Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework

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Specialist or Integrated Approaches Working
withpeople who have a dual diagnosis using an
AssertiveOutreach framework

• Tom Dodd
• National lead for Community teams
• Joint National Lead for Dual Diagnosis
• Chairman of REST
• National Institute for Mental Health, England

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Outline

• The tension between health and social policies
• Capabilities
• Training
• Assertive Outreach Dual Diagnosis
• Outcomes

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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)

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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

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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

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Barrett, M (2005)
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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

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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

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Capabilities Framework

• values
• knowledge
• skills
• practice development

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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

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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 dont
  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)

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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

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Capabilities Framework

• values
• knowledge
• skills
• practice development

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Values

• Practicing ethically
• Promoting recovery
• Making a difference
• Respecting diversity
• Challenging inequality

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Hughes, E (2006)
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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

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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?

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Specialist or Integrated?

• Integration brings benefits
• Dual diagnosis becomes everyones 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

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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

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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

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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
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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

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Outcomes

• Securing better housing
• Increasing employment opportunities
• Increasing social skills
• Impacting on societal problems crime, HIV/AIDS,
  domestic violence, and others
• Access
• Engagement