1. 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

2. 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

3. Models of Treatment
Sequential
Parallel
Integrated

4. 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

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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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