Besøk i regi av RKDD november 2007 John Arrowsmith Wilhelmsen

1. Combined Psychosis and Substance Use (COMPASS) ProgrammeBirmingham and Solihull NHS Mental Health Trust Besøk i regi av RKDD november 2007 John Arrowsmith Wilhelmsen The COMPASS Programme Birmingham 2007

2. ”E-post-fisketuren” til Birmingham • Douglas Turkington (i Norge sept 2006 om ”CBT for psychosis” som spurte • David Kingdon som foreslo • Christine Barrowclough som foreslo • Alex CopelloandHermine L Graham som ba oss kontakte • Derek Tobin - som med sitt team ble vårt hyggelige vertskap – i 2 dager. The COMPASS Programme Birmingham 2007

3. Visitors for Norway 6th & 7th nov 2007 • Based at 12-13 Greenfield Crescent • Information from Derek Tobin (and team) • Q & A with a) Hermine L Graham and Alex Copello b) Two Assertive Outreach teams • Visit to/from two Community Drug teams The COMPASS Programme Birmingham 2007

4. DH (2002) Mental Health Policy Implementation GuideDual Diagnosis Good Practice Guide • The COMPASS programme highlighted as a model of good practice. The COMPASS Programme Birmingham 2007

5. Dual Diagnosis Good Practice Guide forts.. • Substance misuse is usual rather than exceptional amongst people with severe mental health problems and the relationship between the two is complex. • Individuals with these dual problems deserve high quality, patient focused and integrated care. • This should be delivered within mental health services. • This policy is referred to as ”mainstreaming” The COMPASS Programme Birmingham 2007

6. Birmingham and Solihull NHS Mental Health Trust • Catchment area multicultural and inner city with population approx 1,2 mill • ”Mainstream” within the Trust are functionalised tailored community mental health teams – such asassertive outreach (6),early intervention (3), home treatment (5), rehab & recovery (4), community drug (3), team for homeless, inpatient units, forensic services primary community liason (10) etc… The COMPASS Programme Birmingham 2007

7. The COMPASS Programme • evolved since 1997 (1998 i DH 2002) • as a specialist multi-disciplinary team • include(d) a service director/clinical psychologist, research psychologist, three senior community psyciatric nurses, a senior occupational therapist and sessional input from a consultant psychiatrist. • aimed to train and support existing ”mainstream” mental health and substance misuse services • still ”evolving” The COMPASS Programme Birmingham 2007

8. The ”COMPASS” BOOK ”Cognitive-Behavioural Integrated Treatment (C-BIT)” Hermine L Graham (2004) with Alex Copello, Max J Birchwood, Kim T Mueser, Jim Orford, Dermot McGovern, Emma Tkinson, Jenny Maslin, Mike Preece, Derek Tobin and George Georgiou The COMPASS Programme Birmingham 2007

9. The ”COMPASS” BOOK cont • A type of DIY book – operationializing therapeutic interventions in a structured yet flexible way to collaboratly tackle problematic drug/alkohol use amongst clients with severe mental health problems • Overall objective om C-BIT is to negotiate and facilitate – with clients – som positive change in their problematic drug/alhol use • ”Harm reduction” – reduction in amount/type/the way the substance is taken – are alle ”positive changes” – as well as abstinence The COMPASS Programme Birmingham 2007

10. The ”COMPASS” BOOK cont C-BIT consists of core components • an assessment phase Screening and Assessment • four treatment phases 1. Engagement & Building Motivation to Change; 2. Negotiating some Behaviour Change; 3. Early Relapse Prevention 4. Relapse Prevention & Relapse Management • and two additional treatment components Skills Building (6 topics) Working with Families & Social Network Members The COMPASS Programme Birmingham 2007

11. Eksempler fra opplæringsprogrammet: • Taken from Compass CD-rom • Consists of 15 ”modules” for training/skilling staff • Content also based on a survey amongst staff indicating where knowledge and skills were needed and wanted • Implementation requires positive attitudes, dedicated leadership and follow-up supervision. The COMPASS Programme Birmingham 2007

12. Exercise: Why Use? • Why do I (did I) smoke cigarettes; drink caffeinated drinks e.g. coffee, tea, cola; drink alcohol? Make a list of the reasons why, the benefits, and if there are any, some of the less good aspects of these habits. • Why do people with mental health problems use drugs and alcohol? Make a list of the reasons that you are aware of from what service users have told you, or assumptions that you have made. The COMPASS Programme Birmingham 2007

13. Reasons for use • To feel euphoric or feel nothing • To feel more confident • To work longer hours or enhance performance • To belong to a social group (peer pressure) • To kill time (alleviate boredom) • To alleviate physical pain and other health problems • Because it is a habit • To satisfy cravings and avoid withdrawal symptoms • For weight loss • To experience an altered state of consciousness • To unwind after a stressful day The COMPASS Programme Birmingham 2007

14. Cocaine and Crack Cocaine • Stimulant drugs • Legality- class A drugs • What do they look like: cocaine is a white crystalline powder, and crack is white or off-white crystalline rocks • How taken: Cocaine may be taken orally, snorted, inhaled, or injected. Crack: inhaled from a pipe, but sometimes injected. • Effects: Cocaine, in both forms, increases heart rate, breathing, blood pressure, thoughts and activity levels. It also lifts mood and gives a sense of energy and wellbeing. • Signs of use: dilated pupils, dry mouth, elevated body temperature, teeth grinding, agitation, restlessness, excitability, pressure of speech, flight of ideas, weight loss (appetite suppressant). • Risks: paranoia, confusion, and disorganized patterns of behaviour. The “come down” period causes fatigue, and depressed mood. Heart attacks, hgh blood pressure, stroke, and kidney damage The COMPASS Programme Birmingham 2007

15. Opiates • Derived from the opium poppy. • They include heroin, morphine, methadone and codeine. • Central nervous system depressants • Legality: these are class A drugs • What they look like: heroin is a pale brown powder; also available in pharmaceutically manufactured form such as tablets, green or blue syrup (methadone) and glass ampoules (for injection) • How used: mainly smoked or injected, some opiates are available in tablet and suppository form. • Signs of use: pallor, pinprick pupils “pinned”, sedation/drowsiness (“gouching out”), signs of injecting on body • Effects: people feel emotionally numb, warm and drowsy, with an initial intense rush, especially if injected intravenously. • Withdrawals: gooseflesh, shivering, profuse sweating, feeling feverish, aching limbs, yawning, runny eyes, runny nose, gastrointestinal disturbances such as stomach cramps, nausea, vomiting and diarrhoea. • Risks: overdose, injecting related problems, BBVs, accidents The COMPASS Programme Birmingham 2007

16. Benzodiazepines and Substance Use • Benzodiazepines (tranquillisers) such as diazepam are highly addictive and very difficult to withdraw from. • High doses of benzo’s act like alcohol leading to paranoia, disinhibition and aggression. • They interact with other depressants (alcohol, heroin etc) increasing sedative effect and toxicity • If mixed with depressants, can lead to accidental overdose and death. • Have a high “street value”. • Prescription of benzo’s should be for short term (2 weeks) treatment for anxiety only. The COMPASS Programme Birmingham 2007

17. Amphetamine- 2-3 days Ecstasy- 30-48 hours Cannabis: Single use- 3 days Moderate use- 4 days Heavy use- 10 days Chronic heavy use- 36 days Methamphetamine-48 hours Cocaine- 6-8 hours Methadone- 7-9 days Codeine- 24 hours Heroin- 1-2 days Maximum detection times for drugs in urine The COMPASS Programme Birmingham 2007

18. Exercise: Confidentiality: Take 10 minutes to consider: • What are the boundaries of confidentiality within your role around the disclosure of substance use? • At what point would you breach confidentiality, and how would this be communicated to the service user? The COMPASS Programme Birmingham 2007

19. Confidentiality • Doesn’t mean secret! • Be up front about who gets access to information and why. • Illegal activities may have to be reported to the police (dealing drugs, threats of violence, serious crimes) • Child protection issues will need to be reported. • Respect peoples’ right to privacy within limits. • Carers want and need information, and this should be shared only with full consent of the service user unless there are safety/legal issues. • Carers may have important information for the care of the person • Balance needs of individual against safety of others • Fully explain why confidentiality may be breached. • May have to re-engage person at a later stage. The COMPASS Programme Birmingham 2007

20. Cognitive Behavioural Assessment • Gain an understanding about what triggers and maintains their substance use (and other problems) • Generate problem statements that can be turned into goals. • Assess what happens in 6 domains/areas: • Cognitive (what are you thinking? What goes through your mind when…) by this we are trying to elicit the thought processes and decision-making. • Physical (what sensations do you notice in your body?) • Affective (how do you feel when…..) • Behavioural (what do you do as a result of…) • Interpersonal (who are you with and how do they affect you), • Situational (where are you? in what setting does this seem to happen?) The COMPASS Programme Birmingham 2007

21. An exampleWhat is the area to be focused on: alcohol use • When-most evenings, who with-friends, where-pub, why-because I feel miserable and it cheers me up • Domains: affect-it makes me feel happy initially, then I get angry, physiological-I feel relaxed, interpersonal-I am more sociable but I do have more rows when I am drunk. Psychological- feel paranoid by end of evening. • Frequency-daily, intensity- 5 pints, duration- 7pm till 11pm, onset-mate calls for me at 6.30 in the hostel The COMPASS Programme Birmingham 2007

22. Problem statement • John spends the day alone in the hostel. He looks forward to going to the pub with his mates in the evening. He drinks an average of 5 pints (5%) lager. Initially he feels happy, relaxed and sociable, but as he drinks more he starts to think that other people in the pub are talking and laughing at him. Because he is drunk, he ends up shouting at people and then is asked to leave. The COMPASS Programme Birmingham 2007

23. Possible areas of intervention • Improve daily activities • Introduce non-drinking social activities • Explore Johns feelings of paranoia • Assess further his mental state • Psycho-education re alcohol-effects on psychological and physical health • Assess for alcohol dependence • Assess motivation to reduce alcohol The COMPASS Programme Birmingham 2007

24. Working with Beliefs • Identify beliefs about substances • Ask person to consider the evidence for and against the beliefs (e.g. does cannabis always calm you down? • Assist the person to generate some alternative beliefs or thoughts that may be more helpful (e.g. I want to smoke cannabis as I am stressed but it just makes things worse in the long run) • This in turn may help change the consequences (decides not to smoke cannabis) The COMPASS Programme Birmingham 2007

25. Harm Minimisation • This is an approach to treatment that advocates interventions that seek to reduce or minimise the adverse health consequences of substance use. • It acknowledges that not everyone who comes for help wants to stop using substances completely at that point in time. • The main aim is to prevent harm as a result of disease, overdose, or drug-related deaths. • This also incorporates the mental health risks associated with some drugs and alcohol consumption The COMPASS Programme Birmingham 2007

26. Harm Minimisation Interventions • Needle exchanges. • Advice about safer injecting and safer drug use. • Advice about the prevention of infection with blood-borne viruses (HIV, hepatitis B and C). • Testing, advice, counselling and treatments for blood-borne viruses. • Advice about preventing overdose and drug-related deaths. • Education about the effects of illicit substances on mental health, and interactions with prescribed medications. The COMPASS Programme Birmingham 2007

27. Physical Health Issues for Dual Diagnosis • People with mental health and substance use generally suffer from poor physical health. • People with schizophrenia are at risk of developing type II diabetes (possibly in connection with obesity), • heart problems (extended Q wave interval), • smoking related illnesses such as cancer. • People who use substances: • Cardiac problems, • Circulatory problems, • Malnutrition • Poor dental hygiene • Injecting drugs then this comes with an array of associated problems. • Heavy alcohol consumption is associated with a significant number of health problems. The COMPASS Programme Birmingham 2007

28. Injecting and Sexual Health Assessment • All service users with dual diagnosis should be asked about injecting behaviour- they may have tried it in the past • Give a clear rationale questions about injecting and sexual behaviour and advise that they may feel embarrassed • The worker should be in a position to answer questions, offer reassurance and be able to refer to appropriate services that can offer more detailed assessment and interventions. • Requires a basic knowledge of: • blood borne viruses and testing facilities • sexual health clinics and advisors • needle exchanges in the community, • safer injecting practices and safer sex. • Therefore it is important to find out about local services, and have literature available. • Information should be presented in a rational and balanced way. The COMPASS Programme Birmingham 2007

29. Examples of Key Questions • Have you ever injected? (People with dual diagnosis are less frequent injectors but even once before warrants further exploration as to how safe their practice was) • If so, where did you obtain your injecting equipment? (This is to check if sterile equipment was used, or whether equipment that had been used before) • Where do (did) you inject? • May I see where you inject (check for abscesses, ulcers, and general quality of the injecting area) • What is your current form of contraception? (Do they use condoms? If not have a discussion about the importance of using condoms to prevent transmission of sexually transmitted diseases and where condoms can be obtained) • Have you ever had any sexually transmitted diseases? (The risk of HIV is higher in those who have had STD’s. It’s also an indicator of unsafe sex) • What is your appetite like in the last 4 weeks? • What is your typical diet like? • Have you any health concerns at the moment? • When was the last time you saw your G.P. (check if they have a G.P.!)- The COMPASS Programme Birmingham 2007

30. How people change They undergo a series of cognitive and behavioural processes • Involves belief in own ability to change (self-efficacy) • Self-esteem- I am worth changing for • Own rationale for change (the benefits outweigh the cost or loss) The COMPASS Programme Birmingham 2007

31. Cycle of Change (Prochaska and Diclemente, 1996) The COMPASS Programme Birmingham 2007

32. The COMPASS Programme Birmingham 2007

33. Engagement Stage defined as: • Lack of working alliance between worker and client. • Sporadic/chaotic use of services. • Lack of trust (from service user and worker). • High levels of resistance. • Non-adherence to treatment proposed. • Treatment failure. The COMPASS Programme Birmingham 2007

34. Interventions for Engagement • Outreach. • Befriending/ low key. • Creative and flexible approach • Therapeutic optimism. • Practical assistance and crisis intervention- be perceived as helpful. • Stabilisation of psychiatric symptoms (? admission to hospital; medication management) • Sensitivity to client’s life, choices and viewpoint. • Typically not addressing substance use. • Utilise strategies to reduce resistance. • Support and exploring alternate social networks. The COMPASS Programme Birmingham 2007

35. Staged Activities Stage Focus of Activity • Engagement Building relationship, stabilisation of acute problems, medication management • Persuasion Developing reasons for thinking about changing substance use using motivational interviewing techniques, social support, stabilisation of social situation, develop meaningful activities, psychoeducation • Active Treatment Focused counselling and treatment, group and individual work, family work, work and activities • Relapse Prevention Maintaining stability of lifestyle, using relapse prevention strategies, developing alternative life including new peer groups. The COMPASS Programme Birmingham 2007

36. Exercise: Activities for People with Dual Diagnosis Spend a few minutes answering the following questions (in pairs) 1. What activities are available for people with dual diagnosis within your setting? 2. What are the barriers to accessing activities? 3. How could these barriers be overcome? 4. What other activities would you like to see offered? The COMPASS Programme Birmingham 2007

37. What Is MI? • Client centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. (Miller and Rollnick, 2002 2nd ed) The COMPASS Programme Birmingham 2007

38. OARS (skills) • O pen-ended • A ffirming • R eflecting • S ummarising The COMPASS Programme Birmingham 2007

39. Readiness to Change(Rollnick, Mason and Butler, 1999) Readiness to change ruler: NOT READY……......UNSURE…………….READY 0……………………………………………….10 • Importance of change: 0----------10 (willing) • Confidence in ones own ability to make the change: 0-------------10 (able) The COMPASS Programme Birmingham 2007

40. Working with Ambivalence • Identify and explore the nature of ambivalence about a particular behaviour • Always start with the side of “least resistance” • List the good and less good aspects in turn • Encourage elaboration, and identification of less obvious costs and benefits The COMPASS Programme Birmingham 2007

41. Categories of resistant behaviour • Arguing • Challenging, discounting, hostility • Interrupting • Talking over, cutting off • Negating • Blaming, disagreeing, excusing, claiming impunity, minimising, pessimism, reluctance, unwillingness to change/intention not to change • Ignoring • Inattention, non-answer, no response, side-tracking The COMPASS Programme Birmingham 2007

42. Exercise : Your Own Resistance Think of a situation where someone tried to impose a change on you: • How did this make you feel/think • How did you express your feelings/thoughts to others • What did you do to reinforce your position/ maintain your viewpoint • What did other(s) do that made you more resistant • What did others do that decreased resistance The COMPASS Programme Birmingham 2007

43. Relapse Prevention • Increased vulnerability as people are trying to cope without substances (or with reduced supply) and, for some people, being drug free means that their mental health problems may escalate. • Building on lifestyle changes that support stability in both mental health and substance use problems. • Housing • Work • Activity • Supportive peer groups • Relapse can’t be prevented, but risks of lapse can be minimised. • Interventions aim to equip the person with: • an awareness of their own personal triggers to lapse. • appropriate skills (e.g. assertiveness training) • contingency strategies to cope with such triggers. • Self help groups. The COMPASS Programme Birmingham 2007

44. Marlatt & Gordon Model of Relapse Prevention Decreased probability of relapse Copingresponse Increased self-efficacy High-risk situation Rule Violation Effect – dissonance, conflict & self-attribution – guilt & perceived loss of control Decreased self-efficacy Increased probability of relapse No coping response Slip Positive outcome expectancy of behaviour The COMPASS Programme Birmingham 2007

45. Exercise : Your own relapses Discuss in pairs: (10 minutes) • Think about a behaviour you changed, that you relapsed back into (e.g. stopping smoking, starting regular exercise etc) • What triggered the relapse? • How did you feel about the relapse? • What happened as a result? • How did other people react to your relapse? The COMPASS Programme Birmingham 2007

46. Dual Diagnosis Capabilities • Recognise Needs (Integrated Assessment): In partnership with the service user, perform a triage assessment of mental and physical health, substance use, and social functioning and offending; identifying both needs and strengths. As a result of this assessment, the worker should be able to identify where those needs are best met by local services (Dual Diagnosis Capability 9; level 2) • Non-Judgemental Attitude: Be aware of ones own attitudes and values in relation to dual diagnosis and be able to suspend judgement when working with service users, and carers. Challenge others’ attitudes in an appropriate and useful manner. Dual Diagnosis Capability 4 level 2 • Engagement: Be able to develop an effective therapeutic relationship and be able to work flexibly with this client group. Dual Diagnosis Capability 6 level 2 • Ethical, Legal and Confidentiality issues: to be aware of and adhere to the organisation policy on confidentiality and to be able to effectively communicate this to the service user. To be able to seek advice about a potential breach of confidentiality, or legal issue. To be able to manage ethical and moral dilemmas that arise out of working with people with dual diagnosis. Be aware of confidentiality limits and be able to resolve potential breaches of confidentiality in consultation with the service user, their carers and other professionals. (Dual Diagnosis Capability 11 level 1 and 2) The COMPASS Programme Birmingham 2007

47. DIVERSE SKJEMAER • Drug (alcohol) Diary • Advantage-Disadvantage anaysis • Behavioural Experiment worksheet • Relapse-prevention plan • osv.. The COMPASS Programme Birmingham 2007

48. Etter-tanker? • Fornuftig med kobling mellom kliniske miljøer og universitet/forskning • Verdien av CBT, MI og Stage-wise tenking er godt dokumentert og allerede godt kjent i mange norske miljøer • Likevel – interessant med et samarbeid med COMPASS om C-BIT for en særskilt regional implementering? The COMPASS Programme Birmingham 2007