dr tara o'neill and dr liz hughes the role of aot's in dual diagnosis: implications for...

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


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


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


Overview of the Overview of the literatureliterature


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)


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


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


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


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


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)


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)


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)


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


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


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


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..


………….so what works? .so what works?


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


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


Process of ChangeProcess of Change(Prochaska, DiClemente, & Norcross 1992)(Prochaska, DiClemente, & Norcross 1992)

PrecontemplationPrecontemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance RelapseRelapse Spiralling around Spiralling around

stagesstages


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


Integrated Model (USA)Integrated Model (USA)

ComprehensivenessComprehensiveness Stage wiseStage wise close monitoringclose monitoring shared decision makingshared decision making assertive outreachassertive outreach pharmacotherapypharmacotherapy


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’?


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


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


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)


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


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


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


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


How it all fits!How it all fits!


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


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


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


Practice DevelopmentPractice Development Learning NeedsLearning Needs Seek out and use supervisionSeek out and use supervision Commitment to life-long learningCommitment to life-long learning


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


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.


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


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


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


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.)


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.


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.


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 the role of aot's in dual diagnosis: implications for...

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