Dual Diagnosis

HEA 3126

17th October 2011

To gain an understanding of what dual diagnosis means

To become more familiar with the multiple factors that may contribute to substance/drugs use in this client group

Establish facts and myths surrounding the links and relationships between drug/substance use/misuse and mental health

Reflect on your own use of legal drugs/substances

To be aware of the approaches/interventions that may best help this client group

Learning objectives

Exercise 1.

For 5 minutes- in groups- identify what the term ‘dual diagnosis’ 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 substance misuse’ (Crome et al. 2004)

‘…a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently’ (DOH 2002).

‘Dual diagnosis is a label they give you, but even at my most buoyant I think I’ve got more than two problems’ (Quote from a Service user taken

from Rethink 2007)

What is ‘dual diagnosis?’

A professional term.

A broad term, at best, promotes an understanding of two interwoven complex conditions.

Provides a conceptualisation of the phenomenon of substance misuse and mental health

Too narrow a focus? More than just 2 problems?

Medicalised?

Misleading?

A vague and yet stigmatising label?

Is the term ‘dual diagnosis’ helpful? Some points to consider

‘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).

How common is ‘dual diagnosis?’

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?

As varied as the individuals themselves

Socially excluded, may find a sense of belonging and community with other drug users

Counteract the unpleasant side-effects of prescribed psychiatric medication such as limb stiffness, involuntary movements, sexual dysfunction.

Increase energy levels and motivation by stimulating nervous system

Numb or mask painful thoughts and feelings

Alleviate intensity and distress from auditory hallucinations

Aid sleep

Why do people with mental health problems use or misuse drugs/substances? (1)

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

Why do people with mental health problems use or misuse drugs/substances? (2)

Which came first?

Exercise 3.

In groups- discuss whether substances/drugs cause mental health problems or whether mental health problems 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 use causes mental health problems?

More agreement reached that drug/substance misuse can ‘enhance’, ‘exacerbate’ or ‘trigger’ in individuals who are pre-disposed to mental health problems.

Substance/drug use can also mask a mental health problem which is later revealed when use is ceased.

Earlier age of onset of first-episode psychosis is proposed in young people with a vulnerability to schizophrenia and who misuse substances (Addington & Addington 1998). May act as a trigger.

Do substances/drugs cause mental health problems?

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 ‘dual diagnosis’ may mean for services & carers/families

‘ I was pushed around like a tennis ball. The alcohol people said I had a mental illness and the mental illness group said I had a drink problem. 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 their substance use or mental ill-health as a problem

Previous contact with services may have been negative and consequently, there may be poor engagement or mistrust.

What may dual diagnosis mean for service users?

http://youtu.be/2kwtcADn-yM

You Tube clip ‘Integrated treatment’

In groups- think about licit/illicit substances/drugs that might be used:

To numb or mask mental distress

To increase mood and motivation

To improve sleep

To reduce marked periods of mania or restlessness

Feedback in 10 minutes- nominate a spokesperson

Exercise 4: Types of use

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?

Thinking about you own use of legal drugs/substances

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-defined or 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 diagnosis than to miss others who do (Holland & Midson 2004).

Mainstreaming: Should be delivered within mental health services but working closely with specialist substance misuse services (DOH 2002).

Working alongside the individual ‘holistically’ (although don’t exclude families/carers)

How can we respond?

Best way to detect substance use/misuse is to ask users in an open and frank way

Ask sympathetically and reassure that negative consequences will not automatically follow

Might be important to initially consider asking service users on their own (although don’t wholly exclude families, carers or friends).

Slang terms can vary across the country- Be clear about misunderstandings or misuse of drug-using terminology.

Ask the service user

Establishing a therapeutic alliance

Focus on ‘engaging’ with the service user – be flexible in your approach

Maintain an holistic focus

Consider that ‘reduction’ may be more realistic than ‘abstinence’

Provide advice and information

Accept that ‘setbacks’ can occur- that drug/substance reduction does not always move along in an linear mode

Interventions

Known as R.U.L.E ( Rollnick, Miller & Butler 2008).

Resist the Righting Reflex

Understanding the Service User’s Motivations

Listen to the Service User

Empower the Service User

Four guiding principles to aid engagement

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?

DVD- ‘Pillar to post’- a film about dual diagnosis (MIND 2011)

Any further questions?

Feedback

Thank you

Addington, 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 with mental 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). Good Practice in Adult Mental Health. London: Jessica Kingsley Publishers.

MIND (2011). Pillar to Post- a film about dual diagnosis. www.mindincroydon.org.uk

Rethink (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.uk

Rollnick. 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

References