24th October 2012.

Christian Guest.Dual Diagnosis Lead (RDaSH)

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?

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

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.

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.

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”

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?

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.

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

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

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

‘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

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

‘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

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.