Transcript Why do we persist with the term ‘Dual Diagnosis’ within

24th October 2012.
Christian Guest.
Dual Diagnosis Lead (RDaSH)
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Policy implementation guide (2002) -
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Individuals may be excluded on ‘Dual Diagnosis’
term alone
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‘Dual Diagnosis’ term has perhaps become
obsolete
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mainstreaming of co-existing difficulties
Can we argue co-existing difficulties are
supported within mainstream services?
Need to consider the unintended consequences?
Mental
Health
Substance
Misuse
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Provided a working definition and scope of
Dual Diagnosis
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Promoted the national agenda
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Promoted the policy of mainstreaming
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Promoted the need for collaboration
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Highlighted the need to support co-existing
difficulties
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Single label implies homogeneous and identical needs.
Remains synonymous with complexity, challenging
behaviour, homelessness severe mental illness, crime
(DOH, 2009, Pawsey et al 2011,Drake et al 1993).
Perception of ‘Dual Diagnosis’ based on clinician’s
experience and knowledge (Velleman & Baker, 2008)
Term remains ambiguous in clinical practice
Not recognised as a spectrum of severities and needsfrom primary care to inpatient services.
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Weaver et al., (2002) 44% Service user’s in CMHT had dual
diagnosis75% within drug service, 80% alcohol clients had
experienced, depression, anxiety, personality disorders,
psychosis.
Schulte & Holland (2008) -46% service users within mental
health services. 71% in Assertive outreach. 59% in patient
wards.
Cole & Sacks (2008)- prevalence rate of 60% within drug &
alcohol services
Strathdee et al., (2002) 93% of clients (initial screening)
within substance misuse services assessed as having
indications of (‘dual diagnosis’) mild to moderate symptoms.
Access /crisis
team
Substance/
alcohol
services
Community
therapies/IAPT
Intensive
community
teams
In patient
wards
Early
intervention
Teams
Enduring
mental
health
services
Assertive
outreach
team
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Velleman & Baker (2008)- “co-existing problems”
should be adopted, broad and inclusive term.
Label of ‘Dual Diagnosis’ can lead to exclusion ,
inconsistent service provision , unnecessary
signposting (Velleman & Baker 2008)
Pawsey et al., (2011) clients fall between services
neither service wishing to treat “other” problem
Shifting of responsibility to services deemed
more suitable, service users “falling through the
net”
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Department of Health (2009) ,more than the
management of mental health problems
Recovery is a movement away from pathology,
illness and symptoms to health , strengths and
wellness,(Shepherd et al., 2008)
Relies on compassion, hope, creativity, realism
Can the single term ‘Dual Diagnosis’ be any longer
relevant or consistent with the principles of
recovery?
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Complex relationship between mental health and substance
misuse (Wu et al, 2010, Klanecky & McChargue, 2009,)
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Alexander (1987, 1990)- explores ‘Adaptive model’ of addiction
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It is ‘adaptive’ to choose a ‘lesser evil’- reduce voices by
excessive alcohol consumption
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Argues problematic alcohol and substance use is a result of
“substitute adaptations” -alleviation of significant psychological
distress
Problematic alcohol and substance use in adulthood develop as
a result of a combination of early childhood trauma, inadequate
environmental support, and diminishing social networks.
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Employed to attempt to alleviate psychological
distress (adaptive)
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150,000 attendances at general hospital (Hughes&
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4 in 1000 people (Royal College of Psychiatrist report
,2010)
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Self injury not given separate terminology
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Self injury supported by mental health services
culturally
Kosky ,2007)
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Dual Diagnosis Capability framework (Hughes,
2006)
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Ten essential Shared Capabilities (Hope 2004)
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Promoting recovery, working in partnership,
client centred ...
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How does this translate to everyday practice?
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Organisational culture should accommodate and
recognise complex psychosocial factors
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Requires clinical leadership within services
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5 key principles to support a spectrum of coexisting difficulties
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Actively de-emphasis the term ‘Dual Diagnosis’
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Ability to express empathy-compassion, hope,
creativity will promote inclusion and acceptance
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Adapt intervention according to the individuals
readiness to (M.I)
◦ -principles of M.I labels considered unnecessary
obstacles for change
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‘Adaptive models’ support the view that
problematic substance misuse indicates
profound personal/social difficulties
Avoid clinical judgement based on religious,
moral, social or ethical codes
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Dual Diagnosis not exclusive to one service
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No one single identity- significant spectrum of needs
& circumstances
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Existing mental health provision can support a
spectrum of needs (primary care- AOS , in-patient)
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Continues to remain gaps, inconsistent service
provision, exclusion, stigma
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Practitioner’s confidence, attitude & competence
significantly influence intervention and
inclusion/exclusion
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‘Dual Diagnosis’ term established for several
decades-progress made (DOH, 2002)
Terminology, language & culture continue to
evolve according to societal and political values
and beliefs.
Adopt the term ‘co-existing difficulties’
‘Dual Diagnosis’ perhaps become
counterproductive and obsolete within
contemporary services
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[email protected]
Guest, C & Holland, M (2011). Co-existing mental health
and substance misuse difficulties-why do we persist with
the term “dual diagnosis” within mental health services?
Advances in Dual Diagnosis. Vol.4. No.4. pp.162-172.