The Role of AOT's in dual diagnosis: implications for practice, training and workforce development

1. The Role of AOT's in dual diagnosis: implications for practice, training and workforce development Dr Tara O'Neill and Dr Liz Hughes

2. 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

3. Table 1 Dr Tara O'Neill and Dr Liz Hughes

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

5. 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

6. 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

7. 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

8. Aetiological Theories (Mueser, 1998) • Common causal factor • Genetics • Family background • Conduct disorder in childhood • Mental illness causes substance use • Higher rates in people with mental illness • Are people self-medicating symptoms (Khantzian, 1985)? • 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 • No evidence that substance use causes long term mental illness • 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

9. 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

10. 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

11. 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

12. 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

13. Department of Health Mental Health Policy Implementation Guide Dual Diagnosis Good practice Guidelines 2002 Dr Tara O'Neill and Dr Liz Hughes

14. 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

15. 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 providesupport to mainstream Dr Tara O'Neill and Dr Liz Hughes

16. 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 riskassessment. Dr Tara O'Neill and Dr Liz Hughes

17. …….so what works? Dr Tara O'Neill and Dr Liz Hughes

18. 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

19. 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

20. Process of Change(Prochaska, DiClemente, & Norcross 1992) • Precontemplation • Contemplation • Preparation • Action • Maintenance • Relapse • Spiralling around stages Dr Tara O'Neill and Dr Liz Hughes

21. ENGAGEMENT PERSUASION ACTIVE TREATMENT RELAPSE PREVENTION Osher and Kofoed (1989) PRE-CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTAINANCE RELAPSE/ ABSTINENCE Prochaska and DiClemente Four Stage Model Dr Tara O'Neill and Dr Liz Hughes

22. Integrated Model (USA) • Comprehensiveness • Stage wise • close monitoring • shared decision making • assertive outreach • pharmacotherapy Dr Tara O'Neill and Dr Liz Hughes

23. What do AOT’s need to deliver comprehensive care packages to people with ‘dual diagnosis’? Dr Tara O'Neill and Dr Liz Hughes

24. The 10 ESC’s Working in Partnership Respecting Diversity Practising Ethically Challenging Inequality Promoting Recovery Identifying Peoples Needs and Strengths Providing service user centred care Making a difference Promoting Safety and positive risk-taking Personal Development and learning Dr Tara O'Neill and Dr Liz Hughes

25. 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

26. 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) Dr Tara O'Neill and Dr Liz Hughes

27. 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

28. 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

29. 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

30. 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

31. How it all fits! Dr Tara O'Neill and Dr Liz Hughes

32. 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 Dr Tara O'Neill and Dr Liz Hughes

33. 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

34. 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

35. Practice Development Learning Needs Seek out and use supervision Commitment to life-long learning Dr Tara O'Neill and Dr Liz Hughes

36. Dr Tara O'Neill and Dr Liz Hughes

37. 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

38. 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

39. 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

40. 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

41. Dual Diagnosis Training Training needs to increase therapeutic commitment by: Increase peoples motivation Increase skills and knowledge (and self-esteem) Sense of job satisfaction 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

42. 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) Adequacy of knowledge and skills (COMO and CODA) Expectation of job satisfaction (CODA only) Role support (CODA only) 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

43. 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

44. 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