Developing a dual diagnosis role in mental health
Swinden, D., Barrett, M. (2008) Developing a dual diagnosis role within mental health. This is an extended version of the article published in Nursing Times; 104: 19, 26-27.
National guidance and local needs assessment highlighted gaps in care for people with coexisting mental health and substance misuse needs. This article describes the development of the dual diagnosis intervention worker post for inpatient services in North Durham.
This article describes the worker's role, how the post interacts with other structures and outcomes for service users. It also outlines some innovative initiatives that have developed as a result of introducing this role.
Donna Swinden, BSc, RMN, RGN, is modern matron, County Hospital, Durham; Mandy Barrett, MA, BSc, RMN, is project lead for dual diagnosis, Pioneering Care Centre, Newton Aycliffe, County Durham; both at Tees, Esk and Wear Valleys NHS Trust.
The Department of Health's (2002) Dual Diagnosis Good Practice Guide highlighted a lack of integrated care for people with both mental health and substance misuse needs.
Service users reported a range of barriers to accessing effective care, which included being passed between services and excluded from mental health provision because mental health service and substance misuse service providers were not working with each other.
Anecdotally, some people have reported problems related to providers having different philosophies, which led to them adopting conflicting approaches. For example, some were involved with substance misuse services that used harm minimisation approaches and interventions to enhance motivation. Meanwhile, they were also accessing mental healthcare services that required abstinence and interpreted relapse as lack of motivation. This often led to clients becoming confused and disheartened, eventually disengaging from fragmented, unresponsive services.
The County Durham and Darlington dual diagnosis project was established following publication of the DH's (2002) good practice guide, to prepare and implement a local multi-agency strategy based on needs assessment.
Before this guidance was published, awareness of dual diagnosis clients' needs had been growing in the area. This led the Durham and Darlington Drug Action Team to commission research in 2000 to explore local issues relevant to dual diagnosis. Members of the multi-agency project steering group agreed the following inclusive definition of dual diagnosis:
'An individual with concurrent needs arising out of their mental disorder and/or learning disability and their substance misuse.' This inclusive definition reflects the importance of responding to a range of presenting needs and not awaiting formal diagnosis.
DH (2006) guidance for inpatient and day hospital settings identified that most people with dual needs require simple interventions rather than specialist substance misuse input. With appropriate development strategies and ongoing support, staff in mental health services can develop the necessary skills to deliver dual diagnosis interventions, as outlined in the dual diagnosis capability framework Closing the Gap (Hughes, 2006). Local implementation of the capability framework highlights the impact of training and supervision in improving staff skills in the area of dual diagnosis.
The DH (2002) emphasised the need to engage people with dual needs within mainstream mental health services, a policy referred to as 'mainstreaming'. As a result, a collaborative model (also referred to as a joint liaison approach) was developed locally to support and develop mental health practitioners' ability to respond to the substance misuse needs of those with a dual diagnosis. This entails parallel care delivery from mental health and substance misuse care providers, with close collaboration and communication between services to ensure interventions are delivered in a timely manner with clear coordination (Hussein Rassool, 2006).
The approach was agreed with stakeholders as the most appropriate model for working with people with dual needs in this area, due to the geographical spread and rural setting. The process for implementing this approach was set out in a local multi-agency dual diagnosis strategy (County Durham and Darlington Dual Diagnosis Project, 2005). It comprised six key tasks:
Promoting ease of access;
Developing and supporting practitioners;
Communicating and consulting with stakeholders;
This strategy is featured in the Dual Diagnosis Good Practice Handbook (Turning Point, 2007).
A dual diagnosis practitioner network was established in 2004 to promote collaboration between services and share expertise. The network has over 200 members in County Durham and Darlington and is now inviting members from all services working with patients and clients with dual needs across Tees, Esk and Wear Valleys.
Needs assessment conducted for the local dual diagnosis strategy found that 40-50% of people on adult acute inpatient areas presented with dual needs, as identified using the definition agreed by County Durham and Darlington Priority Services NHS Trust. This was considerably higher in psychiatric intensive care units, with a rate of 80-90%. It is difficult to compare local data with other UK prevalence studies because of methodological differences such as variations in the definition of dual diagnosis used.
A clinical audit was conducted to determine staff needs, to enable them to self-assess their capabilities using a locally devised dual diagnosis competency framework audit tool. Staff identified a number of dual diagnosis capabilities requiring further development, including assessment of dual diagnosis need, engagement, early relapse prevention, relapse management and skills building.
Mental health practitioners highlighted a range of strategies required to enable them to meet such needs, including:
Provision of information;
Ongoing support and guidance from staff skilled in dual diagnosis approaches.
Strategies to meet such needs were identified through individual personal development plans.
Hussein Rassool (2006) highlighted negative staff attitudes towards patients and clients with dual diagnosis as a barrier to effective treatment. Negative and discriminatory attitudes in mental health services can present in many ways, such as staff labelling clients' substance misuse as their primary problem and arguing they should be treated elsewhere by specialist staff.
Local research identified that changing attitudes and organisational culture was vital to ensure mental health practitioners recognise that working with people with dual needs is a legitimate part of their role. This is also important in ensuring they modify their approaches accordingly (Barrett, 2005).
Providing knowledgeable and accessible support for staff is key to the process of cultural change (NHS Institute for Innovation and Improvement, 2005). Inpatient services were identified as areas of high prevalence and complexity of dual diagnosis need, with a limited range of interventions available to patients with these needs. As a result, the general manager for adult mental health services in North Durham and project lead for dual diagnosis collaborated with inpatient staff to develop the role of the dual diagnosis therapeutic intervention worker for North Durham inpatient services.
Dual diagnosis worker role
The role of the dual diagnosis worker (DDW) is specifically to provide therapeutic interventions for this client group, for example relaxation, stress management and motivational work, and to support ward staff's work (Fig 1). This is a grade 4 post and the DDW covers three inpatient wards split over two sites. The DDW also liaises with community teams and non-statutory services to ensure continuity of care when patients are discharged from hospital. This liaison work involves identifying support available in the community and keeping community staff informed about the discharge plan.
The DDW's aim is to help clients become aware of the reasons they misuse substances, such as anxiety, and explore alternative coping mechanisms. The DDW also supports staff in developing substance misuse capabilities, which include therapeutic optimism, non-judgemental attitudes, engagement and empathy skills (Hughes, 2006), and fulfils an educational role for staff and carers as well as clients. The role promotes harm minimisation-based approaches and works with client motivation. This involves providing information, health promotion and encouraging people to explore attitudes to substance misuse.
The DDW started in post in August 2006, although work on the proposal began some time earlier. It is an evolving post that has developed over time and will continue to change as the wider dual diagnosis service expands within the trust, and as demand continues to grow. In addition, substance misuse behaviour patterns change and patient needs alter as society as a whole changes.
This new role is part of our trust-wide strategy review in this area of care, the aim of which is to ensure all areas of the trust have access to dual diagnosis services. It is envisaged that this will include rolling out the new post to other inpatient areas. We have also developed a dual diagnosis care pathway, which is laminated and visible on each ward, to assist ward teams in identifying the appropriate service for each client (Fig 2).
The DDW is actively involved in our 'star ward' project, an inpatient initiative championed by the government which aims to promote meaningful activities for patients and to improve treatment outcomes (Janner, 2006). The DDW also contributes to a number of training programmes, and dual diagnosis awareness is part of the trust's induction programme.
The DDW has set up a football group, which so far has only been taken up by male patients, largely because female patients have preferred to access ward-based activities. This may change depending on the client group at the time, as female patients are welcome to join if they wish.
The group has been immensely popular and an awards ceremony was held recently. Patients report that it has increased their confidence and self-esteem, helped them feel fitter and provided an enjoyable social outlet. The group also gives the DDW an opportunity to engage clients in forming a therapeutic alliance in an informal context. Engagement is the essential first stage in working with dual diagnosis clients and often difficult to achieve (Graham, 2004).
The ward staff gave patients a brief questionnaire to complete to evaluate their response to the group. Patient comments include:
'I think that the football is good - it keeps you fit. It also increases patient morale. It gives me the opportunity to forget about my worries and socialise with different groups.'
'Really good - since I started playing, it has improved my stamina. The game is also played in good spirit and a good test of character and fitness.'
'Great team-building, inspiring to get patients off the ward, the game is played with no peer pressure and improves the patients' well-being.'
'Keeping us fit - I enjoy playing football as it's good fun.'
'Made me feel good about myself, keeps you fit and is enjoyable to be off the ward and mixing with others.'
'Got to work as a team, learn to respect and take time for each other.'
The football group initiative was a finalist in the trust's recent Making a Difference awards. Although it did not win, the project has secured funding from Unison for a team football strip.
In September 2007 the DDW and one of the ward's dual diagnosis leads set up a group called Making Changes, which was also a finalist at the recent trust awards. The group meets every Friday morning and provides a forum where inpatients experiencing dual diagnosis can meet and discuss topics affecting them. The name Making Changes was used so that patients would not experience the stigma and discrimination of having a label of drug or alcohol user. The group is open to all those who wish to make some kind of change in their lives; meetings are patient-led and very informal (as requested by patients).
Those who attend the group have a range of complex needs and are constantly searching for extra support to help address these needs. The group has identified a varied range of topics they feel are relevant and wish to explore and discuss. These include:
Thoughts and feelings;
Anger and stress management;
Other lifestyle issues.
Discussions with patients suggest the group gives them the opportunity to 'have their say' in a positive, confidential and supportive arena. It also enables them to gain information and knowledge, which in turn leads to empowerment and increased self-confidence. We are using a variety of methods to monitor its effectiveness. In the future we plan to provide a signposting service to outside agencies for continued support, and we are also developing a resource 'library'.
Impact of the role
The DDW has been able to use a wide range of interventions with patients, such as education, anxiety management, assertiveness training and activity planning, which have helped them to move towards discharge. As he has links with community services, the role has assisted their smooth transition back into the community, thus promoting our ethos of social inclusion. The DDW has also liaised with North East Regional Alcohol Forum to facilitate support for people with alcohol problems.
A recent audit of staff awareness, knowledge and use of the DDW showed that practitioners feel their knowledge of illicit drugs and alcohol misuse has much improved. They also make good use of the DDW by making appropriate and timely referrals, seeking his advice when planning care and involving him in the discharge process. We have also had anecdotal evidence from community teams that patients have reported more positive attitudes from staff.
The DDW has attended conferences and workshops, and has also started training in cognitive behavioural therapy. Updating his knowledge and skills benefits patients as they can then access the latest evidence-based techniques, for example, mindfulness training and resilience training. He also helps educate people about smoking cessation, which forms part of the trust's no-smoking strategy.
Patients with substance misuse problems as well as major mental health difficulties now have the opportunity to access a more holistic approach, in that it helps them to address their problems within the context of their own lives. This complements medical treatment of their symptoms, which is often essential but does not fully address dependence issues.
Clinical support and development system
An important feature of the DDW role is its relationship with other staff and structures within the area. This ensures the post-holder accesses a robust system of support and guidance to provide clear direction and sustain motivation, which is vital in influencing positive changes in culture and practice.
A tiered clinical structure exists to embed dual diagnosis practice across the locality and provides a support structure for the DDW. Dual diagnosis leads are nominated for each acute inpatient ward, community home treatment team and substance misuse team. Their role is to support their own team and neighbouring leads in delivering high-quality, patient-focused care for those with dual diagnosis needs. In addition to giving each other peer support, dual diagnosis leads can access support from the project lead, through formal contracted clinical supervision and informal support as required.
The DDW attends monthly dual diagnosis clinical supervision sessions, part of the wider supervision structure. The local supervision group consists of local dual diagnosis leads from a range of settings, including inpatient services, community mental health, substance misuse and mental health liaison. Building supportive relationships with other dual diagnosis staff develops closer working alliances and promotes collaborative care planning. Ongoing clinical support relating to dual diagnosis is provided between monthly supervision sessions using telephone contact with the project lead as required. The DDW works closely with dual diagnosis leads on the inpatient wards, one of whom provides intensive support in the form of advice, information and clinical supervision.
The DDW has access to the local tiered dual diagnosis training structure, which comprises three strands. Awareness-level training is provided for all staff, and enhanced-level training for dual diagnosis leads and other staff working with clients with a high prevalence and severity of dual needs. Bespoke training is also available on request, tailored to the needs of each clinical area.
In addition to accessing such training, the worker promotes and contributes to it, ensuring staff are aware of the tiered training system and highlighting development needs. The training system includes network events, in-house awareness level training and enhanced level training delivered in partnership with the University of Teesside.
The DDW is also an active member of the Tees, Esk and Wear Valleys dual diagnosis practitioner network, contributing to network events and responding to members' queries.
The dual diagnosis therapeutic intervention worker is a new and evolving role within acute mental health inpatient services. So far, we have received positive feedback from patients, carers and professionals, and a preliminary audit supports the view that the role is beneficial. We now plan to evaluate the role more robustly and, as previously stated, plan to roll out the initiative across the trust.
We would like to thank: Paul Dobson, dual diagnosis therapeutic intervention worker; Karen Wright, dual diagnosis lead; and Jan Maddison, general manager, adult mental health services (north), for their commitment and contribution to the development and support of this post and project.
Barrett, A.J. (2005) Rationalizing risk? The use of non-prescribed substances in severe and enduring mental illness. Journal of Substance Use; 10: 6, 341-346.
County Durham and Darlington Dual Diagnosis Project (2005) Dual Diagnosis: A Multi Agency Strategy for County Durham and Darlington. www.durham.gov.uk
Department of Health (2006) Dual Diagnosis in Mental Health Inpatient and Day Hospital Settings. www.dh.gov.uk
Department of Health (2002) Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. www.dh.gov.uk
Graham, H.L. (2004) Cognitive-Behavioural Integrated Treatment (C-BIT). A Treatment Manual for Substance Misuse in People with Severe Mental Health Problems. Oxford: Wiley.
Hughes, J. (2006) Closing the Gap: A Capability Framework for Working Effectively with People with Combined Mental Health and Substance Use Problems. www.lincoln.ac.uk
Hussein Rassool, G. (2006) Dual Diagnosis Nursing. Oxford: Blackwell.
Janner, M. (2006) Star Wards. www.starwards.org.uk.
NHS Institute for Innovation and Improvement (2005) Improvement Leaders' Guide. Managing the Human Dimensions of Change. Personal and Organisational Development. University of Warwick, Coventry: NHS Institute for Innovation and Improvement. www.nodelaysachiever.nhs.uk
Turning Point (2007) Dual Diagnosis Good Practice Handbook. www.turning-point.co.uk