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Closing the Gap A C A P A B I L I T Y F R A M E W O R K F O R
W O R K I N G E F F E C T I V E L Y W I T H
P E O P L E W I T H C O M B I N E D M E N T A L
H E A L T H A N D S U B S T A N C E U S E
P R O B L E M S ( D U A L D I A G N O S I S )
Liz Hughes
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Dual Diagnosis Framework
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ACKNOWLEDGEMENTS
Firstly we would like to thank Ann Gorry and Tom Dodd, CSIP joint national lead for
dual diagnosis, for prioritising this piece of work within the national programme and
providing resources for the development of this capability framework.
We would also like to acknowledge the contributions of the working party for this
project and thank them for their time, enthusiasm and useful feedback.
Dr Tara O’Neill
Professor Ian Baguley
Ian Hamilton
Sharon Walker
Mandy Barrett
Tabitha Lewis
David Manley
Sean McDaid
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Closing the Gap
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CONTENTS
Executive Summary 4
Background 5
Methodology 12
The Structure of the Framework 13
Using the Capability Framework 14
References 16
Dual Diagnosis Capability Framework 18
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Dual Diagnosis Framework
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EXECUTIVE SUMMARY
PURPOSE
The purpose of the dual diagnosis framework is to assist in the implementation of the
Department of Health Dual Diagnosis Practice Implementation Guide (2002). This policy
document highlights the roles and responsibilities of the various agencies in providing
care for people with dual diagnosis. The main thrust of the policy was that care for those
with serious mental illness and substance use should be provided by the mental health
services (mainstreaming). The policy also highlights the training and service
developments that will be required to implement this in practice. This represents the
first time that capabilities for working with combined mental health and substance use
problems have been clearly identified and defined.
MAINSTREAMING
The mental health service has the primary responsibility to provide comprehensive care
for people with serious mental illnesses such as schizophrenia and co-morbid substance
use problems. The rationale for this is that the mental health service is better placed to
offer services such as assertive outreach, crisis management and long term care than
the substance misuse services. In addition, it is expected that substance use services
should support mental health services in this endeavour.
CHARACTERISTICS OF THE FRAMEWORK
The framework is divided into three sections: values and attitudes, utilising knowledge
and skills and practice development. There are three levels to the each capability: core,
generalist, and specialist.
THE AIM OF THE FRAMEWORK
The aim of the framework is to establish the core competencies required to deliver
effective care for people with combined mental health and substance use problems.
This framework covers all staff that comes into contact with this service user group in a
range of settings.
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BACKGROUND
People with combined mental health problems represent a third of mental health
service users (Menezes, et al 1996), half of substance use service users (Weaver et al,
2001), and 70% of prisoners (ONS 1997).
The most commonly used substances by those with serious mental illness are alcohol,
cannabis and stimulants. Very few are actually physically dependent, but their use of
substances often exacerbates problems with their mental state, finances, legal issues
and poor engagement with services. Their needs are high and treatment outcomes
are poor. Rather than seeing people with dual diagnosis as having two main problems,
it may be more useful to acknowledge that they have complex needs including physical
health, social issues such as housing, relationship and family problems, risk of suicide,
victimisation and violence. They face social exclusion and often have difficulty
accessing appropriate services due to their complex presentations. One of the main
problems is the lack of skills and knowledge in the workforce to address their complex
needs in an integrated and effective way.
The dual diagnosis capabilities framework has sought to identify the core skills, values,
knowledge and attitudes for working with dual diagnosis in any care setting. It has
been developed within a context of radical changes within mental health and
substance use services. However, despite these changes, there has been little
attention given to the needs of people who need help from both services.
Rather than seeing people with dual diagnosis as
having two main problems, it may be more
useful to acknowledge that they have
complex needs
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MENTAL HEALTH SERVICE DEVELOPMENT
The NHS and care services are undergoing a massive modernisation process. Mental
health care has been targeted as one of the key priorities for improvement of care.
The NHS plan (2000) outlined specific plans to strengthen mental health community
care which in turn would reduce the burden on mental health inpatient services. This
has led to the implementation of a range of new services and led to a changing of
roles within the service and creation of new roles. In addition, social and health care
services have merged which has led to multi-disciplinary teams. The emphasis is now
on the capabilities of a person to perform their role effectively and deliver targets set
by the National Service Framework for mental health (1999), as opposed to their
professional background. The mental health practitioner is now working in rapidly
changing diversifying environment, and requires increasingly comprehensive
capabilities.
In accordance with this shift of focus, a number of capability and competency based
frameworks have been developed. These seek to establish and define what people in
mental health and substance use services should be capable of doing in order to meet
service targets. In addition they should be able to standardise what people do in
various roles across the organisations and in different geographical locations.
A capability is defined as having five dimensions:
1. A performance component (what people need to possess)
2. An ethical component (integrating a knowledge of culture, val-
ues, and social awareness into practice)
3. Reflective Practice
4. Capability to effectively implement evidence based practice
5. Commitment to working with new models of professional prac-
tice and responsibility for life-long learning (SCMH, 2001)
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The Knowledge and Skills Framework (2003) sets out the skills required to
perform a role within the NHS. It is divided into 30 dimensions of which 6 are core.
These are
1. Communication
2. Personal safety
3. Health
4. Safety and security
5. Service improvement
6. Quality
7. Equality and diversity.
The other 24 are grouped into health and well-being, estates and facilities,
information, and knowledge and general. Each dimension has four levels, and each
level has indicators to describe how knowledge and skills need to applied at that level.
Job descriptions will be developed from these dimensions and levels according to the
needs of the post.
The National Occupational Standards for Mental Health (MHNOS)
(2004) sets the performance standards for delivery of care. It is used to identify the
skills and knowledge that a person possesses and also what they need to obtain in
order to develop professionally within their role, or to progress to a new role. In
addition, the standards can be used to design and evaluate skills-based training
courses.
The Capable Practitioner Framework (CFP) (2001) was developed by the
Sainsbury Centre and sought to identify a broad unifying framework that encompassed
the broad set of skills, knowledge attitudes required by the mental health workforce to
deliver the NSF standards. It was developed from identifying the key tasks that mental
health professionals performed in a number of professions and roles. The Capable
practitioner helps outline what is required to be competent whereas the MHNOS acts
as a performance indicator of that competence in the work environment. The CPF
seeks to broadly define what is required to deliver effective mental health care rather
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than focus on which profession should do this, and the CFP doesn’t seek to promote
the rise of the generic mental health worker. The CFP is divided into 5 main areas:
ethical practice, Knowledge of mental health and services, the process of care,
interventions, and applications to specific service settings (such as Assertive Outreach,
acute inpatient care, primary care, and services for complex needs, such as dual
diagnosis). Each area has a set of statements of capability for mental health practice
and mapped to the NSF standards it applies to.
The Ten Essential Shared Capabilities (SCMH/NIMHE 2004) were
developed to build on the Capable Practitioner Framework, and its focus is on the core
capabilities that all staff no matter what their professional background or role should
be working from. These were developed to address the significant gaps in pre and
post qualification training in their ability to deliver on MHNSF and NHSP. These were
areas such as user and carer involvement, mental health promotion, values and
evidence based practice, working with families, multidisciplinary working and working
with diversity.
People with dual diagnosis will
present with differing needs depending on the
level of severity of their mental health
and substance use problems
SUBSTANCE MISUSE SERVICE DEVELOPMENTS
The Healthwork UK report “A competent workforce to tackle substance
misuse” (2001) identified serious shortfalls in the ability of the substance use
workforce to provide an effective substance misuse service. In 2001, the government
established a special health authority, The National Treatment Agency (NTA) to
improve the capacity, availability, and effectiveness of drug misuse treatment in
England. The NTA (2002) published Models of Care which outlines how services for
people with substance use should be mapped and delivered, and sets standards of
care. In addition, two important government strategies are driving change within
substance use services. The first is the Updated Drug Strategy (2002) which has four
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Closing the Gap
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broad aims. The first is to prevent drug use beginning in young people, the second is
to reduce the availability of drugs on the street, the third is to reduce drug related
crime, and reduce the number of problematic drug users by providing effective
treatment and rehabilitation. The Alcohol Harm Reduction strategy (2004) aims to
start the process of changing the culture around drinking, for services to be better at
detecting and treating alcohol misuse, to prevent and tackle drug related crime, and
work with the alcohol industry in tackling alcohol related harm. These two strategies
require a workforce strategy that will increase the number of competent workers,
increase their range of skills, and increase their levels of knowledge and skills. The
Drug and Alcohol National Occupational Standards (DANOS) sets out to identify these
requirements in detail and can be used for the creation of job descriptions, training,
appraisal and promotion. The standards are based around three key areas: service
delivery, management and commissioning. Each standard is mapped to the
Knowledge and Skills Framework.
DUAL DIAGNOSIS SERVICE DEVELOPMENTS
Despite the proliferation of policies for the development of mental health and
substance use services, there is little mention in any of these strategies about the
capabilities required of workers in mental health and substance use services to be
able to deliver effective care for people who require both mental health and substance
use interventions (dual diagnosis).
The Department of Health (2002) published the Dual Diagnosis Practice
Implementation Guide which advocates that care for people with serious mental health
problems and substance use should be “mainstreamed” by being provided primarily by
mental health services. The rationale for this is that mental health services are better
placed to offer the intensity of input such as crisis management, assertive outreach,
close monitoring and inpatient care that people with dual diagnosis require. However,
this doesn’t mean that there isn’t a role for substance use services. They are expected
to provide advice support, and if appropriate, joint work to assist the mental health
service provide care for dual diagnosis. It is expected though that they will concentrate
their resources on those people who have severe substance use problems, some of
whom may have mental health problems as well.
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Dual Diagnosis Framework
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People with dual diagnosis will present with differing needs depending on the level of
severity of their mental health and substance use problems (see figure 1).
Identification of these needs will assist in determining which service is better suited to
be the primary care provider. For example, someone with alcohol dependency who
experiences anxiety may be best served by the local alcohol service, and someone with
schizophrenia who smokes cannabis occasionally may be best served by the local
community mental health service.
Figure 1: Scope of Substance use and mental health problems in people with dual
diagnosis (from Department of Health Dual Diagnosis Good Practice Guide, 2002,
p10)
However, in order for mainstreaming to be effective, mental health workers will be
required to deliver effective integrated interventions which are a combination of
approaches from substance use and mental health including screening and detection,
comprehensive assessment, motivational interventions, and relapse prevention (Drake
et al, 1998). Therefore the mental health workforce will need to be capable of
delivering effective evidence based care for people with dual diagnosis. However,
recent surveys have demonstrated that the workforce lacks training and experience in
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Closing the Gap
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substance use and dual diagnosis capabilities (Maslin et al 2001, Brewin, 2004).
Substance use services are expected to have primary responsibility for substance
misusers with mild to moderate mental health problems, but many workers in this field
may lack skills and knowledge around mental health issues, especially if they have no
mental health work experience.
In order to address these deficits, the Dual Diagnosis Practice Implementation Guide
suggests that the workforce have access to appropriate training and practice
development that will increase their capabilities to work effectively with dual diagnosis.
In order to do this, it is essential that the specific capabilities to work with dual
diagnosis are defined so that training and professional development can be
implemented in a uniform fashion with fidelity to the evidence base as it currently
stands.
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METHODOLOGY
This framework has been developed collaboratively with representatives from a
number of key stakeholders. An initial draft of the capabilities was developed by a
small working party (TO, LH, AG) based on expert opinion about best practice (Jeffery
et al 2000), the Dual Diagnosis Good Practice Guidelines (DH 2002) and the evidence
base from the literature (Drake et al 2001, Ley et al 2000, Barrowclough et al 2001).
In order for mainstreaming to be
effective, mental health workers will be required to deliver effective integrated
interventions which are a
combination of approaches from substance
use and mental health
A national working party was established that included representatives from key
organisations. This included Care Services Improvement Programme, Higher Education
establishments (University of Lincoln, Middlesex University, and University of York),
Turning Point, dual diagnosis nurse consultants and dual diagnosis leads from NHS
services, and the Sainsbury Centre for Mental Health. The group met and discussed
the draft in detail and this was then developed into a final draft based on those
comments.
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THE STRUCTURE OF THE FRAMEWORK
The framework is divided into 3 sections: Values, Utilising Knowledge and Skills, and
Practice Development. Within each section, there is a list of capabilities relevant to
that area. Each capability is defined on three levels of competence.
Level 1: Core
Service User 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.
This level is 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, and friends
Level 2: Generalist
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.
This level is 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.
Level 3: Specialist
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.
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USING THE CAPABILITIES FRAMEWORK
The framework can be used in any arena where it would be useful to identify and
develop individual’s capabilities to work effectively with people with serious mental
illness and combined substance use problems. It is can be used as part of the
appraisal system, as part of clinical supervision and for developing the content of a
training course. Participants should be encouraged to self-assess their capabilities
and compare this with how they have been assessed by their supervisor. Areas that
require development would then form part of an overall development plan which may
include for example further training, supervision, or mentoring.
In addition each capability has been mapped to the most relevant competency in the
Knowledge and Skills Framework, the Drug and Alcohol National Occupational
Standards, the Mental Health National Occupational Standards, and the Ten Essential
Shared Capabilities.
1. TRAINING
All dual diagnosis training, no matter what level it is being delivered at, should be able
to map its contents to the capabilities framework, and include various methods of
assessment of those capabilities within the training course. Examples could be
practical exercises within the course e.g. role play and case study exercises, and also
by academic processes such as essays, projects, and dissertations as appropriate.
2. ASSESSMENTS IN THE WORKPLACE
Supervisors could use the framework to assess the capability of the worker. This could
be assessed within supervision sessions, observation of working practices and service
user feedback. Using the framework in this way may also identify learning needs and
a plan for the meeting those needs (either by training, and/or practice development)
could be devised. There is an assessment form that has been developed for this
purpose and can be found in the appendix.
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3. DEVISING JOB DESCRIPTIONS
The capabilities framework could also be used to devise job descriptions at all levels
and across professional boundaries. Employers can pull together a set of capabilities
that are most relevant for the role and the level of capability required.
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REFERENCES Alcohol Concern (2004) National Alcohol Harm Reduction Strategy www.alcoholconcern.org.uk Brewin (2004) Sharing the Knowledge. Mental Health Today. July/August, p 24-26 Department of Health (2001) the Drug and Alcohol National Occupational Standards Department of Health (1999) National Service Framework for Mental Health Department of Health (2000) The NHS Plan Department of Health (2002) Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. DH publications www.dh.gov.uk Drake, R.E., Mercer-McFadden, C., Mueser, K.T., McHugo, G.J. and Bond, G.R. (1998) A Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, volume 24(4), p589-608 National Treatment Agency for Substance Misuse (2002) Models of Care for Substance Misuse Treatment Department of Health (2003) Knowledge and Skills Framework. DH publications www.dh.gov.uk Department of Health (2004) Mental Health Occupational Standards Department of Health (2004) The Ten Essential Shared Capabilities- A Framework for the Whole of the Mental Health Workforce. Department of Health (2005) The National Service Framework- 5 Years on. Healthwork UK (2001) A Competent Workforce to Tackle Substance Misuse: An Analysis of the Need for National Occupational Standards in the Drugs and Alcohol Sector. http://www.skillsforhealth.org.uk Home Office (2002) Updated Drug Strategy 2002 Jeffery, D., Ley, A., Bennun, I., McClaren, S. (2000) Delphi survey of opinion on interventions, service principles, and service organisation for severe mental illness and substance misuse problems. Journal of mental Health, 9(4), p371-384 Ley, A., Jeffery, D., Mclaren, S. and Siegfried, N (2002) Treatment programmes for people with both severe mental illness and substance misuse (Cochrane Review). In: the Cochrane Library, issue 2, 2002. Oxford Maslin, J., Graham, H., Cawley, M., Copello, A., Birchwood, M., Georgiou, G., McGovern, D., Mueser, K.T., and Orford, J. (2001) Combined severe mental health and substance use problems: what are the training and support needs of staff working with this client group?
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Journal of Mental Health, 10, 131-140 Menezes, P.R., Johnson, S., Thornicroft, G., Marshall, J. Prosser, D., Bebbington, P., and Kuipers, E (1996) Drug and Alcohol Problems Amongst Individuals with Severe Mental Illness in South London. British Journal of Psychiatry. 168, 612-619 Office of National Statistics (ONS) (1997) Morbidity in Prisons. HMSO publications Sainsbury Centre for Mental Health (2001) The Capable Practitioner. www.scmh.org.uk Weaver, T., Hickman, M., Rutter, D., Ward, J., Stimson, G and Renton, A (2001) The prevalence and management of co-morbid substance misuse and mental illness: Results of a screening survey in substance misuse and mental health treatment populations. Drug and Alcohol Review, 20, 407-416
RELEVANT ORGANISATIONS AND FURTHER INFORMATION
Centre for Clinical and Academic Workforce Development (University of Lincoln) www.lincoln.ac.uk/ccawi Department of Health www.dh.gov.uk Home Office www.drugs.gov.uk National Institute for Mental Health (Care Services Improvement Partnership) www.csip.org.uk National Treatment Agency www.nta.nhs.uk Rethink www.rethink.org.uk Skills for Health www.skillsforhealth.org.uk Sainsbury Centre for Mental Health www.scmh.org.uk Turning Point www.turningpoint.org.uk
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Dua
l Dia
gnos
is C
apab
ilitie
s Fr
amew
ork
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty F
ram
e-w
ork
refe
ren
ce
Cro
ss r
efer
ence
w
ith
in D
D f
ram
ewor
k
V
alu
es
1 Ro
le le
gitim
acy
“it
is p
art
of m
y ro
le
to w
ork
with
peo
ple
with
com
bine
d m
enta
l hea
lth a
nd
subs
tanc
e us
e pr
ob-
lem
s”
Rec
ogni
se t
hat
it is
a
part
of
ones
ow
n ro
le t
o of
fer
a co
ntrib
utio
n to
-w
ards
the
car
e of
som
e-on
e w
ith c
ombi
ned
men
tal h
ealth
and
sub
-st
ance
use
pro
blem
s
Rec
ogni
se a
nd a
c-ce
pt t
hat
wor
king
w
ith p
eopl
e w
ith
dual
dia
gnos
is is
a
rout
ine
part
of
ones
ro
le
Prom
ote
the
mes
-sa
ge t
hat
all w
orke
rs
shou
ld b
e pl
ayin
g a
part
in t
he c
are
of
peop
le w
ith d
ual
diag
nosi
s ho
wev
er
big
or s
mal
l the
con
-tr
ibut
ion
Chal
leng
ing
Ineq
ual-
ity, M
akin
g a
Diff
er-
ence
, Wor
king
in
Part
ners
hip
(ESC
)
Lear
ning
nee
ds, s
uper
vi-
sion
and
sup
port
M
ulti-
disc
iplin
ary
wor
k-in
g
2 Th
erap
eutic
opt
i-m
ism
“I
bel
ieve
tha
t po
si-
tive
chan
ges
are
poss
ible
for
any
one
with
com
bine
d m
enta
l hea
lth a
nd
subs
tanc
e us
e”
Rec
ogni
se t
hat
chan
ge
for
peop
le w
ith d
ual
diag
nosi
s is
diff
icul
t bu
t no
t im
poss
ible
, and
co
mm
unic
ate
this
to
the
serv
ice
user
, the
ir ca
rers
an
d ot
her
prof
essi
onal
s
Be a
ble
deve
lop
and
mai
ntai
n th
era-
peut
ic o
ptim
ism
and
a
sens
e of
hop
e an
d ge
nera
te t
his
in
the
serv
ice
user
, th
eir
care
rs a
nd
othe
r pr
ofes
sion
als.
Rol
e m
odel
the
ra-
peut
ic o
ptim
ism
, en
cour
age
othe
rs t
o se
e po
sitiv
e ch
ange
s
Prom
otin
g Rec
over
y (E
SC)
Lear
ning
nee
ds, s
uper
vi-
sion
and
sup
port
3 Ac
cept
ance
of
the
uniq
uene
ss o
f ea
ch
indi
vidu
al
See
the
pers
on a
s a
who
le n
ot ju
st in
ter
ms
of “
two
prob
lem
s”, o
r in
te
rms
of t
heir
race
, cul
-tu
re, s
exua
lity,
age
, ge
nder
, or
disa
bilit
y
Be a
ble
to a
ccep
t th
e pe
rson
as
a un
ique
indi
vidu
al
and
resp
ect
thei
r ch
oice
s an
d lif
esty
le
Rol
e m
odel
ling
un-
cond
ition
al a
ccep
-ta
nce
of t
he in
divi
d-ua
l to
othe
r w
orke
rs
care
rs a
nd s
ervi
ce
user
s th
emse
lves
Res
pect
Div
ersi
ty,
Prom
otin
g Rec
over
y (E
SC)
Empa
thy
supe
rvis
ion
19
Closing the Gap
Page 19
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty
Fram
ewor
k re
f-er
ence
Cro
ss r
efer
ence
w
ith
in D
D f
ram
e-w
ork
4 N
on-j
udge
men
tal
attit
ude
Be a
ble
to a
ccep
t pe
ople
w
ith d
ual d
iagn
osis
as
they
are
and
val
ue t
hem
as
indi
vidu
als
Be a
war
e of
one
s ow
n at
titud
es a
nd
valu
es in
rel
atio
n to
du
al d
iagn
osis
and
be
abl
e to
sus
pend
ju
dgem
ent
whe
n w
orki
ng w
ith s
er-
vice
use
rs, a
nd
care
rs.
Chal
leng
e ot
hers
’ att
itude
s in
an
app
ropr
iate
and
us
eful
man
ner
Rol
e m
odel
ling
non-
judg
emen
tal a
ttitu
des,
an
d as
sist
oth
ers
in
expl
orin
g th
eir
own
attit
udes
and
hel
p th
em t
o de
velo
p a
non-
judg
emen
tal a
p-pr
oach
Prac
ticin
g Et
hica
lly
(ESC
) En
gage
men
t Su
perv
isio
n
5 D
emon
stra
te e
mpa
-th
y To
be
able
to
unde
rsta
nd
the
curr
ent
and
past
diff
i-cu
lties
tha
t a
pers
on w
ith
dual
dia
gnos
is m
ay h
ave
expe
rienc
ed
To b
e ab
le t
o un
-de
rsta
nd t
he u
niqu
e ex
perie
nces
a p
er-
son
with
dua
l dia
g-no
sis
may
hav
e ha
d, a
nd b
e ab
le t
o co
mm
unic
ate
this
un
ders
tand
ing
ef-
fect
ivel
y an
d em
-pa
thic
ally
to
serv
ice
user
s, a
nd t
heir
care
rs
To b
e ab
le t
o ed
ucat
e ot
hers
in t
he u
nder
-st
andi
ng o
f th
e co
m-
plex
his
tory
and
nee
ds
of t
his
clie
nt g
roup
in
orde
r to
gen
erat
e em
-pa
thic
res
pons
es in
ot
hers
. To
rol
e-m
odel
th
e de
mon
stra
tion
of
empa
thy
Res
pect
Div
ersi
ty,
Prom
ote
Reco
very
(E
SC)
Enga
gem
ent
Inte
rper
sona
l ski
lls
20
Dual Diagnosis Framework
Page 20
U
tilis
ing
Kn
owle
dge
and
Skill
s
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty
Fram
ewor
k re
f-er
ence
Cro
ss r
efer
ence
w
ith
in D
D f
ram
e-w
ork
6 En
gage
men
t Be
abl
e to
use
inte
rper
-so
nal s
kills
and
att
itude
s to
mak
e pe
ople
with
dua
l di
agno
sis
feel
wel
com
e,
and
deve
lop
an e
ffec
tive
wor
king
rel
atio
nshi
p w
ith
a pe
rson
with
dua
l dia
g-no
sis
Be a
ble
to d
evel
op a
n ef
fect
ive
ther
apeu
tic
rela
tions
hip
and
be
able
to
wor
k fle
xibl
y w
ith t
his
clie
nt g
roup
.
Util
ise
crea
tive
stra
te-
gies
to
enga
ge h
ard
to
reac
h se
rvic
e us
ers
in
appr
opria
te s
ervi
ces
Mak
ing
a D
iffer
-en
ce, W
orki
ng in
Pa
rtne
rshi
p, R
e-sp
ect
Div
ersi
ty,
Prom
ote
Reco
very
, Pr
omot
ing
Safe
ty
and
Posi
tive
Ris
k Ta
king
(ES
C)
Ther
apeu
tic O
ptim
ism
, Ro
le le
gitim
acy,
Dem
-on
stra
te e
mpa
thy,
ac-
cept
ance
of
the
uniq
uene
ss o
f ac
h in
di-
vidu
al, N
on-
judg
emen
tal a
ttitu
de,
Inte
rper
sona
l ski
lls
7 In
terp
erso
nal s
kills
Be
abl
e to
dem
onst
rate
ef
fect
ive
inte
rper
sona
l sk
ills
such
as
liste
ning
and
de
mon
stra
te a
ppro
pria
te
beha
viou
r su
ch a
s ho
n-es
ty, g
enui
nene
ss, a
nd a
w
illin
gnes
s to
rel
ate
to
and
help
with
in li
mits
of
own
capa
bilit
ies
and
rem
it of
ser
vice
.
To b
e ab
le t
o de
mon
-st
rate
eff
ectiv
e sk
ills
such
as
activ
e lis
ten-
ing,
ref
lect
ion,
par
a-ph
rasi
ng, s
umm
aris
-in
g, u
tilis
ing
open
-en
ded
ques
tions
, af-
firm
ing,
ela
bora
tion.
To d
emon
stra
te a
nd
role
-mod
el e
ffec
tive
and
adva
nced
inte
r-pe
rson
al s
kills
. T
o be
ab
le t
o te
ach
and
su-
perv
ise
othe
rs in
de-
velo
ping
eff
ectiv
e in
-te
rper
sona
l ski
lls
Prov
idin
g Se
rvic
e us
er le
d ca
re (
ESC)
M
akin
g a
diff
eren
ce
(ESC
) D
ANO
S AB
1 M
HN
OS
HSC
226
, KS
F H
BW4
Enga
gem
ent
Del
iver
ing
Evid
ence
an
d Va
lues
bas
ed in
ter-
vent
ions
8 Ed
ucat
ion
and
heal
th
prom
otio
n Aw
aren
ess
of w
here
an
indi
vidu
al c
an a
cces
s m
ore
in d
epth
adv
ice
abou
t su
bsta
nce
use
and
men
tal h
ealth
.
Be a
ble
to o
ffer
bas
ic
but
accu
rate
and
up
to d
ate
info
rmat
ion
and
advi
ce a
bout
ef
fect
s of
sub
stan
ces
on m
enta
l and
phy
si-
cal h
ealth
and
vic
e ve
rsa.
Be a
ble
to o
ffer
edu
-ca
tion
and
heal
th p
ro-
mot
ion
inte
rven
tions
ac
ross
of
rang
e of
ph
ysic
al a
nd m
enta
l he
alth
issu
es t
o bo
th
serv
ice
user
s an
d ot
her
wor
kers
Prom
ote
safe
ty a
nd
posi
tive
risk
taki
ng
(ESC
)
Life
long
lear
ning
21
Closing the Gap
Page 21
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty F
ram
ewor
k re
fere
nce
Cro
ss r
ef.
wit
hin
DD
fr
amew
ork
9 Rec
ogni
se n
eeds
(I
nteg
rate
d As
sess
-m
ent)
Be a
ble
to p
erfo
rm a
bas
ic
scre
enin
g as
sess
men
t.
In p
artn
ersh
ip w
ith
the
serv
ice
user
, per
-fo
rm a
tria
ge a
sses
s-m
ent
of m
enta
l and
ph
ysic
al h
ealth
, sub
-st
ance
use
, and
soc
ial
func
tioni
ng a
nd o
f-fe
ndin
g; id
entif
ying
bo
th n
eeds
and
st
reng
ths.
Be
abl
e to
id
entif
y w
here
tho
se
need
s ar
e be
st m
et
by lo
cal s
ervi
ces.
Com
preh
ensi
ve a
s-se
ssm
ent
of p
ast
his-
tory
and
cur
rent
ne
eds,
ove
r tim
e in
fu
ll co
llabo
ratio
n w
ith
serv
ice
user
. Be
abl
e to
sup
port
and
tea
ch
othe
rs t
o pe
rfor
m
com
preh
ensi
ve a
s-se
ssm
ent.
Wor
king
in p
artn
ersh
ip,
Iden
tify
peop
les’
nee
ds
and
stre
ngth
s (E
SC)
DAN
OS
AF2
MH
NO
S M
H_1
4,
KSF
HW
B2 H
EALT
H A
ND
W
ELL-
BEIN
G
DAN
OS
AF3
MH
NO
S H
SC41
7 KS
F H
WB2
Inte
rper
sona
l sk
ills,
eng
age-
men
t, A
ccep
-ta
nce
of t
he
uniq
uene
ss o
f ea
ch in
divi
dual
, em
path
y
10
Ris
k as
sess
men
t an
d m
anag
emen
t To
be
awar
e of
pot
entia
l ris
ks in
rel
atio
n to
peo
ple
with
dua
l dia
gnos
is, a
nd
take
app
ropr
iate
act
ion,
be
eff
ectiv
e at
com
mun
i-ca
ting
chan
ges
in a
per
-so
ns’ p
rese
ntat
ion
whi
ch
may
hav
e an
impa
ct o
n ris
k of
har
m t
o se
lf or
ot
hers
Asse
ss r
isks
and
de-
vise
a m
anag
emen
t pl
an in
con
junc
tion
with
ser
vice
use
r an
d ot
her
rele
vant
per
-so
nnel
, ens
ure
that
all
part
ies
are
awar
e of
th
eir
own
role
in r
isk
man
agem
ent
Advi
se a
nd a
ssis
t ot
h-er
s in
the
ass
essm
ent
and
man
agem
ent
of
risks
in r
elat
ion
to d
ual
diag
nosi
s
Prom
otin
g sa
fety
and
po
sitiv
e ris
k-ta
king
(ES
C)
MH
NO
S M
H_1
8 D
ANO
S AB
5 M
HN
OS
HSC
395
KSF
HW
B3
MH
NO
S H
SC41
7,
KSF
HEA
LTH
AN
D W
ELL-
BEIN
G H
WB2
M
HN
OS
MH
_48
KSF
HW
B2
Inte
rper
sona
l sk
ills
Enga
gem
ent
Ethi
cal,
lega
l an
d co
nfid
entia
l-ity
issu
es
22
Dual Diagnosis Framework
Page 22
Uti
lisin
g K
now
ledg
e an
d Sk
ills
con
tin
ued
…
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty F
ram
ewor
k re
fere
nce
Cro
ss r
efer
-en
ce w
ith
in
DD
fra
me-
wor
k
11
Ethi
cal,
lega
l and
co
nfid
entia
lity
issu
es
To b
e aw
are
of a
nd a
d-he
re t
o th
e or
gani
satio
n po
licy
on c
onfid
entia
lity
to
be a
ble
to e
ffec
tivel
y co
m-
mun
icat
e th
is t
o th
e se
r-vi
ce u
ser.
To
be
able
to
seek
adv
ice
abou
t a
po-
tent
ial b
reac
h of
con
fiden
-tia
lity,
or
lega
l iss
ue.
In a
dditi
on, t
o be
abl
e to
man
age
ethi
cal a
nd
mor
al d
ilem
mas
tha
t ar
ise
out
of w
orki
ng
with
peo
ple
with
dua
l di
agno
sis.
Be
aw
are
of c
onfid
entia
lity
lim-
its a
nd b
e ab
le t
o re
solv
e po
tent
ial
brea
ches
of
conf
iden
-tia
lity
in c
onsu
ltatio
n w
ith t
he s
ervi
ce u
ser,
th
eir
care
rs a
nd o
ther
pr
ofes
sion
als
In a
dditi
on, t
o ha
ve
know
ledg
e of
the
eth
i-ca
l and
lega
l iss
ues
rele
vant
to
wor
king
w
ith d
ual d
iagn
osis
, an
d be
abl
e to
pro
vide
ad
vice
abo
ut h
ow t
o re
solv
e sp
ecifi
c di
lem
-m
as w
ithin
the
con
-st
rain
ts o
f th
e le
gal
and
mor
al f
ram
ewor
ks
as w
ell a
s in
acc
or-
danc
e w
ith o
rgan
isa-
tion
polic
ies.
Prac
ticin
g Et
hica
lly, P
ro-
mot
e Sa
fety
and
Pos
itive
Ris
k-ta
king
(ES
C)
Ris
k as
sess
-m
ent
and
man
-ag
emen
t Rec
ogni
sing
N
eeds
Ca
re-p
lann
ing
Mul
ti-ag
ency
w
orki
ng
Supe
rvis
ion
12
Care
Pla
nnin
g in
par
t-ne
rshi
p w
ith s
ervi
ce
user
To c
ontr
ibut
e to
the
pla
n-ni
ng o
f ca
re f
or p
eopl
e w
ith d
ual d
iagn
osis
To b
e ab
le t
o pl
an
and
coor
dina
te c
are
in
colla
bora
tion
with
pe
rson
with
com
bine
d m
enta
l hea
lth a
nd
subs
tanc
e us
e, t
heir
care
rs, a
nd o
ther
pro
-fe
ssio
nals
To b
e ab
le t
o ad
vise
on
the
pla
nnin
g an
d co
ordi
natio
n of
car
e ac
ross
diff
eren
t se
r-vi
ces
and
diff
eren
t ne
eds
Prov
idin
g Se
rvic
e U
ser
led
care
, Wor
king
in P
artn
er-
ship
, Pro
mot
ing
Reco
very
(E
SC)
DAN
OS
AG1
DAN
OS
AI2
MH
NO
S M
H_2
3 KS
F H
WB7
Rec
ogni
sing
N
eeds
In
terp
erso
nal
skill
s M
ulti-
agen
cy/
prof
essi
onal
w
orki
ng
23
Closing the Gap
Page 23
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty F
ram
ewor
k re
fere
nce
Cro
ss r
efer
-en
ce w
ith
in
DD
fra
mew
ork
13
Del
iver
ing
evi-
denc
e an
d va
l-ue
s ba
sed
inte
r-ve
ntio
ns
Del
iver
hig
h qu
ality
car
e w
ithin
the
lim
its o
f on
es
own
capa
bilit
ies,
rol
e, a
nd
capa
city
of
orga
nisa
tion
Be a
ble
to u
tilis
e kn
owl-
edge
and
ski
lls t
o de
liver
ev
iden
ce-b
ased
inte
rven
-tio
ns in
clud
ing
brie
f in
ter-
vent
ions
, mot
ivat
iona
l in
terv
iew
ing,
rel
apse
pre
-ve
ntio
n an
d co
gniti
ve b
e-ha
viou
r th
erap
y to
peo
ple
with
com
bine
d m
enta
l he
alth
pro
blem
s w
ithin
ow
n lim
its a
nd c
apac
ity
and
rem
it of
one
s ow
n or
gani
satio
n. T
o kn
ow
whe
re e
lse
a se
rvic
e us
e ca
n ac
cess
app
ropr
iate
sp
ecia
list
care
and
fac
ili-
tate
tha
t ac
cess
. To
be
able
to
acce
ss s
uppo
rt a
nd
supe
rvis
ion
to p
erfo
rm
such
inte
rven
tions
.
To b
e ab
le t
o of
fer
effe
ctiv
e ev
iden
ce
base
d ps
ycho
soci
al
inte
rven
tions
app
ropr
i-at
e to
the
nee
ds o
f th
e se
rvic
e us
er w
ith
dual
dia
gnos
is (
such
as
cog
nitiv
e be
havi
our
ther
apy,
mot
ivat
iona
l in
terv
iew
ing,
rel
apse
pr
even
tion,
fam
ily
wor
k et
c), t
o be
abl
e to
fle
xibl
y ad
apt
thes
e ap
proa
ches
to
the
indi
vidu
al n
eeds
of
the
serv
ice
user
, and
be
able
to
teac
h an
d su
-pe
rvis
e ot
hers
in t
he
appl
icat
ion
of t
hese
te
chni
ques
Mak
ing
a D
iffer
ence
, Pro
-m
otin
g Rec
over
y, P
ract
ic-
ing
Ethi
cally
(ES
C)
DAN
OS
AI1
Inte
rper
sona
l sk
ills
Enga
gem
ent
Care
pla
nnin
g Rec
ogni
sing
ne
eds
Life
long
lear
ning
su
perv
isio
n
14
Eval
uate
car
e Be
abl
e to
ass
ist
in t
he
eval
uatio
n of
car
e pr
ovid
ed
in c
olla
bora
tion
with
ser
-vi
ce u
ser
To b
e ab
le t
o co
llabo
ra-
tivel
y re
view
and
eva
luat
e ca
re p
rovi
ded
with
ser
vice
us
er, c
arer
s an
d ot
her
prof
essi
onal
s.
To b
e fle
xi-
ble
in c
hang
ing
plan
s if
they
are
not
mee
ting
the
need
s of
the
ser
vice
use
r.
To s
uper
vise
oth
ers
in
the
eval
uatio
n of
car
e an
d ow
n pr
actic
e. T
o be
abl
e to
eva
luat
e ca
re u
sing
sta
ndar
d-is
ed t
ools
as
wel
l as
subj
ectiv
e m
easu
res
and
serv
ice
user
fee
d-ba
ck.
Prov
idin
g Se
rvic
e U
ser
Led
Care
(ES
C)
DAN
OS
Ai2
MH
NO
S M
H_2
3 KS
F H
WB2
Care
pla
nnin
g D
eliv
erin
g ev
i-de
nce
and
val-
ues
base
d In
ter-
vent
ions
M
ulti-
agen
cy/
prof
essi
onal
w
orki
ng
24
Dual Diagnosis Framework
Page 24
Uti
lisin
g K
now
ledg
e an
d Sk
ills
con
tin
ued
…
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty F
ram
ewor
k C
ross
ref
er-
ence
wit
hin
15
Hel
p pe
ople
ac
cess
car
e fr
om o
ther
se
rvic
es
Be a
ble
to p
rovi
de a
dvic
e ab
out
loca
l ser
vice
s, a
nd
know
how
to
acce
ss t
hese
se
rvic
es.
To h
ave
loca
l kno
wle
dge
of s
ervi
ces
appr
opria
te t
o m
eetin
g ne
eds
of p
eopl
e w
ith c
ombi
ned
men
tal
heal
th a
nd s
ubst
ance
use
; th
eir
elig
ibili
ty c
riter
ia;
to
know
how
to
refe
r to
suc
h ag
enci
es, a
nd t
o s
uppo
rt
the
serv
ice
user
whi
lst
the
refe
rral
is b
eing
pro
cess
ed
To b
e ab
le t
o ad
vice
pe
ople
on
wha
t se
r-vi
ces
are
avai
labl
e to
m
eet
the
need
s of
pe
ople
with
dua
l dia
g-no
sis
in t
he lo
cal a
rea.
To
iden
tify
gaps
in
serv
ices
and
be
proa
c-tiv
e in
lobb
ying
for
de
velo
pmen
ts t
o fil
l th
ose
gaps
.
Mak
ing
a D
iffer
ence
, Cha
l-le
ngin
g In
equa
lity
(ESC
) D
ANO
S AG
3 D
ANO
S AG
2 M
HN
OS
MH
_3
KSF
HW
B4
MH
NO
S H
SC 3
30,
KSF
HW
B4
MH
NO
S H
SC38
6
Mul
ti-ag
ency
/pr
ofes
sion
al
wor
king
16
Mul
ti-ag
ency
/pr
ofes
sion
al
wor
king
To b
e ab
le t
o fo
rm e
ffec
-tiv
e w
orki
ng r
elat
ions
hips
w
ith o
ther
age
ncie
s an
d pr
ofes
sion
als
that
may
be
invo
lved
with
the
car
e of
du
al d
iagn
osis
To u
nder
stan
d th
e ro
les
and
resp
onsi
bilit
ies
of t
he
rang
e of
pro
fess
iona
ls a
nd
serv
ice
prov
ider
s, a
nd t
o sh
are
care
, and
wor
k in
pa
rtne
rshi
p w
ith t
hem
To b
e ab
le t
o w
ork
acro
ss v
ario
us s
ervi
ce
and
prof
essi
onal
bo
unda
ries
unde
r-st
andi
ng t
he s
peci
fic
issu
es t
hat
som
eone
w
ith d
ual d
iagn
osis
m
ay r
aise
with
in a
nd
betw
een
team
s/se
rvic
es.
Be a
ble
to
reso
lve
conf
licts
in
trea
tmen
t de
cisi
ons
MH
NO
S M
H_7
9 an
d M
H_8
2 D
ANO
S BI
6 KS
F G
7
Hel
p pe
ople
ac
cess
car
e fr
om
othe
r se
rvic
es
Inte
rper
sona
l sk
ills
Enga
gem
ent
25
Closing the Gap
Page 25
P
ract
ice
Dev
elop
men
t
C
apab
ility
Le
vel 1
Le
vel 2
Le
vel3
C
ompe
ten
cy/
Cap
abili
ty
Fram
ewor
k re
fere
nce
Cro
ss r
efer
ence
wit
hin
D
D f
ram
ewor
k
17
Lear
ning
N
eeds
Be
abl
e to
iden
tify
exac
tly
wha
t yo
u do
kno
w, a
nd
your
ow
n le
arni
ng n
eeds
ar
e in
rel
atio
n to
dua
l di
agno
sis
To b
e ab
le t
o re
flect
on
own
prac
tice,
and
iden
tify
stre
ngth
s an
d ne
eds
in
rela
tion
to w
orki
ng w
ith
dual
dia
gnos
is
In a
dditi
on, b
e ab
le t
o cr
iti-
cally
ana
lyse
ow
n pr
actic
e in
rel
atio
n to
dua
l dia
gnos
is,
iden
tify
own
lear
ning
dev
el-
opm
ent
and
supp
ort
need
s,
assi
st o
ther
s in
rev
iew
ing
thei
r kn
owle
dge,
ski
lls a
nd
prac
tice,
and
hel
p th
em t
o de
vise
lear
ning
goa
ls
Prac
tice
Dev
el-
opm
ent
and
Lear
ning
(ES
C)
Supe
rvis
ion
Life
Lon
g Le
arni
ng
18
Seek
out
and
us
e su
perv
i-si
on, b
oth
form
al a
nd
peer
To b
e ab
le t
o ut
ilise
su-
perv
isio
n to
dev
elop
w
orki
ng p
ract
ices
in r
ela-
tion
to d
ual d
iagn
osis
To o
btai
n su
perv
isio
n to
di
scus
s du
al d
iagn
osis
clin
i-ca
l cas
es a
nd d
evel
op o
wn
prac
tice
and
rela
te t
heor
y to
pra
ctic
e
To o
btai
n an
d us
e sp
ecia
list
supe
rvis
ion
to d
evel
op a
nd
refin
e ex
pert
ise
in d
ual d
i-ag
nosi
s.
To b
e ab
le t
o of
fer
supe
rvis
ion
to a
ran
ge o
f st
aff
on b
oth
a re
gula
r an
d oc
casi
onal
bas
is t
o as
sist
ot
hers
in d
evel
opin
g th
eir
prac
tice
in r
elat
ion
to d
ual
diag
nosi
s.
Prac
tice
Dev
el-
opm
ent
and
Lear
ning
(ES
C)
Lear
ning
Nee
ds, L
ife lo
ng
Lear
ning
19
Life
Lon
g Le
arni
ng
To b
e ab
le t
o ac
cess
and
ut
ilise
lear
ning
opp
ortu
ni-
ties
in a
var
iety
of
form
al
and
info
rmal
As w
ell a
s th
is, t
o be
aw
are
of h
ow t
o up
date
cur
rent
kn
owle
dge
and
skill
s in
re
latio
n to
wor
king
with
du
al d
iagn
osis
In a
dditi
on, t
o ke
ep u
p to
da
te w
ith c
urre
nt p
olic
y an
d re
sear
ch a
roun
d th
e na
ture
of
dua
l dia
gnos
is a
nd e
vi-
denc
e ba
se f
or e
ffec
tive
inte
rven
tions
, and
be
able
to
inco
rpor
ate
this
into
ow
n pr
actic
e an
d th
e te
achi
ng
and
supe
rvis
ion
of o
ther
s
Prac
tice
Dev
el-
opm
ent
and
Lear
ning
(ES
C)
Supe
rvis
ion,
Lea
rnin
g N
eeds
October 2006
For further information please contact: Centre for Clinical and Academic Workforce Innovation
University of Lincoln Floor 2, Mill 3
Pleasley Vale Business Park Outgang Lane
Mansfield Notts. NG19 8RL
Tel: 01623 819 140 Email: [email protected]