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Article Type: Editorial From: Advances in Dual Diagnosis, Volume 4, Issue 4
“Dual Diagnosis” is dead – long live “complex and multiple needs”!
There is a general feeling of change and transition in the air; partly because of the autumn approaching and partly the imminent changes planned and enacted in health and social care (at the time of writing the Health and Social Care Bill is being debated in the House of Lords). Health and social care is never delivered in a vacuum and we should be mindful of the political context in which these exist and operate. More than ever, services will need to justify their costs and show value for money. In a time of cuts to the public sector and the rise of the “deserving” versus the “undeserving” poor (disabled people are facing increased hostility from strangers in past 12 months after review of benefits system: The Guardian, 14 May 2011) it is worth considering the public perception of people with dual diagnosis and whether they will be perceived as “deserving” of state help (in services and welfare) or whether they will be vilified and excluded even more. I suspect that the double stigma of a mental health and substance use problem will create more hostility and exclusion. The journal is also undergoing a period of transition both in change of publisher to changes to editorial team. Dr Cheryl Kipping stood down as one of the editors this year. Cheryl worked hard from the inception of the journal in developing its aims, style and content, commissioning papers, and editing many of the issues. I want to express my personal gratitude for her support and hard work over the last few years and she will be missed. However, she is retaining a role on the editorial board and we appreciate her ongoing contributions to the future development of this publication. However, I am also delighted to welcome Dr Gail Gilchrist to the role of co-editor. Gail is a Head of the Centre for Applied Social Research at the University of Greenwich in London. She has been working in addiction-related research since 1995 – in Scotland, England, Spain and Australia. She gained her PhD from the University of Glasgow investigating the psychiatric morbidity among female drug users in the city. Since then she has investigated the relationship between substance abuse and psychiatric disorders, intimate partner violence, blood borne viruses and parenthood; and is currently developing and testing group psychosocial interventions to reduce psychiatric symptoms and substance use, intimate partner violence and risk taking behaviours among substance users. Gail will be editing special issues related to these interests and has some exciting international experts lined up to contribute. One of the issues we have had with this journal is that to date it has been focused on UK (English) service developments within mental health services, and we are keen to publish more articles that focus on the needs of other groups such as substance users. In addition to violence and gender we also want to have a future issue focusing on psychological interventions for common mental health problems in substance misusers. The initiative “Increasing Access to Psychological Therapies” (IAPT) in the UK aimed to ensure that those presenting with common mental health problems got timely access to talking therapies at a level appropriate to their needs. IAPT is well established across England and evaluation seems to indicate that it is offering a good service (Clark et al., 2009). However, substance misuse is often an exclusion criteria for IAPT. This means that a significant proportion of substance misusers in treatment are not getting access to treatment for their mental health problems, and this in turn could significantly affect their recovery in not only their substance use problem but in other aspects of their life. However, there are now a small number of initiatives that are beginning to evaluate IAPT for substance users. Future issues of the journal will address this in more detail.
In this issue we will be grappling with some important issues related to terminology, as well as workforce development and innovation in substance misuse and forensic mental health. I have always personally struggled with the term “dual diagnosis”. I have rarely assessed anyone who has simply two problems, and often no formal diagnosis. So what are we really talking about when we use dual diagnosis? Would it be more useful, both in terms of meeting needs and configuring services, if we saw this group as having multiple and complex needs. A significant group of people using health and social care services have multiple sub-threshold problems and therefore do not quite meet the criteria for particular services, or are so chaotic that they are hard to engage. The debate about terminology is important, and one we have covered before (Roberts, 2010), and needs to be revisited in the light of how health and social care services are being re-commissioned and delivered. No single agency will be able to address all the needs of this group, and they require a locally agreed, coordinated and effective multi-agency response. It is likely (although there is little empirical evidence as yet for this) that a coordinated approach will be more cost-effective as the aim would be to reduce duplication and increase engagement and stability. However, the cost-savings would be distributed thinly across services. For example, providing more out of hours mental health crisis support may reduce the use of ambulance and Accident and Emergency (A&E), but the savings in A&E would not be passed over to mental health trust to support the ongoing development of the crisis team. Christian Guest and Dr Mark Holland’s discussion paper is critical of the use of terminology “dual diagnosis” and call for it to be actively “de-emphasised”. They provide a useful background to the understanding of the phenomenon known as “dual diagnosis”. They argue that the term dual diagnosis is unhelpful and adds to the exclusion of service users from services. They prefer the term “co-existing difficulties”. Guest and Holland promote a recovery-focused approach which has compassion at its heart. Within this approach, a bio-psycho-social model of understanding an individuals difficulties should be adopted rather than the more limited disease (medical model). They suggest that it is more helpful to understand substance misuse as an adaption to underlying difficulties (past and/or present) rather than purely as a disease in itself. This will help in developing a comprehensive care plan that will address the issues that have triggered and perpetuate the problems as opposed to simply treating the surface problems. Guest and Holland summarise an effective approach as having “Five Key Principals”: empathy, adaptive approach to suit the motivational state of the service user, avoiding clinical judgements based on moral or ethical judgements alone, adopt adaptive model of understanding substance use, and finally de-emphasise dual diagnosis.
Anna Page from Revolving Doors has been heavily involved in the production of MEAM’s Vision Paper for Multiple Needs and Exclusions and this was launched at the Houses of Commons in September. This paper serves to highlight the unmet needs of people with multiple and complex needs who often slip through the net of care. This group includes people with mental health, substance misuse, homelessness, physical health problems and other social problems. Often each individual problem is not severe enough on its own to cross the threshold of a particular service, but the combination of multiple problems creates a high level of need. A lack of coordinated local responses often leads to chaotic and sporadic use of services (such as A&E) in crisis but without a long-term plan, this group of people end up as “revolving doors” clients. Often (very unhelpfully) termed “frequent flyers”,patched up and sent on their way. The vision paper was developed with consultation with service users and their stories are given as examples throughout the paper. Anna calls for the government to recognise this group and to prioritise the development of more effective local responses.
Richard Edwards and colleagues report on an exploratory project which aimed to introduce a structured group intervention to a forensic secure mental health setting to address substance misuse issues within the population. This was an adapted version of an intervention developed by Bellack and colleagues in the USA which showed some promise in an exploratory trial with community mental health service users. Edwards and colleagues report on the development of this initiative including the challenges of new ways of working in forensic settings. Edwards and colleagues found that it was especially challenging to release the staff for the preparation and facilitation of this group and this cost may actually be prohibitive. The group was received positively by participants and the next step would be to look at impact on outcomes in a more formal research project. It may be that the costs incurred in facilitation may be outweighed by benefits in terms of service user outcome improvements.
Gail and I both attended and presented at the II International Dual Disorders conference in Barcelona. I was struck by the wide scope of the presentations in terms of types of mental health and substance use problems (not solely a focus on serious and enduring mental health problems). It highlighted for me that, in the UK, we have really concentrated on those with serious mental illness who also have substance misuse issues (usually cannabis and/or alcohol) and yet there is an enormous unmet need in substance misusers in terms of anxiety, depression and even post traumatic stress disorders.
I was delighted to receive a paper from Australia from Nicole Lee and colleagues which addressing workforce development in relation to common mental health problems in alcohol and drug services. Their paper describes the impact of implementation of the Psycheck, which is a brief assessment and intervention package for substance misuse staff to use in routine care. They looked at fidelity within the organisation following the training and found that where it had been implemented and supported, there was more adherence to the model. They found that integrating mental health assessment into routine practice and having a local champion were key to successful implementation.
I hope you enjoy this latest edition, and I look forward to taking the journal into a new phase in the coming months. Please contact either Gail or myself if you have ideas for topics or have a paper to contribute.
The Guardian (2011), “Disabled face increasing hostility from strangers”, available at: www.guardian.co.uk/society/2011/may/14/disabled-face-increasing-hostility-strangers (accessed 20 October 2011)
Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R. and Wright, B. (2009), “Improving access to psychological therapy: initial evaluation of two UK demonstration sites”, Behaviour Research and Therapy, Vol. 47 No. 11, pp. 910–20
Bellack, A., Bennett, M.E., Gearon, J.S., Brown, C.H. and Yang, Y.A. (2006), “A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness”, Archives of General Psychiatry, Vol. 63, pp. 426–32