Tom Dodd National lead for Community teams Joint National Lead for Dual Diagnosis Chairman of REST

Specialist or Integrated Approaches: Working with

people who have a dual diagnosis using an Assertive

Outreach frameworkTom Dodd

National lead for Community teamsJoint National Lead for Dual Diagnosis

Chairman of RESTNational Institute for Mental Health, England

Outline

• The tension between health and social policies

• Capabilities

• Training

• Assertive Outreach & Dual Diagnosis

• Outcomes

Policy

• There appear to be a number of outcomes for policy, depending on its source: – To reduce criminal activity and disrupt the financial

means of obtaining drugs (Home Office)– Increase the numbers of people in drug-treatment

programmes (National Treatment Agency)– Increase drug awareness through early intervention

and prevention (Home Office and Department of Health)

– the public health agenda - hepatitis, physical dependence, suicide, mortality. (Department of Health)

Policy

• The interdependence of these outcomes is not reflected in working arrangements between agencies responsible, in terms of cross cutting policy, funding arrangements, governance or commissioning.

• Police, Mental Health Services, Criminal Justice System, Prisons

Dual Diagnosis Good Practice Guide

• local services must develop focused definitions of dual diagnosis which reflect local patterns of need and clarify the target group for services

• these definitions must be agreed between relevant agencies

• where they exist specialist teams of dual diagnosis workers should provide support to mainstream mental health services

NEEDS LED SERVICE PROVISION FRAMEWORKFor Working Age Adults with Dual Diagnosis Issues

1LIMITED NEEDS ARISING FROM BINGE, HAZARDOUS OR

EXCESSIVE EXPERIMENTAL OR RECREATIONAL MISUSE OF SUBSTANCES

2MODERATE LEVEL OF NEEDS ARISING FROM

HAZARDOUS OR EXCESSIVE

MISUSE OR PSYCHOLOGICAL DEPENDENCE ON SUBSTANCES

3HIGH LEVEL OF NEEDS ARISING FROM PHYSICAL DEPENDENCE ON SUBSTANCES

AHIGH LEVEL OF NEEDS ARISING FROM SEVERE MENTAL ILLNESS

Secondary Care Mental Health lead, support from Substance Misuse e.g. Community Mental Health Team, Assertive Outreach lead; Substance Misuse Voluntary Sector Providers support

Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT, Assertive Outreach lead; Substance Misuse Social Services / Social Care & Health support

Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT, Assertive Outreach lead; Substance Misuse Treatment Service support

BMODERATE LEVEL OF NEEDS ARISING FROM MENTAL HEALTH PROBLEMS

Primary or Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT lead; Voluntary Sector Providers (Substance Misuse & Mental Health) support

Primary or Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT lead; Voluntary Sector Providers (Substance Misuse & Mental Health) support

Primary or Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT lead; Substance Misuse Treatment Service support

CLIMITED NEEDS ARISING FROM MENTAL HEALTH PROBLEMS REQUIRING SHORT TERM INTERVENTION

Primary Care lead, support from Substance Misuse e.g. G.P. lead; Voluntary Sector Providers (Substance Misuse & Mental Health) support

Substance Misuse lead, support from Primary Care e.g. Sub. Misuse Social Care & Health / Social Services lead; G.P. or Primary Care Link Worker and Voluntary Sector Providers (Sub. Misuse & Mental Health) support

Substance Misuse lead, support from Primary Care Mental Health e.g. Sub. Misuse Treatment Service lead, support from G.P. and Voluntary Sector Providers (Substance Misuse)

Barrett, M (2005)

NEEDS LED SERVICE PROVISION FRAMEWORKFor Working Age Adults with Dual Diagnosis Issues

1LIMITED NEEDS ARISING FROM BINGE, HAZARDOUS OR EXCESSIVE EXPERIMENTAL OR RECREATIONAL MISUSE OF SUBSTANCES

2MODERATE LEVEL OF NEEDS ARISING FROM HAZARDOUS OR EXCESSIVE

MISUSE OR PSYCHOLOGICAL DEPENDENCE ON SUBSTANCES

3HIGH LEVEL OF NEEDS ARISING FROM PHYSICAL DEPENDENCE ON SUBSTANCES

AHIGH LEVEL OF NEEDS ARISING FROM SEVERE MENTAL ILLNESS

Secondary Care Mental Health lead, support from Substance Misuse e.g. Community Mental Health Team, Assertive Outreach lead; Substance Misuse Voluntary Sector Providers support

Secondary Care Mental Health lead, support from Substance Misuse e.g. CM HT, Assertive Outreach lead; Substance Misuse Social Services / Social Care & Health support

Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT, Assertive Outreach lead; Substance Misuse Treatment Service support

Dual Diagnosis Good Practice Guide

• all staff in assertive outreach teams must be trained and equipped to work with dual diagnosis

• adequate numbers of staff in crisis resolution, early intervention, community mental health teams and inpatient services must also be suitably trained

• all health and social care economies must map services and need

Awareness Training• Defining the client group• Detection and assessment of Dual Diagnosis• Prevalence and Risk • Treatment outcomes in Dual Diagnosis• Harm minimisation and risk management• Policy and Guidance• Relationship between drugs, alcohol and mental health• Models of treatment provision• Local typology and care pathways• Stages of change model• Local service provision

Capabilities Framework

• values

• knowledge

• skills

• practice development

Level 1 Capabilities

• Needs: Service users who are at risk of developing long term problems with substance use and mental health. People with more severe problems who come into contact with these agencies and workers as first point of contact. People engaged with other agencies and for whom the worker plays a specific role in their care.

• Aimed at all workers who come into contact with this service user group especially as first contacts to care

• Example: primary care workers, A & E staff, police, criminal justice workers, housing, support workers, health care assistants, non-statutory sector employees, volunteers, service users, carers, friends

• Training: 1-2 day awareness raising workshops

Level 2 Capabilities

• Needs: People with moderate problems with a range of problems relating to substance use and mental health problems, also including potential physical and social needs.

• Aimed at generic post-qualification workers who work with dual diagnosis regularly, but don’t have a specific role with this group.

• Example: mental health social workers, mental health nurses, psychologists, psychiatrists, substance use staff, occupational therapists, probation officers.

• Training example: 5-10 days skills based modules and short courses (possibly accredited)

Level 3 Capabilities

• Needs: people with chronic long term and complex physical psychological and social needs.

• Aimed at people in designated senior dual diagnosis roles who have a responsibility to manage and train others in dual diagnosis interventions.

• Example: Dual Diagnosis Development workers.• Training example: higher degree with a focus on dual

diagnosis, module of higher degree e.g dual diagnosis module of a Masters in Addictions

Capabilities Framework

• values

• knowledge

• skills

• practice development

Values

• Practicing ethically

• Promoting recovery

• Making a difference

• Respecting diversity

• Challenging inequality

Capability

Values Level 1 Level 2 Level 3 Capability

Framework reference

Role legitimacy“it is part of my role to work with people with combined mental health and substance use problems”

Recognise that it is a part of ones own role to offer a contribution towards the care of someone with combined mental health and substance use problems

Recognise and accept that working with people with dual diagnosis is a routine part of ones role

Promote the message that all workers should be playing a part in the care of people with dual diagnosis however big or small the contribution

Challenging Inequality, Making a Difference, Working in Partnership

Therapeutic optimism“I believe that positive changes are possible for anyone with combined mental health and substance use”

Recognise that change for people with dual diagnosis is difficult but not impossible, and communicate this to the service user, their carers and other professionals

Be able develop and maintain therapeutic optimism and a sense of hope and generate this in the service user, their carers and other professionals.

Role model therapeutic optimism, encourage others to see positive changes

Promoting Recovery

Utilising Knowledge and Skills

Level 1 Level 2 Level 3 Capability Framework Reference

engagement Be able to use interpersonal skills and attitudes to make people with dual diagnosis feel welcome, and develop an effective working relationship with a person with dual diagnosis

Be able to develop an effective therapeutic relationship and be able to work flexibly with this client group.

Utilise creative strategies to engage hard to reach service users in appropriate services

Making a Difference, Working in Partnership, Respect Diversity, Promote Recovery, Promoting Safety and Positive Risk Taking

Education and health promotion

Awareness of where an individual can access more in depth advice about substance use and mental health.

Be able to offer basic but accurate and up to date advice about effects of substances on mental and physical health and vice versa.

Be able to offer education and health promotion interventions across of range of physical and mental health issues to both service users and other workers

Promote safety and positive risk taking

Hughes, E (2006)

Dual Diagnosis Good Practice Guide

• small and time limited local project teams including mental health and substance misuse specialists working to the LIT should prepare the focused definition together with care pathways and clinical governance guidelines

• all services, including drug and alcohol services, must ensure that clients with severe mental health problems and substance misuse are subject to the Care Programme Approach and have a full risk assessment

Specialist or Integrated?

• Specialism can introduce risks:– Access is limited– Target group is large, resource is small– Easy solution to a complex problem?– Whole system approach – can the system

cope? – Workforce – who will deliver?

Specialist or Integrated?

• Integration brings benefits:– Dual diagnosis becomes everyone’s business– All parts of the system have some capacity to

work with this client group and their families– Service users are less likely to be stereotyped– Reduced stigma with a ‘mainstream’ approach– Promotes partnership working

Assertive Outreach & Dual Diagnosis

• In England, many AO teams report 30-50%+ of their caseloads have a dual diagnosis.

• 50% of people with a severe mental disorder also experience problematic drug use (NAMI 2006)

• Some Early Intervention teams report 70-100% of their caseloads have a dual diagnosis

Assertive Outreach & Dual Diagnosis

• People with a dual diagnosis often experience consequences such as:– Increased violence– Reduced concordance with treatment– Reduced functioning– Increased relapse– Homelessness– Involved with criminal justice system or prison

Assertive Outreach & Dual Diagnosis

• People with a dual diagnosis benefit from:– job and housing assistance– family work– money management – relationship support – long-term involvement that can be begun at

whatever stage of recovery they are in – positivity, hope and optimism as a foundation

NAMI 2006

Why Assertive Outreach?

• Team approach• Community

networking• Resilience• Longer term working• Range of skills and

professionals• Range of treatment

options

• Cultural sensitivity• Recovery as an

underpinning value• Engagement• Relapse prevention• Working with families• Holistic and inclusive

approach

Integrated Approach

Assertive Outreach

One setting Co-ordinated Working with both substance misuse and mental health

Abstinence is not a precondition for work with people

Family involvement Not a moralistic model Makes best use of social networks

Outcomes

• Securing better housing

• Increasing employment opportunities

• Increasing social skills

• Impacting on societal problems: crime, HIV/AIDS, domestic violence, and others

• Access

• Engagement