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Dual diagnosis
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drinkanddrugsnews
| October 2014
www.drinkanddrugsnews.com
There’s much to
be done to bring
together substance
misuse and mental health
services so we can offer
effective care for dual diagnosis,
says
Taf Kunorubwe
by Rethink and Turning Point; and IAPT’s
Positive practice guide
.
In the space of an article I could not adequately explore the various definitions,
historical context, prevalence, service user experiences, or therapeutic interventions
relating to dual diagnosis. Rather, I am aiming to share some helpful practice and
to contribute to the discussion around how to support such service users.
Firstly, I cannot advocate training strongly enough; even basic awareness or
assessment skills will benefit service users and boost workers’ competencies and
confidence, and basic training should be available as part of everyone’s induction
process. If this isn’t currently provided, you may wish to consider self-directed
study or free e-learning packages such as the
Dual diagnosis, making progress e-
learning resource
http://www.celecoventry.co.uk/projects/dualdiagnosis/.
For those regularly involved I would recommend further development via
advanced practitioner training, which you may be able to access as part of your
professional development plan, through bursaries or self-funding.
Not only would training help workers to better support service users, it can
also be a catalyst for culture change in services, shifting from attitudes such as
‘don’t ask don’t tell’, exclusion and non-compliance, towards non-judgemental
positions, empathy and support. This will hopefully allow service users to be
open and honest about their experiences and help engagement, allowing
services to come to a shared understanding with them about recovery. Also, at a
professional level, this more integrated culture should help to move us closer to
a feeling of cohesion instead of ‘us and them’.
With non-judgemental, empathetic and supportive attitudes, we can embark
on engaging more with service users. By this, I do not mean simply allowing
access to services, but removing additional barriers and encouraging active
engagement. Experience of this at the pre-assessment stage has been through
outreach work, health promotion or working in conjunction with services that
are first points of contact, such as food banks. During assessment we can
actively engage by using therapeutic skills and entering into a conversation
about how their substance use and mental health interrelate, psychoeducation
and therapeutic treatment options – all of which will help to reach a joint
decision and enable any subsequent work to be towards a joint view of recovery.
Once in treatment, I have often found a crossover of interventions, which
aids engagement as we are addressing underlying processes. An example of this
is in CBT sessions: we explore the impact that negative automatic thoughts
have on depressed moods and how to challenge these. By the end of therapy,
these coping strategies can effectively challenge negative automatic thoughts in
relation to substance misuse.
In instances where we possibly require further expertise, joint work can be
helpful, and it doesn’t require superhuman effort to collaborate with mental health
services. In my experience this can be as simple as attending teammeetings, joint
care planning, outreach, risk management and supervision. Not only does this aid
active engagement with all the services involved, but it also means we have a
shared culture of recovery, avoid repetition for clients, help to achieve integrated
interventions and contribute to staff being supported. An example of this was
through joint outreach with mental health services. We re-engaged with a high-
risk service user and helped him to stabilise; whereas before when he disengaged,
he deteriorated until he was detained under the Mental Health Act.
Not only does joint work benefit clients and aid engagement, but it is also
helpful in developing an awareness of services, the treatment approaches
available, referral routes, screening measures and the support they offer. I found
this helpful when considering additional support for service users and enabling
‘Before we can offer you a psychiatric
assessment, you need to be abstinent
for a minimum of two months.’
HOW OFTEN DO SERVICE USERS RECEIVE SUCH RESPONSES?
My experience of
working in mental health care, IAPT (the Improving Access to Psychological
Therapies programme), substance treatment services and as a mindfulness
teacher has shown me that this happens all too often. The most simplistic
explanation of dual diagnosis is experiencing one of a range of mental health
problems in conjunction with substance misuse. However I would caution
against relying on a literal interpretation as multiple, complex and
interdependent needs are often involved.
Unfortunately dual diagnosis has been a diagnosis of exclusion, with service
users omitted frommental health services for substance misuse and substance
treatment services unable to offer the level of support needed. This is despite
widespread recognition that this client group has multiple needs, worse social
outcomes and the need for holistic approaches. This is recognised by many studies
and documents, including the Department of Health’s
Dual diagnosis good
practice guide; making every adult matter
(a coalition of four national charities –
DrugScope, Mind, Clinks and Homeless Link); the
Dual Diagnosis Toolkit
produced