Emerald Group Publishing Limited
Article Type: Editorial From: Advances in Dual Diagnosis, Volume 7, Issue 4
Integration for dual diagnosis: is it still the “impossible dream”?
I was recently at a Mental Health Nursing Research conference, and attended a presentation provocatively arguing that we should end the specialist training for mental health nurses. In the UK, nurses are trained in their field of practice prior to registration, unlike other countries such as USA and Australia where all nurses undergo a “generic” training and specialise after qualifying. The argument for generic training is that the co-morbidity of physical health needs is so great in service users with serious mental health problems yet these needs are largely ignored in mental health services. On the other side of the coin, general medical settings are not addressing the mental health problems so often accompanying long-term medical conditions. This argument is persuasive and the prevalence figures on unmet need speaks for itself. However, I would argue that generic workers are not the answer and we can use what we have learnt over the past 20 years of research around how to best meet the needs of people with co-morbid mental health and substance use. We know that training generic mental health workers to deliver dual diagnosis interventions shows no real benefit to service use outcomes. Attitudes towards this group don't seem to be altered by the training provided, even though self-reported knowledge and skills were significantly higher post training. A set of shared values is vital in working with such a marginalised and stigmatised group. It is clear that this can’t be “taught” and so another more promising method may be working alongside other professionals and service users. So I would therefore argue that we need “specialists” as “jack of all trades, master of nothing” means effectively no treatment for people with complex needs who need and deserve something more sophisticated, but importantly, the right attitude.
Whilst so far not formally evaluated, a more promising model (than mainstreaming generic model) is that of the “specialist” within the team, i.e. link workers. In addition I have always believed that in any given geographical area we have all the skills and expertise we need to really help people with dual diagnosis move on with their lives; the problem has always been how to effectively collaborate without the “turf wars”, barriers of confidentiality and rigid protocols, and lack of willingness to get together to work through these issues. Again I can only speak for the UK, but the constant re-tendering of services, changes to key personnel, and the recent overhaul of commissioning has meant that it has been a heroic effort to keep local integration going. The other important point to make is that people with co-existing mental health and substance use issues are the ultimate expert in their own recovery and I really don’t think we have harnessed the potential that lies within each person attending the services. I was at a recent service user forum in Leeds (The Zip Group) and this message came out loud and clear, as well as the need for services to adopt a positive “recovery” focus and see change is possible for all people who present with complex needs. So when we think of integration its not just a focus on how substance use and mental health treatment services can work together, its also vital that there is central consideration to how people who use services can be empowered to take control of their recovery not just for the treatment itself, but how to build a positive and rewarding life beyond treatment. I feel people with dual diagnosis have been missed off the recovery agenda and its time to put them back in the centre of their care and recovery.
This issue picks up on all these themes and I am delighted that we have a range of papers spanning three continents.
Benjamin Stewart has reported on analysis of a national database for injecting drug users (IDUs) related to self-reported mental health problems and mental health service use, comparing data from 2006 to 2012. They found that self-reported mental health problems (mainly anxiety) have risen between these two dates. They conclude that this may reflect a greater willingness to admit mental health issues through greater awareness (mental health literacy), and that mental health reforms including increasing access to psychological services for IDUs may be contributing. However, as mental health problems are so common in drug users, Stewart concludes that there needs to be an improvement in how we monitor mental health of disadvantaged groups (including IDUs).
Two papers report on case studies of local areas and the challenges and successes of integrating local services for people with dual diagnosis (Bell in the UK and Davidson in the USA). Completely different health-care systems yet the themes and issues are remarkably similar. Richard Bell reports on a service evaluation undertaken in the Leeds City area in the UK. The aim of this study was to gain a sense of the prevalence of dual diagnosis with mental health and substance use services, and also to understand the current level of care being provided (as benchmarked against a city-wide protocol). What they found was that most services could identify people with dual diagnosis using their services but this was patchy in places. In addition, despite a huge wave of training being offered, few workers had progressed beyond a very basic training course. In addition, there was confusion about what training was available and who it was targeted at. There was some good examples of joint working between services but this tended to be informal and facilitated by people who knew each other and already had established working relationships. Whilst this was not a formal research study, it has highlighted areas for development within the Leeds City area.
Larry Davidson writes about the Philadelphia experience of integrating services for dual diagnosis. He emphasises that integration should go beyond “the end of addition” and become more recovery orientated which means looking at how people rebuild their lives in the community. He advocates co-location of services, increased collaboration and development of set of shared values by all services.
Finally, and building on this theme of recovery, Tom Parkman writes about his study of the impact of mutual aid (peer led) group for people who have left addictions treatment on their mental well-being. This group is peer led and focuses on re-integration into the community by way of supported activities and mutual support. The people who attended reported on how this group had enhanced their mental well being by providing structure, reducing stress, and alleviating boredom. However, for some people (who had very little support in their lives outside the group) there was a risk that they could become highly reliant on it, and therefore struggle to then move on to full re-integration into the community.