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

    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

    “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

    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

    “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
    , 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

    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.”



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