Dr Tara O'Neill and Dr Liz Hughes 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 Table 1 Serious mental illness E.g. someone with bipolar affective disorder who smokes cannabis twice 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

Dr Tara O'Neill and Dr Liz Hughes Overview of the literature Overview of the literature

Dr Tara O'Neill and Dr Liz Hughes UK Prevalence Studies  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% (recent- last 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  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)  Common causal factor Genetics Genetics Family background Family background Conduct disorder in childhood Conduct disorder in childhood  Mental illness causes substance use Higher rates in people with mental illness Higher 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 choice Brunette (1997) no relationship between symptoms and drug of choice  Substance use causes mental illness Substance use can cause temporary organic states that mimic mental illness Substance use can cause temporary organic states that mimic mental illness No evidence that substance use causes long term mental illness No 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 other

Dr Tara O'Neill and Dr Liz Hughes How do drugs and alcohol fit with risk?  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  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  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  Substance use is usual rather than exceptional in people with mental illness  People with dual diagnosis have a right to access good quality, patient focused and integrated care  This should be delivered within mental health services: “mainstreaming”  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  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  Cochrane Reviews (2004, 2008)  MIDAS RCT- CBT and MI  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)  Precontemplation  Contemplation  Preparation  Action  Maintenance  Relapse  Spiralling around stages

Dr Tara O'Neill and Dr Liz Hughes Four Stage Model  ENGAGEMENT  PERSUASION  ACTIVE TREATMENT  RELAPSE PREVENTION  Osher and Kofoed (1989)  PRE- CONTEMPLATION  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 1. Working in Partnership 2. Respecting Diversity 3. Practising Ethically 4. Challenging Inequality 5. Promoting Recovery 6. Identifying Peoples Needs and Strengths 7. Providing service user centred care 8. Making a difference 9. Promoting Safety and positive risk-taking 10. 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? 1. A performance component (what people need to possess) 2. A ethical component (integrating a knowledge of culture, values, 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 practice and responsibility for life- long learning. (SCMH 2001)

Dr Tara O'Neill and Dr Liz Hughes  Competence  Having a factual knowledge of how to do something- practical level  Effectiveness at an individual level  Ability to perform duties to a set standard  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)  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  Level 1 CORE Aimed at all workers in contact with this service user group e.g. primary care workers, A & E staff, non- statutory agency workers Aimed at all workers in contact with this service user group e.g. primary care workers, A & E staff, non- statutory agency workers  Level 2 Generalist Generic post-qualification workers in non-specialist roles (secondary and tertiary care) e.g. community mental health workers, substance misuse 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 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 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  Engagement  Interpersonal skills  Education and health promotion  Recognise needs (assessment)  Risk assessment and management  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 KSFDual Diagnosis Capability Core 1-communication7-interpersonal skills 6-engagement Core 2-personal and people development18-seek out and use supervision 17- learning needs, 2-therapeutic optimism 19-life-long learning 1- Role legitimacy Core 6-Equality and Diversity11-ethical and legal issues 3-acceptance of uniqueness of each individual 4-non-judgemental attitude 5-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 need 10 risk assessment and risk management 14-evaluate care HWB3 protection of health and well-being10 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 treatments12 care planning in partnership with service user 13 delivering evidence based interventions G7Capacity and Capability16- 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 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  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  Training needs to increase therapeutic commitment by: Increase peoples motivation Increase peoples motivation Increase skills and knowledge (and self-esteem) Increase skills and knowledge (and self-esteem) Sense of job satisfaction Sense of job satisfaction The right to work with substance use 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?  The answer is: partly! The COMO and CODA have shown that the 5 day 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 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 ’.