Source – The Guardian.com
People who have mental health along with substance use problems (known as dual diagnosis) have multiple needs, and yet struggle to find services to help them.
Those with complex needs have often experienced a great deal of adversity in their lives, including childhood abuse and deprivation, loss of close family, and poverty. As an adult, having multiple needs brings consequences such as homelessness, unemployment and exploitation, and there is a high risk of poor physical health, suicide, self-harm and of perpetrating violence. Those with dual diagnosis are also unpopular, partly because of society’s entrenched attitudes to substance use problems, which are perceived as a lifestyle choice rather than a health condition deserving of care and treatment.
Dual diagnosis is one of the biggest challenges facing mental health and substance use services, but after 15 years of a variety of initiatives it’s hard to see how things have changed on the front line. I still hear about the same challenges that were around in the 90s. Mental health services can often exclude people if their problem is perceived to be substance-related and, conversely, substance use services exclude people if their substance use doesn’t fit their criteria.
One of the solutions put forward is to train staff in mental health and substance use with transferable skills and knowledge. Dual diagnosis is the norm, not the exception, and therefore is everyone’s business. Dual diagnosis training has been rolled out, but though it can improve knowledge and skills, it doesn’t always change perceptions and values.
One particular incident stands out from when I was a dual diagnosis worker. It was a Monday, and I arrived at the local psychiatric inpatient unit to see if there were any referrals for me. The nurse in charge greeted me with a “we’ve got one of yours” and a roll of the eyes. A single utterance speaks so much. It demonstrates an absence of compassion – that nurse did not see this person as deserving of care.
My heart sank. I spent a while chatting to “one of mine” and he told me of the trauma, homelessness, desperation, and hopelessness that had led to his suicide attempt at the weekend. He told me that staff at A&E and the mental health team on the ward had treated him with disdain; he did not feel welcome, and so was unlikely to want to stay in treatment and access the help he needed.
One of the consistent messages from service users I have talked to over the years is that they want people to listen, to be with them “where they are at” (as opposed to pushing their agenda on them), not to judge them for their choices, and to have hope. Engaging patients is critical, as we know that loss of contact with services is typically associated with worse outcomes and in some case, increased risk of suicide, self-harm and violence.
Much of the dual diagnosis development in the noughties was supported by the national dual diagnosis programme at the Department of Health. Since the localism agenda of the coalition government, and now the Conservative government, and the cuts to government central budgets, many of the national programmes have disappeared. This is further complicated by the almost complete transfer of substance use services to the third sector and the absence of mental health staff in these new services. Currently dual diagnosis work is based on postcode lottery, and is piecemeal at best.
Testimony must be paid to Progress, a consortium of consultant nurses in dual diagnosis who work locally and as a collective, for free, to keep a resources and information website going, as well as to lobby for better services at government level through the all party parliamentary group for complex needs.
In addition, there are some fantastic examples of where service providers and users work together to improve provision. Leeds is a particular example. An active service user involvement group (the Zip Group) is able to influence the city services at all levels. A vibrant network of users and service staff meet regularly and a funded lead person coordinates the venture.
We face two clear challenges: changing the perceptions of service providers to recognise the complex needs of people with dual diagnosis (which includes a shift in attitudes to substance use), and being able to provide effective services to people with high needs, in a time of unprecedented crisis in mental health provision and loss of mental health expertise within the substance use sector.
The UK dual diagnosis scene is running on nothing but goodwill by a few enthusiastic champions – how long can anything be sustained on this basis? With the increasing need to provide evidence for commissioning, it’s time to harness the data that we have at our finger tips to lobby service providers and commissioners for new roles and new initiatives.