Learning objectivesTo gain an understanding of what dual diagnosis meansTo become more familiar with the multiple factors that maycontribute to substance/drugs use in this client groupEstablish facts and myths surrounding the links and relationshipsbetween drug/substance use/misuse and mental healthReflect on your own use of legal drugs/substancesTo be aware of the approaches/interventions that may best helpthis client group
What is ‘dual diagnosis?’Exercise 1.For 5 minutes- in groups- identify what the term ‘dualdiagnosis’ means to you and also consider:How helpful is the term?How unhelpful is the term?Are there any other terms that could be used?Nominate a spokesperson to feedback
What is ‘dual diagnosis?’‘The co-existence of psychiatric disorder and substancemisuse’ (Crome et al. 2004)‘…a broad spectrum of mental health and substancemisuse problems that an individual might experienceconcurrently’ (DOH 2002).‘Dual diagnosis is a label they give you, but even at mymost buoyant I think I’ve got more than two problems’(Quote from a Service user taken from Rethink 2007)
Is the term ‘dual diagnosis’ helpful? Some points to considerA professional term.A broad term, at best, promotes an understanding of two interwoven complexconditions.Provides a conceptualisation of the phenomenon of substance misuse andmental healthToo narrow a focus? More than just 2 problems?Medicalised?Misleading?A vague and yet stigmatising label?
How common is ‘dual diagnosis?’ ‘Substance misuse is usual rather than exceptional amongst people with mental health problems’ (DOH 2002) May affect between 30 to 70% of those presenting to health and social care settings (Crome et al. 2009). At the same time, approximately 50% of patients in drug & alcohol services have a mental health problem (Rethink 2007). First-episode psychosis: A sample of 168 young people showed that 37% of the sample reported drug use, drug misuse and alcohol misuse (Cantwell et al. 1999).
Why do people with mental health problems use or misuse drugs/substances? Exercise 2. In groups- Explore the various reasons as to why people with mental health problems may use/misuse substances/drugs. Consider the following areas: Social/environmental/cultural factors Mental state Effects of prescribed medication(s) Physical factors Feedback in 10 minutes- nominate a spokesperson
Why do people with mental health problems use or misuse drugs/substances? (1)As varied as the individuals themselvesSocially excluded, may find a sense of belonging and community with otherdrug usersCounteract the unpleasant side-effects of prescribed psychiatric medicationsuch as limb stiffness, involuntary movements, sexual dysfunction.Increase energy levels and motivation by stimulating nervous systemNumb or mask painful thoughts and feelingsAlleviate intensity and distress from auditory hallucinationsAid sleep
Why do people with mental health problems use or misuse drugs/substances? (2) Shorted-lived sense of euphoria and confidence Vulnerability: may be a ‘soft’ target for drug dealers Boredom/unemployment ‘Anti-depressants not always enough’ ‘Living on the streets-to keep a lid on it’ Enjoyment Availability- Peer pressure To reduce marked periods of mania/excitability
Do substances/drugs cause mental health problems?Exercise 3.In groups- discuss whether substances/drugs causemental health problems or whether mental healthproblems lead to substance/drug use?Feedback in 5 minutes- once again, nominate a spokesperson
Do substances/drugs cause mental health problems?There remains on-going debate about the extent to which substance/drug usecauses mental health problems?More agreement reached that drug/substance misuse can ‘enhance’,‘exacerbate’ or ‘trigger’ in individuals who are pre-disposed to mental healthproblems.Substance/drug use can also mask a mental health problem which is laterrevealed when use is ceased.Earlier age of onset of first-episode psychosis is proposed in young peoplewith a vulnerability to schizophrenia and who misuse substances (Addington& Addington 1998). May act as a trigger.
What ‘dual diagnosis’ may mean for services & carers/families Pessimistic attitudes and values: could be viewed as ‘criminal’, ‘manipulative’, ‘aggressive’, ‘intoxicated’, ‘bringing it on themselves’. May be viewed by services as ‘problematic’ or ‘revolving door’. Preoccupations with ‘what came first’- whose responsibility is it? Restrictive ‘gate-keeping’ practices In a climate of finite resources, may be removed from caseload list for poor or non-engagement with appointments
What may dual diagnosis mean for service users?‘ I was pushed around like a tennis ball. The alcohol people said Ihad a mental illness and the mental illness group said I had a drinkproblem. Neither of them did very much for me’ (Rorstad &Chesinski 1996).‘Passing the book’May not be ready to address their substance misuse problems,when their carers and professionals believe they should.May perceive their issues differently and may not view theirsubstance use or mental ill-health as a problemPrevious contact with services may have been negative andconsequently, there may be poor engagement or mistrust.
You Tube clip ‘Integrated treatment’http://youtu.be/2kwtcADn-yM
Exercise 4: Types of useIn groups- think about licit/illicit substances/drugs that might be used:To numb or mask mental distressTo increase mood and motivationTo improve sleepTo reduce marked periods of mania or restlessnessFeedback in 10 minutes- nominate a spokesperson
Thinking about you own use of legal drugs/substances Do you enjoy a drink of beer, wine or spirits? Do you smoke? Do you like caffeinated drinks such as tea and coffee? Does your own use of the above drugs/substances ever exceed ‘healthy limits?’ Would you be willing to give up these ‘pleasures’ if someone else told you to? Why?
How can we respond?A few guiding principles to consider:Co-morbid mental illness and substance misuse is commonplace, therefore:Be inclusive rather than excluding: on the basis of health needs NOT on ill-definedor ill-judged causes.Cast a wide-net: ‘Err on the side of caution’ and ‘maintain a high index of suspicion’ –It is better practice to misidentify a service user not experiencing dual diagnosisthan to miss others who do (Holland & Midson 2004).Mainstreaming: Should be delivered within mental health services but workingclosely with specialist substance misuse services (DOH 2002).Working alongside the individual ‘holistically’ (although don’t excludefamilies/carers)
Ask the service userBest way to detect substance use/misuse is to ask users in an openand frank wayAsk sympathetically and reassure that negative consequences willnot automatically followMight be important to initially consider asking service users on theirown (although don’t wholly exclude families, carers or friends).Slang terms can vary across the country- Be clear aboutmisunderstandings or misuse of drug-using terminology.
InterventionsEstablishing a therapeutic allianceFocus on ‘engaging’ with the service user – be flexible in yourapproachMaintain an holistic focusConsider that ‘reduction’ may be more realistic than ‘abstinence’Provide advice and informationAccept that ‘setbacks’ can occur- that drug/substance reduction doesnot always move along in an linear mode
Four guiding principles to aid engagementKnown as R.U.L.E ( Rollnick, Miller & Butler 2008).Resist the Righting ReflexUnderstanding the Service User’s MotivationsListen to the Service UserEmpower the Service User
DVD- ‘Pillar to post’- a film about dual diagnosis (MIND 2011) For the next 20 minutes, watch this short film documentary and consider: Why people use street drugs? How supported do service users feel? What types of interventions/approaches might help?
ReferencesAddington, J. & Addington, D. (1998). Effect of substance misuse in early psychosis. British Journal of Psychiatry, 172, (suppl.33), 134-136.Cantwell, R. et al. (1999). Prevalance of substance use in first-episode psychosis. British Journal of Psychiatry, 174, 150-153.Crome, I., Ghodse, H., Gilvarry, E. & McArdle, P. (2004). Young People and Substance Misuse. London: Gaskell.Crome, I. Chambers, P., Frischer, M. et al. (2009). The relationship between dual diagnosis: substance misuse and dealing withmental health issues. Social Care Institute for Excellence, 30, 1-23.DOH (2002). Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. London: The Stationary Office.Holland, M. & Midson, V. (2004). Substance Misuse and Mental Health . Chapter 16 IN Ryan, T. & Pritchard, J. (2004). GoodPractice in Adult Mental Health. London: Jessica Kingsley Publishers.MIND (2011). Pillar to Post- a film about dual diagnosis. www.mindincroydon.org.ukRethink (2007). Dual diagnosis toolkit: Mental health and substance misuse: A practical guide for professionals and practitioners(online) last accessed 13 March 2008 at www.rethink.org.ukRollnick. S., Miller, W.R. & Butler, C. (2008). Motivational interviewing in health care: helping patients change behavior. New York:Guildford Press.Rorstad, P. & Chesinski, K. (1996). Dual Diagnosis: Facing the Challenge. Kenley: Wynne Howard Publishing