Transcript The Role of AOT's in dual diagnosis: implications for

The Role of AOT's in dual
diagnosis: implications for
practice,
training and workforce
development
Dr Tara O'Neill and Dr Liz Hughes
Definitions
 The
term “dual diagnosis” is generally
applied to people who have two disorders
 Combined mental health and substance
use problems
 More than “dual problems”- likely to have
complex health and social needs
 Wide range of people with varying degrees
of need- need individualised treatment
Dr Tara O'Neill and Dr Liz Hughes
Serious mental illness
E.g. someone with
bipolar affective disorder
who smokes cannabis
twice per week
E.g. Someone with
schizophrenia
and alcohol dependence
Table 1
Minor substance use
E.G. Someone with anxiety who
snorts cocaine occasionally
Severe substance use
E.g. someone with heroin
dependency and depression
Minor mental
illness
Dr Tara
O'Neill and Dr Liz Hughes
Overview of the
literature
Dr Tara O'Neill and Dr Liz Hughes
UK Prevalence Studies
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Duke (1995) Community services 37% (1 year)
Menezes 1996 Inner London MH services 36%
(1 year)
Cantwell (1999) Nottingham first episode
psychosis 37% (1 year)
Weaver (2001) Inner London Community mental
health and substance use services 24% (recentlast 30 days)
Phillips 2003 Inner 49% (last 6 months)
Dr Tara O'Neill and Dr Liz Hughes
Prevalence
 1/3
people with psychosis have concurrent
substance use problem (alcohol, cannabis,
stimulants)
 ½ people in substance use treatment also
have mental health problems (depression,
anxiety, PD)
 Higher rates to be found in inpatient,
forensic and prison population
Dr Tara O'Neill and Dr Liz Hughes
Consequences of co-morbidity
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Increased likelihood of self-harm and violence
Poor physical health (including HIV, hep B and C)
Frequent relapse and re hospitalisation
Difficulty getting access to appropriate aftercare
Poor medication adherence
Family problems
Homelessness
Higher overall service costs
Higher overall risk of untoward incidents
Dr Tara O'Neill and Dr Liz Hughes
Aetiological Theories
(Mueser, 1998)
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Common causal factor
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Mental illness causes substance use
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Higher rates in people with mental illness
Are people self-medicating symptoms (Khantzian, 1985)?
Brunette (1997) no relationship between symptoms and drug of choice
Substance use causes mental illness
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Genetics
Family background
Conduct disorder in childhood
Substance use can cause temporary organic states that mimic mental
illness
No evidence that substance use causes long term mental illness
More likely that it exacerbates or triggers off (Johns, 2001)
Bi-directional- one influences course of the other
Dr Tara O'Neill and Dr Liz Hughes
How do drugs and alcohol fit
with risk?
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Intoxication- accidents, impaired judgements
Craving- increased irritability, inability to cope
Withdrawal- compulsion to obtain more, physical
risks
Life-style and social context
Impulsivity
Decreased adherence to medication….worsening of
psychotic symptoms
Treatment drop-out
Dr Tara O'Neill and Dr Liz Hughes
Challenges for People with
Serious Mental health problems
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Cognitive impairments
 Sedation from medication
 Management of side-effects
 Poor coping skills
 Hopelessness
 Social factors-peer group influences
 Ignorance re health risks
(Bellack and Diclemente, 1999)
Dr Tara O'Neill and Dr Liz Hughes
Self-medication
The use of substances to alleviate painful or
uncomfortable emotional or physical states.
 Negative symptoms of psychosis (apathy,
flattened affect, slowed thoughts)
 Side-effects of medication (EPSE, akathisia,
neuroleptic dysphoria)
 General distress as a result of having a chronic
illness (boredom, loneliness, distressing
symptoms)
Dr Tara O'Neill and Dr Liz Hughes
Key Policy Drivers 2009
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National Service Framework- Good Practice
Guidelines (2002)
Avoidable Deaths (2006)
Themed Review report (2008)
HCC In Patient Service Review (2008)
NHSLA Risk Management Standards(2008)
New Horizons…..
Bradley Report (2009)
Dr Tara O'Neill and Dr Liz Hughes
Department of Health
Mental Health Policy Implementation Guide
Dual Diagnosis Good practice Guidelines 2002
Dr Tara O'Neill and Dr Liz Hughes
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Substance use is usual rather than exceptional
in people with mental illness
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People with dual diagnosis have a right to
access good quality, patient focused and
integrated care
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This should be delivered within mental health
services: “mainstreaming”
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This is to prevent patients being shunted from
one service to another
Dr Tara O'Neill and Dr Liz Hughes
 This
should not reduce role of substance
misuse services- they will still provide care
for substance users and advise on
substance related issues
 Services
need to identify and respond to
local need
 Specialist
workers should provide support
to mainstream
Dr Tara O'Neill and Dr Liz Hughes
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All AOT should be equipped to work with DD
 Adequate staff in crisis resolution, cmht and
inpatient mental health services should be
suitably trained
 All health and social care economies should
map services and need
 All services including drug and alcohol should
ensure that this client group are subject to CPA
and have full risk assessment.
Dr Tara O'Neill and Dr Liz Hughes
 …….so
what works?
Dr Tara O'Neill and Dr Liz Hughes
Evidence Base
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Cochrane Reviews (2004, 2008)
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MIDAS RCT- CBT and MI
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Nice Clinical Guideline Development Group
beginning 2009
Dr Tara O'Neill and Dr Liz Hughes
Key Approaches
 Principle
elements of Integrated Model
 Motivational Interviewing
Principles/techniques
 Relapse Prevention
 Psychosocial Interventions for Psychosis
 Harm Minimisation
 Stress-Vulnerability Hypothesis
 CBT
Dr Tara O'Neill and Dr Liz Hughes
Process of Change
(Prochaska, DiClemente, & Norcross 1992)
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Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Spiralling around
stages
Dr Tara O'Neill and Dr Liz Hughes
Four Stage Model
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ENGAGEMENT
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PERSUASION
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ACTIVE
TREATMENT
 RELAPSE
PREVENTION
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Osher and Kofoed (1989)
PRECONTEMPLATION
CONTEMPLATION
PREPARATION
ACTION
MAINTAINANCE
RELAPSE/
ABSTINENCE
Prochaska and DiClemente
Dr Tara O'Neill and Dr Liz Hughes
Integrated Model (USA)
 Comprehensiveness
 Stage
wise
 close monitoring
 shared decision making
 assertive outreach
 pharmacotherapy
Dr Tara O'Neill and Dr Liz Hughes
What do AOT’s need to deliver
comprehensive care packages
to people with ‘dual
diagnosis’?
Dr Tara O'Neill and Dr Liz Hughes
The 10 ESC’s
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10.
Working in Partnership
Respecting Diversity
Practising Ethically
Challenging Inequality
Promoting Recovery
Identifying Peoples Needs and Strengths
Providing service user centred care
Making a difference
Promoting Safety and positive risk-taking
Personal Development and learning
Dr Tara O'Neill and Dr Liz Hughes
What are Competencies
 Describe
good practice
 To measure performance
 The coverage and focus of a service
 The structure and content of educational
and training and related qualifications
Dr Tara O'Neill and Dr Liz Hughes
What is a Capability?
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5.
A performance component (what people need
to possess)
A ethical component (integrating a knowledge
of culture, values, and social awareness into
practice)
Reflective Practice
Capability to effectively implement evidence
based practice
Commitment to working with new models of
professional practice and responsibility for lifelong learning.
(SCMH 2001)
Dr Tara O'Neill and Dr Liz Hughes
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Competence
 Having a factual
knowledge of how to
do somethingpractical level
 Effectiveness at an
individual level
 Ability to perform
duties to a set
standard
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Capability
 Relate knowledge to
practice- within a
given context
 Strength within the
individual- self
awareness, managing
the most difficult
situations/people
 Organisational level
capabilities
Dr Tara O'Neill and Dr Liz Hughes
Therefore a capability
encompasses competence
but is wider in its scope as
it covers attitude,
application of theory and
values to practice, and is
reflective- it is simply the
individuals ability to apply
the competence in practice
Dr Tara O'Neill and Dr Liz Hughes
What is the purpose of a capability
framework?
 Building
teams/roles- hire people with
those required capabilities (plan training)
 Benefit service users- would be working
with someone who understands and is
more effective an individual level
 Improve outcomes for service users
Dr Tara O'Neill and Dr Liz Hughes
The Knowledge and Skills
Framework (DH, 2003)
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Covers all workers in the NHS
Not mental health specific
Single explicit framework by which all NHS workers can
be reviewed and developed=Agenda for Change
Describes the knowledge and skills the individual needs
to apply in a specific role
It is about application of knowledge and skills not the
knowledge and skills the individual may possess
The MHNOS describes the knowledge and skills more
precisely
Dr Tara O'Neill and Dr Liz Hughes
How it all fits!
Dr Tara O'Neill and Dr Liz Hughes
Capabilities Framework for Dual
Diagnosis
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Level 1 CORE
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Level 2 Generalist
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Aimed at all workers in contact with this service user
group e.g. primary care workers, A & E staff, nonstatutory agency workers
Generic post-qualification workers in non-specialist
roles (secondary and tertiary care) e.g. community
mental health workers, substance misuse workers
Level 3 Specialist
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those people in senior roles that have specific
experience or qualifications, a special interest, or
specific role in dual diagnosis, and who have a
practice development, and/or training remit related to
dual diagnosis Dr Tara O'Neill and Dr Liz Hughes
The Framework
Values
 Role legitimacy
 Therapeutic optimism
 Acceptance of the uniqueness of each
individual
 Non-judgemental attitude
 Demonstrate empathy
Dr Tara O'Neill and Dr Liz Hughes
Utilising Knowledge and Skills
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Engagement
Interpersonal skills
Education and health
promotion
Recognise needs
(assessment)
Risk assessment and
management
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Ethical legal and
confidentiality issues
 Care planning in
partnership with service
user
 Delivering evidence and
values based
interventions
 Evaluate care
 Help people access help
from other services
 Multi-agency/professional
working
Dr Tara O'Neill and Dr Liz Hughes
Practice Development
 Learning
Needs
 Seek out and use supervision
 Commitment to life-long learning
Dr Tara O'Neill and Dr Liz Hughes
KSF
Dual Diagnosis Capability
Core 1-communication
7-interpersonal skills
6-engagement
Core 2-personal and people development
18-seek out and use supervision
17- learning needs, 2-therapeutic optimism
19-life-long learning 1- Role legitimacy
Core 6-Equality and Diversity
11-ethical and legal issues
3-acceptance of uniqueness of each individual
4-non-judgemental attitude
5-demonstrate empathy
HWB1- promotional of health and wellbeing
8-education and health promotion
HWB2- assessment and care planning to
meet health and well-being needs
9-recognise need
10 risk assessment and risk management
14-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 user
13 delivering evidence based interventions
G7Capacity and Capability
16- Multi-agency and multi-professional working
Dr Tara O'Neill and Dr Liz Hughes
How do you create a capable
workforce/ team?
2002 Good Practice guide: “mainstreaming”
 Workforce need to be equipped with capability to
deliver effective care for dual diagnosis
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BUT: workforce lack skills, knowledge and
attitudes
SO: training in dual diagnosis interventions to be
developed and made available to mental health
and substance use staff.
Dr Tara O'Neill and Dr Liz Hughes
The problems with training
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Lots of training delivered; little formal evaluation
beyond trainee satisfaction
 From research, there is limited evidence that
training in dual diagnosis interventions has
significant effect on service user outcomes
(COMO, CODA, COMPASS)
 Trainees demonstrate some gains on attitude,
knowledge and self-rated skills, but capabilities
not measured
Dr Tara O'Neill and Dr Liz Hughes
COMO and CODA evaluation
 Attitudes
towards working with drinkers
and drugs users
 Dual Diagnosis Attitudes
 Self-efficacy- how confident they felt about
delivering key skills
 Knowledge About Dual Diagnosis
 Maslach Burn-out Scale
 Minnesota Job satisfaction Scale
Dr Tara O'Neill and Dr Liz Hughes
Predictors of Attitude (CODA)
 AAPPQ
total scores- length of substance
use experience and number of relevant
study days
 Self-efficacy- length of substance misuse
experience
 DD attitudes- number of study days
 Knowledge- no predictors
Dr Tara O'Neill and Dr Liz Hughes
Dual Diagnosis Training
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Training needs to increase therapeutic
commitment by:
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Increase peoples motivation
Increase skills and knowledge (and self-esteem)
Sense of job satisfaction
The right to work with substance use
(Role support may be beyond scope of a training
programme alone: supervision and support
afterwards.)
Dr Tara O'Neill and Dr Liz Hughes
Does the 5 day training do
this?
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The answer is: partly!
The COMO and CODA have shown that the 5 day
course increases:
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AAPPQ composite score (CODA only)
Adequacy of knowledge and skills (COMO and CODA)
Expectation of job satisfaction (CODA only)
Role support (CODA only)
Self-esteem about working with drinkers (COMO and CODA)
Overall, the CODA findings suggest that whole team
training could be a more effective method of increasing
attitudes to DD.
Dr Tara O'Neill and Dr Liz Hughes
What the training doesn’t
affect
 Role
legitimacy
 Motivation to work with substance users
 These
are important attitudes to shift in
mental health services if mainstreaming is
to work!
 These may require service and
organisational changes in attitude, not just
the responsibility of the training.
Dr 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’.
Dr Tara O'Neill and Dr Liz Hughes