1. The Dual Diagnosis Practitioner Role in an Assertive Outreach Team Patrick Goodwin and Craig Sherrock Dual Diagnosis Practitioners

2. Contents National policy, guidance and literature on dual diagnosis and assertive outreach An overview of mental health and substance misuse service provision in Lewisham The two differing models of dual diagnosis provision in Lewisham’s Assertive Outreach service Challenges and achievements of the two differing models

3. Policy and guidance on dual diagnosis and assertive outreach Keys to Engagement (SCMH 1998) –Identified a group of people traditional mental health services failed to engage –Members of this group would be likely to have substance misuse histories and to need ready access to specialist support for their substance use

4. Policy and guidance on dual diagnosis and assertive outreach The Dual Diagnosis Good Practice Guide (DoH 2002) –Concurrent existence of a substance misuse problem and one or more mental disorders –Promoting an ‘integrated approach’ to treatment –Care should be ‘mainstreamed’ in mental health services –The emphasis of ‘dual diagnosis practitioner’ role should be on consultation, not care co-ordination

5. Policy and guidance on dual diagnosis and assertive outreach Mental Health Policy Implementation Guide (DoH 2001) –Effective Assertive Outreach teams would need the core skills to assess and treat common substance misuse problems –Specialist posts to do direct work as well as to support and supervise other workers to do direct work

6. Literature on the dual diagnosis role in assertive outreach Fidelity to an Assertive Outreach model that includes the element of a substance misuse specialist has better substance use outcomes for service users (McHugo et al 1999) A specialist substance misuse post is often not implemented in assertive outreach services in the US (McGrew et al 2003) or the UK (Wright et al 2003)

7. Overview of community services in Lewisham Inner-city London Borough Three Community Mental Health Teams (CMHTs) covering three different geographical areas Three small Assertive Outreach (AO) teams closely linked to each CMHT One statutory substance misuse community service One voluntary sector alcohol agency and two voluntary sector drug agencies

8. Overview of Lewisham Dual Diagnosis Service A borough wide Dual Diagnosis Service with: –Team leader –In-patient practitioner –Three CMHT based practitioners –Two practitioners in the AO teams: one embedded in the North AO team one working across Central and South AO teams

9. Overview of Lewisham Dual Diagnosis Service Purposes of the service are to: Provide education/training, support and supervision to generic mental health practitioners Manage a small caseload Co-ordinate between mental health and substance misuse services Facilitate care pathways between services

10. Components of the dual diagnosis practitioner role in the North AO team Care co-ordination Provision of a 5-day training programme Practice development and supervision Joint assessment and joint work

11. Targeting components of the role Clinical Alcohol/Drug Use Scales – Revised (AUS-R and DUS-R) Service users scored as: –Abstinent –Using without impairment –Abusing substances –Dependent on substances –Dependency leading to institutionalisation

12. North team’s service user profile AlcoholDrugs Number% % Abstinent19382142 Use without impairment20401020 Abusing substances6 } 12 } 5 } 10 } Dependent use4118229191838 Institutionalisation12510

13. North team’s service user profile 46% of clients are abusing or dependent on a substance of some form (i.e. alcohol or drugs) 22% of clients are abusing or dependent on alcohol 38% of clients are abusing or dependent on drugs 14% of clients are abusing or dependent on both alcohol and drugs

14. Care co-ordination Work carried out within the Care Programme Approach framework Focused on clients with dependent use or with more disruptive levels of abuse Interventions based on 4-stage treatment model (Osher and Kofoed, 1989): –Engagement –Persuasion/Building Motivation –Active treatment –Relapse prevention

15. Care co-ordination Engagement of service user Motivational Interviewing: –Encourages thinking about change –Exploration and resolution of ambivalence to change Harm minimisation: –Acknowledges some may not want to change or are unable to change their use –Can reduce social, health and economic consequences of on-going use

16. Care co-ordination P’s case: –50 year old man –Diagnoses of schizophrenia and dependent heroin and crack cocaine use –Psychotic symptoms of paranoia, hallucinations and delusions –Injecting drug use as well as prescribed methadone –Poor attendance at appointments; poor self-care; unstable housing; involved in begging

17. Care co-ordination Harm minimisation and MI interventions include: Support with medication use Harm minimisation around injecting practice Management of physical health problems Ensuring basic needs are being met Co-ordination between mental health and substance misuse services Use of MI to help P think about what changes he can make to his substance use

18. Care co-ordination Outcomes for P: –Over a two year period –Reduced crack cocaine use –Change in injecting pattern away from groin and now rotating sites –Consistent engagement with statutory drug service –No change in C-DUS score

19. 5-day training programme Open to all professions working in mental health Focused on: –Drug and alcohol awareness –Assessing drug and alcohol use –Appropriate interventions dependent on the client’s stage of change –Introduction to MI skills Assertive Outreach workers have a particular commitment to attending

20. Practice development and supervision Continues and develops learning started in the 5-day training Examples include: –Role modelling –Demonstrations, advice and assistance with assessments, care planning and risk management –Health promotion and education

21. Joint assessment and joint work Aimed at clients with less disruptive substance use Assessment in collaboration with care co-ordinator to support practice development Possible outcomes: –Formulation of a care plan then carried out by service user and care co-ordinator with regular reviews and supervision by dual diagnosis worker –Time limited direct work

22. Challenges for the original model Joint funding from addictions services and the AO budget leads to tensions in the role: –NTA targets are unrepresentative of the client population –Competing demands on clinical time between Dual Diagnosis Service and AO core tasks Long-term nature of practice development

23. Achievements of the original model Majority of AO workers have done the 5-day training The dual diagnosis role is seen as effective and is valued by AO workers Engagement, stabilisation and treatment of previously unengaged clients Reduced admissions for care co-ordinated clients

24. The dual diagnosis practitioner role in the Central and South AO teams No care co-ordination Focus on consultancy – building skills of team to work effectively with people with a dual diagnosis Provision of 5-day training programme Practice development and supervision Joint assessment and joint work

25. Planning change Need to get team managers on board Planning meeting with key personnel (team managers, dual diagnosis team leader, consultant nurse) Need to make teams aware of the change in AO dual diagnosis role - role of managers - role of dual diagnosis practitioner Quarterly reviews with key personnel.

26. Planning role development Profile service users to identify which are likely to benefit most from a joint working approach Baseline data using Clinician Alcohol/Drug Use Scales – Revised - abstinent - use without impairment - abuse - dependent - dependence leading to institutionalisation

27. Central and South service users’ profile AlcoholDrugs Number% % Abstinent 47 58 61 76 Use without impairment 23 29 6 8 Abusing substances5 } 6 } 4 } 5 } Dependent use3104135 616 Institutionalisation2 3 45

28. Central and South service users’ profile 21.5% of clients are abusing or dependent on a substance of some form (i.e. alcohol or drugs) 13% of clients are abusing or dependent on alcohol 16 % of clients are abusing or dependent on drugs 7.5% of clients are abusing or dependent on both alcohol and drugs

29. Practice development Identifying which staff need to attend 5 day training Identifying staff skills and their willingness to do joint work and engage in supervision Identifying which meetings/forums dual diagnosis can usefully provide input to

30. Breakdown of time over a week 2 days Central Lewisham AO 2 days South Lewisham AO ½ day Dual Diagnosis Team - clinical and team meetings ½ day ‘other’ - planning and delivering training - attending own training and supervision - statistics for DAAT

31. Joint work case study L’s Case 44 Year Old Man Diagnosis of schizophrenia and harmful cannabis/alcohol use Persecutory delusions, hallucinations Living in supported accommodation, periods of aggression related to cannabis and alcohol use Assessment in collaboration with care co-ordinator to support practice development

32. Joint work case study Development of care plan between L, care co-ordinator and hostel staff Initial reluctance from care co-ordinator to continue joint work Pragmatic solutions - Time directed work with L - Practice development with hostel staff - 1 in 3/4 visits jointly with care co-ordinator - 3 Way meetings with all agencies.

33. Treatment approaches Building motivation Decisional balance matrix (pro’s and cons chart) Readiness rulers Goal setting Cravings diary Coping strategies Triggers High risk awareness

34. Challenges Staff have different expectations of dual diagnosis role based on experiences of previous model Some care co-ordinators reluctant to continue their involvement once dual diagnosis practitioner involved Proposed disinvestment from dual diagnosis budget due to de- commissioning Competing demands of Role: - Working across two teams - Preparing and delivering Training - Statistics

35. Achievements Baseline data (C-DUS, C-AUS) completed Positive feedback in Quarterly Meetings from Management Positive feedback from service users Care co-ordinators and clinical staff have reported Improved outcomes in dually diagnosed clients

36. The Dual Diagnosis Practitioner Role in an Assertive Outreach Team Any questions? patrick.goodwin@slam.nhs.uk craig.sherrock@slam.nhs.uk