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Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
The Role of AOT's in dual The Role of AOT's in dual diagnosis: implications for diagnosis: implications for
practice, practice, training and workforce training and workforce
developmentdevelopment
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
DefinitionsDefinitions
The term “dual diagnosis” is generally The term “dual diagnosis” is generally applied to people who have two disorders applied to people who have two disorders
Combined mental health and substance Combined mental health and substance use problemsuse problems
More than “dual problems”- likely to have More than “dual problems”- likely to have complex health and social needscomplex health and social needs
Wide range of people with varying degrees Wide range of people with varying degrees of need- need individualised treatmentof need- need individualised treatment
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Table 1
Serious mental illness
E.g. someone with bipolar affective disorderwho smokes cannabistwice per week
E.g. Someone with schizophrenia
and alcohol dependence
Minor substance use
E.G. Someone with anxiety who snorts cocaine
occasionally
Minor mental illness
Severe substance use
E.g. someone with heroin dependency and depression
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Overview of the Overview of the literatureliterature
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
UK Prevalence StudiesUK Prevalence Studies
Duke (1995) Community services 37% (1 year)Duke (1995) Community services 37% (1 year) Menezes 1996 Inner London MH services 36% Menezes 1996 Inner London MH services 36%
(1 year)(1 year) Cantwell (1999) Nottingham first episode Cantwell (1999) Nottingham first episode
psychosis 37% (1 year)psychosis 37% (1 year) Weaver (2001) Inner London Community mental Weaver (2001) Inner London Community mental
health and substance use services 24% (recent-health and substance use services 24% (recent-last 30 days)last 30 days)
Phillips 2003 Inner 49% (last 6 months)Phillips 2003 Inner 49% (last 6 months)
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
PrevalencePrevalence
1/3 people with psychosis have concurrent 1/3 people with psychosis have concurrent substance use problem (alcohol, cannabis, substance use problem (alcohol, cannabis, stimulants)stimulants)
½ people in substance use treatment also ½ people in substance use treatment also have mental health problems (depression, have mental health problems (depression, anxiety, PD)anxiety, PD)
Higher rates to be found in inpatient, Higher rates to be found in inpatient, forensic and prison populationforensic and prison population
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Consequences of co-morbidityConsequences of co-morbidity
Increased likelihood of self-harm and violenceIncreased likelihood of self-harm and violence Poor physical health (including HIV, hep B and C)Poor physical health (including HIV, hep B and C) Frequent relapse and re hospitalisationFrequent relapse and re hospitalisation Difficulty getting access to appropriate aftercare Difficulty getting access to appropriate aftercare Poor medication adherencePoor medication adherence Family problemsFamily problems HomelessnessHomelessness Higher overall service costsHigher overall service costs Higher overall risk of untoward incidentsHigher overall risk of untoward incidents
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Aetiological Theories Aetiological Theories (Mueser, 1998)(Mueser, 1998)
Common causal factorCommon causal factor GeneticsGenetics Family backgroundFamily background Conduct disorder in childhoodConduct disorder in childhood
Mental illness causes substance useMental illness causes substance use Higher rates in people with mental illnessHigher rates in people with mental illness Are people self-medicating symptoms (Khantzian, 1985)?Are people self-medicating symptoms (Khantzian, 1985)? Brunette (1997) no relationship between symptoms and drug of choiceBrunette (1997) no relationship between symptoms and drug of choice
Substance use causes mental illnessSubstance use causes mental illness Substance use can cause temporary organic states that mimic mental Substance use can cause temporary organic states that mimic mental
illnessillness No evidence that substance use causes long term mental illnessNo evidence that substance use causes long term mental illness More likely that it exacerbates or triggers off (Johns, 2001)More likely that it exacerbates or triggers off (Johns, 2001)
Bi-directional- one influences course of the otherBi-directional- one influences course of the other
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
How do drugs and alcohol fit How do drugs and alcohol fit with risk?with risk?
Intoxication- accidents, impaired judgementsIntoxication- accidents, impaired judgements Craving- increased irritability, inability to copeCraving- increased irritability, inability to cope Withdrawal- compulsion to obtain more, physical Withdrawal- compulsion to obtain more, physical
risksrisks Life-style and social contextLife-style and social context ImpulsivityImpulsivity Decreased adherence to medication….worsening of Decreased adherence to medication….worsening of
psychotic symptomspsychotic symptoms Treatment drop-outTreatment drop-out
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Challenges for People with Challenges for People with Serious Mental health problemsSerious Mental health problems
Cognitive impairmentsCognitive impairments Sedation from medicationSedation from medication Management of side-effectsManagement of side-effects Poor coping skillsPoor coping skills HopelessnessHopelessness Social factors-peer group influencesSocial factors-peer group influences Ignorance re health risksIgnorance re health risks(Bellack and Diclemente, 1999)(Bellack and Diclemente, 1999)
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Self-medicationSelf-medication
The use of substances to alleviate painful or The use of substances to alleviate painful or uncomfortable emotional or physical states.uncomfortable emotional or physical states.
Negative symptoms of psychosis (apathy, Negative symptoms of psychosis (apathy, flattened affect, slowed thoughts)flattened affect, slowed thoughts)
Side-effects of medication (EPSE, akathisia, Side-effects of medication (EPSE, akathisia, neuroleptic dysphoria)neuroleptic dysphoria)
General distress as a result of having a chronic General distress as a result of having a chronic illness (boredom, loneliness, distressing illness (boredom, loneliness, distressing symptoms)symptoms)
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Key Policy Drivers 2009Key Policy Drivers 2009
National Service Framework- Good Practice National Service Framework- Good Practice Guidelines (2002)Guidelines (2002)
Avoidable Deaths (2006)Avoidable Deaths (2006) Themed Review report (2008)Themed Review report (2008) HCC In Patient Service Review (2008)HCC In Patient Service Review (2008) NHSLA Risk Management Standards(2008)NHSLA Risk Management Standards(2008) New Horizons…..New Horizons….. Bradley Report (2009)Bradley Report (2009)
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Department of Health Department of Health Mental Health Policy Implementation GuideMental Health Policy Implementation Guide
Dual Diagnosis Good practice Guidelines 2002Dual Diagnosis Good practice Guidelines 2002
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Substance use isSubstance use is usual usual rather than exceptional rather than exceptional in people with mental illnessin people with mental illness
People with dual diagnosis have a right to People with dual diagnosis have a right to access good quality, patient focused and access good quality, patient focused and integrated careintegrated care
This should be delivered within mental health This should be delivered within mental health services: “mainstreaming”services: “mainstreaming”
This is to prevent patients being shunted from This is to prevent patients being shunted from one service to anotherone service to another
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
This should not reduce role of substance This should not reduce role of substance misuse services- they will still provide care misuse services- they will still provide care for substance users and advise on for substance users and advise on substance related issuessubstance related issues
Services need to identify and respond to Services need to identify and respond to local needlocal need
Specialist workers should provideSpecialist workers should provide support support to mainstreamto mainstream
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
All AOT should be equipped to work with DDAll AOT should be equipped to work with DD Adequate staff in crisis resolution, cmht and Adequate staff in crisis resolution, cmht and
inpatient mental health services should be inpatient mental health services should be suitably trainedsuitably trained
All health and social care economies should All health and social care economies should map services and needmap services and need
All services including drug and alcohol should All services including drug and alcohol should ensure that this client group are subject to CPA ensure that this client group are subject to CPA and have full riskand have full risk assessmentassessment..
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
………….so what works? .so what works?
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Evidence BaseEvidence Base
Cochrane Reviews (2004, 2008)Cochrane Reviews (2004, 2008)
MIDAS RCT- CBT and MIMIDAS RCT- CBT and MI
Nice Clinical Guideline Development Group Nice Clinical Guideline Development Group beginning 2009beginning 2009
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Key ApproachesKey Approaches
Principle elements of Integrated ModelPrinciple elements of Integrated Model Motivational Interviewing Motivational Interviewing
Principles/techniquesPrinciples/techniques Relapse PreventionRelapse Prevention Psychosocial Interventions for PsychosisPsychosocial Interventions for Psychosis Harm MinimisationHarm Minimisation Stress-Vulnerability HypothesisStress-Vulnerability Hypothesis CBTCBT
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Process of ChangeProcess of Change(Prochaska, DiClemente, & Norcross 1992)(Prochaska, DiClemente, & Norcross 1992)
PrecontemplationPrecontemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance RelapseRelapse Spiralling around Spiralling around
stagesstages
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Four Stage ModelFour Stage Model
ENGAGEMENTENGAGEMENT
PERSUASIONPERSUASION
ACTIVE ACTIVE TREATMENTTREATMENT
RELAPSE RELAPSE PREVENTIONPREVENTION
Osher and Kofoed (1989)Osher and Kofoed (1989)
PRE-PRE-CONTEMPLATIONCONTEMPLATION
CONTEMPLATIONCONTEMPLATION PREPARATIONPREPARATION ACTIONACTION MAINTAINANCEMAINTAINANCE RELAPSE/ RELAPSE/
ABSTINENCEABSTINENCEProchaska and DiClementeProchaska and DiClemente
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Integrated Model (USA)Integrated Model (USA)
ComprehensivenessComprehensiveness Stage wiseStage wise close monitoringclose monitoring shared decision makingshared decision making assertive outreachassertive outreach pharmacotherapypharmacotherapy
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
What do AOT’s need to deliver What do AOT’s need to deliver comprehensive care packages comprehensive care packages
to people with ‘dual to people with ‘dual diagnosis’?diagnosis’?
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
The 10 ESC’sThe 10 ESC’s
1.1. Working in PartnershipWorking in Partnership2.2. Respecting DiversityRespecting Diversity3.3. Practising EthicallyPractising Ethically4.4. Challenging InequalityChallenging Inequality5.5. Promoting RecoveryPromoting Recovery6.6. Identifying Peoples Needs and StrengthsIdentifying Peoples Needs and Strengths7.7. Providing service user centred careProviding service user centred care8.8. Making a differenceMaking a difference9.9. Promoting Safety and positive risk-takingPromoting Safety and positive risk-taking10.10. Personal Development and learningPersonal Development and learning
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
What are CompetenciesWhat are Competencies
Describe good practiceDescribe good practice To measure To measure performanceperformance The coverage and focus of a serviceThe coverage and focus of a service The structure and content of educational The structure and content of educational
and training and related qualificationsand training and related qualifications
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
What is a Capability?What is a Capability?
1.1. A performance component (what people need A performance component (what people need to possess)to possess)
2.2. A ethical component (integrating a knowledge A ethical component (integrating a knowledge of culture, values, and social awareness into of culture, values, and social awareness into practice)practice)
3.3. Reflective PracticeReflective Practice4.4. Capability to effectively implement evidence Capability to effectively implement evidence
based practicebased practice5.5. Commitment to working with new models of Commitment to working with new models of
professional practice and responsibility for life-professional practice and responsibility for life-long learning.long learning.
(SCMH 2001)(SCMH 2001)
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
CompetenceCompetence Having a factual Having a factual
knowledge of how to knowledge of how to do something- do something- practical levelpractical level
Effectiveness at an Effectiveness at an individual levelindividual level
Ability to perform Ability to perform duties to a set duties to a set standardstandard
CapabilityCapability Relate knowledge to Relate knowledge to
practice- within a practice- within a given contextgiven context
Strength within the Strength within the individual- self individual- self awareness, managing awareness, managing the most difficult the most difficult situations/peoplesituations/people
Organisational level Organisational level capabilitiescapabilities
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Therefore a capability Therefore a capability encompasses competence encompasses competence but is wider in its scope as but is wider in its scope as
it covers attitude, it covers attitude, application of theory and application of theory and values to practice, and is values to practice, and is reflective- it is simply the reflective- it is simply the
individuals ability to apply individuals ability to apply the competence in practicethe competence in practice
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
What is the purpose of a capability What is the purpose of a capability framework?framework?
Building teams/roles- hire people with Building teams/roles- hire people with those required capabilities (plan training)those required capabilities (plan training)
Benefit service users- would be working Benefit service users- would be working with someone who understands and is with someone who understands and is more effective an individual levelmore effective an individual level
Improve outcomes for service usersImprove outcomes for service users
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
The Knowledge and Skills The Knowledge and Skills Framework (DH, 2003)Framework (DH, 2003)
Covers all workers in the NHSCovers all workers in the NHS Not mental health specificNot mental health specific Single explicit framework by which all NHS workers can Single explicit framework by which all NHS workers can
be reviewed and developed=Agenda for Changebe reviewed and developed=Agenda for Change Describes the knowledge and skills the individual needs Describes the knowledge and skills the individual needs
to apply in a specific roleto apply in a specific role It is about application of knowledge and skills not the It is about application of knowledge and skills not the
knowledge and skills the individual may possessknowledge and skills the individual may possess The MHNOS describes the knowledge and skills more The MHNOS describes the knowledge and skills more
preciselyprecisely
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Capabilities Framework for Dual Capabilities Framework for Dual DiagnosisDiagnosis
Level 1 CORELevel 1 CORE Aimed at all workers in contact with this service user Aimed at all workers in contact with this service user
group e.g. primary care workers, A & E staff, non-group e.g. primary care workers, A & E staff, non-statutory agency workersstatutory agency workers
Level 2 GeneralistLevel 2 Generalist Generic post-qualification workers in non-specialist Generic post-qualification workers in non-specialist
roles (secondary and tertiary care) e.g. community roles (secondary and tertiary care) e.g. community mental health workers, substance misuse workersmental health workers, substance misuse workers
Level 3 SpecialistLevel 3 Specialist those people in senior roles that have specific those people in senior roles that have specific
experience or qualifications, a special interest, or experience or qualifications, a special interest, or specific role in dual diagnosis, and who have a practice specific role in dual diagnosis, and who have a practice development, and/or training remit related to dual development, and/or training remit related to dual diagnosisdiagnosis
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
The FrameworkThe FrameworkValuesValues Role legitimacyRole legitimacy Therapeutic optimismTherapeutic optimism Acceptance of the uniqueness of each Acceptance of the uniqueness of each
individualindividual Non-judgemental attitudeNon-judgemental attitude Demonstrate empathyDemonstrate empathy
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Utilising Knowledge and SkillsUtilising Knowledge and Skills EngagementEngagement Interpersonal skillsInterpersonal skills Education and health Education and health
promotionpromotion Recognise needs Recognise needs
(assessment)(assessment) Risk assessment and Risk assessment and
managementmanagement
Ethical legal and Ethical legal and confidentiality issuesconfidentiality issues
Care planning in Care planning in partnership with service partnership with service useruser
Delivering evidence and Delivering evidence and values based interventionsvalues based interventions
Evaluate careEvaluate care Help people access help Help people access help
from other servicesfrom other services Multi-agency/professional Multi-agency/professional
workingworking
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Practice DevelopmentPractice Development Learning NeedsLearning Needs Seek out and use supervisionSeek out and use supervision Commitment to life-long learningCommitment to life-long learning
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
KSF Dual Diagnosis Capability
Core 1-communication 7-interpersonal skills6-engagement
Core 2-personal and people development
18-seek out and use supervision17- learning needs, 2-therapeutic optimism19-life-long learning 1- Role legitimacy
Core 6-Equality and Diversity 11-ethical and legal issues3-acceptance of uniqueness of each individual4-non-judgemental attitude5-demonstrate empathy
HWB1- promotional of health and well-being
8-education and health promotion
HWB2- assessment and care planning to meet health and well-being needs
9-recognise need10 risk assessment and risk management14-evaluate care
HWB3 protection of health and well-being
10 risk assessment and risk management
HWB4-enablement to address health and well-being needs
15- help people access care from other services
HWB7-interventions and treatments 12 care planning in partnership with service user13 delivering evidence based interventions
G7Capacity and Capability 16- Multi-agency and multi-professional working
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
How do you create a capable How do you create a capable workforce/ team?workforce/ team?
2002 Good Practice guide: “mainstreaming”2002 Good Practice guide: “mainstreaming” Workforce need to be equipped with capability to Workforce need to be equipped with capability to
deliver effective care for dual diagnosisdeliver effective care for dual diagnosis
BUT: workforce lack skills, knowledge and BUT: workforce lack skills, knowledge and attitudesattitudes
SO: training in dual diagnosis interventions to be SO: training in dual diagnosis interventions to be developed and made available to mental health developed and made available to mental health and substance use staff.and substance use staff.
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
The problems with trainingThe problems with training Lots of training delivered; little formal evaluation Lots of training delivered; little formal evaluation
beyond trainee satisfactionbeyond trainee satisfaction From research, there is limited evidence that From research, there is limited evidence that
training in dual diagnosis interventions has training in dual diagnosis interventions has significant effect on service user outcomes significant effect on service user outcomes (COMO, CODA, COMPASS)(COMO, CODA, COMPASS)
Trainees demonstrate some gains on attitude, Trainees demonstrate some gains on attitude, knowledge and self-rated skills, but capabilities knowledge and self-rated skills, but capabilities not measurednot measured
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
COMO and CODA evaluationCOMO and CODA evaluation
Attitudes towards working with drinkers Attitudes towards working with drinkers and drugs usersand drugs users
Dual Diagnosis AttitudesDual Diagnosis Attitudes Self-efficacy- how confident they felt about Self-efficacy- how confident they felt about
delivering key skillsdelivering key skills Knowledge About Dual DiagnosisKnowledge About Dual Diagnosis Maslach Burn-out ScaleMaslach Burn-out Scale Minnesota Job satisfaction ScaleMinnesota Job satisfaction Scale
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Predictors of Attitude (CODA)Predictors of Attitude (CODA)
AAPPQ total scores- length of substance AAPPQ total scores- length of substance use experience and number of relevant use experience and number of relevant study daysstudy days
Self-efficacy- length of substance misuse Self-efficacy- length of substance misuse experienceexperience
DD attitudes- number of study daysDD attitudes- number of study days Knowledge- no predictorsKnowledge- no predictors
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Dual Diagnosis TrainingDual Diagnosis Training
Training needs to increase therapeutic Training needs to increase therapeutic commitment by:commitment by: Increase peoples motivationIncrease peoples motivation Increase skills and knowledge (and self-esteem)Increase skills and knowledge (and self-esteem) Sense of job satisfactionSense of job satisfaction The right to work with substance useThe right to work with substance use
(Role support may be beyond scope of a training (Role support may be beyond scope of a training programme alone: supervision and support programme alone: supervision and support afterwards.)afterwards.)
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Does the 5 day training do Does the 5 day training do this?this?
The answer is: partly!The answer is: partly!The COMO and CODA have shown that the 5 day The COMO and CODA have shown that the 5 day course increases:course increases:
AAPPQ composite score (CODA only)AAPPQ composite score (CODA only) Adequacy of knowledge and skills (COMO and CODA)Adequacy of knowledge and skills (COMO and CODA) Expectation of job satisfaction (CODA only)Expectation of job satisfaction (CODA only) Role support (CODA only)Role support (CODA only) Self-esteem about working with drinkers (COMO and CODA)Self-esteem about working with drinkers (COMO and CODA)
Overall, the CODA findings suggest that whole team Overall, the CODA findings suggest that whole team training could be a more effective method of increasing training could be a more effective method of increasing attitudes to DD.attitudes to DD.
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
What the training doesn’t What the training doesn’t affectaffect
Role legitimacyRole legitimacy Motivation to work with substance usersMotivation to work with substance users
These are important attitudes to shift in These are important attitudes to shift in mental health services if mainstreaming is mental health services if mainstreaming is to work!to work!
These may require service and These may require service and organisational changes in attitude, not just organisational changes in attitude, not just the responsibility of the training.the responsibility of the training.
Dr Tara O'Neill and Dr Liz HughesDr Tara O'Neill and Dr Liz Hughes
Group Exercise/ Discussion
In pairs…..
Describe the skills mix of your team, in light of the capabilities framework. Think about who might be operating at level 1, 2, or 3. How does the team deal with dual diagnosis? What are your teams strengths and weaknesses? What might need to be in put in place, or what is in place to make your team a ‘capable’ team for working with service users with ‘dual diagnosis’.