1. 24 th October 2012. Christian Guest. Dual Diagnosis Lead (RDaSH)

2.  Policy implementation guide (2002) - mainstreaming of co-existing difficulties  Individuals may be excluded on ‘Dual Diagnosis’ term alone  ‘Dual Diagnosis’ term has perhaps become obsolete  Can we argue co-existing difficulties are supported within mainstream services?  Need to consider the unintended consequences?

3. MentalSubstance Misuse Health

4.  Provided a working definition and scope of Dual Diagnosis  Promoted the national agenda  Promoted the policy of mainstreaming  Promoted the need for collaboration  Highlighted the need to support co-existing difficulties

5.  Single label implies homogeneous and identical needs.  Remains synonymous with complexity, challenging behaviour, homelessness severe mental illness, crime (DOH, 2009, Pawsey et al 2011,Drake et al 1993).  Perception of ‘Dual Diagnosis’ based on clinician’s experience and knowledge (Velleman & Baker, 2008)  Term remains ambiguous in clinical practice  Not recognised as a spectrum of severities and needs- from primary care to inpatient services.

6.  Weaver et al., (2002) 44% Service user’s in CMHT had dual diagnosis-  75% within drug service, 80% alcohol clients had experienced, depression, anxiety, personality disorders, psychosis.  Schulte & Holland (2008) -46% service users within mental health services. 71% in Assertive outreach. 59% in patient wards.  Cole & Sacks (2008)- prevalence rate of 60% within drug & alcohol services  Strathdee et al., (2002) 93% of clients (initial screening) within substance misuse services assessed as having indications of (‘dual diagnosis’) mild to moderate symptoms.

7. Access /crisis team Substance/ alcohol services Community therapies/IAPT Intensive community teams In patient wards Early intervention Teams Enduring mental health services Assertive outreach team

8.  Velleman & Baker (2008)- “co-existing problems” should be adopted, broad and inclusive term.  Label of ‘Dual Diagnosis’ can lead to exclusion, inconsistent service provision, unnecessary signposting (Velleman & Baker 2008)  Pawsey et al., (2011) clients fall between services neither service wishing to treat “other” problem  Shifting of responsibility to services deemed more suitable, service users “falling through the net”

9.  Department of Health (2009),more than the management of mental health problems  Recovery is a movement away from pathology, illness and symptoms to health, strengths and wellness, (Shepherd et al., 2008)  Relies on compassion, hope, creativity, realism  Can the single term ‘Dual Diagnosis’ be any longer relevant or consistent with the principles of recovery ?

10.  Complex relationship between mental health and substance misuse (Wu et al, 2010, Klanecky & McChargue, 2009,)  Alexander (1987, 1990)- explores ‘Adaptive model’ of addiction  It is ‘adaptive’ to choose a ‘lesser evil’- reduce voices by excessive alcohol consumption  Argues problematic alcohol and substance use is a result of “substitute adaptations” -alleviation of significant psychological distress  Problematic alcohol and substance use in adulthood develop as a result of a combination of early childhood trauma, inadequate environmental support, and diminishing social networks.

12.  Employed to attempt to alleviate psychological distress (adaptive)  150,000 attendances at general hospital (Hughes& Kosky,2007)  4 in 1000 people (Royal College of Psychiatrist report,2010)  Self injury not given separate terminology  Self injury supported by mental health services culturally

13.  Dual Diagnosis Capability framework (Hughes, 2006)  Ten essential Shared Capabilities (Hope 2004)  Promoting recovery, working in partnership, client centred...  How does this translate to everyday practice?  Organisational culture should accommodate and recognise complex psychosocial factors  Requires clinical leadership within services

14.  5 key principles to support a spectrum of co- existing difficulties  Actively de-emphasis the term ‘Dual Diagnosis’  Ability to express empathy-compassion, hope, creativity will promote inclusion and acceptance  Adapt intervention according to the individuals readiness to (M.I) ◦ -principles of M.I labels considered unnecessary obstacles for change

15.  ‘Adaptive models’ support the view that problematic substance misuse indicates profound personal/social difficulties  Avoid clinical judgement based on religious, moral, social or ethical codes

16.  Dual Diagnosis not exclusive to one service  No one single identity- significant spectrum of needs & circumstances  Existing mental health provision can support a spectrum of needs (primary care- AOS, in-patient)  Continues to remain gaps, inconsistent service provision, exclusion, stigma  Practitioner’s confidence, attitude & competence significantly influence intervention and inclusion/exclusion

17.  ‘Dual Diagnosis’ term established for several decades-progress made (DOH, 2002)  Terminology, language & culture continue to evolve according to societal and political values and beliefs.  Adopt the term ‘co-existing difficulties’  ‘Dual Diagnosis’ perhaps become counterproductive and obsolete within contemporary services

18.  christian.guest@rdash.nhs.uk  Guest, C & Holland, M (2011). Co-existing mental health and substance misuse difficulties-why do we persist with the term “dual diagnosis” within mental health services? Advances in Dual Diagnosis. Vol.4. No.4. pp.162-172.