Complexity of Dual Diagnosis Treatment and Care - Research Paper Example

Complexity of Dual Diagnosis Treatment and Care The service user in this essay is a 28 year old African lady diagnosed with dual diagnosis. With respect for confidentiality, she will be referred to as Abigail in this assignment. Abigail has a 10 year history of substance abuse and related previous admissions to hospital. She is single with her disappointed family giving very little support to her. Abigail is currently living in a local support accommodation. However, due to her chaotic behaviour and continuous drug use, she is at risk of being evicted from the premises. She has been homeless in the past. She tends to socialize with people who use drugs and is therefore finding it difficult to stop using substances. She has been known to mental health services for few years and has a history of disengagement from community services. Due to her continuous substance abuse and deterioration in mental state, she had been admitted to inpatient ward for treatment. She is currently on monthly depot injection but tends to miss her appointments with the care coordinator for medication and follow-up and would not make contact with services until she is in a crisis. For example, when facing eviction from the support accommodation, when having benefits problems or after violent altercation with other residents or assault on staff, she attends drugs and alcohol drop-in sessions, but she is not finding this helpful. She reports feeling depressed about her situation and she recently overdosed with medication. She is unable to stop using substances although is aware of the effects this has on her mental health and her life. The author chose her for this assignment, as her mentor who is a community psychiatric nurse, found her complex and difficult to work with due to her multiple needs and disengagement from service. In this essay, the complexity of dual diagnosis treatment will be discussed from the health care professional perspective as well as service user perspective, demonstrating an in-depth analysis of the concepts and theories relating to this diagnosis and application to service delivery. According to Todd, Harrison, Ikuesan, Self, Pevalin and Baldacchino (2002), dual diagnosis is usually prescribed to individual service users diagnosed with mental illness as well as alcohol and/or drug misuse. However this terminology has become more complex, and interplay between mental illness and substance misuse has implication for clinical as well as social and legal practice. Todd et al. (2002) argued that recently, more emphasis has been placed on complex needs of such service users and researchers are therefore taking a more social perspective. Research suggests that dual diagnosis is considered complex for several reasons, including complex needs of service users, diagnosis and treatment. Additionally, complex dual diagnosis can often lead to problems such as unemployment and homelessness among others. According to Mind (1998), service users diagnosed with dual diagnosis are often noted to have complex needs, which are some of the additional difficulties that service users face apart from medical and psychological problems often related to social, housing and lifestyle matters. In addition, individuals diagnosed with dual diagnosis are more likely to relapse, not comply with their treatment, have higher risk of violence and become aggressive, as well as exhibiting poorer treatment outcome (Brooner, Greenfield, Schmidt & Billow 2003; Drake & Wallach 2000). The relationship between mental illness and substance misuse is complex and it is still unclear whether mental illness makes individuals more likely to use substances or using drugs and alcohol worsens the development of mental illness or both (National Mental Health Development Unit & NHS Confederation 2009). It is very likely that Abigail will be evicted from her current residence due to her continued substance use and her chaotic behaviour. According to Rassool (2002), there is a high tendency for vulnerability among people with dual diagnosis as many supported the accommodations report which argued that they are not in a position to offer services to them. He further suggested that this is probably the most frustrating aspect of community work involving dual diagnosis service users because, due to their mental health issues and drugs and alcohol use in their premises, they often don’t fit the criteria for supported accommodation. Unemployment and homelessness and housing instability seems to be strongly related to people with dual diagnosis (Caton, Shrout, Eagle, Opler, Felix & Domingues 1994). Often behavioural problems due to substance use and mental illness can prevent people from securing and maintaining stable housing. In addition violence is strongly related to substance use and such violence is in most cases directed at people within the immediate living environments (Steadman, 1998). In addition, Rassool (2006) stated that people from black and ethnic minority groups face stigma, social exclusion and prejudice. The National Mental Health Development Unit and The NHS Confederation (2009) argued that getting the right treatment for individuals with dual diagnosis is important, but due to the complex nature and variety of needs that these people present, treatment and provision of care becomes challenging. Currently there is no set treatment for service users with dual diagnosis and this is mostly due to many problems they face, mainly involving both substance misuse and mental health services (DH, 2002). Similarly, Social Exclusion Unit Report (2004) argued for services that dual diagnosis service users need, which are not purely health-related but also involve a number of other factors that would need to be addressed by several treatment services or agencies. Jackson-Koku (2001) stated that in the United Kingdom, drugs and alcohol services often operate separately from mental health services, which leads to fragmentation of care and in most cases impacts negatively on service users. Abou-Saleh (2004) suggested that service users with dual diagnosis “fall into the cracks” between mental health and drugs and alcohol-related services. Whereas the general assumption of drugs and alcohol services is that their clients want to be helped and are willing to change their drug habit, mental health services are expected to treat all patients including the ones detained under the Mental Health Act. According to Mind (2004), often, there is a slight disagreement between services on how best service users with dual diagnosis can be helped. Service users suffering from both mental illnesses and using substances are often perceived as difficult to treat, not engaging and chaotic, and therefore, many healthcare professionals do not have enough confidence to care for them. Furthermore, healthcare professionals working in substance misuse and mental health field use different approaches when working with dual diagnosis clients as well as different training that are specifically related to their speciality of work. For example, a mental health practitioner often works under the assumption that service users should work on stopping or reducing their drug misuse habit in order to make improvement in mental state and recover, which contradicts the substance misuse service approach to treatment which does not make the same assumptions. According to the Dual Diagnosis Good Practice Guide, dual diagnosis remains poorly understood by some healthcare professionals as there appears to be a lack of effective and ongoing training on how to work with service users with substance misuse and mental health problems (Department of Health 2002). The Dual Diagnosis Good Practice Guide, regardless of the complexity of this disorder, advocates for mental health services taking a lead responsibility when working with dual diagnosis clients (Department of Health, 2002). This approach would ensure that service users don’t get transferred to different services or fall through the net of care. According to Checinski (2002), the treatment programme for dual diagnosis service users is based on integrated care pathway which is a more coordinated treatment. The use of care programme approach (CPA) in mental health settings would ensure that the individual needs of service users are addressed as well as promoting better liaison between services involved in care and treatment of such individuals. Care coordinators looking after service users with dual diagnosis have an important role in coordinating care and liaising within a wide range of services in order to address their complex needs. The Sainsbury Centre for Mental Health (1998) suggested that one of the difficulties that mental health workers face when working with dually diagnosed service users is that these patients are difficult to engage with and often do not comply with their treatment plans which is similar to the service user challenges discussed in this essay. Often, due to her chaotic lifestyle and continued substance use, Abigail would disengage from services and only seek help when in crisis. However, this crisis can be seen as opportunity by care coordinators as they can work on their service user treatment and care (Moeser, Noorsdsy, Drake, & Fox 2003). Moeser at al. (2003) argued that during times of crisis, service users are more likely to be aware of consequences of their non-engagement and continued substance use and therefore more likely to consider changing their behaviours and more actively engage in treatment. Research shows that working with dual diagnosis service users is challenging and requires holistic approach when addressing individual needs. Dealing with both mental health issues as well as substance misuse is complex and can make recovery complicated (Department of Health 2004). Furthermore, service users with dual diagnosis often face social stigma as they are not only experiencing mental health problems but are having addiction problems too (Mind 2004). This has also been shared with Evans and Sullivan (1989) who observed that dually diagnosed clients have often experienced social stigma in relation to their substance use and mental illness challenges. In addition, dual diagnosis clients experience social exclusion either due to having mental health problems which increases their vulnerability to abuse from others or due to other social factors such as unemployment and housing issues resulting from their substance misuse problems. Continued substance use and addiction problems can create marginalization for an individual. Coupled with mental illness, this can often result in being cut off from the society (Rassool 2006). Dual diagnosis has been regarded as more of a social structure than a disease (Cooper 2010). Social construction has been defined as a subconscious attitude of the society to segregate a certain kind of person on the basis of insignificant factors like race, class or gender (Flores 2012). Research shows that stigma is very common in the field of psychiatry (Biernat & Davidion 2000). Corrigan and Watson (2002) suggested that people with mental health problems not only have to struggle with symptoms of mental illness, but are also faced with prejudice and stereotypes that mental illness misconception comes with. As a result of this, people with mental health problems can be deprived of opportunities that define a good quality of life relating to health as well as social factors. Similarly, stigma is often evident in the field of addictions and is often used to discourage unhealthy behaviours such as substance use that can have negative impact on individuals and the society as a whole (Corrigan et al. 2002). Service users with substance misuse problems can be perceived as having personal control over their addiction and be blamed for their continued use and problems they experience as a result (Corrigan, Kuwabara & O’Shaughnessy 2009). Stigma is of many different forms and manifests itself in many ways. It could prevent delivery of proper treatment by service providers. It could also socially isolate a person or prevent them from disclosing their true problems. Stigmatization could increase isolation from society and increase the feelings of exclusion and social withdrawal (Nursing Times 2012). All these effects result in delayed treatment when the mental states of victims deteriorate and individuals relapse resulting in increased costs (Biernat & Dovidio 2000). Since dual diagnosis involves a combination of both mental illness and problematic substance use, patients face double the usual amount of derogatory behaviour (McCormick 2015). Therefore, research shows that the stigma of dual diagnosis could significantly influence the ability of an individual to cope with the condition effectively and could negatively impact on the individual service user self esteem and confidence (Nursing Times 2012). This could be seen in Abigail who often reported feeling depressed about her current situation and lacking confidence to make changes in her life. According to Turning Point Report (2004), dual diagnosis stigma and social isolation could be more prevalent in people from ethnic minority communities as they also face stigma from their own community. Although Abigail identifies herself as British, having moved from Africa to the United Kingdom when she was only ten and adapting to the Western culture easily, the rest of her family are very much accustomed to African beliefs and values. She believed that their lack of support was due to them feeling ashamed and let down by her as she failed to fulfil her role as the eldest child. Amuyunzu-Nyamongo (2013) argued that mental illness and continued substance use in women attracts stigma among a majority in Africa. She reported an example that many households with mentally ill individuals would hide them in fear of discrimination and ostracism from their own communities. Furthermore, public attitude towards women that use substances is more negative that towards similar men. This is partly due to their perceived inability to fulfil traditional gender roles often attributed to young women such as marriage and looking after children among others (Sorsdahl, Stein & Myers 2012). In addition to being aware of stigma associated with dual diagnosis and cultural factors that may influence service user recovery, healthcare professionals working with such individuals should acknowledge the importance of support from family and family dynamics facing the service user (Rassool 2002). Research suggests that in psychiatric illnesses, families could get affected in the same way as the service user and could contribute towards recovery just as much as the service user does (Mueser & Glynn 1995). Due to her chaotic behaviour and continued substance use, Abigails family feels disappointed with her which is critical of her current situation. Abigail reported that her family often pressurize her to stop using drugs and go back to college to find employment. This pressure from family is causing a lot of anxiety to her and is making her avoid any contact with them as a result. Manley and Rayner (2006) argued that often, substance misuse causes family conflicts. This could result in stressed families as well as increased stress to the individual through criticism, hostility and emotional over-involvement of family members (BPS 2002). Abigail‘s inability to abstain from substance use and consequent relapse in her mental state could be partly due to the pressure she experiences from her family. High expressed emotion is found to be a main contributor to relapse among dual diagnosis service users (McDonaugh 2005). However, although criticism in expressed emotion is not acceptable, sometimes, it is the only way some families show that they care (Gammble & Brennan 2005). According to Watts (2007), families often blame individuals for lack of recovery with the view that they are in control of their problem and are not dealing with them appropriately, which causes stress and confusion within the family and making the service user more prone to relapse. For health care professionals working with dual diagnosis service users, it is important to acknowledge that relapse is often experienced and that it is a normal occurrence for individuals recovering from addictive behaviour (Miller & Rollnick 1991). According to Wanigaratne, Wallace, Pullin, Keaney and Farmer (1990), one of the contributory factors in relapse is social pressure. Wallace et al. (1990) suggested that sometimes, relapse could be used as a coping mechanism by individuals who use substances to deal with stress from the pressure to conform to behaviours that the society believes are normal. Therefore, the role of a healthcare professional would be to accept relapse as part of service user recovery and acknowledge the influence of highly expressed emotion on recovery. In addition, Brunette and Mueser (2006) argued that for dual diagnosis individuals, it is important to stabilize their mental state especially for those that use substances to cope with their mental illness. Lack of motivation among such individuals should be addressed by healthcare professionals by providing information about mental health and substance use and how they interact (Watts 2007). In this essay complexity of treating dual diagnosis is discussed, taking into consideration the influence of stigma, feelings of social isolation, culture and family dynamics that could influence service user recovery and engagement in treatment, all of which healthcare professionals should be aware of when providing care and treatment to service users. This essay outlined some of the difficulties healthcare professionals as well as service users experience when dealing with dual diagnosis. Working with dual diagnosis service users is considered as challenging due to the complex needs individuals present as described in Abigails case study. Rassool (2006) stated that having one diagnosis such as mental illness could affect individual functioning; having two could have overwhelming effects. The service users with dual diagnosis often have other difficulties that are not purely medical or psychological but involve other problems such as housing and social, all for which they need support. In addition, stigma, cultural backgrounds and family dynamics could hamper their recovery and how well they engage in treatment. Due to the complexity of multiple problems encountered by these service users, some would need treatment from multiple agencies (Rassool 2002). The responsibility of coordinating these referrals lies with CMHT and service user care coordinator. Integrated treatment, meaning treatment for both mental illness and substance misuse, should be provided to ensure that both disorders are treated effectively and gaps in service delivery are avoided (Mueser et al. 2003). According to Mueser et al. (2003), this approach would ensure that a wide range of problems encountered by service users are addressed. The main focus of treatment for dual diagnosis should be minimizing harmful effects this diagnosis can have on individual life. Given the complexity of working with dual diagnosis service users, there is need for healthcare professionals to equip themselves with skills and knowledge in order to manage this disorder effectively (Jackson-Koku 2001). It is now appreciated that healthcare professionals should recognize that service users may experience stigma and social exclusion and the effects that this could have on their lives and self esteem (Todd, Freen, Harrison, Ikuesan, Self, Pevalin & Baldacchino 2004). Recognizing the needs of different populations and their cultural beliefs and values would ensure service user individual needs are addressed as well as healthcare professionals are providing care with respect and acceptance (Turning Point 2004). This essay provides an in-depth understanding of dual diagnosis, particularly on the complexities involved and approaches to treatment from the perspective of healthcare professionals and service users. The experience of Abigail, a 28 year old female dual diagnosis service user, provides the basis for this evaluation. Abigail suffers from mental health illness and misuses drugs. While she currently lives in a support accommodation, she faces numerous challenges including being homeless and violence, aggravated by lack of support from her family. Despite being a British citizen, her African roots have cultural beliefs which make her immensely stigmatised by the society, including her family which immense pressure on her to change for good. Her mentor, a community psychiatric nurse, finds it complex and difficult to work with her due to her numerous needs and non-adherence to service. This represents the difficulty faced by healthcare providers in offering care to dual diagnosis service users. Dual diagnosis service users have diverse complex needs which traverse psychological and medical problems to include social, lifestyle and housing challenges. Additionally, they face immense stigma from the society and family which, while it aims at deterring the associated behaviour, hampers the path to recovery. Dual diagnosis thus comes out as more of a social issue than a disease. Combining two conditions, drug misuse whose treatment is pegged on individual willingness and mental health illness whose treatment is meant for all patients, dual diagnosis requires a holistic treatment approach. The Dual Diagnosis Good Practice Guide advocates for mental health to take precedence over drug misuse treatment where care programme approach (CPA) has been found to be effective in coordinating care and liaising with varied services that address the complex needs of patients. It has also been suggested that times of crises are the best for treatment as the service user would be aware of the consequences of disengagement and thus cooperate. Therefore, even with no set treatment standard for dual diagnosis in place, there are measures that could be taken to treat the complex disease. Read More