SCIE Research briefing 30: The relationship between dual diagnosis: substance misuse and dealing with mental health issues

By Ilana Crome and Pat Chambers, with Martin Frisher, Roger Bloor and Diane Roberts

Published January 2009

This briefing examines the issues presented by service users with dual diagnosis for UK practitioners in health and social care. Confusingly, the term ‘dual diagnosis’ is used to describe several combinations of physical, psychological or developmental conditions; but for the purpose of this briefing, it refers to the co-existence of substance misuse and mental health problems. This briefing considers all age groups and uses the term ‘substance’ to refer to illegal or illicit drugs; alcohol; nicotine and prescription drugs. The terms ‘substance’ and ‘drug’ are used interchangeably. ‘Mental health problems’ refers to severe or enduring conditions, while ‘substance misuse’ refers to chronic or complex substance use problems. The briefing does not consider specific pharmacological or other treatment interventions in detail, but focuses on issues arising at the health and social care interface. It draws on research and literature from other countries, including the US where the majority of research on dual diagnosis has been conducted; to provide an overview for health and social care practitioners in the UK. Where there are gaps in the research, for example, in regard to service user involvement, recovery approaches and personalisation of services, the briefing draws upon evidence from relevant fields such as mental health and substance misuse. Throughout this briefing the terms, patient, client, and service user are used interchangeably to reflect the different usages prevalent within different sectors of health and social care.

What is the issue?

There are many different terms used to describe the combination of, and association between, substance misuse and mental illness with the most commonly used being ‘dual diagnosis’ and ‘comorbidity’. These terms reflect the coexistence of substance use, misuse, harmful use or addiction, and psychological or psychiatric problems. Two or more substance disorder or psychiatric conditions may be present at the same time, or may occur at different times. There may also be physical illnesses that further complicate the picture, and the social manifestations may add another level of complexity.

A working definition of ‘substance misuse’ is the use of substances that are socially, medically or legally unacceptable, or that have the potential for harm. It should be noted that just one dose of a drug can sometimes be fatal and, therefore, any substance use must be considered important. In order to objectively identify occurrence of substance misuse, two similar (though not identical) systems have emerged. These are the World Health Organisation International Classification of Diseases (ICD-10) (1) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV). (2) The criteria established under either system (see appendix A) may be used for the diagnosis of harmful use and dependence syndrome (addiction).

The term ‘drug’ may be used to refer to licit substances (tobacco and alcohol) and illicit substances, such as opiates and opioids (e. g. heroin and ‘street’ methadone); stimulants (cocaine, crack, amphetamines and ecstasy); volatile substances; and cannabis. It also includes prescription drugs (e. g. benzodiazepines) taken in a manner that was not indicated or intended by a medical practitioner, and the misuse of over-the-counter preparations such as codeine-based products (e. g. cough medicines, decongestants). Furthermore, a combination of prescribed and over-the-counter medications may also be problematic, even where the individual medications are used correctly. This is known as ‘polypharmacy’, while the deliberate use of combinations of substances may result in ‘polydrug’ ‘misuse’, ‘harmful use’ or ‘dependence’ (addiction). Both polypharmacy and polydrug misuse may co-exist with physical or psychological conditions and result in dual diagnosis.

Why is it important?

Mental health and substance misuse problems are major public health and social issues. They are commonly encountered in the general population, but are perhaps more apparent in health and social care settings. In 1999 the Department of Health commissioned a review of psychiatric disorder and substance misuse (4) which led to a series of interlocking projects, which included the Drug Misuse Research Initiative, (5, 6, 7, 8) and a comprehensive literature review, (9) and a training and information manual. This was followed by policy guidance in the National Service Framework for Mental Health (10) and subsequent guidance on implementation. (11, 12) Similar developments in Scotland included ‘Mind the Gaps’ and a good practice guide. (13, 14) More recently, this work has been included in a Europe-wide project. (15) There have also been a range of other guidance documents which make reference to co-morbidity. (16, 17, 18, 19, 20, 21, 22, 23, 24, 25)

There are many reasons for the apparent increase in comorbidity, including the de-institutionalisation of patients with mental disorder and increasing substance use in the community. Consequently, there is greater heterogeneity in the presentations of people with dual diagnosis. (9)

Individuals may present during an episode of intoxication or withdrawal; may be dependent on one or more substances; and may suffer from more than one psychiatric symptom or syndrome as a result. It may, therefore, be challenging to distinguish ‘what comes first’ for all of these reasons, and a pre-occupation with ‘what comes first’ often results in potential service users being excluded from help. (26) Service organisation tends to revolve around specific disorders (e. g. mental health, physical health, substance use), which does not take account of the complicated realities of the individuals concerned, even though this feature may, in part, contribute to poor outcomes. (7, 27, 28, 29) Services are likely to have different histories, and differing philosophies and ways of working with people who use those services. Most significantly, they may have little experience of each other’s field. (26) For example, recovery approaches (30) that currently predominant in mental health services have not been embraced in substance use services. (31) The nature of the comorbidity may bar some service users from a particular service. For example, the criteria for accessing a mental health service may exclude those who misuse substances and vice versa. (12, 26) Without access to specialist services, people with a dual diagnosis, who may already find it difficult to engage with services, will not only continue to have serious health and social care needs, but are even more likely to be resistant to approaching services in the future. (12) Professionals involved in health and social care services are likely to face ethical and legal dilemmas. (32) For instance, while seeking to encourage service users to engage with services (and minimize disengagement) difficult issues relating to risk (either to the individual, those within their social network, or the public) may have to be addressed, and where the service user is a primary carer, child protection procedures must be given due attention. (33) This may involve complex intra-agency working between adults’ and children’s services, and the importance of challenging traditional separations between services in situations where there are parents with mental health problems has been noted elsewhere. (136, 138, 137) On rare occasions, and following the new Mental Health Act 2007 (www.dh.gov.uk/mentalhealth) it may be necessary to consider detention as an option. In regard to the new Act, it is still too early to comment upon the extent to which either detention or compulsory treatment orders may be appropriately used with service users with a dual diagnosis, or to comment upon their effectiveness. While there is considerable stigma attached to substance misuse and mental disorder there is some evidence that this is gradually shifting. (3) Nonetheless, dual diagnosis remains an extremely complex field, and while progress has been made, service users with a dual diagnosis can present considerable challenges to services that struggle to satisfactorily address their needs. (14)

What does the research show?

The majority of the research on dual diagnosis has been undertaken in the United States but there is increasing interest across Europe, including the UK. However, differences in the health and social care provisions in each country mean that not all of these findings are applicable to a UK context. It should also be noted that medical research predominates in dual diagnosis and very little research has been undertaken from a social work or social care perspective. Nevertheless, generalisation from research into mental health issues might suggest that social isolation, stigmatisation and social exclusion are likely to be common experiences, as well as generally poor provision for some groups of people from ethnic minorities. (136) Importantly, the voice of service users and their families or carers is lacking in the majority of the research literature; a notable exception is a Scottish study (29) discussed later in this review. Several non-statutory organisations and service user organisations, such as Mind, Turning Point and Rethink, have drawn on the experience of service users with a dual diagnosis and their carers to develop ‘toolkits’ (26) and good practice handbooks. (14)

Relationship between drug misuse and mental health problems

Research shows that substance use, intoxication, harmful use, withdrawal and dependence may lead to or exacerbate psychiatric or psychological symptoms or syndromes. (15) Conversely, psychological morbidity and psychiatric disorder may lead to substance use, harmful use and dependence (addiction). The most common associations for substance misuse are with depression, anxiety and schizophrenia, but eating, post traumatic stress, attention deficit, hyperactivity and memory disorders also occur. (17, 34-36) Alcohol problems, for example, are often seen with bipolar disorders, schizophrenia, and personality disorders, (37) while concurrent use of other illicit substances is well recognized in opiate dependence. Cocaine users, too, who may supplement their use with alcohol, may also have affective disorders and personality disorders.

In general, four inter-relationships in dual diagnosis are recognised:

• A primary psychiatric illness may precipitate or lead to substance use, misuse, harmful use, and dependent use, which may also be associated with physical illness and affect social ability.
• Substance use, misuse, harmful use and dependent use may exacerbate a mental health problem and physical health problem, e. g. painful conditions, and any associated social functioning.
• Substance use e. g. intoxication, misuse, harmful use and dependent use may lead to psychological symptomatology not amounting to a diagnosis, and to social problems.
• Substance use, misuse, harmful use and dependent use may lead to psychiatric illnesses, physical illness, and social dysfunction.

Prevalence – how common are the conditions?

The UK has amongst the highest levels of substance misuse in Europe. (38, 16, 39) The situation is, however, dynamic and it has become well recognised that combinations of substances may be misused. This includes two of the most commonly encountered substances, alcohol and nicotine. Since the early 1990s, despite a fall in overall prevalence of smoking from 45 per cent of the adult population in 1974 to 22 per cent in 2006, it has been higher among 20 to 24 year olds than other age groups. (40)

Alcohol

Around 25 per cent of the population drink above the recommended safe limits, with per capita alcohol consumption doubling over the last fifty years and continuing to rise. (41, 42, 43) There are some seven million hazardous drinkers in the UK. Hospital admissions for conditions related to alcohol consumption have doubled in the last ten years and death rates have doubled over the last fifteen years. (44) Alcohol misuse costs the country £20 billion per annum.

Illicit drugs

It is estimated that about eleven million people (35 per cent) aged 16-59 have used illicit drugs in their lifetime, with some three and a quarter million (10 per cent) having used illicit drugs in the previous year; and two million (6 per cent) in the previous month. (39) Cannabis is the commonly used drug, with 8 per cent of 16-59 year olds reporting use in the previous year. The use of Class A drugs increased between 1998 and 2006/7, and just over a million people aged 16-59 have used Class A drugs in the previous year. (39) Trends in drug use since 1998 indicate that drug misuse has stabilised or decreased, though even a conservative estimate suggests that drug misuse costs the country £15 billion per annum. (39)

Comorbidity

Co-existing mental health and substance problems are very common in health and social care practice. In a study on primary care in the UK during 1993-1998 the prevalence of co-existing drug and psychiatric conditions increased by 62 per cent in England and Wales, with the rates of drug problems and psychoses, schizophrenia, and paranoia increasing by 147 per cent, 128 per cent and 144 per cent, respectively. (5, 6) In 1998, therefore, a typical general practice might have encountered eleven cases of comorbidity. This has implications for primary care and the workload of general practitioners. An examination of screening rates for a diverse range of services showed substantial differences between community mental health teams (37 per cent), inpatient mental health (56 per cent), forensic (62 per cent), substance misuse (93 per cent) and primary care services (24 per cent). (45)

Another study, on mental health centres and substance misuse services in the UK, showed that three quarters of drug service users and 85 per cent of alcohol service users had mental health problems, mostly affective disorders and anxiety disorders. Approximately one third of the drug treatment population and half of the alcohol treatment population also had multiple morbidity, i. e. the co-occurrence of several psychiatric disorders or substance misuse disorders. (7) The costs of caring for service users with dual diagnosis is higher than for single conditions because of the need for greater service utilisation. (46, 47) Nearly 40 per cent of drug users had not received help for their mental health problems and just over 40 per cent of mental health service users reported drug use and/or hazardous or harmful levels of alcohol use in the past year. These individuals were perceived as being more aggressive, chaotic and less compliant with care plans. (7, 48, 49)

Drug users attending treatment also tend to carry a heavy burden of additional health problems, which in turn adversely affect their mental health, and are accompanied by high rates of unemployment. (50, 51) Serious physical illness is, of course, an additional comorbidity and one that is, perhaps, overlooked, underrated, and under-treated. (52) Physical problems such as pain, infection, injury and cancer, may result from substance misuse and may lead to mental illness. If not adequately treated these conditions not only add to the suffering of individuals, but may also undermine any treatment that is provided for substance misuse. As a result, people with multiple conditions often do not receive or access the full range of care that they need.

Problems may also commence in childhood or adolescence and continue into old age. (16, 53, 41, 42, 54-57) Childhood abuse is, for example, known to contribute to the prevalence of comorbid personality disorder in addiction populations. (58, 59, 60) Women who use substances and have been exposed to sexual, physical and emotional abuse as children are more likely to experience emotional distress than a control group of women substance misusers who do not have that background. (61, 62)

Explanation for differing rates of co-occurring disorders depends on many factors including:

• Differences or lack of standardisation between diagnostic classification systems and diagnostic instruments used for mental disorder and those for substance use disorders.
• The setting in which condition is studied, e. g. a clinical setting being more likely to yield high rates than general population studies.
• Services that may conceptualise and diagnose the same users differently.
• An individual’s substance use that may fluctuate in type, quantity and/or frequency.
• Time of assessment which may influence the result, e. g. during withdrawal or intoxication.
• Mental health presentations which may vary depending on environmental triggers.
• Geographic differences between regions, types of presentation and rural or urban communities.
• The combination of events that constitute an individual’s life history.

Social complications

Combinations of problems often lead to difficulties in the domains of health, education, and the criminal justice system. Medication non-compliance, substance abuse and severe mental illness are associated with violence, although violence perpetrated by the severely mentally ill accounts for a small proportion of violent acts in the community. (63-66) In essence, problems associated with dual diagnosis tend toward a poorer prognosis and greater disability. This includes a greater likelihood of medical, psychiatric and social problems that arise as a result of poor compliance with treatment, unplanned discharge, relapse and rehospitalisation. (67, 68, 69) Self-harm, often by overdose, and eventual suicide are also strongly associated, as is early mortality. It is recognised, for example, that service users with ‘dual diagnosis’, who constitute 27 per cent of suicides, are inadequately treated. (70, 71, 72)

Drug-related violent crime can be divided between:

• violence arising from the effects of the drug
• violence associated with the interaction of a psychiatric illness and drug use
• violence associated with acquisition of drugs
• violence associated with disputes between drug users, dealers or gangs. (17)

There is evidence to suggest that a combination of a psychosis and co-morbid use of drugs results in a higher rate and severity of violence than in a population with psychosis and no co-morbid substance use. (73) Reviews of aggressive behaviour in users of heroin have also indicated that high rates of aggressive behaviour in this group may be independent of their use of heroin and more related to personality factors that are also associated with the risk of heroin dependence. (74)

Social instability and marginalisation, as manifested by homelessness, economic deprivation, unemployment, crime and violence, characterise this group, who are also at increased risk of victimisation, and may have experienced childhood and adolescent trauma, educational and social skill deficits arising from family problems, and childhood abuse. (75, 76, 77) As a result of these complications, comorbid service users present not only to primary care, secondary care and general medical, surgical and mental health services, but to social care and welfare services, such as education, housing, social work (child protection and adult services), and the criminal justice system. (24, 78, 79, 80) It has been noted that it is the emotional and socio-economic issues that present the major challenges to recovery both for the individual and their families. (81) The social complications may be so pressing that many people with comorbidity may not present to health services. A wide range of social care professionals therefore need to be alert to the possibility of dual diagnosis and be skilled in assessing whether mental, physical and substance problems are at the core of the social presentations. Despite multiple vulnerabilities, there is a consistent failure to recognise this complex and demanding sub-set of service users.

Screening and assessment

Irrespective of the service to which problems are first presented, screening and assessment is fundamental to achieving better diagnostic outcomes. Considerations include; the experience of the assessment, the environment of the assessment, (82) a high index of suspicion, a robust assessment process that includes a thorough history, and the use of appropriate screening and assessment tools. (83, 84) As with the Single Assessment Process for older people and the Common Assessment Framework for young people, in a multi-disciplinary context it is necessary to have a well-recognised and well-established common approach. (85) Without rigorous detection, problems will be missed or attributed inappropriately, and may result in the subsequent treatment or care response being inadequate, incorrect, or even neglectful. There are a range of instruments for screening and the assessment of different substances (86) – a discussion of their merits lies beyond the scope of this briefing. The more commonly used ones which can help professionals to develop appropriate protocols can be found in the reference list.

Screening and assessment must seek to understand the service user’s story and perspective on their illness, and should not exclude their family or carers. (87) Although screening and assessment may incorporate standardised tools and involve some medical investigations (blood, urine, and hair analysis), an evaluation of occupational capacity, social or relationship functioning and quality of life are also important in determining the client’s life experience. Assessment is likely to take place over the mid to long term and thus require regular monitoring as well as continual interaction and collaboration between colleagues working in allied services. The use of common protocols and processes is desirable because it avoids the unnecessary repetition of multiple assessments, which service users may find exhausting and may lead to resistance to further assessment. It also helps to establish common understanding of terminology, definitions, approaches, interventions and outcome expectations. (3, 10, 88-92)

Stereotypical assumptions may also have an adverse impact on effective assessment of dual diagnosis. Practitioners and carers may, for example, deny the use of substances in older people despite being aware of the implications of use on physical and mental conditions. For example, they may collude with them in bringing alcohol into the care home, or if they learn of this, ignore it, because they do not know what to do. This obviously hinders treatment or support that may be required. (93)

Interventions

If possible, the first objective of intervention following assessment is to engage the service user in reduction or abstinence. If this can be achieved, this often markedly reduces the psychiatric illness or psychological symptomatology although sometimes this is not feasible. Where a person is suicidal, for example, treatment may have to be initiated immediately, often within an inpatient setting. In general however, there is some consensus that if a client still has symptoms of mental illness after four to six weeks of abstinence or reduction in substance use, then specific pharmacological and psychological treatments need to be considered. Although the evidence on pharmacological effectiveness is promising or even in some instances, proven, there is a risk of interaction between medications for dual diagnosis and substances, or with the medication for physical illnesses. The British Association of Psychopharmacology guidelines (24) therefore urge caution by stressing the side effects of toxicity, i. e. cardio toxicity and death in overdose. As a result, motivational interviewing, cognitive behavioural work (individually or in groups), and measures aimed at the family, are the interventions that have been most consistently studied. (103, 104, 105)

Several key themes are evident in the literature (138) and these include, the need for:

• a flexible, person-centred, empathetic, nonconfrontational and non-judgmental approach which is important for maintaining an appropriate intervention programme
• trusting supportive relationships with clinical or social work professionals
• establishing a shared understanding
• promoting optimism and building motivation to deal with substance problems and other associated difficulties
• understanding the chronology of the disorders, but maintaining a holistic focus in addressing the substance misuse, psychological, social and physical health problems
• prioritising problem solving
• a harm reduction approach to substance misuse in the first instance
• advice and information about the impact of substance use.

Motivational enhancement, cognitive behaviour therapy, and contingency management are some of the better established treatments. (94-101) The willingness of services to offer immediate practical support in relation to basic needs (food, shelter) may sometimes improve motivation to engage with services. (26)

A recent systematic review on the psychological and pharmacological treatment of comorbid substance misuse and mental illness identified fifty-nine studies. (24, 102) Despite this, the review could not identify treatments that were equally efficacious for substance misuse and psychiatric disorder. It also considered the efficacy of integrated treatment to be unclear, partly through lack of data. However, the review did conclude that existing efficacious treatment for reducing either psychiatric symptoms or substance misuse also work with dual diagnosis patients. Unfortunately, many of the studies reviewed, had no standard classification of dual diagnosis, relied upon small sample sizes, lacked substance use and psychiatric outcome measures, did not take into account interactions between substance use and medication, had not been replicated; lacked measures of overall service utilisation, and provided insufficient information about possible ‘racial’, cultural and ethnic differences. (107, 108) It is therefore acknowledged that a marked improvement in study methodologies is required to ensure rigorous experimental designs with sufficiently large samples, long-term follow up studies with outcome measures for both substance misuse and psychiatric conditions, as well as social and physical functioning, and a focus on different patient categories. (53, 108) It is essential that there is a sufficient consideration of social parameters such as culture, ethnicity, class, gender, as well as levels of deprivation, when evaluating the merits of different interventions. (109) However, there is sufficient evidence to support the need for thorough assessment, liaison and joint working between a variety of service providers, (110, (111) and it has also been suggested that in light of the positive experience of recovery approaches in mental health services, it is reasonable to conclude that such approaches may prove useful in working with service users who have a dual diagnosis. (30, 31, 14)

Although there are no clear models and guidance for best practice or best treatment, there are many pointers as to what the elements or components of a less risky and more comprehensive approach should be, though by whom, when, and in what context these components should be delivered is not clear. (112, 113, 114) Nevertheless, practitioners should, take into account the following points: (115)

• They may need to plan the treatment programme over a prolonged period due to their complexity.
• Service users find stability and continuity of care reassuring and beneficial because of their multiple difficulties.
• There may be a need to accommodate chaotic life styles which make scheduling appointments or engaging in routines challenging.
• Development of mechanisms to pre-empt or manage crises which occur unpredictably.
• The particular needs of more vulnerable groups e. g. homeless people, teenagers, and older people.
• Availability of detailed knowledge of available services and the need for support in accessing them.
• The need for constant review and re-appraisal of the changing situation.
• Active and ongoing engagement and support of families and/or carers.
• Training and supervision of junior or inexperienced staff by experienced practitioners.
• The experience and knowledge of non-statutory organisations in working with people with a dual diagnosis may need to be drawn upon.

Service provision models

Several models have been proposed. One is a ‘tiered’ or ‘stepped’ model of care where the least severely affected would be treated in primary care level services, and where specialist substance misuse or mental health services would be utilised according to the predominant issues. (18, 19, 20, 21, 13, 14) Another suggestion is for specialist dual diagnosis services to treat those people who have severe problems in each of these domains of services, but as there is currently no convincing evidence as to what works best for this heterogeneous group, each local area will have to develop a framework for optimal management depending on the variety and level of resources available to them.

A Scottish study which actively sought the views of service users, commissioners and providers, to explore the health and social care needs of dual diagnosis patients, provided some important information about the organisation of provision and barriers to implementation. (29) The picture that emerged was that those with dual diagnosis struggled with the daily realities of everyday life, and had experienced a series of multiple ‘losses’ including, for example, routine lifestyle, social networks, employment and security. The study showed that services were often inappropriate and might even further undermine users’ fragile self-esteem and coping strategies. It noted the importance of raising awareness about support that was available in order to better help users navigate very complex care pathways (where these existed). Service providers perceived the users as a group as being ‘chaotic’, and though provision varied from place to place, it was generally inadequate and unsatisfactory. Exceptionally, however, key individuals had established a therapeutic relationship with service users and there were some examples of good practice, though the provision of support within mainstream service provision can only be as good as the expertise of the professionals within these services. (116-118, 23)

Training

There is widespread agreement that education and training for service users, carers, health and social care providers, commissioners, and the general public, should prioritise awareness raising. (86, (119) There is also a pressing need for training in clinical competence in the management of this group of service users. Many doctors (general practitioners as well as specialists) have a role in the treatment, management and coordination of care. (23, 52, 86) In addition, some groups require even more coordinated care than others, including the homeless; offenders; those with learning disabilities; women; teenagers; and older people. (53-56, 60, 65, 76-77, 82, 120-125) Therefore, multi disciplinary training for practitioners should be an essential component from undergraduate level to continuing professional development. Innovative methods for engaging and retaining the interest of the workforce in updating their skills and knowledge is also important.

Implications from the research

For organisations

People who are identified with a dual diagnosis are extremely heterogeneous in terms of their demographic characteristics, individual biographies, family relationships, pathways to comorbidity, and the type and severity of their mental, physical and substance use disorders. Consequently, the developmental trajectories (or histories) of service users with dual diagnosis are not straightforward or linear. The lack of clear and common causal pathways results in a service user group which is so variable that it is often excluded from services because of the concentration and complex combinations of problems. (126, 127) Whatever the trajectory, service structures should seek to support rather than exclude potential service users and provide a coherent response. (128) Services should be working towards enabling those with a dual diagnosis to live as meaningful and satisfying lives as possible – the complexity of problems should not be used an excuse not to pursue recovery. (31) The continuing development of more responsive models of service delivery in terms of self-directed care and personalisation are likely to provide valuable opportunities for recognising and responding to the diversity of individual circumstances and needs. Indeed, lessons from generic mental health and learning disability services may help facilitate much needed cultural change. (31) Despite the recognised benefits of interprofessional working in many areas of health and social care, there is a shortage of coordinated and comprehensive services for those with dual diagnosis that can, paradoxically, lead eventually to increased service utilisation and poorer outcomes. (129-132) Inclusive care pathways need to be developed and it is essential that these include protocols for interprofessional and joint working that translate into something meaningful in the real life situation of the service user and their carers. (14)

For the policy community

Commissioners and policy makers need to be engaged with service provision in a way that ensures they are aware of the multitude of problems that need to be managed without avoiding the challenges that they pose. Research and policy formulation therefore has to both recognise and address such challenges. This client group is, for example, often excluded from research that tends to concentrate upon the less complex problems, such as patients with only one substance problem and no associated disorders. Involvement of service users with a dual diagnosis in the planning, delivery and evaluation of services is vital in addressing such omissions. (14) In addition, policies should acknowledge the needs of practitioners working with service users in ways that provide a sound basis on which to deliver an integrated and appropriate continuous safe rewarding service. Evidence arising from developments in mental health services in regard to the recovery model and the particular needs and problems of people from different ethnic and cultural backgrounds should prompt a re-examination of the assumptions and organisation of services to those who have a dual diagnosis.

For practitioners

Evidence from developments in practice in mental health and learning disability supports the need for a shift from a passive model of care to one that perceives service users as active participants in their own recovery. This requires a shift of emphasis from pathology and morbidity to one that recognises strengths and accepts that recovery may not involve total abstinence. (31) Successful engagement and appropriate ongoing assessment are key processes when working with people who have a dual diagnosis. Training practitioners in the skills of engaging, screening and assessing those with complex needs should be core elements in health and social care education and training. It is important, too, that professional and academic training (i. e. continuing education in all relevant medical, health and social care courses) highlights the problems associated with substance use, mental illness, physical illness and the social ramifications of interaction between them. This capacity has to be increased by in-house training, enhancement of competencies through additional specialist training, and regular supervision. Inter-professional training and working in particular is vital to enable staff from different professions to better understand and respect each other’s values, perspectives and skills. (133)

Given the multiplicity of social, familial and economic problems relating to dual diagnosis, social workers are well placed to contribute to multidisciplinary assessments, to work in partnership with and advocate on behalf of service users and their families, and to facilitate their engagement with service provision and planning. A person-centred approach that recognises an individual’s unique biography and circumstances will not only enhance the likelihood of a positive relationship between practitioner and client, but should also provide a secure basis upon which to begin to tailor services to particular needs. Care plans that focus upon outcomes rather than on services, should be holistic and address the totality of service users’ lives. (135) The active involvement of service users, families and/or carers at all stages of service delivery is vital, and ‘whole family’ approaches are much more likely to have better outcomes, (87) though of course, the potentially fluctuating impact of dual diagnosis upon a person’s motivation and decision-making capabilities will impact upon the capacity to participate effectively. In the initial stages of contact, services users and their families often respond well to those services/practitioners that are able to offer practical support and immediate help in emergencies. (26) Approaches that focus on recovery, rather than upon adherence to a particular treatment regime, are recommended (see ‘Ten Top Tips’) (30), and where possible, opportunities for increased self-direction and personalisation of service should be provided.

For people using services and their carers

It is important for service users and their carers to appreciate that intervention may require a substantial time investment to produce effective results. It is also important to realise that practitioners are likely to offer differing interventions to different groups of people with a dual diagnosis as respond to differing circumstances. (134) In all cases, the underlying unpredictability of the conditions giving rise to dual diagnosis can produce difficulties in implementing programmes and may make it more difficult to provide or sustain choice and self-direction in service provision. Users and carers therefore need to work with practitioners to find ways of meeting these challenges. Obtaining help and advice from available services and support groups is important in achieving optimally effective outcomes for all concerned. Service providers should be sensitive to the particular challenges facing someone living with or supporting a person with dual diagnosis and should not neglect a proper assessment of their needs.