Why do we persist with the term ‘Dual Diagnosis’ within mental health services?

1. Why do we persist with the term ‘Dual Diagnosis’ within mental health services? 24th October 2012. Christian Guest. Dual Diagnosis Lead (RDaSH)

2. Supporting multiple needs within contemporary practice • Policy implementation guide (2002) - mainstreaming of co-existing difficulties • Individuals may be excluded on ‘Dual Diagnosis’ term alone • ‘Dual Diagnosis’ term has perhaps become obsolete • Can we argue co-existing difficulties are supported within mainstream services? • Need to consider the unintended consequences?

3. Dual Diagnosis- more than two parts

4. Advantages of the term ‘Dual Diagnosis’ (DOH ,2002) • Provided a working definition and scope of Dual Diagnosis • Promoted the national agenda • Promoted the policy of mainstreaming • Promoted the need for collaboration • Highlighted the need to support co-existing difficulties

5. Disadvantages of ‘Dual Diagnosis’ • 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 needs- from primary care to inpatient services.

6. Prevalence rate of co- existing difficulties • Weaver et al., (2002) 44% Service user’s in CMHT had dual diagnosis- • 75% 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.

7. Spectrum of co-existing difficulties

8. Exclusion from services • 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”

9. Recovery based mental health • 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?

10. Psychosocial influences of substance misuse • Complex relationship between mental health and substance misuse (Wu et al, 2010, Klanecky & McChargue, 2009,) • Alexander (1987, 1990)- explores ‘Adaptive model’ of addiction • It is ‘adaptive’ to choose a ‘lesser evil’- reduce voices by excessive alcohol consumption • 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.

11. Cycle of reinforcement

12. Deliberate self injury • Employed to attempt to alleviate psychological distress (adaptive) • 150,000 attendances at general hospital (Hughes& Kosky ,2007) • 4 in 1000 people (Royal College of Psychiatrist report ,2010) • Self injury not given separate terminology • Self injury supported by mental health services culturally

13. Developing a capable workforce • Dual Diagnosis Capability framework (Hughes, 2006) • Tenessential Shared Capabilities (Hope 2004) • Promoting recovery, working in partnership, client centred ... • How does this translate to everyday practice? • Organisational culture should accommodate and recognise complex psychosocial factors • Requires clinical leadership within services

14. ‘5key principles’ • 5 key principles to support a spectrum of co-existing difficulties • Actively de-emphasis the term ‘Dual Diagnosis’ • Ability to express empathy-compassion, hope, creativity will promote inclusion and acceptance • Adapt intervention according to the individuals readiness to (M.I) • -principles of M.I labels considered unnecessary obstacles for change

15. ‘5key principles’ • ‘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

16. To consider. . . • Dual Diagnosis not exclusive to one service • No one single identity- significant spectrum of needs & circumstances • Existing mental health provision can support a spectrum of needs (primary care- AOS , in-patient) • Continues to remain gaps, inconsistent service provision, exclusion, stigma • Practitioner’s confidence, attitude & competence significantly influence intervention and inclusion/exclusion

17. Concluding thoughts ... • ‘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

18. Thank you. • christian.guest@rdash.nhs.uk • 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.