AoA dual diagnosis training day Brendan Georgeson Treatment Coordinator Walsingham House www.stjamesprioryproject.org.uk
Introduction, who’s who? Learning outcomes covered: 1. Understand how counselling approach and style need to be modified in order to engage, support and motivate clients with co-existing mental health problems. 2. Evaluate the suitability of interventions to meet an individuals identified needs and to help dually diagnosed clients use existing resources. 9.30 – 10.00
one thing you would like to achieve from the day and
one place you would rather be than here today
WALSINGHAM HOUSE, BRISTOL
10.00 – 10.10pm Walsingham House is an Integrated Model of service delivery Dual diagnosis is the occurrence of substance misuse and mental illness in the same person at the same time  . The diagnosis can incorporate more than problematic drug use or mental health problem and includes personality disorder. The severity of the illness is not an issue for Walsingham House although the cognitive ability to participate in a therapeutic treatment programme is essential. Walsingham house is committed to offering an equity of service regardless of previous or current psychiatric diagnosis.  Anon (2000) Drug Misuse and Mental Health: Learning Lessons on Dual Diagnosis. Report to the All Parliamentary Drug Misuse Group
10.10 – 10.30pm What we offer>
Integrated treatment approach via user-focused treatment plan for dual diagnosed clients.
Regular mental state monitoring via qualified specialist.
Access to locality services if in crisis, including referral for mental health act assessment in the unlikely event that deterioration of mental health state occurs.
Non-medicalised approach. We understand the need for medication but also that our clients come from very complex and often disadvantaged backgrounds. The social context of the persons presentation must be acknowledged. The psychological impact of life events are recognised implicitly throughout the treatment process.
Walsingham House advocates a biopsychosocial approach to the treatment of dual disorders.
Walsingham House values the diverse experiences of dual diagnosed clients whilst acknowledging we may not share those experiences.
The philosophy of Walsingham House is abstinence based with regard to substance misuse. We understand the use of mood altering medication is a separate issue for dual diagnosed clients.
A CBT and MI approach is used with dual diagnosed clients to enable them to recontextualise their experience of mood altering chemicals to achieve long term stability.
Regular communication with community teams and facilities for care plan review.
10.30 – 10.40pm What we aim for>
To enable the client to understand that medication and drug misuse are separate events.
With agreement of the client and community team (if relevant), to introduce medication holidays to assess the clients true mental state once stability in the treatment environment is achieved. This may not be practical in all cases. We recognise that a person’s mental health diagnosis may have been influenced by lifestyle choices and substance misuse and diagnosis needs review in abstinence.
If a previously unknown co-morbidity is realised throughout the treatment process then appropriate discharge planning and continued care planning will be incorporated into the treatment plan.
Equity in the treatment of dual diagnosed clients alongside primary substance mis-users.
10.40 – 10.50 What we ask for>
1 If subject to CPA (care programme approach) 
a For clients to enter treatment with an up to date care plan including crisis management planning.
b Core assessment, risk assessment and contact sheet to be made available to Walsingham House.
c Psychiatric responsibility to remain with the community team and be available for medication reviews/advice.
d Care co-ordinator to be contactable and to attend at least one CPA review whilst the client is in Walsingham House to include discharge planning of client from Walsingham House.
e Mental health services and referring/commissioning agency (if different) to maintain joined-up service approach, especially with regard to discharge of client.
f Client remains the responsibility of the community team to enable continuity of care in the event of early discharge
2 If client unknown or discharged from locality mental health services.
a Referrer to provide as much background information as possible with regard to mental health need.
b Referrer to inform Walsingham House of last known contacts within psychiatric services.
c Prior to admission (during motivational phase of the referring agency), clients to be registered with a GP in their home locality. GP to review medication prior to treatment. Note: GP registration is a requirement for locality service provision and onward referral to community services post treatment can be hindered without such links.
d For clients coming from prison not registered with a GP, alternative arrangements with regard to onward referral will be made on a client by client basis.
 Department of Health (1999) National Service Framework for Mental Health London DH
BREAK 10.50 – 11.10
11.10 – 12.30
FEARS!!! What are our fears when working with this client group?
Generate a list
Five year report of the national confidential inquiry into suicide and homicide by people with mental illness December 2006
The National Confidential Inquiry into Suicide and Homicide began at the University of Manchester in 1996. The Inquiry team includes psychiatrists and researchers that study mental health care services. We want to find out more about what works well and where things can go wrong in mental health care. Our steering group, which oversees the work, is chaired by Professor Sheila Hollins and includes service users and carers as well as health and social care professionals.
Study on homicide Key findings and recommendations include :
?% of all homicides in England and Wales were by people with a history of mental illness between April 2000 and December 2003.
The number of homicide convictions by people with history of mental illness remains stable at approximately 50 per year. Homicides carried out by patients with a diagnosis of schizophrenia also remain steady at approximately 15 per year.
Random attacks on members of the public by people with mental illness, have remained at five per year, indicating that community care has not increased the risk to the general public.
Services should ensure that high-risk patients receive enhanced CPA (the Government’s Care Programme Approach), backed up by peer review in the most high-risk cases.
Study on suicide Key findings and recommendations include:
The number of suicides by psychiatric in-patients shows a downward trend with 67 fewer deaths in 2004 than in 1997.
Death on the ward by hanging/strangulation has fallen by 51% (27 cases) over the same period.
Patient deaths following non-compliance with treatment has fallen from 22% (929 cases) in the previous Inquiry report to 14% (813 cases).
Services need to do more to prevent in-patients absconding; 227 (27%) of in-patient deaths occurring whilst the patient was off the ward without permission between April 2000 and December 2004.
Of the 1271 post-discharge suicides in the report, 192 (15%) occurred in the first week after discharge and 255 (22%) before the first follow up appointment. The transition from the ward back into the community should be carefully managed with agreed plans to address stressors that may be encountered, and mechanisms in place for patients to contact services if a crisis occurs.
Restrictions to Service
Walsingham House will assess each person on an individual basis. We like to maintain a balance of resident mix (gender, treatment order, dual diagnosis etc) and may have to restrict admission dates in order to maintain that balance.
These are some of the restrictions affecting a person’s suitability for Walsingham House;
current suicidal ideation/intent
current self harming behaviours
active severe eating disorders
dangerous and sever personality disorder
unacceptable risk of harm to others
severe inappropriate sexualised behaviour
Skills base of service
Walsingham House has 4 qualified addiction counsellors plus one qualified support worker.
To enable us to work with the complex nature of dual disorder we consult a dual diagnosis specialist who attends on a sessional basis. He is governed by the rules and regulations of BASW (British Association of Social Workers), which covers indemnity
We also have clinical input from a psychiatrist who has a special interest in dual diagnosis.
There is a need for Walsingham House to hold the temporary clinical (psychiatric) management for clients with a dual diagnosis. This is especially relevant for out-of-area clients.
Clinical Management for this service is:
Diagnosis and treatment of mental disorder.
It is likely that the client has come to Walsingham House with a diagnosed mental disorder complicated by substance misuse. Treatment of the disorder will need review.
Review of treatment (medication)
Review of diagnosis once client is abstinent from illicit substances.
Introduction of carefully monitored medication ‘holidays’ to assess efficacy of existing treatment (if appropriate).
Crisis/urgent response to unforeseen circumstance
Liaison with GP service for prescribing.
The clinical responsibility is held by Walsingham House only whilst the client is resident. Responsibility will revert to referring locality once client is not resident. If the client is known to a community mental health team and has a psychiatrist, it is expected that partnership arrangements be set-up between the RMO and the psychiatrist at Walsingham House.
A consultant psychiatrist will provide sessional input and have capacity for a crisis/urgent response.
Psychiatrist will be involved in initial dual diagnosis assessment once client is resident and input into the continued care arrangements.
Psychiatric review will occur 5 to 6 weeks following admission for review of diagnosis and treatment. Introduction of medication holidays will occur at this time, if appropriate.
Further psychiatric review will be determined if appropriate.
There will be close working arrangements between the psychiatrist and dual diagnosis specialist to monitor changes to the treatment of mental disorder.
The psychiatrist and dual diagnosis specialist will share appropriate information with the locality team and the receiving agency regarding management of disorder for after care planning considerations.
Arrangements with the GP practice to be established with agreements for prescribing informed by the recommendations of the consultant psychiatrist.
Need to be aware of the cost of private prescriptions in the rare event of out off hour crisis prescribing need.
First example a client diagnosed with schizophrenia and primary crack addiction.
32 year old female
from prison, we assessed her in prison,
Assertive Outreach Team involved
Positive symptoms and that were medication resistant. Positive symptoms involved voices from the TV, in her room people from the past drug dealers, negative symptoms
low mood and urge to stay in bed
Hidden alcohol problem
Completed treatment but left early
Second example a client diagnosis with general personality disorder
26 year old male
telephone assessed in prison
very chaotic with a restraining order from ex partner
needed a consistent boundaried approach
Tipping point – who will burnout first him or the counsellors?
Treatment successfully completed
LUNCH BACK FOR 2PM PLEASE
INTERVENTIONS AND TREATMENT 2.00 – 2.30
Group work – 5 groups of 5 to explore what interventions you believe you could do for complex needs individuals. Consider your transferable skills as well as any specialist knowledge you may have. (15 minutes)
Regroup and feedback
Interventions Theory 2.30 – 2.35
Stress vulnerability model - CBT
Specific Coping Strategies- General
Specific Coping Strategies - Psychosis
Biopsychosocial Model 2.35 – 2.45
Interventions and approaches to support people with mental health issues: -
Alternative and complementary therapies
A wide range of complementary therapies are used by people experiencing mental health issues, including:
Bowlby’s major conclusion, grounded in the available empirical evidence, was that to grow up mentally healthy, “the infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment” (Bowlby, 1951, p. 13).
Just as children are absolutely dependent on their parents for sustenance, so in all but the most primitive communities, are parents, especially their mothers, dependent on a greater society for economic provision. If a community values its children it must cherish their parents. (Bowlby, 1951, p. 84)
Bowlby Maternal Care and Mental Health by the WHO. 1951
Treatment options – interpersonal group therapy or peer support to develop healthy attachments
Self-management is about:
‘ maintaining morale and having hope for the future. It is about relationships with other people, spirituality, managing symptoms and medication, healthy living, having an occupation and a social life and developing basic living skills’
Specific Coping Strategies- General 2.55 – 3.05
Reducing Fear and increasing Control
Protective strategies e.g. symbolic objects like crucifix, lucky charm
Take a break; relaxation techniques
Predicting and planning for difficult or trigger situations
Reassurance, downward arrow technique i.e. talk through the fantasy until a logical conclusion is reached
Turn the situation around e.g. reframe, offer alternative explanations
Talk and support e.g. Hearing Voices Network, Post natal depression group
Encourage hope and recovery rather than pessimism
Build up other aspects of their life, focus on what they can do not what they can’t
Structure - this provides distraction through meaningful occupation either paid or voluntary
Specific Coping Strategies – Psychosis 3.05 – 3.15
Focus on emotion rather than fact to find the pattern
Find out about unusual experiences e.g. investigate the voices or symptoms, ask about the where, when, who? What are you typically doing when symptoms occur. Examine diet. Identify triggers.
Active Coping and Problem solving
Not attracting negative attention e.g. talk to your mobile phone instead of the voices. Limit responses to times of the day. Delay orders.
Meditation i.e. visualise something protective
Distraction e.g. TV, walking, board games, window shopping, travelling on the bus, jigsaws.
Sub vocalising i.e. talk in your head things like counting, reciting a poem, a mantra
Mechanical e.g. reading aloud, holding pencil across mouth, elastic band on wrist
Thinking things through, reality testing, thought blocking, thought ignoring
Mental Health First Aid A new national training programme suitable for all individuals and employees A 12-hour intensive course, which can be delivered over two days or in four separate sessions, as part of a new national training programme developed and regulated by the National Institute for Mental Health in England (NIMHE) and the Care Services Improvement Partnership (CSIP). One in four British adults will experience at least one diagnosable mental health problem in any one year. The intention of this programme is to promote awareness of mental health issues amongst the general public and to train non-professionals to recognise those affected by mental health problems and offer initial help and guidance towards professional support. By training these "mental health first aiders" within the community and the workplace, it aims to tackle the prejudice and stigma traditionally associated with mental health problems, and to improve the outcomes for those affected and their families, friends, colleagues and employers.
BREAK 3.15 – 3.30
IMAGINE! 3.30 – 4.00
In groups of five get together and pretend to be commissioning managers for a whole county. Design your ideal dual diagnosis service for the whole county. Your budget is 300K for a year and recently an addict with a personality disorder stabbed a shop keeper whilst on leave from a local psychiatric unit, which was reported in all the local and national papers.
The New Synthesis 4.00 – 4.10
- The key concept is co-locating
- By professionals in the drug/alcohol fields and mental health fields working with clients in each other’s workspace , co-locating , they create nodes of integration. These nodes of integration linked through parallel working create a matrix.
Serial Model : different staff in different services at different times (hence sequential)
Parallel Model : different staff in different services at same time (hence parallel)
Integrated Model : same staff in same service at the same time (hence integrated)
Matrix Model : different staff same service same time (hence matrix)
The Matrix Model in Focus 4.15 – 4.25
The Matrix Model is a solution to a number of identified problems within the treatment field of co-morbidity. Those problems are;
Lack of capacity within mental health services
Lack of specialist training within respective professions meaning mental health workers with low level substance misuse training and skills, substance misuse workers with low level mental health training and skills
Lack of communication and joined up working between the two fields
Lack of money to pay for specialist integrated services services
Lack of resources to build truly integrated services
Clients falling through the gap
The point of formulating this theoretical framework is to provide a common frame of reference to move forward in a very practical way now! This model is only a phone call away from implementation and any worker can make that call to their opposite number in the other field.