Promoting Awareness among Clients with Dual Diagnosis - Dissertation Example

 Promoting Awareness among Clients with Dual Diagnosis 1. Introduction 1.1. Background to the study Public health issues have never been so acutely debated before and dual diagnosis has come to occupy the centre stage in public health sphere nowadays due to a variety of complex reasons. Dual diagnosis is a condition in which a co-occurrence of mental disorders along with alcohol dependency or/and drug addiction can be noticed. Thus dual diagnosis is interchangeably identified with co-morbidity and its complexity is not only befuddling at times to the casual observer but also highly misleading (Evans and Sullivan, 2000). Predesigned programs of intervention in dual diagnosis patient care are initiated with a view to achieving clinical and post-clinical objectives that are incorporated into the overall plan. As such they tend to be positively correlated with outcomes that range from various treatment regimes and meetings between the nurse and the patient (Alexander, Fawcett & Runciman, Editors, 2006). Invariably the causal factors that have been identified as a priori behavioral tendencies or symptomatic behavioral patterns displayed by the potential patient are influenced by a series of proclivities such as habitual dependency on drugs among trauma patients including combatants coming from the theaters of war, family disputes, incurable illnesses, divorce and a multiplicity of psychotic and psychosomatic disorders. These causal factors apart there is a host of other endogenous and exogenous variables which play a pivotal role in affecting the mood swings of individuals who are susceptible to dual disorder symptoms. The implications that arise from this kind of dual diagnosis environment have received little attention if at all in the currently available literature on the subject. Implications associated with dual diagnosis have been diverse and complex and therefore learning outcomes have been heavily influenced by these implications. But nonetheless the degree of such influence cannot be determined unless an adequate system of metrics is developed to measure these outcomes so that the methodological parameters would sufficiently outline the extent and depth of such influences. This paper would focus on just these facets in addition to the overall learning outcomes to delineate the theoretical constructs underlying these implications arising from the dual diagnosis patient environment and determine a feasible contingency model to capture the behavioral tendencies of such individuals. 1.2. Reasons for choosing the topic This topic “promoting awareness among clients with dual diagnosis” was chosen with a view to focusing attention on a very important but often neglected aspect of mental health care. Despite an ever growing interest in the dual diagnosis phenomenon there has been very little effort if any on the part of researchers to identify and address the significant issues related to the subject. This researcher has identified the various issues and outcomes thereof connected with dual diagnosis while at the same time counseling and nursing practice has been undergoing a sea change. The lack of awareness among clients about dual diagnosis and its long run implications has been one of the strongest reasons for the choice of this topic by the researcher. 1.3. Definitions of concepts This study would define the concepts dual diagnosis, implications, mental disorders, drug addiction and alcoholism. 1.4. Aims of the project To establish a set of correlations among primary and immediate variables of dual diagnosis. To establish a set of correlations and regressions among endogenous and exogenous variables of dual diagnosis and its impact on the individual client. To investigate the learning outcomes associated with dual diagnosis and the extent of its impact on such outcomes. To study the diverse and complex implications involved in dual diagnosis phenomenon and determine their variability and conformance to nursing practice. Finally to draw conclusions on the learning outcomes and make recommendations for catalytic changes in the sphere of dual diagnosis and subsequent treatment. 1.5. Hypothesis or key themes The primacy and immediacy of a priori and a posteriori implications of dual diagnosis have been subject to a wider perspective-based research effort over the years despite the woeful inadequacy of analytical approaches to the decisive elements in creating awareness among clients facing dual diagnosis. In this instance the nursing practice has more or less been focused on the client’s immediate needs to overcome the otherwise inescapable consequences of dual diagnosis. Thus the contingency model building effort for a more client-centric approach to dual diagnosis by the nurse and counselor would prevent those implications at least to a certain extent. But nonetheless there are other causative factors as well that need to be delineated in understanding these implications better (Coombs & Howatt, 2005). As much as a lack of awareness among clients about these implications of dual diagnosis is of critical significance in the nursing practice, inadequate knowledge of probable outcomes in the process of treatment is also of equal significance to the whole exercise. 2. Literature review The literature review of this paper is basically determined by the current emphasis on topical causative factors in dual diagnosis and the implications thereof. As a corollary the consequences of such dual diagnosis too would be considered and this literature review would delineate the learning outcomes related to the symbiotic relationship between the nurse/counselor and the patient as an ultimate cohesive approach to contingency model building effort (Freshwater & Bishop, 2004). The lack of awareness among the majority of clients about dual diagnosis and its implications signifies a particular aspect of this symbiotic relationship. Recent research on the subject has sought to focus considerable attention on the obvious links between dual diagnosis and the patient’s limited access to proper counseling and nursing (Soloman, Zimberg & Shollar, editors, 1993). Dual diagnosis, co-occurring illnesses or concurrent disorders all refer to the same duality condition in which there are two diagnoses – one on psychiatric problems and the other on substance abuse or alcoholism. In other words, when an individual suffers from dual diagnosis there can be some dependency on chemical stimulants and an emotional disturbance. Thus the individual is not only suffering from two illnesses simultaneously but also that they have an impact on each other thus mutually reinforcing the negative impact on the individual patient. When symptoms overlap or co-morbidity occurs diagnosis becomes very difficult thus rendering the health professional’s task even more difficult and complex (Schmal, Ekleberry & Hendrickson, 2004). This mutually reinforcing symbiosis between the psychiatric disorder and substance abuse or alcoholism might defy realistic and quick diagnosis and symptoms might acquire a very critical dimension. There are many implications that would arise from this symbiosis and even the patient might not be aware of the existence of these implications so that ultimately the level co-morbidity would reach a critical value thus leading to greater intervention by health professionals. In this instance the nurse’s professional involvement happens to assume a greater degree of significance (Cormack, 2000). The following implications arising out of dual diagnosis have been highlighted by many researchers in the recent past. ► More often than not psychiatric symptoms could be camouflaged by substance or/and alcohol dependency. ►On the aftermath of prolonged dependency and sudden withdrawal the symptoms could be mistaken for some psychological illness or disturbance. ►When a psychiatric condition remains unattended for too long, relapsing into substance use or alcohol is inevitable. ►When chemical dependency is not treated psychological symptoms might recur. Recent studies on dual diagnosis have also focused attention on a number of connected issues as follows (Watkins, Lewellen & Barrett, 2000). Self-imposed isolation and withdrawal from the society and relations. Risk-prone behavioral tendencies such as violent response to conflict while working or driving. Friction at work place or/and places of visit. Complications arising from dual diagnosis would lead to ever increasing frequency of visits to health professionals. Divorce, family disputes and troubled intimate relations. Coming into conflict with law. Multiple admissions for a variety of psychiatric disorders. Total absence of any meaningful relations. Gournay et al (1995) have specifically suggested two spheres for intervention. In the first instance according to them specialist clinical support system could have a dual diagnosis team of specialists. Secondly they suggest that each team be provided with specialist education on dual diagnosis along with clinic-based supervision. Drake and Noordsy (1994) propose four pivotal areas for nursing intervention in dual diagnosis patients. They are engagement, persuasion, active treatment and the prevention of relapse (Drake and Noordsy, 1994). Thus the health professionals like nurses would have to focus attention on a variety of factors in order to understand both the patients’ needs and problems. The professional health related problems apart there are a series of social and psychological issues that would require the attention of the nurse in the treatment context. A heightened awareness of both the implications and other problems of dual diagnosis by clients would serve as a catalyst in transforming the treatment and counseling environment from its currently constrained atmosphere to a more liberal one. Addiction has also attracted the attention of authorities at various levels of policy planning (Miller, 2004). Miller identifies some critical factors of dual diagnosis related clinical environments that have an impact on the subsequent nursing interventions. Thus the environmental factors, especially clinical factors must be given a place of priority in this analysis so that learning outcomes can be delineated with a degree of comprehension. 3. Analysis Diagnosis is one of the most important structural determinants of nursing intervention. Diagnosis in fact determines the outcomes of the nursing intervention process. In the historical developmental process nursing intervention has been going through major changes in the elements of its internal and external structures. This structural transformation has had a substantial influence on both the treatment methods and scope of such methods in the light of a strategic shift in the perception of diagnosis techniques and their broader application across a variety of “disorders”. With the development of diagnosis criteria like the Diagnostic and Statistical Manual (DSM), and the subsequent improvement of techniques for diagnosing and understanding of symptoms, the treatment design, planning and implementation process was revolutionized. This in turn produced a wider spectrum of positive outcomes including those associated with tangible and intangible benefits. While a more positive correlation was established between benefits and intervention outcomes, there were also some bottlenecks that evolved with the very diagnosis techniques. For instance as a corollary of the new developments individual and institutional freedom enjoyed by health professionals increased but only to replace the converse parallel that prevailed before, i.e. the professional straightjacket. Assessment frameworks and processes in dual diagnosis and treatment planning occupy a very important place due to the fact that the relationship between the nurse/counselor and the client is a continuous one with each successive stage of the process of diagnosis and treatment. The assessment process is also a bilateral one in that nurses happen to increase their awareness of the client’s mental disposition. According to Krauzler & Tinsley (2004) such processes help the counselor/nurse to understand the client with specific stress on the internal and external parameters of diagnosis and treatment ( Herzen and Porzelius, Ediotrs, 2001). In the same vein it helps the client to understand and be involved in the counseling process as characterized by an inescapable mutually reinforcing relationship between the two (Selingman, 2004). Despite the benefits there are also some concerns about the probable outcomes of diagnosis. In the first instance there are as many limitations and controversies as positive outcomes associated with the clinical validity and compatibility of the diagnosis systems, the competence of clinicians in diagnosing and whether counselors should diagnose or not. Two of the most negative factors in diagnosis are the focus on confirming information, and self–fulfilling prophecy that jeopardize the validity of the diagnosis (Ortman, 2001). Another important issue is multicultural competence in diagnosis of mental disorders. Postmodern viewpoints on nursing interventions in dual diagnosis clinical environments support the relativity of the psychological problems to the cultural environment stressing the importance of cultural differences and their reflected effect on the symptoms, attitudes, and behaviors of culturally different clients (Davies & Logan, 2003). 3.1. Clinical implications, policies and legislation Clinical implications arising from dual diagnosis have been discussed with reference to policies and legislation in the UK while the nursing practice and intervention in the clinical setting have received much less attention due to the prevailing situation of confusion as to what extent such clinically-based nursing initiatives would be able to set priorities in this significant health care sphere. National Health Service (NHS) Plan is not necessarily a legal document but it sets the standards to be followed by health professionals in meeting the standards in respect of all national health services. Legislation does not adequately define mental disorders except to address the borderline characteristics. Thus by implication those patients suffering from such mental illnesses as eating and personality disorders and depression might not come under the seriously ill category of mental patients . However this in-deterministic approach has caused such confusion among even those patients with dual diagnosis. NHS policy direction has suffered from a very short-sighted approach though. Despite its laudable efforts there have been numerous delays and uncertainties in identifying and addressing the requirements of a systematic development plan for professional intervention in dual diagnosis health care environments (Cullum, Cilkiska, Haynes & Marks, 2008).The consequences of this lack of policy direction could be seen in how dual diagnose patients have been subject to a variety of institutional and treatment mishaps. But nonetheless recently many researchers have suggested the significance of evidence-based nursing interventions with pre-designed metrics of success measurement. As at present those commissioning bodies that have been set up by trusts are responsible for the putting in place of evaluation criteria. These criteria serve as standards for the NHS Executive’s policy evaluation efforts. While nursing interventions have been advocated on two specific fronts – clinical support and education in creating awareness among clients of dual diagnosis – there have been parallel efforts too to identify and adds the various needs and pressures of dual diagnosis patients in both formal and informal contexts. Health policies adopted by the NHS largely focus on mental health sphere and dual diagnosis is just sub area of interest and therefore its implications have received less attention. However, the US Diagnostic and Statistical Manual of Mental Disorders (DSM) has been used in defining and identifying various symptoms of mental disorders in many parts of the world including Britain. 3.2. Assessment The current assessment process was preceded by a variety of intelligence scales including Wechsler-Bellevue Intelligence Scale developed in 1938. These were followed by inventions and tests that assessed aptitudes, personalities and interests of clients. Structured assessment processes are nothing new in the sphere of counseling. It’s in fact the most important in diagnosis because it enables the nurse to identify the relative severity of symptoms, to define treatment goals and regimes and finally to enlist the client’s support for the overall treatment planning process. Modern health professionals adopt contingency process building approaches in order to achieve long term client motivation and collaboration so that progressive treatment could either be scaled down or altogether discontinued if the client shows improvement. Termination of treatment however has to be carried out under strict supervision of symptoms through structured assessment. The intake interview is one of the qualitative methods of assessment and is used with discretion by the counselor as the first method for gathering information about clients, their background, and their problems. It is the first step in the new relationship between the client and the counselor. However, the outcome of the intake interview can be negatively influenced by client resistance and interviewer inexperience. Along with tests, inventories and interviews, observation is another technique of qualitative information gathering, which provides insight into people's behavior in extra-counseling settings. Many qualitative methods of gathering information are necessary but not sufficient to complete a comprehensive assessment. Factors such as difficulty with self-expression, hostility and resistance, confusion, or severe disturbance are often impediments in the way of testing the client’s situation. In such situations quantitative approaches play an important role in assessment and diagnosis. Standardized inventories are divided into three categories based on the variable they are designed to measure. Inventories that measure ability are tests of inborn and learned capacities that measure intelligence, achievement, and aptitudes. They provide information regarding academic strengths and weaknesses as well as to indicate the level of learning of a client relative to a specific sample (Hinkel, 2005). A second category of inventories is the interest inventory. "Interest can be defined as constellations of likes and dislikes manifested through the activities people pursue, the objectives they value, and their patterns of behavior” (Seligman, 2004). This type of inventories, unlike the ability inventories, is more likely to be well accepted by the subject because of their non-threatening nature, which is relayed by the absence of a categorically right or a wrong answer. The last but not the least important category of inventories, is the personality inventory. This type of inventory provides either holistic information about one’s personality or concentrates on a particular aspect of personality. They provide information which might not be provided directly due to lack of ability or willingness. Personality inventories can be divided into general personality inventories, clinical personality inventories and specialized personality inventories (Marushi, Editor, 2004). 3.3. Nursing intervention Nursing intervention as a professional guidance technique is comparatively newer and its current status is primarily the result of a breakaway from the traditional profession of psychotherapy. It’s all about professional guidance and this conceptualization helps in designing, planning and implementation of nursing intervention strategies in an authentic professional setting. Here a clear distinction between guidance and intervention is of importance to the analysis. Guidance refers to a systematic process of helping individuals to decide on the relative merits of available choices. On the other hand intervention is primarily focused on helping the individual to make changes in the process of treatment. While guidance is more or less akin to helping individuals to make choices, nursing intervention helps them to identify what strategic options are available to them and at what opportunity costs etc. This in turn helps them to change their own decisions. There are both a priori and a posteriori elements in this approach. Though advantages outweigh disadvantages in counseling priorities might be overlooked by individuals if they happen to change decisions without the help of a nurse. Professional guidance is part of the help process provided by health professionals such as nurses. The relative importance of the whole process lies in its empowering capacity to enable the individual patient to make decisions by using strategic options available to them. This paper in analyzing the importance of diagnosis and treatment planning in nursing interventions would also focus on the strategic importance of dual diagnosis and its implications for the subsequent decision making process (Mueser, Noordsy, Drake & Fox, 2003). The relative significance of diagnosis and treatment planning in counseling has to be considered against this backdrop and the subsequent category constructs in techniques of diagnosis and treatment planning have enabled the researcher to build up a contingency model of clinical counseling and therapeutic intervention. Thus a broader definition of counseling to include a multitude of procedural, professional, design, planning and implementing conceptualizations would be more feasible in this context. 3.4. Health education and health promotion Health education and health promotion among dual diagnosis patients must be centered on motivation. Motivation is an important factor that contributes to the counselor and client relationship ending in a successful counseling process. Various degrees of motivation can be determined depending on the nature of referral. Self-referred clients are the most motivated ones because their motivation is an intrinsic one empowered by self-determination and will to change. However, clients who are referred by family, and especially those who are court-mandated to treatment, are more reserved to engage in the counseling process. This reticence is caused by the external pressure. These clients are not motivated by a desire to change. They are persuaded by family members, friends or even by the law. However, clients motivated by another's achievement are likely to be strongly motivated, even though they may not fully understand the process of intervention by the nurse. Another factor that determines the relevance and success of the health professional’s or nurse’s intervention in creating awareness of dual diagnosis is the nature of the problem presented by the client. In other words, the problems and concerns of clients must be amenable to treatment by intervention. Usually, these are common concerns and problems regarding relationship and communication difficulties, poor or unclear self image, depression or anxiety, trembling behaviors or habits, and so on. Though intervention can help people who have a variety of concerns, it is likely to be unsuccessful if used as stand-alone treatment in some cases. People struggling with severe personality disorders or with cognitive mental disorders and those who oppose nursing interventions, or those who exceedingly externalize the cause of their problems are more likely to pose a challenge for the nurse and the subsequent intervention process, by rendering it inefficient. This can be due to a lack of medication evaluations or other professional or social help resources. Health education and dual diagnosis have much more in common including the nursing intervention planning. The professional nursing intervention plans need to be put in place with a view to educating clients so that a degree of increased awareness about the complex implications of dual diagnosis would help the client to adjust to his environment better. 3.5. Challenges faced by nurses while dealing with dual diagnosis clients Assessment criteria need to be developed in conformance with category constructs and theoretical constructs. Category constructs and theoretical underpinnings that underlie each category construct in diagnosis and treatment planning in counseling, have to be delineated in order to understand the extent and the nature of the impact created by different procedural and clinical techniques adopted by the nurse and the nursing intervention. In this analysis a controversy that exists in between the definitions of nursing intervention and psychotherapy ought to be cleared, viz. nursing intervention and psychotherapy have been treated by many researchers as identical concepts. For instance Snyder (1961) defines psychotherapeutic intervention as “the face to face relationship in which a psychologically trained individual is consciously attempting by verbal means to assist another person or persons to modify emotional attitudes that are socially maladjusted and in which the subject is relatively aware of the personality reorganization through which he is going”. This is part of a recent general trend to identify nursing intervention with psychotherapy and is of extreme relevance here. This paper would instead place emphasis on assessment of dual diagnosis patients’ recovery phases in order to achieve a synthesis between the nurse’s efforts and recovery. In other words there should be some strictly definable measurable criteria for the assessment of the impact of nursing interventions in dual diagnosis patients. The currently available adjustment measures adopted by both the NHS and private nursing homes have been of varying degrees of success though. In the absence of supporting techniques the nurse’s task both in intervention design and planning becomes difficult. 3.6. Dual diagnosis and risk A number of risk factors have been identified with dual diagnosis. In the first instance despite successful nursing intervention, there is a very high level of risk involved in not only treatment planning but also in subsequent treatment sessions. The next step in treatment planning is to determine the best nursing intervention setting for a particular client (Lano, 2002). Depending on how many people and which people are involved in the session or process, the setting possibilities are as follows: Individual intervention, Group intervention, and Family intervention. Again, depending on the personal resources, personality characteristics, and the nature of a client’s problem, it is to be decided if for the client it is more beneficial to participate in one-on-one intervention or if the support of group intervention is more beneficial. Sometimes the involvement of other clients is considered to be beneficial for the intervention process. Many health professionals consider, the family dynamics, which are at the root of many of the personal problems presented by the clients. Risk factors such as the danger of frequent relapse and co-morbidity becoming complex cannot be ignored by the nurse. Even if the client shows improvement there is the risk of relapse due to domestic environmental factors. The treated patient is being sent back to his own home environment where the roots of the problem lie. Finally such clients would not be able to endure the long run effect of environmental factors. Thus the degree of susceptibility too has to be taken into consideration. 3.7. Treatment and the prevention of relapse Once the necessary data has been obtained through intake interview and standardized tests, they will help the counselor to initiate the diagnosis and treatment planning processes. The Multi-axial Assessment uses DSM to comprehensively analyze the client in a holistic way. This type of assessment uses five ways, or axes, to diagnose the client. Relapse can be prevented when the following steps are followed with care by the nurse. Clinical disorders and other conditions that may be a focus of clinical attention. Personality disorders and mental retardation. General medical conditions represented by a physical disorder, possibly relevant for the emotional condition of the client. Psychosocial and environmental problems that are possible stressors for the client. Axis five is a scale of global assessment of functioning (GAF), which measures the client’s level of functioning. Determined by symptom severity and functioning, GAF is a 1-100 scale placing the better functioning at the higher end of the scale. The Multi-axial Assessment is the last step in diagnosing and the first step in establishing a treatment plan and therefore helps in preventing relapse. 3.8. Medication The timing, length of the session, frequency of nursing intervention, and duration of each intervention are important technical aspects of the intervention process. The severity of symptoms, existence of self-endangering tendencies, the motivation of the client, and impediments such as limitations of insurance coverage are all key factors in deciding the length of the sessions and frequency and duration of the counseling. However, all this is decided in concordance with the client’s needs and possibilities. Even though nurses are not competent to prescribe medication, there are a number of reasons for which nurses should be familiar with the medications frequently used to treat mental disorders and their effects. First, at the point when the intervention starts the client may have already been taking medication, which might give an idea not only of the present and past status of the client, but would help the nurse avoid a bias in diagnosis. Knowing what a medication can or cannot do and knowing its side effects helps the monitor to monitor closely the client’s progress, so he is able to decide whether to send the client for a medication evaluation or not. The knowledge of pharmacology is enough for the nurse to identify and address the most vital needs of the client though the nurse in fact might be ignorant of the medical how medicinal properties of certain drugs in combination would react on the patient. During treatment planning, and often during counseling, the nurse might recommend adjunct services to improve the efficiency of the intervention process. A wide range of adjunct services are available to improve social life and personal growth in general for the society, and especially for those people who are in need. Therefore the needs of the client are the most important determinant in when, how and which adjunct services will be used in addition to intervention (McCrady &Epstein, Editors, 1999). Finally, the last step in treatment planning is the prognosis. Considering the generally accepted prognosis for a specific mental disorder, and taking into account the personal resources and motivation of the client, the prognosis may be terminologically established as follows: very good, good, fair, poor or guarded. However, seeking for a treatment plan with an optimistic prognosis by establishing realistic goals and valid interventions increases the likelihood of the desired outcomes of the intervention process. 4. Recommendations The virtual complexity of theoretical constructs apart, there is less appreciation of the NHS system by nurses in practically daunting circumstances of clinical practice. There must be a greater degree of participation in workshops and seminars by such nurses to understand the complex implications of the NHS system in a nursing intervention environment. A truly dynamic model of metrics based on algorithms of the nurse-client relationship dynamics should be established to measure various values attributable to controllable variables such as mood switching behavior of clients (Watts, 1999). A parallel set of criteria must be set up in order to establish positive or/and negative correlations between the theoretically determined treatment models as enunciated by Seligman, the strategic choices available to the nurse and outcomes thereof. It’s all the more imperative to engage the individual and relevant institutions in a continuous process of dialogue to create a paradigm continuum for an effective nurse-client relationship. The existing definitions of not so serious mental disorders must be updated in order to include some of the eating and personality disorders in the mental health category to design and implement a comprehensive treatment regime for dual diagnosis patients. Finally a variety of nursing intervention environments must be developed in order to facilitate the understanding of dual diagnosis clients in their domestic context as a precondition for successful treatment. Conclusion Throughout this analysis the researcher focused on the theoretical underpinnings and contingency models with a strong delineation of paradigm constructs to substantiate the importance of dual diagnosis and the nurse-client relationship. While focusing on the constructive role played by the nurse in creating awareness among the potential client’s symptoms and mapping out the subsequent treatment plan, the researcher has placed emphasis on the probable learning outcomes related to all aspects of the nurse-client relationship. All the aspects analyzed above are necessary for efficient intervention though which particular one carries more weight than which particular one is rather difficult to establish. Theoretical model building done on the contingency model is more appropriate here because the underlying paradigm constructs for the evaluation of the relative importance of dual diagnosis and creating awareness of dual diagnosis among clients have been subject to a broader perspective-based analysis. In this context the following conclusions have been drawn and the subsequent recommendations have been presented with a view to enlarging the scope of discussion on the subject. There is a greater degree of potential for futuristic intervention in creating awareness among clients about their dual diagnosis and implications thereof when an appropriate methodological approach is adopted. For instance particular groups of clients might come closer to certain paradigm of contextualization while many others might diverge. Thus a convergent paradigm of dual diagnosis clients needs to be established for a better understanding of the problem (Pierson, Field & Jordan, 2007). The conceptualizations related to dual diagnosis process and the subsequent planning process of the treatment regime have been sought to be qualified with the mutually empowering dynamic relationship with the client as well. This mutual impact on the relationship between the nurse and the client is emphasized with equanimity to bring out the various perspectives on the cintervention environment (Hersen and Porzelius, Editors, 2001). The theoretical parameters which have been outlined in support of this effort have to be acknowledged as the most feasible and most helpful in constructing a contingency model for understanding the importance of creating awareness among clients of dual diagnosis. Finally it must be noted that dual diagnosis and the related implications as mentioned above have had their far reaching impact on the nursing profession both in the environmental intervention context and beyond in the decision making process. While there are many divergent opinions expressed about the learning outcomes of dual diagnosis and environmental factors, there is at least a margin of unanimity in respect of causative factors and client behavioral patterns. As such this study has conclusively established the correlations between the nursing intervention practices and dual diagnosis client’s necessity for increased awareness of his/her conditions. Also it has conclusively established the presence of causative elements in client’s behavioral dynamics. The identification of such causative elements needs more concentrated intervention programs to help the client to overcome those negative effects. REFERENCES 1.Alexander, M. F , Fawcett, J. N. & Runciman. P. J, Editors, (2006) Nursing Practice: Hospital and Home -- The Adult. Oxford, Elsevier Health Sciences. 2. Coombs, R.H. & Howatt, W. A. (2005) The Addiction Counselor's Desk Reference, New Jersey, Wiley Publishers. 3. Cormack, D. F. (2000) The Research Process in Nursing, 4th edition, Oxford, Blackwell Science. 4. Cullum, N, Ciliska, Haynes, R. B & Marks, S. (2008) Evidence-based Nursing-An Introduction, Oxford, Blackwell. 5. Davies, B. & Logan, J. (2003) Reading Research. A User-friendly Guide for Nurses and Other Health Professionals, Mosby. 6. Evans, K. & Sullivan, J. M (2000) Dual Diagnosis: Counseling the Mentally Ill Substance Abuser, 2nd edition, New York, The Guilford Press. 7. Freshwater, D. & Bishop, V. (2004) Nursing Research in Context: Appreciation, Application and Professional Development, Basingstoke, Palgrave MacMillan. 8. Hersen, M. & Porzelius, L. K, Editors (2001) Diagnosis, Conceptualization, and Treatment Planning for Adults: A Step-by-step Guide, New Jersey, Lawrence Erlbaum. 9. Kranzler, R. N. & Tinsley, J. A, Editors (2004) Dual Diagnosis and Psychiatric Treatment: Substance Abuse and Comorbid Disorders, 2nd edition, New York, Informa HealthCare. 10. Lano, N. (2002) Ogier’s Reading Research: How to Make Research More Approachable, 3rd edition, London, Bailliere Tindall. 11. McCrady, B. S. & Epstein, E. E, Editors (1999) Addictions: A Guidebook for Professionals, New York, Oxford University Press. 12. Miller, G. (2004) Learning the Language of Addiction Counselling, 2nd edition, New Jersey, Wiley. 13. Mueser, K. T, Noordsy, D. L, Drake, R. E. & Fox, L. (2003) Integrated Treatment for Dual Disorders: A Guide to Effective Practice, New York, The Guilford Press 14. Noordsy, D.I, Drake, R. E. & Miller, N.(Editor) (1994) Case Mangement: Treating Coexisting Psychiatric and Addictive Disorders. A Practical Guide, Center City, MN, Hazelden, pp.231- 244 15. Ortman, D. (2001) The Dual Diagnosis Recovery Sourcebook: A Physical, Mental, and Spiritual Approach to Addiction with an Emotional Disorder, New York, McGraw-Hill. 16. Pearson, A, Field, J. & Jordan, L. (2007) Evidence-based Clinical Practice in Nursing and Health Care. Oxford, Blackwell. 17. Schmal, M, Ekleberry, S. & Hendrickson, E. (2004) Treating Co-Occurring Disorders: A Handbook for Mental Health and Substance Abuse Professionals (Hawort Addictions Treatment), Oxford, Routledge 18. Seligman, L. (2004) Diagnosis and Treatment Planning in Counseling, 3rd edition, New York, Springer. 19. Snyder, W. U. (1961).The Psychotherapy Relationship. London, Macmillan 20. Solomon, J, Zimberg, S. & Shollar, E, Editors (1993) Dual Diagnosis: Evaluation, Treatment, Training, and Program Development, New York, Springer. 21. Watkins, T. R, Lewellen, A. & Barrett, M. C. (2000) Dual Diagnosis: An Integrated Approach to Treatment, London, Sage Publications. 22. Wright, S, Gournay, K,Glorney, E. & Thornicroft, G.(2000) Dual diagnosis in the suburbs: prevalence, need, and in-patient service use, Social Psychiatry and Psychiatric Epidemiology, Steinkopff Publisher, pp.297-304. BIBLIOGRPAHY 1. Austrian, S. G. (2000) Mental Disorders, Medications, and Clinical Social Work. 2nd edition, New York, Columbia University Press. 2. Barlow, D. H, Editor, (2007). Clinical Handbook of Psychological Disorders,: A Step-by-Step Treatment Manual (Barlow: Clinical Handbook of Psychological Disorders), 4th edition, New York, The Guilford Press. 3. Denning, P. (2004) Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. New York, The Guilford Press. 4. Dodes, L. M. (2002) The Heart of Addiction: A New Approach to Understanding and Managing Alcoholism and Other Addictive Behaviors. New York, HarperCollins Publishers. 5. Giuseppe (Editor) & Carra (2003) Dual Diagnosis: Filling the Gap. Chesham, John Libbey. 6. Nathan, P. E. & Gorman, J. M. (2007) A Guide to Treatments that Work, 3rd edition, New York, Oxford University Press. 7. O'Connell, D. F. & Beyer, E. P. (2002) Managing the Dually Diagnosed Patient: Current Issues and Clinical Approaches, 2nd edition, New York, Routledge. 8. Rassool, G.H, Editor, (2002) Dual Diagnosis: Substance Misuse and Psychiatric Disorders Oxford, Wiley-Blackwell. 9. Richard A. & Morin, M. D. (2004) Masquerade: Unmasking Dual Diagnosis. Portland, Arnica Publishing. 10. Rosenthal, R. (2003) Dual Diagnosis (Key Readings in Addiction Psychiatry, 2). New York, Routledge. 11. Thompson, C. & Dowding, D. (2002) Clinical decision making and judgement in nursing, Oxford, Churchill Livingstone Read More