges” vs acute treatment Setting of priorities and allocation of resources Continuum of services, definition of stepped care, and integration of services Staffing patterns and skills base

Evidence Based Interventions Health Technology Board Scotland – Preventing Relapse in Alcohol Dependence Motivational Enhancement Coping and Social Skills Training Behavioural Self-Control Training Marital +Family Therapy (including CRA) For drug treatment, NICE recommends MI and Contingency Management Staff training to deliver treatment to protocol Matrix- Guide to Psychological Therapies

Three Common Principles of Effective Behavioural Interventions (Carroll and Rounsaville, 2006) Enhancing Motivation Examples: Brief Interventions Motivational Interviewing Motivational Enhancement Behavioural Self Control Training Community Reinforcement and Family Training Developing Control over Impulsive Behaviour Examples: Coping and Social Skills Training Contingency Management Behavioural Self Control Training Compassionate Mind Training Reinforcement Management (Developing a rewarding, alternative lifestyle) Examples: Community Reinforcement Approach Contingency Management Compassionate Mind Training

Considering the Role of Psychology in Addiction Services National Policy Road to Recovery Changing our Relationship with Alcohol Delivering for Mental Health Effective Interventions HTBS cost and clinically effective interventions for alcohol NICE recommended interventions for drug treatment Local Policy Goals and priorities of treatment Continuum of services available Levels of service and integration Staffing levels and skill base Local Challenges Benzodiazepine use Alcohol related brain damage Cognitive impairment Level of violence Complex comorbidity

Unique Challenges in Scotland – Benzodiazepine Use Scotland drug treatment effectiveness study found 76% benzo use in the community vs. ~33% in a community sample in England New patient statistics – 33% in Greater Glasgow and 1% in England Potentially a significant impact on services with anterograde amnesia, paradoxical effects and reduced effectiveness of CBT

Unique Challenges in Scotland – ARBD and Korsakoff’s Psychosis Incidence of 81.25 per million in 1995 in East End of Glasgow Hostel dwellers in Glasgow – 82% had cognitive impairment and 21% diagnosed with ARBD

Unique Challenges in Scotland – Non-Fatal Overdoses Prevalence of fatal overdoses in Scotland over twice that of England and Wales Even when comparing areas of high prevalence, Glasgow has more than twice the prevalence rate DORIS found ratio of fatal to non-fatal overdoses of 1:26.4 (though not sure how defined) Number of heroin OD’s has been found to be a predictor of cognitive impairment

Unique Challenges in Scotland – Other Cognitive Impairment Acquired brain injury is an unknown, but given the level of alcohol consumption and violence…. Darke et al. found short and long term verbal memory severely impaired in their study of stable methadone patients Multiple studies with various populations and measurements suggest that there is impairment among chronic substance users in their ability to recognise consequences and inhibit impulses

Unique Challenges in Scotland – Cultural Issues Level of violence History of gangs/groups Sectarian violence Cultural issues of protecting one’s self and need to adapt programmes Homicide rate almost twice that of England Violence is strongly correlated with alcohol

Unique Challenges in Scotland – Psychological Factors and Trauma Given level of violence, need to consider trauma levels Use of dissociation to cope which makes interventions more difficult Dissociative substances preferred

Unique Challenges in Scotland – Complex Comorbidity Example of head injury, mental health, alcohol use, and long-term functioning Suicide rate is almost twice that of England Sense of hopelessness is often identified Challenge is how to help people learn how to bring about change within a culture and environment that discourages change and often a lack of belief in the possibility

Unique Challenges in Scotland – Ways Forward Need to consider creative ways to help people move through a journey of change – using strategies in addition to those that are verbal (identify ways that people learn best) Three principles outlined along with optimism Be aware of issues of threat, dissociation and cognitive impairment Motivational strategies work

Considering the Role of Psychology in Addiction Services National Policy Road to Recovery Changing our Relationship with Alcohol Delivering for Mental Health Effective Interventions HTBS cost and clinically effective interventions for alcohol NICE recommended interventions for drug treatment Local Policy Goals and priorities of treatment Continuum of services available Levels of service and integration Staffing levels and skill base Local Challenges Benzodiazepine use Alcohol related brain damage Cognitive impairment Level of violence Complex comorbidity

Translating C-BIT to a Scottish Setting “Poly substance cocktail” as opposed to stimulants/alcohol/cannabis pattern Complex mental health, physical health and substance use Use of worksheets to define principles Practice of worksheets within training with different types of examples Role play

Translating C-BIT to a Scottish Setting Use of multi-media to meet learning needs Discussion of creative ways to use the materials Specific issues of memory and cognitive impairment discussed Two day follow-up to facilitate application to practice