One of the major challenges to mental health staff is associated
with the management of mentally ill clients in the community, who
misuse alcohol and other drugs.
At least one third of all individuals with a mental illness are
known to have problems with substance misuse (Regier et al. 1990).
The effects of drugs can cause numerous medical, behavioural and
social problems for this client group. Considerable service
organisational problems are also often associated with the management
of clients, causing them to fall through gaps in the treatment system
(McDermott, F. & Pyett, P. 1995). There is a dearth of literature
on the needs of mental health staff in relation to the management of
clients with a mental illness, who misuse drugs. This needs assessment
was conducted to find out more about the relevant practices, drug
and alcohol knowledge, beliefs and needs of community mental health
staff.
Forty-seven multidisciplinary community mental health staff
participated in the study. Data was collected by the use of a 35 point
questionnaire, which identified prevalence of drug and alcohol
problems; perceptions of participants' effectiveness and confidence;
level of drug and alcohol knowledge; perceptions of the effectiveness
of clinical interventions; frequency of client assessment and
referral; and resources/training requirements.
Additional qualitative information was obtained by a 7 topic
interview, which identified participants' role in relation to drugs
and alcohol; problem areas and level of management difficulty;
prevalence of problems by drug type; services referred to; and service
needs.
1. Prevalence:
Participants reported that about one third of their clients had
significant alcohol or other drug problems, predominantly with
cannabis and alcohol.
2. Effectiveness:
Most participants perceived themselves to have a low level of
effectiveness when dealing with drug and alcohol problems.
Participants felt most effective in dealing with alcohol (64%) and
least effective in the areas of illicit drugs (43%) and smoking (25%).
3. Confidence:
There was also a low perception of confidence, particularly in the
areas of benzodiazapine (57%) and illicit drugs (52%), as well as in
the use of skills-based strategies, such as motivational interviewing
(52%) and relapse prevention (32%). Participants felt most confident
in the area of alcohol (64%) and in the referral (78%) and assessment
of clients (66%).
4. Knowledge:
There were a number of identified gaps in the participants' knowledge
scores (mean = 64%) about alcohol, illicit drugs, benzodiazapine,
smoking and general drug and alcohol issues.
5. Effectiveness of interventions
Participants believed that A.A. (100%) and residential rehabilitation
(96%) were effective interventions compared to skills-based strategies
such as controlled drinking (67%).
6. Frequency of drug assessment:
87% of participants routinely obtained information about clients'
alcohol use but less so for other drugs such as tobacco (72%) and
benzodiazapine (66%).
7. Frequency of referral
45% of participants indicated that they rarely or never referred
clients to services for drug and alcohol advice.
8. Role:
All participants believed that they had a role in assessment and
referral of drug and alcohol problems and most as having a role in
education and providing information to clients.
9. Problem areas:
Many participants reported great difficulty in working with clients
with problems of substance abuse. Common problem areas noted were in
relation to lack of client insight and motivation to deal with their
misuse of drugs; frequency of relapse to drug use; and lack of
appropriate accommodation, detoxification and rehabilitation
facilities. Training and resource requirements Nearly all participants
thought that a specialist position or service to coordinate management
of these dual problems would assist them in working more effectively
with clients. Most participants also thought that clinical supervision
and training sessions, particularly in relation to skills-based
strategies, such as brief intervention, motivational interviewing and
relapse prevention would be helpful.
10. Significant relationships:
Participants, who felt that they were effective in helping clients
achieve change in their use of drugs, were significantly more likely
to feel confident in working with these clients. Also, participants
with longer employment in the mental health field, felt significantly
more confident and more knowledgeable about drug and alcohol issues
than participants, who had been employed for shorter periods. These
participants also routinely assessed clients and referred them for
specialist advice more often and utilized more specialised
interventions. This has training and liaison implications for newer
staff.
RECOMMENDATIONS
The study and review of relevant literature identified a number of
needs in the management of mental illness and substance abuse.
Accordingly, a number of recommendations were made, which included the
following:
- The development of relevant services, which address the need for
data collection, appropriate policies, clinical guidelines, case
management, client advocacy and community liaison links;
- An integrated approach to service provision by the Mental Health
and Alcohol and Other Drug Services in relation to cross referral,
cross training initiatives and conjoint assessments as well as
increased access to and liaison between services;
- Effective treatment approaches and principles in relation to
harm minimisation, utilisation of treatment matching and
appropriate drug and alcohol interventions;
- Specialist education and training, particularly in relation to
assessment and effective skills-based strategies;
- The establishment of a specialist pilot position to plan,
develop and evaluate appropriate client services and provide
consultancy and training to relevant staff.
REFERENCES
McDermott,F.& Pyett, P. (1995). Not
welcome anywhere -- people who have both a serious psychiatric
disorder and problematic drug or alcohol use. Victorian Community
Managed Mental Health Services: Melbourne
Regier, D., Farmer, M., Rae, D. Goodwin, F., Judd,
L., Keith, S. & Locke, B. (1990). Co-morbidity of mental
disorders with alcohol and other drug abuse
Results from the E.C.A. Study. Journal of the American
Medical Association, 264, 2511-2518.
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