1. Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community teams Joint National Lead for Dual Diagnosis Chairman of REST National Institute for Mental Health, England

2. Outline The tension between health and social policies Capabilities Training Assertive Outreach & Dual Diagnosis Outcomes

3. 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)

4. 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

5. 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

6. NEEDS LED SERVICE PROVISION FRAMEWORK For Working Age Adults with Dual Diagnosis Issues 1 LIMITED NEEDS ARISING FROM BINGE, HAZARDOUS OR EXCESSIVE EXPERIMENTAL OR RECREATIONAL MISUSE OF SUBSTANCES 2 MODERATE LEVEL OF NEEDS ARISING FROM HAZARDOUS OR EXCESSIVE MISUSE OR PSYCHOLOGICAL DEPENDENCE ON SUBSTANCES 3 HIGH LEVEL OF NEEDS ARISING FROM PHYSICAL DEPENDENCE ON SUBSTANCES A HIGH LEVEL OF NEEDS ARISING FROM SEVERE MENTAL ILLNESS Secondary Care Mental Health lead, support from Substance Misuse e.g. Community Mental Health Team, Assertive Outreach lead; Substance Misuse Voluntary Sector Providers support Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT, Assertive Outreach lead; Substance Misuse Social Services / Social Care & Health support Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT, Assertive Outreach lead; Substance Misuse Treatment Service support B MODERATE LEVEL OF NEEDS ARISING FROM MENTAL HEALTH PROBLEMS Primary or Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT lead; Voluntary Sector Providers (Substance Misuse & Mental Health) support Primary or Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT lead; Substance Misuse Treatment Service support C LIMITED NEEDS ARISING FROM MENTAL HEALTH PROBLEMS REQUIRING SHORT TERM INTERVENTION Primary Care lead, support from Substance Misuse e.g. G.P. lead; Voluntary Sector Providers (Substance Misuse & Mental Health) support Substance Misuse lead, support from Primary Care e.g. Sub. Misuse Social Care & Health / Social Services lead; G.P. or Primary Care Link Worker and Voluntary Sector Providers (Sub. Misuse & Mental Health) support Substance Misuse lead, support from Primary Care Mental Health e.g. Sub. Misuse Treatment Service lead, support from G.P. and Voluntary Sector Providers (Substance Misuse) Barrett, M (2005)

7. NEEDS LED SERVICE PROVISION FRAMEWORK For Working Age Adults with Dual Diagnosis Issues 1 LIMITED NEEDS ARISING FROM BINGE, HAZARDOUS OR EXCESSIVE EXPERIMENTAL OR RECREATIONAL MISUSE OF SUBSTANCES 2 MODERATE LEVEL OF NEEDS ARISING FROM HAZARDOUS OR EXCESSIVE MISUSE OR PSYCHOLOGICAL DEPENDENCE ON SUBSTANCES 3 HIGH LEVEL OF NEEDS ARISING FROM PHYSICAL DEPENDENCE ON SUBSTANCES A HIGH LEVEL OF NEEDS ARISING FROM SEVERE MENTAL ILLNESS Secondary Care Mental Health lead, support from Substance Misuse e.g. Community Mental Health Team, Assertive Outreach lead; Substance Misuse Voluntary Sector Providers support Secondary Care Mental Health lead, support from Substance Misuse e.g. CM HT, Assertive Outreach lead; Substance Misuse Social Services / Social Care & Health support Secondary Care Mental Health lead, support from Substance Misuse e.g. CMHT, Assertive Outreach lead; Substance Misuse Treatment Service support

8. 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

9. 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

10. Capabilities Framework values knowledge skills practice development

11. 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

12. 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 don’t 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)

13. 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

14. Capabilities Framework values knowledge skills practice development

15. Values Practicing ethically Promoting recovery Making a difference Respecting diversity Challenging inequality

16. Capability Values Level 1Level 2Level 3Capability Framework reference Role legitimacy “it is part of my role to work with people with combined mental health and substance use problems” Recognise that it is a part of ones own role to offer a contribution towards the care of someone with combined mental health and substance use problems Recognise and accept that working with people with dual diagnosis is a routine part of ones role Promote the message that all workers should be playing a part in the care of people with dual diagnosis however big or small the contribution Challenging Inequality, Making a Difference, Working in Partnership Therapeutic optimism “I believe that positive changes are possible for anyone with combined mental health and substance use” Recognise that change for people with dual diagnosis is difficult but not impossible, and communicate this to the service user, their carers and other professionals Be able develop and maintain therapeutic optimism and a sense of hope and generate this in the service user, their carers and other professionals. Role model therapeutic optimism, encourage others to see positive changes Promoting Recovery

17. Utilising Knowledge and Skills Level 1Level 2Level 3Capability Framework Reference engagement Be able to use interpersonal skills and attitudes to make people with dual diagnosis feel welcome, and develop an effective working relationship with a person with dual diagnosis Be able to develop an effective therapeutic relationship and be able to work flexibly with this client group. Utilise creative strategies to engage hard to reach service users in appropriate services Making a Difference, Working in Partnership, Respect Diversity, Promote Recovery, Promoting Safety and Positive Risk Taking Education and health promotion Awareness of where an individual can access more in depth advice about substance use and mental health. Be able to offer basic but accurate and up to date advice about effects of substances on mental and physical health and vice versa. Be able to offer education and health promotion interventions across of range of physical and mental health issues to both service users and other workers Promote safety and positive risk taking Hughes, E (2006)

18. 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

19. 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?

20. Specialist or Integrated? Integration brings benefits: –Dual diagnosis becomes everyone’s 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

21. 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

22. 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

23. 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

24. 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

25. Integrated Approach Assertive Outreach One setting  Co-ordinated  Working with both substance misuse and mental health  Abstinence is not a precondition for work with people  Family involvement  Not a moralistic model  Makes best use of social networks 

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