This brief paper concerns itself with the multi-dimensional nature
of nursing and focuses on how an educational scholarship from the
Royal College of Nursing assisted the author to develop professional
expertise, devise training and build a foundation to future training
in the clinical area of severe mental illness and substance misuse.
Substance misuse in mental illness, or dual diagnosis as it
has more recently been referred to, is quite common. In the UK
prevalence is reported as 27% and 32% by Holland
(1999) and Menezes (1996) respectively; in
the US 47% of people with schizophrenia misuse substances (Regier
1992) and in Australia Bagient (1995)
estimated close to 50% of the male schizophrenic inpatient population
used illicit substances.
The complication of substance misuse in severe mental illness has
raised many questions relating to the skills of clinicians and
strategic ability of purchasers and planners. The stark reality of
mental illness and community care is that only recently has it
received full and articulate support from the government (DOH
1999) in the form of the National Service Frameworks for Mental
Health. In view of the slow evolution of effective treatment in mental
illness alone it is not surprising to find dual diagnosis barely
addressed.
With this in mind the author has attempted to pose broad questions
concerning dual diagnosis from both clinical and service planning
perspectives that compare to other nursing domains. The importance of
pursuing a ‘double-barrelled’ approach in this instance reflects
individual client needs and the needs of the client group as a whole.
Choosing education as a vehicle for change and development ensures
both access to, and collaboration in, the process of change. It also
guarantees a return of energy and commitment from trainees since few
people attend educational events of a specialist nature without having
a strong interest themselves in the subject matter.
Dual Diagnosis and
evidence based practice
[ Back to Top ]
The concern registered by mental health professionals (Gournay
and Sandford 1996, Holland 1999) has demanded a closer examination
of both the problems associated with substance use in mental illness
and the range of interventions available. There have been anecdotal
accounts from a range of parties involved in mental health such as
MIND, National Schizophrenia Fellowship, DOH and CPNA offering advice
and information to help those people experiencing co-morbid substance
use and mental health problems.
An area of deficit however has been that of evidence based
practice. Despite the research associated with psychological
management of psychosis (Haddock and Slade 1996)
and in particular Cognitive-Behavioural Family Interventions (Brooker
and Butterworth 1991). Few significant research findings are available
when the complication of substance abuse exists.
Notwithstanding the problems of implementing evidence-based
practice a number of services in North America have demonstrated
positive results in respect of the implementation of specialist
assessment and treatment scales (Mueser et al 1995).
Australia has also been creative by conducting several innovative
projects that have yielded extremely promising findings.
The author, with the assistance of the RCN, followed up a recent
visit to specialist dual diagnosis services in New Hampshire with a
whistle-stop tour of New South Wales (Australia), an area specifically
chosen because of its cultural/social resemblance to the UK and its
efforts to incorporate the specialist scales devised by Mueser et al
(1995) into practice.
Background to the
NSW Tour
[ Back to Top ]
Next steps: Fact finding, clarifying scholarship aims and
organising the tour
Several issues were raised when planning the New South Wales tour.
Which specialist dual diagnosis services could accommodate visiting
professionals, provide them with insight, some training and then
support them in their implementation efforts on return to their native
land?
This initial step in the process was facilitated by the existence
of a fortuitous network between New Hampshire dual diagnosis services
(Kim Mueser and Tom Fox), and practitioners in London, Dorset ( Paul
O’Haloran, Jood Gibbins) and Sydney (Gordon
Lambert). Each service and individual concurred on a number of
clinical points: (i) Long term psychotic clients should receive
priority, (ii) Family based intervention should be a primary
intervention and (iii) approaches which enhance motivation were
essential.
Evidence based assessment scales and expert opinion here served to
strengthen the author's resolve in constructing a training
package that accurately reflects this irresistible combination of
intervention types.
A visit to the dual diagnosis services in Dorsett (Gibbins
1998) and undergoing further training in motivational interviewing
techniques gave the author the opportunity to discuss several
pertinent issues relating to dual diagnosis. Jood Gibbins, an
authority on the subject, provided some worthwhile advice and support
that demonstrated her commitment to training and her view that
training is the key ingredient to delivering better services to the
dually diagnosed.
A meeting with Paul O’Haloran, Head of Practice Development and
Training at the Sainsbury's Centre for Mental Health in London hooked
the author into services in Sydney. Paul O’Haloran, a clinical
psychologist, is an expert in the area of assertive outreach, having
been instrumental in its development for Northern Sydney during the
mid nineties. The discussions and his advice echoed commonly held
concerns about the fruitless activity of providing contextually
inappropriate training. For instance, importing assertive case
management models without the legislative framework and service
configuration necessary for their accurate replication.
The Australian contact, Gordon Lambert of the Illawarra Institute
for Mental Health at Wollongong University, organised an itinerary
that incorporated several key features: Dual diagnosis training;
inpatient services; family interventions, and alcohol & other drug
services (AOD).
The itinerary negotiated with Gordon Lambert reflected the
scholarship aims which were to enhance existing mental health and
substance misuse service provision primarily by training and secondly
by contributing to expert opinion on service development issues.
The Tour
[ Back to Top ]
Site visits, discussions with key people, exposure in clinical
settings, supervision and advice from service users provided a rich
and stimulating experience which was supplemented by expert tuition
from South Western Sydney Area Health Service Clinical Nurse
Consultant in dual disorders, Dave Rich.
The variety of experience, the degree of success demonstrated
throughout, whilst encouraging to the author was somewhat confounding
also. From a clear belief that training in validated rating scales
would provide robust skills for clinicians the author reflected upon
the broader range of needs for clinicians and clients alike. In short,
dual diagnosis development appeared less homogenous than the primary
aim of the scholarship had first suggested.
The family intervention programmes resembled those in New Hampshire
that similarly resemble those in the UK. Nothing new, but clear
evidence that services are progressing in the same way that can only
strengthen findings of effectiveness.
Of particular interest was the development of assertive outreach in
Northern Sydney. Here services were based upon the New Hampshire model
(Drake et al 1996) by providing specialist dual
diagnosis teams. They survived two years, the duration of the initial
funding, and then reverted to the original configuration and model,
nonetheless improved with the added component of new expertise in
substance misuse. Projects which are innovative but time limited are
common in Australia.
The antithesis of the Northern Sydney project prevails in South
West Sydney where David Rich preaches empowerment of all
professionals, Carers and Consumers, be they substance misuse or
mental health orientated. This might seem idealistic and attractive
from a conservative perspective with little reconfiguration required.
However the supervision, support and expertise provided by Mr Rich is
producing significant results. In brief the services have adopted an
inclusive approach to dual diagnosis, little or no exclusion occurs in
either psychiatric or AOD services when clients present with an
apparent secondary substance misuse or mental health problem.Problems
that arise in clinical and service domains as a result of inclusion
receive special attention from Mr Rich in an imaginative capacity as
arbitrator and facilitator. An infectious cocktail that senior
management and experienced clinicians alike have been unable to
resist.
The issue of service configuration and the exclusion of people with
two disorders are well documented (Rorstad and
Chesinski 1996). South Western Sydney's Midas (Mental Illness with
problematic Drug and Alcohol uSe) Programme addresses the training and
service gap syndrome simultaneously and the practical measures in
place there are;
- One day workshops in assessment and intervention for dual
disorders targetted at needs of specific service providers
- Workshops and training for Non-government agencies
- Carer Support provided by the programme, often using trained
volunteers
- Accredited modular courses
- Small project work founded in qualitative or quantitative
methodology
- Newsletters
- Website communication and dissemination (All Australians love
Information Technology)
- Midas groups in ward and community settings
- Therapeutic and educational work in specialist accommodation
projects
- Clinical supervision
- Group supervision
- Troubleshooting
- Planning advice and consultancy
The measures are implemented in a collaborative manner
incorporating staff, clients and carers of all levels into each
initiative or activity and Midas has a strong commitment to
collaboration across service and geographical borders.
The final stop was the James Fletcher Hospital in Newcastle, North
of Sydney by eighty miles. Here a specialist dual diagnosis ward and
outpatient service (Kirkwood House) has
been developed. Originally three psychiatric admission wards existed,
all of which experienced the usual difficulties with clients and staff
when substance misuse was implicated (Holland 1999
). Clients had additional psychiatric and engagement problems whilst
approximately two thirds of the staff felt negatively or did not feel
positive towards this client group. A logical development occurred.
The staff who did not demonstrate negative or critical behaviour and
attitudes formed the team for Kirkwood House, designated for dual
diagnosis clients only. The results include greater adherence to
medication and higher levels of motivation to reduce substance misuse
than previously existed. More detail can be sought through Richard
Clancy.
Of particular significance is their success in harnessing and
generating optimism in the team, an element Drake describes as
critical in his many publications relating to the New Hampshire dual
diagnosis service developments referred to above (Drake et al 1996)
Devising and
negotiating suitable training
Where should a course be held? Who should receive the training?
What precisely should be included within the training?
[ Back to Top ]
Questions, that appeared so simple earlier in the project, had now
become multifaceted, complex and possibly over ambitious. At this
juncture the objective was to inject a degree of organisation and
structure that related to the initial aim. What was the original idea
behind the project? Back to the basic premise. Research based
intervention in dual diagnosis would help clinicians and the resultant
success, or failure for that matter, should snowball or dissolve.
The author had received training in New Hampshire relating to
treatment groups and assertive community treatment, in particular the
implementation of specialist rating scales. The Australian experience
of empowering or specialising in dual diagnosis treatment
provided a richer contextual feel for meeting the scholarship aims. It
also enabled a network of support and mutual interest to be developed
which appears to be an important and sustaining bi-product of the
scholarship with longer term potential. Dual diagnosis after all is
unlikely to disappear; it is far more likely to generate an evidence
base in the manner that schizophrenia has today.
As a result of the discussions held at the University of Manchester
with Ian Baguley, Head of Division of Mental Health, it became clear
that a training package of moderate proportions
could simultaneously meet the scholarship objectives and those of the Collaboration
Of Psychosocial Educators (COPE). The training, if
evaluated well, could be developed to modular level potentially
attracting research funding. COPE, formerly known as THORN, delivers
BSc and MSc courses in Psychosocial Interventions (PSI) in the North
West of England. A strong evidence base for PSI exists among Community
Psychiatric Nurses (Lancashire et al 1996)
and the considered opinion was that any proposed dual diagnosis
training must meet with COPE philosophy; i.e., interventions must be
valid, reliable and robust enough to be replicated in practice
settings.
A training programme was devised to include two assessment rating
scales (Clinical Drug Use Scale and Clinical Alcohol Use Scale)
(Mueser et al 1995) and a treatment scale (Substance Abuse Treatment
Scale) (Mueser et al 1995). The programme was supplemented by
background or introductory material on the subject and by a double
session on pharmacological interactions of substances and psychotropic
medication.
The programme needed to be thought provoking and pragmatic, the
sort of programme that boosted the clinician’s battery of assessment
tools and added to their repertoire of clinical skills.
Evaluation
and further development
[ Back to Top ]
To date the programme has been delivered to six groups,
99 clinicians in total in Liverpool, Preston, and Manchester
(including a pilot in Nottingham as part of Nottingham University’s
existing dual diagnosis module). A triangulated study is currently in
progress but initial statistical information
from three groups strongly suggests that the scales and
pharmacological components of the programme have been beneficial to
therapeutic intervention with this client group.
It is envisaged that the specialist dual diagnosis training will
become a permanent aspect of the COPE course in the North West. It may
indeed become the cornerstone of a module that incorporates local
experts in the field. A rich vein of skilled and accomplished
clinicians from all disciplines exist in the North West who have
skills in specific elements of dual disorder. To convene a consortium
of specialist trainers, devise a detailed course and deliver on a
regular frequent basis in the region could comfortably address the
training deficits clinicians and services experience (Holland 1998,
Dericott and McKeown 1996).
Such a course would be reminiscent of the development in
Wollongong, (It’s a coincidence that at least two of the trainers
from there now work in England). The THORN department at the Institute
of Psychiatry has a Co-morbidity training programme. Liz Brewin, the
course leader and the author endeavour to further develop training in
both regions which adhere to the PSI principles and maintain the core
ingredients described above.
Scholarship Conclusions
[ Back to Top ]
The aims of the scholarship have been only partially met; it has
served to develop confidence and skill in the author (and most
trainees), however positive aspects not envisaged at the outset, such
as the professional network and enthusiasm of peers, have acted as a
catalyst to training development that appears to be gaining
considerable momentum.
The issues alluded to in the introduction concerned with the
complex activity of nursing remain important matters to ponder on. How
do nurses accommodate information and skills whilst meeting the
demands of their clients, managers and professional bodies, whose
requirements do not always coincide? The scholarship has acted, in the
author’s view, as a microcosm of these salient nursing matters. A
conclusion can been drawn, that may be influenced by Australian
philosophy, that complexity is in the eye of the beholder and that
perhaps clarity emerges with the gentle passage of time, providing you
don’t take your eye off the ball!
References
[ Back to Top ]
Bagient M, Holme G and Hafner RJ. (1995).
Self reports of the interaction between substance abuse and
schizophrenia. Australian and New Zealand Journal of Psychiatry. 29:
69-74
Brooker C, Butterworth CA. (1991) Working with families caring for
a relative with schizophrenia: The evolving role of the community
psychiatric nurse. International Journal of Nursing Studies. 28
(2):189-200.
Derricott, J., McKeown, M. 1996. Dual Diagnosis; Future Directions
in Training. Association of Nurses in Substance Abuse Journal.
3(1): 34-37.
DOH. (1999). National Service Framework for
Mental health.
Drake, RE., Mueser, KT., Clark, RE., Wallach,
MA. (1996). The Course, Treatment and Outcome of Substance Disorder in
Persons with Severe Mental Illness. American Journal of
Orthopsychiatry. 66(1): 42-51.
Gibbins J. (1998). Towards Integrated Care
for Patients With Dual Diagnosis. The Dorset Healthcare NHS Trust
Experience. The Mental Health Review. December 20-24
Gournay, K., Sandford, T. 1996. Double Bind. Nursing
Times. 92(28): 28-29.
Haddock G, Slade PD. (1996)
Cognitive-Behavioural Interventions with Psychotic Disorders.
Routledge, London.
Holland MA. (1998).Substance use and mental
health problems: meeting the challenge. British Journal of Nursing.
7(15): 896-900.
Holland MA. (1999)How substance use affects people with mental
illness. Nursing Times. 95 (24): 46-48.
Lancashire S, Haddock G, Butterworth T,
Tarrier N, Baguley I. (1996). Training Mental Health Professionals to
use Psychosocial Interventions with People who have Severe Mental
Health Problems. Clinician. 14(6): 32-39.
Menezes, PR., Johnson, S., Thornicroft, G.,
Marshall, J., Prosser, D., Bebbington, P., Kuipers, E. (1996). Drug
and Alcohol Problems among Individuals with Severe Mental Illnesses in
South London. British Journal of Psychiatry. 168: 612-619.
Mueser K, Drake R, Clark R, McHugo G,
Mercer-McFadden, Ackerson T. (1995). Toolkit for Evaluating
Substance Abuse in Persons with Severe Mental Illness. Human
Services Research Institute. New Hampshire.
Regier D, Farmer N, Rae D. (1990).
Co-morbidity of mental disorders with alcohol and other drugs of
abuse: results from the epidemiological catchment area. (ECA). Journal
of American Medical Association. 264: 2511 -2518.
Rorstad P and Chesinski K. (1996) Dual
Diagnosis: Facing the Challenge. Kenley. Wynne Howard
Publishing.
[ Back to Top ]
Evaluation of Clinician Rating Scales and the Substance
Abuse Treatment Scale in the Treatment of Dual Diagnosis Clients
Recently Mark Holland provided training in the assessment and
treatment of people with co-morbid substance abuse and severe mental
illness.
In order to discover whether the assessment and treatment scales
used in the training can enhance clinical practice the following
questionairre was completed and the results are shown.
|
