Pilot Dual Diagnosis Training: London Prison Service 2005-2006

1. Pilot Dual Diagnosis Training: London Prison Service 2005-2006 Liz Hughes Centre for Clinical and Academic Workforce Innovation (CCAWI), University of Lincoln

2. Timetable • 9.30 Introductions • 10.00 background to course • 10.30 break • 10.45 Capabilities • 11.15 your experiences • 12.00 overview of dual diagnosis • 12.30 lunch • 1.30 groups- drug/alcohol and mental health awareness • 3.00 coffee • 3.15 back to main group; summary • 4.00 close

3. Outline of presentation • Background to project • Methodology • Outcomes • Discussion and recommendations

4. Dual diagnosis • The co-occurrence of two or more “diagnosable” disorders (according to diagnostic criteria such as ICD10) • Each disorder usually exerts an influence on the course of the other (thus complicating the clinical picture) • This term has been increasingly used to represent a group of people who have mental health and substance use disorders (although in reality it is more than two problems: they usually have complex needs including physical, legal, financial and social needs)

5. Background • Significant developments in prison health care including development and expansion of mental health and substance use services • Despite this, reports suggest that frontline staff are lacking capabilities to deliver on the policy targets (SCMH 2006; DH 2005) • Lack of integration between substance use and mental health services • In order for prison services to provide equivalence; substance use and mental health services will need to work more closely together, and have clear strategy for providing care for prisoners with dual diagnosis

6. Prevalence • No research into dual diagnosis specifically in prison. • Psychiatric morbidity research suggests that rates of mental disorders is much higher than general population • 90% have substance use, mental health problem or both. • Research has demonstrated that people with co-morbid mental health and substance use problems have poorer outcomes when compared to those with single diagnoses • Re-offending rates are likely to be higher • 32% of people who committed suicide in prison had co-morbid disorders.

7. Training project • Funded by DH for development and piloting of training package for prison mental health and substance use staff • Consisted of training needs, development of training package, implementation of training, evaluation • 5 prisons acted as pilot sites across London: HMP Wandsworth, HMP Wormwood Scrubs, HMP/ YOI Feltham, HMP Belmarsh, and HMP Highdown

8. Training needs • 80 questionnaires given to mental health and substance use staff at all sites (29% returned) • People were aware of the capabilities that were important for working with this group, but most common response to what they actually do was “referral” • Barriers to care included lack of time, poor communication between services, and security issues • They lacked a theoretical framework for working with dual diagnosis • Very few people had relevant training and experience (26%) • None of the addictions staff reported any mental health training. • They were unsure of their training needs.

9. Service user consultation • Service user consultant group (n=4) • Drawn from London mental health trust • One had previous experience of criminal justice system; all had experienced both mental health and substance use issues • Most important issue for them was staff attitudes, giving people space and time to talk, and working at different levels of motivation

10. Training Manual • Series of modules: each related to 2hours of classroom teaching or self-directed learning. • 17 modules covering range of topics related to dual diagnosis. • Combination of theory, exercises and clinical skills

11. Introduction Drug and alcohol awareness Mental health awareness Interaction of drugs and alcohol and mental health Assessment Physical health Risk Treatment models Engagement Persuasion (MI) Resistance Active treatment Relapse prevention Multi agency working Practice development Manual/training Content

12. Training methods • 5 day training: • one day per week for 5 weeks • On site; classroom based • manual • Blended learning • Manual • 3 x 2 hour group supervision sessions on site every two weeks.

13. Outcomes • 70% of participants returned follow-up questionnaire on attitude, confidence and knowledge about dual diagnosis • There was significant improvement on attitudes and confidence across all participants irrespective of training method) • There were no differences between the training methods in scores. • The manual was evaluated slightly higher in the 5 day training group

14. Qualitative feedback • Manual was identified as one of the most useful things • People also liked the skills practice (role-play) • People wanted more on mental health • The 5 day training seemed to be the preferred mode of training delivery. • People in the blended learning had not been able to complete the exercises in the manual within their working day. • Service user feedback for manual was very positive. • People felt that getting together with workers from other services was very useful (both modes of training did this)

15. Skills for Health Demonstration Project: Dual Diagnosis Training for criminal justice staff • Collaboration between Thames Valley, University of Lincoln, DH (offender health), and West London Life-long Learning Network • Review materials • Training needs assessment • Mapping competancies based on job descriptions • Revise materials and HEI accreditation • Pilot the course in London area March 2009

16. Challenges • Number of different types of workers involved • Prison service • Health (primary health, mental health inreach) • Drugs (CARATs) • Offender managers • Release for training • No backfill monies • Lack of suitable venues within prisons • Implementation after training • Ongoing supervision? • Booster sessions

17. Challenges continued • Access to prisoners for interventions • Movement of prisoners- lack of consistency of care • Access for face to face contact • Lack of privacy • Different competence frameworks • Mental health NOS • DANOS etc

18. Some possible solutions • London- we will be training outside prison walls using central location • Engagement of all stakeholders to ensure training is given priority (getting managers sign-up) • Screening applicants for suitability (including motivation)

19. The Future • Accreditation of course at levels relevant to various participants (individualised) • Educational pathway mapped • Regional roll-out using regional HEIs and central team will control quality

20. Expectations • Punctuality • Is essential for the learning experience for all • If you are more than 5 minutes late, you will have to wait till next break to come in • We start promptly at 9.30 and after all breaks • Participation • Role-play • Discussion • Homework • assignment • Respect • Healthy debate • Agree to differ • Confidentiality • Switch off mobiles • No sleeping in class! • Behaviour is only what is expected at workplace- it’s the same here

21. Overview of Course Day 1 introduction to dual diagnosis, drugs and alcohol Day 2: models of treatment, motivation to change Day 3: assessment and risk Day 4: ambivalence, resistance goal setting Day 5 Relapse prevention

22. Assignments • Multiple choice questionnaire • Workbook assignments • Case presentation (during course) • Plus: all formative homework- evidence must be provided • Attendance is 80% or more (this equates to 0.5 day)

23. Background • Modernisation of the NHS • National Service Framework for mental health sets out standards for care • Shift from hospital to community • New roles and ways of working • Service user focused • Values and evidence based practice • Mental health services delivered in partnership with social care

24. The KSF • 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

25. The Structure of the KSF • Based on 6 core dimensions relevant to every post in the NHS: • Communication • Personal and people development • Health safety and security • Service improvement • Quality • Equality and diversity

26. The remaining dimensions are more specific-they apply to some but not all • Divided into groups: • Health and well-being • E.g. HWB1 promotion of health and well-being and prevention of adverse effects to health and well-being • Estates and facilities • E.g. EF1 systems, vehicles and equipment • Information and knowledge • IK1 Information processing • General • G1 Learning and Development

27. What is a Capability? • A performance component (what people need to possess • A ethical component (integrating a knowledge of culture, values, and social awareness into practice) • Reflective Practice • Capability to effectively implement evidence based practice • Commitment to working with new models of professional practice and responsibility for life-long learning. (SCMH 2001)

28. Using Capability and Competency Frameworks

29. MH_23 Plan and review effectiveness of therapeutic interventions with individuals with mental health needs KSF HWB7 level 2 Interventions and Treatments Contribute to planning delivering and monitoring interventions and/or treatments The MHNOS is mapped to the KSF

30. DANOS AF3: Carry out comprehensive substance misuse assessment KSF HWB2 level 3 Assessment and care planning to meet peoples’ health and well-being needs Level 3: assess health and well-being needs and develop, monitor and review care plans to meet specific needs DANOS mapped to the KSF

31. Dual Diagnosis Policy and Research • 2002 Good Practice guide: “mainstreaming” • Workforce need to be equipped with capabilty to deliver effective care for dual diagnosis BUT Problem: 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.

32. 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

33. 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 • Level 2 Generalist • 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

34. The Framework Values • Role legitimacy • Therapeutic optimism • Acceptance of the uniqueness of each individual • Non-judgemental attitude • Demonstrate empathy

35. Engagement Interpersonal skills Education and health promotion Recognise needs (assessment) Risk assessment and managment 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 Utilising Knowledge and Skills

36. Practice Development • Learning Needs • Seek out and use supervision • Commitment to life-long learning

37. Using the Framework • Training • Assessment in workplace • Devising job descriptions • Aim to produce consistency and fidelity of dual diagnosis capabilities.

38. DD Framework is mapped to the NOS and KSF • Recognise need • Assessment (3 levels) • DANOS AF2 • MHNOS_14 • KSF HWB2

39. Future Developments • Dual Diagnosis training package- advanced module of the 10 ESCs (April 2007) • Development of a tool to measure dual diagnosis capabilities • Develop effective methods of implementation of dual diagnosis interventions in routine care (following training)

40. Competences • Describe good practice • To measure performance • The coverage and focus of a service • The structure and content of educational and training and related qualifications

41. How it all fits!

42. Objectives • Define and understand “dual diagnosis” • Be aware of the prevalence rates • Be able to list associated consequences of having combined mental health and substance use problems. • To be aware of the different models of service delivery

43. 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

44. Discussion 1 What have been your experiences of working with people with dual diagnosis within your work setting? Think about issues concerning: • the individual • the carer • yourselves • the service that you work for.

45. What have been your experiences of working with people with dual diagnosis within your work setting? • Within the prison services • Duplication of work • Inreach • Healthcare • SMS • But who co-ordinates • Falls through gap • Separate targets

46. Think about issues concerning: the individual the careryourselvesthe service that you work for. • Short time to work with them – custody suite • Prison releases on Fridays – unscripted for the weekend • Engagement barrier if in “uniform” – custody • Vulnerability of SU – dealers etc

47. What have been your experiences of working with people with dual diagnosis within your work setting? • Integrated treatment – who takes responsibility • Lack of information sharing • Have “specialists” in the team • Frustration of aftercare facilities • Boroughs refusing to asses those in prison • Medication concordance • Both MH, SM and effects of MH drug side effects

48. Think about issues concerning: the individual the careryourselvesthe service that you work for. • Assumptions and stereotypes • Creates barriers to access of services • New IDTS • Short time to work with SU • Where does primary care fit? • SU and staff lack confidence in the services ability – because no info sent on with the SU

49. What have been your experiences of working with people with dual diagnosis within your work setting? • Time and target driven culture (National) • SU group need longer term interventions which is prevented by these targets • Loses the SU • IDTS • Conflict about perception of SU problems • SMS feel someone has MH problem, MH services disagree

50. Think about issues concerning: the individual the careryourselvesthe service that you work for. • Treatment confirmation • People go without medication • Security problems/reasons prevent discussion/feedback to carers