specialist or integrated approaches: working with people who have a dual diagnosis using an...
TRANSCRIPT
![Page 1: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/1.jpg)
Specialist or Integrated Approaches: Working with
people who have a dual diagnosis using an Assertive
Outreach frameworkTom Dodd
National lead for Community teamsJoint National Lead for Dual Diagnosis
Chairman of RESTNational Institute for Mental Health, England
![Page 2: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/2.jpg)
Outline
• The tension between health and social policies
• Capabilities
• Training
• Assertive Outreach & Dual Diagnosis
• Outcomes
![Page 3: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/3.jpg)
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)
![Page 4: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/4.jpg)
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
![Page 5: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/5.jpg)
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
![Page 6: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/6.jpg)
NEEDS LED SERVICE PROVISION FRAMEWORKFor Working Age Adults with Dual Diagnosis Issues
1LIMITED NEEDS ARISING FROM BINGE, HAZARDOUS OR
EXCESSIVE EXPERIMENTAL OR RECREATIONAL MISUSE OF SUBSTANCES
2MODERATE LEVEL OF NEEDS ARISING FROM
HAZARDOUS OR EXCESSIVE
MISUSE OR PSYCHOLOGICAL DEPENDENCE ON SUBSTANCES
3HIGH LEVEL OF NEEDS ARISING FROM PHYSICAL DEPENDENCE ON SUBSTANCES
AHIGH 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
BMODERATE 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; 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
CLIMITED 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)
![Page 7: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/7.jpg)
NEEDS LED SERVICE PROVISION FRAMEWORKFor Working Age Adults with Dual Diagnosis Issues
1LIMITED NEEDS ARISING FROM BINGE, HAZARDOUS OR EXCESSIVE EXPERIMENTAL OR RECREATIONAL MISUSE OF SUBSTANCES
2MODERATE LEVEL OF NEEDS ARISING FROM HAZARDOUS OR EXCESSIVE
MISUSE OR PSYCHOLOGICAL DEPENDENCE ON SUBSTANCES
3HIGH LEVEL OF NEEDS ARISING FROM PHYSICAL DEPENDENCE ON SUBSTANCES
AHIGH 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
![Page 8: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/8.jpg)
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
![Page 9: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/9.jpg)
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
![Page 10: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/10.jpg)
Capabilities Framework
• values
• knowledge
• skills
• practice development
![Page 11: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/11.jpg)
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
![Page 12: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/12.jpg)
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)
![Page 13: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/13.jpg)
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
![Page 14: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/14.jpg)
Capabilities Framework
• values
• knowledge
• skills
• practice development
![Page 15: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/15.jpg)
Values
• Practicing ethically
• Promoting recovery
• Making a difference
• Respecting diversity
• Challenging inequality
![Page 16: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/16.jpg)
Capability
Values Level 1 Level 2 Level 3 Capability
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
![Page 17: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/17.jpg)
Utilising Knowledge and Skills
Level 1 Level 2 Level 3 Capability 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)
![Page 18: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/18.jpg)
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
![Page 19: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/19.jpg)
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?
![Page 20: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/20.jpg)
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
![Page 21: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/21.jpg)
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
![Page 22: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/22.jpg)
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
![Page 23: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/23.jpg)
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
![Page 24: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/24.jpg)
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
![Page 25: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/25.jpg)
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
![Page 26: Specialist or Integrated Approaches: Working with people who have a dual diagnosis using an Assertive Outreach framework Tom Dodd National lead for Community](https://reader035.vdocuments.net/reader035/viewer/2022062717/56649e2d5503460f94b1cda1/html5/thumbnails/26.jpg)
Outcomes
• Securing better housing
• Increasing employment opportunities
• Increasing social skills
• Impacting on societal problems: crime, HIV/AIDS, domestic violence, and others
• Access
• Engagement