1. Module 9: Treatment Models

2. Objectives To be able to list the principles of Integrated Treatment for dual diagnosis To be able to describe how people change To be able to describe the stages of the Cycle of Change To be able to describe the Four Stage Model of treatment for dual diagnosis and how it fits with the cycle of change.

3. Dual Diagnosis Capabilities Interpersonal Skills: To be able to demonstrate effective skills such as active listening, reflection, paraphrasing, summarising, utilising open-ended questions, affirming, elaboration. Dual Diagnosis Capability 7 level 2 Delivering Evidence and Values Based Interventions: Be able to utilise knowledge and skills to deliver evidence-based interventions including brief interventions, motivational interviewing, relapse prevention and cognitive behaviour therapy to people with combined mental health problems within own limits and capacity and remit of ones own organisation. To know where else a service use can access appropriate specialist care and facilitate that access. To be able to access support and supervision to perform such interventions. Dual Diagnosis Capability 13 level

4. Integrated Treatment Model (Drake et al, 2001) Comprehensive service- this group has complex needs and the service needs to be able to recognise and address these needs. Stage wise- people come into treatment at various stages of change (levels of motivation). Long term view- Making changes is a slow process so the service should be expecting to work with someone with a dual diagnosis over months and years rather than weeks Assertive Outreach- This group are typically hard to engage in treatment. Shared Agreement- The service user should be as actively involved in decisions about their care as possible. It is also important to include any other significant people in care planning and decision making. Medication management- People with dual diagnosis are more likely to be non-adherent to medication, and if they do take it, are more likely to suffer from side-effects. Therefore medication issues need to be addressed.

5. Exercise1: How integrated are you? Take ten minutes to consider the six principles of Integrated Treatment and answer these two questions: How far does the service that you work for provide those principles? What else could be done to align your service to these principles?

6. How people change They undergo a series of cognitive and behavioural processes Involves belief in own ability to change (self-efficacy) Self-esteem- I am worth changing for Own rationale for change (the benefits outweigh the cost or loss)

7. Cycle of Change (Prochaska and Diclemente, 1996)

8. Stages of Change Pre-contemplation: lack of acknowledgement that what they are doing is a problem; in fact it is often seen as a solution (“in denial”). Contemplation: beginning to think about change, but not quite ready. Characterised by AMBIVALENCE; the weighing up of the pros and cons of problem and solution. Preparation: Individuals are formulating a plan of action Action The individual puts the plans devised in the previous stage into practice (ready, willing and able) Maintenance- This is a period of continued change that is being maintained by active strategies. Relapse: normal, predictable stage in the process of change. Exploring relapse can be a useful learning experience.

9. The Four Stage Model of Dual Diagnosis Treatment (Osher and Kofoed, 1989) Defines what should be happening in treatment at different levels of engagement and motivation: Stage 1:Engagement- sees the importance of collaborative relationship before starting work on substance use Stage 2: Persuasion- also called “building readiness to change” working on ambivalence Stage 3: Active treatment- ready to change therefore focused interventions Stage 4: Relapse prevention- protecting abstinence or reduction May spend many years in first two stages People can slip between stages at any point; the worker’s approach is guided by the service user.

10. Four Stage Model and Cycle of Change TREATMENT ENGAGEMENT PERSUASION ACTIVE TREATMENT RELAPSE PREVENTION INDIVIDUAL MOTIVATION PRE-CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTAINANCE RELAPSE/ ABSTINENCE

11. Staged Activities StageFocus of Activity EngagementBuilding relationship, stabilisation of acute problems, medication management PersuasionDeveloping reasons for thinking about changing substance use using motivational interviewing techniques, social support, stabilisation of social situation, develop meaningful activities, psychoeducation Active TreatmentFocused counselling and treatment, group and individual work, family work, work and activities Relapse PreventionMaintaining stability of lifestyle, using relapse prevention strategies, developing alternative life including new peer groups.