Tackling dual diagnosis: Amber Project, St James Priory and Turning Point’s Support Link

BUILDING TRUST

Based in west Hertfordshire, Turning Point’s Support Link is an outreach project providing intensive community support for up to 55 people at any one time with a dual diagnosis. Often service users have additional needs such as eating disorders, self-harming or a history of offending behaviour.

“A key part of our philosophy is to build trust and respect by focusing on issues which service users feel are important to them before going on to address some of the deeper issues associated with their mental health and substance use,” says service manager, Clare Buckmaster, who works alongside a team leader and six project workers. “The aim is for service users to gain confidence, improve their quality of life and reduce hospital re-admissions.”

As well as providing practical support, such as securing and keeping tenancies, assistance with benefits and budgeting, and accessing health care, Support Link’s other services include long-term emotional support, an out-of-hours telephone service and advocacy. This entails support in care programme approach meetings, court hearings, and acting as appropriate adults if service users are arrested and to help in obtaining specialist legal advice.

By concentrating on a person’s strengths through the use of solution-focused therapy, Support Link, which is funded through Hertfordshire’s joint commissioning team, has seen sustained changes in behaviour. “We have fewer incidences of self-harm, reduced hospital admissions, an increase in the confidence and self-esteem of service users, and have seen a greater willingness to engage with other relevant community services and activities,” says Buckmaster.

She adds: “We adopt a long-term perspective, recognising that people may need to work on many areas of their life before they are stable enough to reduce or stop their substance use. Their mental health difficulties and substance use is just part of a much bigger picture and may not be their most pressing priority.”

➔ Contact: clare.buckmaster@turning-point.co.uk

What do you think?

“Some workers feel at a loss to know how to work with this client group. Here is a good example to professionals of how to engage successfully with a group whose breadth of needs is often overlooked.”

Mike Young, general manager, mental health, Kirklees Council

VALUABLE AMBER

Many people within the lesbian, gay, bisexual and transgender (LGBT) communities fall outside mainstream mental health or addiction services either because of their multiple needs or a reluctance to engage because of perceived homophobia. It was this that gave the green light to The Amber Project.

Run by Casa (a charity that provides support for people with drug and alcohol problems and multiple needs) and Pace (which provides mental health and well-being services to LGBT communities), the project provides information, assessment, individual and group therapy.

The aim is to support users to become more aware of their psychological, emotional and interpersonal difficulties and reduce, control or stabilise substance use.

“Service users are encouraged to define their own needs and goals,” says psychotherapist Deborah Killeen. “This non-directive approach enables workers to remain open to the range of issues in an individual’s life and empowers service users to make decisions for themselves.”

Nor is substance use seen as an obstacle to therapeutic engagement. “We see it as part of the way in which the service user relates to the world, self and others,” adds Belinda Hollows, also a psychotherapist with the project.

The service helps the “significant others” of users to access services themselves and support the care of the primary service user. Carers may also attend a family, partners and friends service.

The approach is clearly working. This supposedly difficult-to-engage group have attended sessions regularly and nearly all continue to attend for the full length of their contract. The high demand has resulted in waiting times of up to two months, but service users have not been put off and have been willing to wait.

The project has learned that a LGBT-specific service allows service users to be open about their sexuality and life experiences. Equally significant is the project’s approach to view substance use and mental health symptoms as matters to be understood not simply managed. “Allowing service users to define their own goals for therapy enables them to access services without first having to commit to cutting down or giving up their drug use,” says Killeen.

Hollows adds: “They have been relieved to use a service where they are not required to sort out their substance use issues before receiving psychotherapy that addresses their mental health and emotional distress.”

➔ Contact: belinda.hollows@casa.org.uk /  dkilleen@pace.dircon.co.uk

What do you think?

“This sounds brilliant. I would love something like this near me. I think – no, I know – that I would feel safe there with people who understand me and who won’t judge me or make me give up my drugs as a condition of attending.”

Carl lives in the Midlands, is gay and has a dual diagnosis

INTO THE MATRIX

Being passed from pillar to post has been a perennial problem for people with a dual diagnosis. They might be sent to one place for their substance misuse, one for their mental health treatment and another for additional problems.

It was this “hard experience at the coalface of dual diagnosis treatment” for Brendan Georgeson, treatment co-ordinator at St James Priory drug and alcohol project in Bristol, which led to the setting up of a new approach.

“One day it occurred to us to invite the local community mental health team (CMHT) to see their client while they were in treatment for addiction,” says Georgeson. “This then was the start of some great working relationships with the mental health services.”

The services agreed to adopt a “matrix model” of working. Georgeson explains: “This is where the care programme approach process includes input from the drug service, and the physical space used for sessions and meetings is also in the drug service. This differs from the parallel model where they are in different places.”

No extra training is needed because the different staff teams already have the right skills. “Any lack of communication is resolved as the staff are all in the same building at point of contact with the client,” adds Georgeson. “Nor does it cost any more because you don’t have to employ specialist services. And, the biggest stumbling block of all – capacity – is resolved as you are only working with the clients you already have, not any extra.”

Georgeson admits that the capacity argument is usually the hardest to understand. “Often mental health workers will think that they are suddenly going to have to start taking on clients from substance misuse services against their will and fear being overwhelmed and the substance misuse workers panic thinking that severely disordered clients will be dumped on them.”

But this isn’t how the matrix model works. “If a CMHT discovers that their client has a substance misuse problem they ask them if they want help to address this,” explains Georgeson. “If they do then they phone their local substance misuse team and make a referral.

“It is the duty of the community drug and alcohol team to refer the client to a service that best matches the client’s substance misuse need. The mental health service engagement should be continued as normal. The same process should work in reverse for the substance misuse client.”

For Georgeson, the matrix model enables a more coherent joined-up way of working. “It should hopefully reduce crisis intervention and while not increasing or decreasing capacity, it will allow more clients to be helped effectively in the long run,” he says.

➔ Contact: www.stjamesprioryproject.org.uk

What do you think?

“The Matrix model offers co-location and by implication much closer working between substance misuse and mental health services and thereby aims to substantially reduce the risk of dual diagnosis service users falling through the net. If the two teams work collaboratively this certainly has advantages over separate services that often appear to bat service users backwards and forwards between them.”

Peter Spelman, principal officer, mental health, London Borough of Redbridge

This article appeared in the 27 September issue under the headline “Dual challenge”