Double jeopardy

Services tend to be tailored either to people with mental health
problems or to those with drug or alcohol misuse problems, not to
both. So what happens when a person presents with needs in both
categories? Natalie Valios investigates.

Brian Curry threw himself from his mother’s 14th floor flat
hours after being turned away from hospital when he sought
treatment for depression. At last month’s inquest, doctors said
they couldn’t help him because he was a drug “addict” rather than a
mental health patient. His brother insisted that Curry had wanted
to be treated for his depression, not his drug misuse.

The inherent difficulty for service users with a dual diagnosis
is the lack of co-ordinated care between services dealing with
substance misuse and mental health, and the reluctance of both
parties to take responsibility for clients.

Despite estimates that up to one third of people with mental
health problems have a concurrent substance misuse problem, it is
all too common for clients to fall through the social care services
net. Mental health services exclude them, labelling them
“untreatable” because of their substance misuse, and vice
versa.

Last year, the all-party parliamentary drugs misuse group
described current service provision for dual diagnosis as
unsatisfactory.¹ It called for the drugs tsar and mental
health tsar to develop a joint national strategy. The chances of
this happening depend, of course, on former drugs tsar Keith
Hellawell being replaced after his unexpected departure earlier
this month.

To date, there is no UK-based evidence to suggest which types of
interventions, and which setting, work best with such service
users. In London, a handful of dedicated, multi-disciplinary teams
work with dual diagnosis clients. One is Maple Unit, funded by
Barnet, Enfield and Haringey mental health NHS trust. It operates
in the Haringey and Edmonton area of north east London and
currently has 50 service users. Dual diagnosis clients present
unique challenges to workers. They are doubly stigmatised, and each
problem is accompanied by its own set of prejudices, says Maple
Unit manager Kim Moore.

“We forget that you don’t wake up one morning and say: ‘Today
I’m going to be a drug user.’ It’s a negative spiral, and yet it’s
almost like having a prison sentence – you are perpetually being
judged for it,” says Moore.

Research last year outlined several social and clinical problems
associated with dual diagnosis, including poorer psychosocial
adjustment, increased risk of violence, higher rates of hospital
admission and greater likelihood of failure to take medication or
follow treatment.²

However, relatively little is known about this user group. There
is no agreed definition of “dual diagnosis”, no solid figures on
prevalence, and inconsistent views on the situation’s
chicken-and-egg nature – which comes first: the mental illness or
the substance misuse?

This is set to change. For the first time, dual diagnosis has
been acknowledged as an issue: the national service framework for
mental health stresses the need to assess clients for substance
misuse alongside mental health problems; and the user group also
gets a mention in drug action team guidance.

Is this enough? No, according to Richard McKendrick, operations
manager at Turning Point, the charity helping people with alcohol,
drug and mental health problems and learning difficulties.

“We have the drug treatment agency, the national service
framework, and the supposed national alcohol strategy that has been
on the cards for several years – none of these do justice to the
overlap. At political and social agenda level, dual diagnosis is
not being addressed, so why should it be addressed at a street
level?” he says.

Frontline staff may themselves contribute to the problem of
clients being pigeon-holed into one service or another. Many have
worked with a specific service user group for some time and see
themselves as either a mental health worker or a substance misuse
worker, not both.

The most striking finding to come out of last year’s research
was a huge training gap. Most staff had received little or no
substantial formal training in working with drug or alcohol
problems or, in some cases, mental health, yet they were working
with a group of people with dual diagnosis.

“It was only where a staff member had some formal training in
mental health and substance misuse that they offered service users
something over and above engagement. It might be that the reason
for staff not providing structured dual diagnosis work was because
they did not feel qualified to do so,” the research states.

Funding streams have also obstructed appropriate and holistic
services. Historically, for services to receive funding, their
client groups have had to neatly fit into compartments – they were
older people, people with mental health problems, or people with a
substance misuse problem – not all three.

And while a current buzzword is joint commissioning, this
process generally takes place between local authorities and health
authorities on one specialism, rather than between different
services within the same local authority.

But Richard Ford, head of services research at the Sainsbury
Centre for Mental Health, doesn’t buy the funding excuse: “We are
doing clients a gross disservice if we get caught up in the funding
of it. Drug and alcohol services for people with mental illness
must be part of mainstream mental health responsibility, and that
must be at provider and commissioning level.”

Even Turning Point is guilty of labelling, admits
McKendrick.

“I know of few, if any, specific dual diagnosis services. All
our services fit into drugs, alcohol or mental health. And while we
work with dual diagnosis service users, there’s a need for a
service where neither issue takes precedence.”

This is precisely the nature of work at Sunderland Council,
where substance misuse services have developed out of the social
services department’s mental health services.

Both services work from the same building, with drug and alcohol
service staff sitting near two community mental health teams. Staff
from the drug and alcohol service provide immediate advice and
support to mental health social workers when they have dual
diagnosis users on their caseloads, says Sue Ramprogus, divisional
manager of mental health services and drug and alcohol
services.

Community psychiatric nurses and mental health social workers
take part in a three-day training course on dual diagnosis at the
Sainsbury Centre for Mental Health, as well as training programmes
run by Leeds Addiction Unit.

The drug and alcohol service comprises two specialist social
workers, one of whom is also an approved social worker, and a third
worker from voluntary agency North East Council of Addictions. The
service is soon to gain another social worker and a support
worker.

“By co-working, we try to ensure that it’s less likely that
people fall between mental health and drug and alcohol services,”
says Ramprogus. CC

¹ All Party Parliamentary Drugs Misuse Group,
Drug Misuse and Mental Health: Learning lessons on dual
diagnosis, DrugScope, 2000

² H Scott, E Minghella, R Ford, “Dual
Diagnosis”, Mental Health Care, 2001

Case study

Diana Lee (not her real name) has a borderline personality
disorder and alcohol dependency syndrome. She was turned away from
an alcohol advisory group because of her mental health diagnosis.
Fortunately, she was referred to a dual diagnosis service.

“Alcohol was a way of coping, and at times it still is,” she
says. “The dual diagnosis service doesn’t give up on you if you
relapse, as most places do.”

She tried controlled drinking, but recognises that she is better
abstaining. “When I drink I act more on impulse and things seem to
get worse for me – and then I can’t cope.”

However, she admits that she hasn’t stopped completely, and
finds she still reaches for a drink when she is upset or
frustrated. A few days before our interview, Lee went on a drinking
binge after walking out of a psychiatric ward. “The doctors and
nurses didn’t believe that I hadn’t been using drugs or drink. So,
I left thinking: ‘If you want to accuse me of a crime, I’ll do
it’.”

Now 28, Lee has been drinking heavily since she was a young
teenager. “I was sexually abused by a member of my family, and I’ve
been a prostitute for 13 years. I had loads of things on my plate.
Drink and drugs were my life, my way of coping.”

After years of being frightened about what was wrong with her,
she found that a mental health diagnosis came as a relief.

The number of times Lee has been admitted to a psychiatric unit
has reduced since her referral to the dual diagnosis service.
Although she is struggling to abstain from drinking, she is
convinced that without the dual diagnosis service her future would
have been bleak.

“If it wasn’t for this service I would still be heavily drinking
or dead – either from cutting myself, an overdose or my liver
giving up on me.”