Mental health articles

Substance misuse among people with mental health problems is recognised asbeing usual rather than exceptional; so it follows that mental health services should consider it routinely in assessment and be prepared to offer appropriate treatment and intervention. Adopting a comprehensive and inclusive assessment approach will lead to clearer diagnosis, treatment and information. The way substance misuse isperceived as deviant often results in the mental health service user being reluctantto discuss the extent of their drug use. If service users believe they will either berefused treatment or referred on, they are less likely to engage with the services,resulting in poor treatment outcomes. Assessment shouldinclude risks associated with substance misuse and mental health problems andshould be part of holistic treatment plans.

There are a number of differences in the approaches of mental health and drugservices, which are reinforced by rigid professional boundaries and the lack of staff training. Attitudes and policies that discriminate against service users shouldbe challenged. Kingston CDAT (Community Drug and Alcohol Team) has movedaway from a ‘no motivation – no service’ approach common to substance misuseagencies, and a number of mental health services have moved from their position ofbeing unable, or unwilling, to offer a service unless people are free of non-prescribed substances. These changes are more likely to take place when staff understand thelinks between mental health problems and substance misuse. Failure to recognisethese links results in service users not getting appropriate services and staff becoming increasingly disillusioned and burnt out (Department of Health 2002).Joint training and working across boundaries are possible ways forward; ifservices can work together, they are more likely to engage with service users,establish effective interventions and reduce duplication of work. Mainstream mentalhealth services have a responsibility to meet the needs of people with dual diagnosis. To do this effectively, staff need appropriate trainingand to develop links with specialist substance misuse agencies.

Both substance misuse and severe mental illness are often long-term conditionswhereby the client may have periods of stability and relapse; so practitioners shouldadopt a positive and optimistic approach and consider treatment as an ongoingprocess. This can be difficult, as working with this group of people is recognised asbeing extremely challenging. Good and regular supervision is required and caseloadsshould be monitored and kept at a realistically workable level.

The Department of Health highlights four stages of treatment, which are:

• engagement

• motivation for change

• active treatment

• relapse prevention.

Engagement refers to establishing and maintaining a therapeutic alliance betweenthe service user and agency staff and is best achieved by developing a nonconfrontationaland empathic approach to the individual’s substance misuse. Byaddressing their immediate needs, such as health, financial, housing, rather thanprimarily seeking ways to get a service user to stop misusing substances, the healthprofessional is less likely to make the service user feel threatened and judged, whichwill make for a better therapeutic alliance.

Establishing the service user’s motivation for change is important. This canbe achieved by exploring their perspective and the benefits they get from usingsubstances. Recognising that there are positive benefits for their substance misusewill enable the practitioner to explore possible alternatives. For instance, if theservice user smokes cannabis to help them sleep, perhaps alternatives could besuggested, such as reducing the use of stimulants, exploring expectations associatedwith sleep or prescribing medication, and lifestyle changes should also be explored.Considering their current and past problems and the influence substance misusehad on them may encourage the service user to be motivated towards change.

Setting out lists of pros and cons associated with the drug and giving clear, accurateinformation about the effect of the drug on their mental health may also be beneficial.

It is essential, though, that information is given in a factual way and not to coerceor attempt to frighten the service user to change; rather they should be invited toconsider the information given to them. Service users report feeling that mentalhealth workers often fail to ask why clients misuse substances; instead they reportthat mental health workers use terms such as ‘non-compliance’, which carries anegative and sabotaging connotation.

These techniques are elements of ‘motivational interviewing’, an intervention considered to be effective when working with substancemisusers. It is based on the idea that for any change to take place the substancemisuser needs to be motivated, and in order to get to this point they will need tosee how reducing their substance misuse will improve their mental health and lifegenerally.

Recognising that it may take months for a service user to be ready to changetheir substance misuse suggests staff need to be patient and develop ways of stayingengaged and not disillusioned. At the same time, the substance misusers may stillrequire support to manage their mental health problems.

Ways forward to establishing effective intervention strategies begin with betterintegration between services and clear working protocols. Exploring attitudes, challengingstereotypes and improving communication are the first steps to developingbetter relationships across services.

Mapping existing services in an area will provide information as to what isavailable and how best to move forward. Following exploration of establishedagencies and their role within dual diagnosis, discussion can take place as to the options available to service users. Developing care pathways, service aims andperceived roles within dual diagnosis will help to clarify gaps in existing provisionand areas for development. It is necessary to be clear about the service model to beused. Treatment interventions may include but are not limited to:

• joint treatment approaches

• assertive outreach

• motivational interventions

• individual counselling

• social support

• long-term plans.

Relapse prevention should be part of the ongoing process. Encouraging serviceusers to consider how they will manage relapse and to recognise triggers for relapsewill empower them and facilitate a sense of responsibility and control over theirexperience. Staff will need to be flexible and avoid being punitive or critical of relapses.

Current guidelines encourage harm-reduction techniques in preference to purelyabstinence-based programmes. However, this doesnot mean if abstinence is the service user’s aim that it should not be considered,but done so using a step-by-step approach, and by setting realistic, attainable goals.Attention needs to be paid to service users’ social networks and meaningfulactivities. Having little to do in the day apart from mixing with other people whomisuse substances adds to the difficulty people experience in changing their lives.Re-establishing family contacts helps many people, and developing a sense ofself-esteem has been found to be effective in helping people to move on.

Low self-esteem develops from ‘a learned, negative global judgement aboutself which shapes how a person thinks, feels and acts on a day to day basis’. Increased self-esteem has been found to act as a protective factoragainst depression, suicidal behaviour and substance mi and low self-esteemis common in dual diagnosis.

Tags: abuse, medical, substance abuse