co-ocuring substance misuse and psychosis : Dual diagnosis
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Dual diagnosis is defined as the co-occurrence of mental
health and substance misuse problems (Velleman 2007). They are separate disorders that have an
independent course but also influence the properties of each other (Carey 1989
in Gafoor and Rassool 1998). However there are some criticisms with the term
dual diagnosis. Originally the term was
used to describe people with learning difficulties who also had a mental health
disorder (Yates and Wilson 2001) which can make it confusing. The
term dual implies that this group of
people have two diagnosed conditions however this is not usually the case with
the problems involved with both substance misuse and dependence being many
(Velleman 2007) and diagnosis is an
inappropriate name according to Afuwape (2003) as the individuals in this group
rarely receive a formal diagnosis of both problems. It also medicalizes the
problems and the issues are not just medical or psychiatric, they involve
problems including housing, social care and often the criminal justice system.
According to Philips (1998:346) the
psychiatric response to co-occurring problems is at best unimaginative, and at
worst harmful and ill informed.
Research
suggests that substance misuse amongst people with mental health problems
should be considered as usual rather than exceptional (DOH 2002). The
relationship between the two problems is complex. There are several ways that
they inter-play with each other these are described by the DOH (2002:7) as
·
A
primary psychiatric illness precipitating
or leading to substance misuse
·
substance misuse worsening or altering
the course of a psychiatric illness
·
intoxication and/or substance
dependence leading to psychological symptoms
·
substance misuse and/or withdrawal
leading to psychiatric symptoms or illnesses.
There
are several different theories put forward to explain the development of dual
diagnosis. One theory is that the de-institutionalization of people with severe
mental health problems has led to this group of people being exposed to drugs
and alcohol in the community where drugs are more accessible to the population
as a whole (Drake et al, 2008, Mueser et al, 2003). However Yates (1999 in Yates and Wilson 2001)
suggest that the group may not be a new phenomenon but may be the result of
being better able to identify problematic subcultures within traditional
service user groups.
Social
isolation is a real problem attached to mental illness (Rogers and Pilgrim
2003). There is a suggestion that some
mentally ill people may be drawn into a drug using culture as it may appear less stigmatized and less
isolated than the one they currently inhabit as a person with a mental illness
(Gafoor and Rassool 1998). However paradoxically serious addiction can lead to
social exclusion (Alverson et al, 2001 in Mueser et al, 2003).
Khantzian
(1997 in Drake et al 2008) put forward a theory that suggested that people with
mental illnesses use specific substances to self medicate against a particular
negative feelings that mental illness provides. This would mean that substances
are not chosen at random but are picked for identifiable reasons and different
substances are preferred by particular diagnostic groups. However according to
Mueser et al (2003) there is no research to support this theory and it is
suggested instead that people with mental illness use drugs and alcohol in the
same way as the rest of the population but are likely to continue using them
and at higher rates. Mueser et al (2003) present the theory of the alleviation
of dysphoria. This is similar to the self medication theory except it suggests
that people with mental illness use substances to alleviate the feelings of
dysphoria rather than specific symptoms.
Dysphoria is reported to have a powerful effect on efficacy and
achievements (Kavanagh and Connolly 2007). They then continue using a
particular type of substance as it alleviates negative feelings.
However
there is a lot of evidence from service users themselves who say they use
substances to help alleviate the symptoms of the illness or the side effects of
prescribed drugs (Boyle et al, 2004). As research has shown that substances
such as drugs and alcohol can be helpful to focus away from auditory
hallucinations (Dixon et al 1990 in Gafoor and Rassool, 1998) or counteract
lethargy bought on by some medication that is prescribed for mental illness
(Philips and Labrow 1998). Thus it could
be suggested that once a person uses substances and finds relief from their
symptoms that they are more likely to continue using them. In my future practice I think it is important
to take time to understand what dual diagnosis feels like for service users as
they are the people who have to live with the problems.
Another
theory is the multiple risk factor theory (Mueser et al 2003). This is based on
the stress – vulnerability model which says there are a wide range of factors
that increase the likelihood of someone developing a mental health problem.
These include social and environmental, psychological and physical. The social
and environmental factors include social isolation, poverty, gender,
discrimination and the environment in which people live. The psychological
factors include loss, highly critical relationships, bereavement and abuse. The
physical factors are based on biological make-up such as genetics (Zubin and
Spring 1977 in Golightly 2006). In the instance of the multiple risk factor
theory not only are the factors above taken into account but also lack of
structured activity in the day, living in areas with high drug use, lack of
adult role models and association with people who use drugs. The more of these
factors that are inter playing in a person’s life the more likely they are to
have a problem with substance misuse and mental ill health. There is also research that shows that those
who have experienced trauma in childhood are at a high risk of developing
mental health problems and/ or substance misuse problems (Rohsenhow et al 1988 in
Yates and Wilson 2001).
The last ten years has seen various policies released
which try to address the issues surrounding treating people with co-occurring
disorders. In 1996 the government
produced a policy called Building Bridges (DOH 1996). This was a guide to
inter-agency work for the care and protection of people with mental illness. It
was one of the first policies in Britain to mention co-occurring problems of
mental health and substance misuse. It stated that people with these problems
may require treatment from both sets of specialist services and close links
should be maintained between the two services.
After this came the National Service Framework for Mental Health (DOH 1999)
which also suggested that the needs of these service users would also be met
best within mental health services and drug and alcohol services. It also
suggests that assessments of individuals with mental health needs should also
consider the potential of substance misuse.
However there are reports to say
that service users were ‘slipping through the net’ and not receiving services
at all (DOH 2002). Interestingly now the advice in the Good Practice Guide (DOH
2002) is that the service user group will be best helped by a process called
mainstreaming in which service users will be helped within mental health
services. Where people have less severe problems they can be treated by
substance misuse services.
When
the Good Practice Guide (DOH 2002) was published it commented that there was
little evidence base to interventions in England so most research comes from America.
Thus in practice I will make sure I am aware of new research as it happens.
Yip (2003) suggests that although
historically people with the label of dual diagnosis have been un-responsive to
treatment and intervention this may have more to do with the in-effectiveness of treatments used (Ackerman
1993 in Yip 2003) or lack of evidence base to interventions used.
As outlined in the DOH guide (2002) it
is important that all service users with severe co-occurring problems are
subject to the Care Programme Approach. This is a frame work introduced in 1991
to provide the care of mentally ill people outside of hospital. It requires
health and social care to work together which if it works well should prevent
people from falling through the gap. This means that there will be a systematic
assessment which will address needs. From the assessment a care plan is arranged
which needs to be agreed by all members of the multi-disciplinary team and the
service user. There is a named key worker who coordinates care and keeps in
regular contact with the service user and the whole plan should be reviewed at
least every six months (DOH 1996) the care plan will have a name and number the
service user can get in touch with in an emergency. It is also important to remember that the
service user should have a copy (Golightly 2006). After listening to the testimony of a service
user I would make sure in practice that I ensure the service user understands
what has been written.
According
to Noordsy et al (2000 in Mueser et al) re-establishing life roles and responsibilities
is the foundation of recovery. Problems with self-care and independent
living skills are often found in people with severe mental illness and these
can be made worse by substance misuse.
Loss of housing is a major problem for people from this group. If
interventions are to be successful the service user needs stable and secure
accommodation. There is research into
therapeutic communities for people with co-occurring disorders. The research
that has been undertaken shows positive results especially for people that are
usually hard to engage with treatment (Drake et al 2008). Long term residential
treatment has been found to be more effective than short term treatment
(Brunette et al 2001 in Drake et al 2008). However as Hawkins and Gilburt
(2004) finds there are very few residential treatment centres that are
specifically for people with dual diagnosis. Where service users live in environments where
substance use is common and whose primary contacts are also users of substances
it may be difficult for them to decrease their substance use (Yates and Wilson
2001) which is why a therapeutic community could be successful as it provides
community and care.
Service users in this group are among some of the most
socially excluded (ODPM 2004). As a social worker I would make sure that I
would ensure that the service user is enabled to access support from the
relevant services and if necessary to advocate on their behalf. Service users
have been reported as saying they have had a difficult time trying to access
appropriate services (Hawkins and Gilburt 2004). Historically services for
mental health and substance misuse services have evolved separately meaning
that service users need to present to one or the other to access help (DOH
2003) and if one of the presenting symptoms is not serious enough specialist
help is not always offered (ODPM 2004). Joint
working is essential between agencies and a multi-disciplinary team so
specialism’s can be shared and the outcome is the best for the service users. Hawkins and Gilburt (2004) suggest that an integrated
approach is the most effective as all needs are met. An integrated model
requires both psychiatric and substance misuse interventions but delivered by
the same worker or team so that it is a co-ordinated mode (DOH 2002). Within this approach there is scope for
further interventions such as group therapy, cognitive behavioural therapy and
motivational interviewing which will be considered next.
Motivational interviewing (MI) is defined by Miller and Rollick
(2002) as a client centred method of change that looks at and resolves
ambivalence to enhance motivation. According to Martino et al (2002) its
emphasis is on developing and achieving personal goals. There is a growing body of evidence which
supports MI as a means of helping service users to engage with services as it
is non-confrontational and can be suited to each individual. It can be a brief treatment which is suitable
for people with co-occurring problems who may find it hard to engage or commit
to longer term work (Handmaker et al 2002). It also helps service users gain
some insight into their lives; it is very much a client centred approach with
the skills of reflective listening and open questions which are also social
work skills. Unlike other interventions
in can be taught to workers who are not specialists in addiction (Kavanagh and
Conolly 2007). It can be tailored to suit individual’s needs which are ideal as
people with co-occurring problems are a homogeneous group.
Another important intervention to be
considered that is often not considered with this group is harm reduction. In
research the role of harm reduction with substance users is positive with it
leading to increased engagement and retention rates with services (Philips and
Labrow 2000). Some agencies ask for abstinence before treatment can begin but
this is not always achievable. As hepatitis C and HIV is a big risk to this group
(Anthony and Helzer 1991 in Yates and
Wilson 2001) it is important that strategies are available such as needle
exchange or education of safer practice.
Through harm reduction other needs can also be addressed such as health
(Hawkins and Gilburt 2004). This is important as people with co-occurring
problems often have other health problems ( DOH 2002) however harm reduction is
not suitable for all service users for example those who lack capacity (Philips
and Labrow 2000).
When
working with this client group it is important to have knowledge of the laws
that will affect their lives. Under the
Mental Health Act 1983 (MHA) definitions of mental impairment and psychopathic disorder exclude behaviour
that just results from dependence to drugs or alcohol. However, alcohol and
drug problems can fall under the MHA 1983 if psychosis results from substance
use. There needs to be a mental disorder alongside alcohol and/or drug effects
which is difficult to assess. Social workers need to be aware of the
effect of substance use on someone’s mental health. Section 1(3) of the Mental
Health Act 1983 specifies that no-one will be made subject to the provisions of
the Act solely for dependence on alcohol or drugs. (Dawson 2007) It is worrying that the Human Rights Act 1998 has the
power to exclude people with alcohol
or drug problems. Article 5,section 1e ‘Everyone
has a right to liberty and security of person’, contains some
exceptions (providing due legal process) which includes alcoholics and drug addicts (OPSI, 2002).
.
It is clear from the above that there is still a lot of research to be done
with this large, heterogeneous group. As mental health and substance misuse
carries with it such stigma it is important that services are made accessible
and dividing people up between two services can make it harder for people to
access services. I will endeavour to
enable service users to engage in a journey of recovery by being supportive,
non-judgemental and non-confrontational and as far as possible be a consistent
person in what is a long journey of recovery.