Mental health practitioners highlighted a range of strategies required to enable them to meet such needs, including:. Hussein Rassool highlighted negative staff attitudes towards patients and clients with dual diagnosis as a barrier to effective treatment. Local research identified that changing attitudes and organisational culture was vital to ensure mental health practitioners recognise that working with people with dual needs is a legitimate part of their role.
This is also important in ensuring they modify their approaches accordingly Barrett, Providing knowledgeable and accessible support for staff is key to the process of cultural change NHS Institute for Innovation and Improvement, Inpatient services were identified as areas of high prevalence and complexity of dual diagnosis need, with a limited range of interventions available to patients with these needs.
As a result, the general manager for adult mental health services in North Durham and project lead for dual diagnosis collaborated with inpatient staff to develop the role of the dual diagnosis therapeutic intervention worker for North Durham inpatient services. This is a grade 4 post and the DDW covers three inpatient wards split over two sites.
The DDW also liaises with community teams and non-statutory services to ensure continuity of care when patients are discharged from hospital.
This liaison work involves identifying support available in the community and keeping community staff informed about the discharge plan. The DDW also supports staff in developing substance misuse capabilities, which include therapeutic optimism, non-judgemental attitudes, engagement and empathy skills Hughes, , and fulfils an educational role for staff and carers as well as clients.
The role promotes harm minimisation-based approaches and works with client motivation. This involves providing information, health promotion and encouraging people to explore attitudes to substance misuse. The DDW started in post in August , although work on the proposal began some time earlier. It is an evolving post that has developed over time and will continue to change as the wider dual diagnosis service expands within the trust, and as demand continues to grow. In addition, substance misuse behaviour patterns change and patient needs alter as society as a whole changes.
This new role is part of our trust-wide strategy review in this area of care, the aim of which is to ensure all areas of the trust have access to dual diagnosis services. It is envisaged that this will include rolling out the new post to other inpatient areas.
We have also developed a dual diagnosis care pathway, which is laminated and visible on each ward, to assist ward teams in identifying the appropriate service for each client Fig 2.
The DDW has set up a football group, which so far has only been taken up by male patients, largely because female patients have preferred to access ward-based activities. This may change depending on the client group at the time, as female patients are welcome to join if they wish. The group has been immensely popular and an awards ceremony was held recently. Patients report that it has increased their confidence and self-esteem, helped them feel fitter and provided an enjoyable social outlet.
The group also gives the DDW an opportunity to engage clients in forming a therapeutic alliance in an informal context. Engagement is the essential first stage in working with dual diagnosis clients and often difficult to achieve Graham, The ward staff gave patients a brief questionnaire to complete to evaluate their response to the group. Patient comments include:.
It also increases patient morale. It gives me the opportunity to forget about my worries and socialise with different groups. The game is also played in good spirit and a good test of character and fitness. Although it did not win, the project has secured funding from Unison for a team football strip. The group meets every Friday morning and provides a forum where inpatients experiencing dual diagnosis can meet and discuss topics affecting them.
The name Making Changes was used so that patients would not experience the stigma and discrimination of having a label of drug or alcohol user.
The group is open to all those who wish to make some kind of change in their lives; meetings are patient-led and very informal as requested by patients.
Those who attend the group have a range of complex needs and are constantly searching for extra support to help address these needs. The group has identified a varied range of topics they feel are relevant and wish to explore and discuss. These include:. It also enables them to gain information and knowledge, which in turn leads to empowerment and increased self-confidence. We are using a variety of methods to monitor its effectiveness. The DDW has been able to use a wide range of interventions with patients, such as education, anxiety management, assertiveness training and activity planning, which have helped them to move towards discharge.
As he has links with community services, the role has assisted their smooth transition back into the community, thus promoting our ethos of social inclusion. A recent audit of staff awareness, knowledge and use of the DDW showed that practitioners feel their knowledge of illicit drugs and alcohol misuse has much improved. They also make good use of the DDW by making appropriate and timely referrals, seeking his advice when planning care and involving him in the discharge process.
We have also had anecdotal evidence from community teams that patients have reported more positive attitudes from staff. The DDW has attended conferences and workshops, and has also started training in cognitive behavioural therapy. Updating his knowledge and skills benefits patients as they can then access the latest evidence-based techniques, for example, mindfulness training and resilience training.
Patients with substance misuse problems as well as major mental health difficulties now have the opportunity to access a more holistic approach, in that it helps them to address their problems within the context of their own lives.
This complements medical treatment of their symptoms, which is often essential but does not fully address dependence issues. An important feature of the DDW role is its relationship with other staff and structures within the area. This ensures the post-holder accesses a robust system of support and guidance to provide clear direction and sustain motivation, which is vital in influencing positive changes in culture and practice.
A tiered clinical structure exists to embed dual diagnosis practice across the locality and provides a support structure for the DDW. Dual diagnosis leads are nominated for each acute inpatient ward, community home treatment team and substance misuse team. Their role is to support their own team and neighbouring leads in delivering high-quality, patient-focused care for those with dual diagnosis needs.
In addition to giving each other peer support, dual diagnosis leads can access support from the project lead, through formal contracted clinical supervision and informal support as required. The DDW attends monthly dual diagnosis clinical supervision sessions, part of the wider supervision structure.
The local supervision group consists of local dual diagnosis leads from a range of settings, including inpatient services, community mental health, substance misuse and mental health liaison. Building supportive relationships with other dual diagnosis staff develops closer working alliances and promotes collaborative care planning. Together commission research to provide evidence for practitioners and policymaker to help them improve care for people experiencing mental distress.
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