“In the past, the idea of recovery has sometimes been equated with abstinence. More recently, however, a new kind of recovery-based approach has been developed as a basis for consensus across the drug field. It acknowledges that different people will need different kinds of services at different times, and shifts the focus to achieving the outcomes that matter to people and their families and friends – such as improved health, a place at college or a job, somewhere decent to live, leisure activities and positive relationships with others. A range of different approaches can facilitate these outcomes for different people and at different points in their journey out of drug dependency.”
Recovery and drug dependency: a new deal for families (DrugScope/Adfam 2009)
Patients who have a combination of mental illness and an addiction to drink and/or drugs pose many, many challenges to ward staff. On top of living with this ‘dual diagnosis’, this group of patients also often have to contend with overwhelming social and physical health problems. Ward staff have to manage all this while sometimes needing to actively suppress judgemental feelings about the extent to which the person has “brought this on themselves.” This exercise in extreme empathy may require regular trips to some of the resources mentioned in Idea #7 Mentalising. (Quick recap – mentalising is about being aware of what’s going on in our own minds and in others’ minds. It’s particularly important and difficult to sustain our mentalising when we’re feeling very strongly about something.)
The enormous demands placed on staff caring for patients with dual diagnosis makes it essential that staff are themselves given first class training and support. Flipping that round, in order for patients to receive the specialised information, training and support they need, staff themselves must have this.
The relationship between the substance misuse and the illness is complex and often self-perpetuating. For example, someone with Borderline Personality Disorder who uses cannabis as a way of coping with extreme psychic distress may find that this interferes with work or home life, compounding their sense of isolation and despair. Some of the interactive dynamics between a mental illness and substance misuse are:
- Substance misuse directly causing mental health symptoms eg hallucinations or agitation
- Substance misuse aggravating some symptoms – eg cannabis might help someone feel more detached from extreme distress but create paranoia
- Substance misuse aggravating or distorting treatments. As with prescribed medication, taking more than one chemical can change the effects of any or all of them, eg by becoming toxic or reducing/increasing their impact. Similarly, withdrawing from street drugs can produce or imitate symptoms of mental illness. Many psychotherapists believe that substance misuse interferes with effective therapy.
- People using substances to cope with the impact of their mental illness
People wrestling with the powerful combination of mental illness and substance abuse usually also face considerable difficulties in other areas of their lives, such as:
- Physical health (eg respiratory disorders, seizures, risk of HIV infection for injecting drug users)
- Finances including work and benefits
- Social and lifestyle including work or other meaningful daytime occupation
- Risk of harm to self and others
- Stigma. It’s crucial for services not to inadvertently reinforce this. Very low self-esteem is a common feature both of mental illness and substance misuse and is a huge obstacle to recovery. It’s impossible to over-estimate the impact of staff acting with care, understanding, empathy and respect in helping patients to recover.
The multiplicity, complexity and interaction of these (and perhaps a desire to demedicalise the label) has created – a new label! Mentally ill people who have fraught lifestlyes partly because of their use drink or drugs are sometimes referred to as having ‘complex needs’.
- Alcoholics Anonymous, CHAPTER an employment charity meets regularly within the hospital. BHC
- The ward also facilitates patients attending such services as AA together.
- Leicester Drug and Alcohol Team provide a weekly ward-based drop in session on relapse prevention.
- Addiction support, including printed information, individual and group sessions.
- Volunteers supporting patients with addictions, including Buddying schemes
In 2002 the Department of Health produced the excellent (clear, pragmatic, compassionate, practical) Dual Diagnosis Good Practice Guide. Among the, very wise if we may say so, information and advice they provide:
- an optimistic and longitudinal perspective regarding the substance misuse problem and its treatment are necessary
- expect substance misuse to be usual rather than exceptional among people with severe mental illness
- alcohol is the most commonly misused substance by people with mental illness
- staff should avoid prematurely pushing clients towards abstinence but adopt a harm reduction approach
The NICE Guidelines Drug misuse: Psychosocial interventions (2007) also include very helpful reminders:
- ensure that all service users have full access to a wide range of services
- ensure that maintaining the service user’s engagement with services remains a major focus of the care plan
- maintain effective collaboration with other care providers.
- establish and sustain a respectful and supportive relationship with the service user
It’s essential to hold onto the fact that despite the dauntingly complex problems experienced by people with dual diagnosis, there are a range of effective treatment options. To recap on the Dual Diagnosis Good Practice Guide’s optimism:
While the risks are greater where substance misuse and mental health problems coexist there is no reason for a pessimistic approach. Most clients can and will achieve positive outcomes with the right treatments and support.
Here are the features of excellent care for patients with dual diagnosis as recommended by the experts, including voluntary organisations and service users:
Patients with dual diagnosis may be experiencing an overwhelming sense of lack of control over their lives, illness, substance use and treatment. Being sectioned may well amplify this, although for some people it provides a reassuring sense of at least external control or structures being introduced. And of being accepted, respected and supported. A primary goal is to help patients develop robust internal controls, and motivation is the key.
The greater the individual’s health and social needs and their treatment preferences are taken into account, the better the outcome. The more collaborative staff are with people, the higher their motivation and the more effective the interventions.
Treatment and care should take into account service users’ needs and preferences. People who misuse drugs should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare team. Informed decision-making is the mantra. Because of the centrality of relationships in treatment, good communication is essential, and needs to be culturally appropriate and accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Few of us would be able to give up something on which we’re heavily reliant if we’re overwhelmed by problems with housing, debt, court appearances and so on. Patients have to get help with these non-health needs to feel able to embark on what is usually a tough, and erratic, journey to overcoming their addiction.
3. Involving friends and family
“A key motif of the recovery approach is the importance of personalised interventions, rather than a standardised ‘one size fits all’ approach. There are many routes into drug dependency and many journeys away from it. Picking up an interest or hobby again, or repairing a particular relationship – with a former partner or parent or child, for example – can be every bit as important to recovery as clinical or therapeutic interventions. Families can be uniquely well-placed to engage with people with drug problems in a way that is responsive to their unique personalities, interests, needs and motivations, and so should have a special role to play in the personalisation agenda.”
Recovery and drug dependency
There are two separate issues here. Firstly, discussing with patients whether or how they want to involve their friends and relatives in their care and treatment plans. And secondly, recognising the often extraordinary stresses that friends and family can experience (and the mental health risks of these) and providing the information and support they need. Some of the difficulties faced by friends and family are described in the DrugScope/Adfam report, including:
- Families being relied on to provide support without being adequately supported themselves
- Families subsidising treatment provision, paying privately to give drug users options unavailable through statutory services
- Families not getting help when they want to disengage from supporting a drug using relative
- Families needing to recover too
As the report emphasises: “Families can be a source of hope, aspiration and ambition, and rebuilding family relationships is a key constituent of recovery.”
Staff can transform the experiences of friends and family by giving them the opportunity to:
- have an assessment of their personal, social and mental health needs
- get information and advice on the impact of drug misuse, through meeting with them, printed materials and online resources
- connect with local self-help groups
- provide information about, and facilitate contact with, support groups, such as self-help groups specifically focused on addressing families’ and carers’ needs
- take part in family therapy
The charity Adfam provides excellent information, training and signposting services.
The evidence-base shows that abstinence-oriented, maintenance-oriented and harm-reduction interventions can all be effective, depending on the specifics of an individual’s situation. It’s no longer the case that the only option believed to work is total abstinence, which is great for those who can manage it but irrelevant or actively demoralising and demotivating for those who aren’t ready for this.
The Department of Health’s view, and most hospitals’ aspiration, is that patients should have access to the same range of psychosocial interventions in hospital as in community settings.
5. Peer led
Substance misuse services, especially abstinence-based ones, are very unusual in the mental health field for recognising the importance of including staff with direct experience of the condition. (See Idea #11 – Peer support.) The “been there, done that, now no longer doing that” impact means that patients feeling truly understood is hugely motivating, and former substance misusers have insights and coping techniques that are hard or impossible for other staff to provide.
Substance misuse services in the UK strongly, perhaps excessively, rely on self-help groups such as Alcoholics Anonymous, most of which are abstinence based and built around 12 Step Principles. The combination of easy availability of meetings almost anywhere you live, group and individual support, full-on abstinence, plenty of ritual and delegation of responsibility to a ‘higher power’ enables thousands of people to sustainably overcome their addiction. The problem is the tens of thousands of others for whom any one or more of the above features are impossible or unattractive. Staff should explore whether there are harm-reduction support groups locally.
Staff can actively support patients getting involved with self-help groups eg by identifying when and where meetings take place, helping with transport and offering to accompany them to the first session. Many hospitals run or at least host support groups on-site, either for inpatients, people in the community or both
7. Support and psychotherapy
There are a range of approaches, in addition to 12 Step programmes, which can help people sustainably recover from substance misuse.
But let’s start with 12 Step Programmes such as Alcoholics Anonymous, as they have such an impressive network of local branches, and are tightly structured and effective for those who can manage the programme’s demands. It’s interesting to see how AA describes its purpose:
Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.
The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self-supporting through our own contributions. A.A. is not allied with any sect, denomination, politics, organisation or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.
In practice AA groups are usually based on sobriety, not ‘controlled drinking’, which AA regards as impossible. It’s all or nothing. Their view is that even one drink can often trigger a relapse. Yet they say: The only requirement for membership is a desire to stop drinking. This leaves considerable scope for people who would welcome the support and practical help of a 12 Steps group but doesn’t yet feel able to commit to complete abstinence. (In Stages of Change terms, they are at pre-contemplation, contemplation or preparation stages.) The culture of the local groups is strongly empathetic and non-judgemental, so people shouldn’t feel put off by the programmes’ reputation for complete abstinence.
They may, nevertheless, have difficulties with other aspects of 12 Step programmes, such as the strongly religious language used. Again, AA and other groups invariably have a very flexible view of what a belief in a ‘higher power’ consists of.
But for those people who aren’t yet ready for the undoubted rigours of a 12 Step Programme, there are therapeutic alternatives. And many people combine treatments, for example having family therapy and attending AA meetings for the mutual support it provides. Lifering is an excellent organisation in America providing a (much smaller) network of mutual support groups for addicts, one which is secular and harm-minimisation oriented. Its tone is very different to AA’s:
People in LifeRing groups tend to have a matter-of-fact attitude about substance addiction. Chemical dependency is not a sin that you have to confess and atone for. Science does not yet have all the answers about what causes addiction, but the most likely reason why most people became hooked is that they drank or drugged too much. Heredity often has something to do with it, but it also happens to people with no family history of substance use. It happens to people with all kinds of personalities, including people who are warm and caring, brilliant and generous. It does no good to punish or psychoanalyze yourself. LifeRing recovery meetings exist not to judge you or shame you or guilt you for your drugged/drunken past, but to support you in building your sober present and future. The point is to make a fresh start and learn how to live sober.
Lifering have an online forum which some of your patients might be interested in.
A forum is where people ‘post comments’ or basically send an email via a website. There are usually topic based ‘conversations’, which can be read by other people, depending on the particular privacy and security policies of each website.
A chatroom, on the other hand, is where people send a sort of text on a website. A short message. Other people in the virtual room (i.e. other internet users) join in the conversation, which happens in ‘real time’, unlike the gaps between messages being put up on a forum. Sorry about all that geekyness. The point is, that Lifering also have an online chat room:
Other evidence-based treatments include:
- Motivational interviewing, (a form of cognitive behaviour therapy)
- Family therapy
- Five step interventions (support for families)
- Behavioural couples therapy
- Community reinforcement approach (an alcoholism treatment which bolsters people’s motivation and skills)
- Multi-Systemic Therapy (MST), a family and community-based therapy for young people with complex problems, including drug abuse
Additionally, all good therapists will include tackling substance abuse within the treatment programme. And all treatments should be staged according to an individual’s readiness for change and engagement with services, as compellingly described in the transtheoretical model. This identifies six stages and provides evidence, based on thousands of people who have overcome various addictions, about the need to tailor services and approaches to the particular stage a person is in:
- Pre-contemplation (Not Ready)-“People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic”
- Contemplation (Getting Ready)-“People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions”
- Preparation (Ready)-“People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change”
- Action – “People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours”
- Maintenance – “People have been able to sustain action for awhile and are working to prevent relapse”
- Termination – “Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping”
- I had been drinking too much alcohol which was really messing up my head. I learnt about units of alcohol and how to drink responsibly in the future. I rarely drink now and my goodness what a difference it has made!
- I now realise how much my drinking and drug taking affected me and my family. With
- support I am now free of all of “that”. The only way is up!
- I just had to tell myself ‘I’m going to be strong and keep away from the people who drag me down and who are bad influence’. Being on the ward let’s you think about the next step in your life and you can make a positive change.
- It can feel like you’ve got nothing when you find yourself on the ward. But in a way it’s like a fresh start, a new beginning, kind of like a detox.
Research by Weaver and colleagues suggests that between 22 and 44% of adult psychiatric inpatients also have problematic drug or alcohol use, up to half being drug dependent. In high secure hospitals, between 60 and 80% of patients have a history of substance use before their admission. It seems that less than 20% of mental health inpatients receive treatment for their substance use.
The impact of substance misuse leaks directly into hospitals, with many (especially in inner-city areas) having to energetically combat the use of drink and drugs by patients and/or visitors on the wards.
Conversely, inpatient care has a significant advantage to its community cousins. A newly admitted patient’s colourful array of symptoms may initially be impossible to separate into those which are psychiatric and those which are because the person is drunk, stoned or otherwise in a temporarily chemically altered state. With the patient continuously in hospital care over a period of hours or days, the effects of the drink and/or drugs will wear off and it is then possible to determine what are the contributory elements of the illness and the substances.
The document, Dual diagnosis in mental health inpatient and day hospital settings addresses many of the particularly complex issues of caring for this group of inpatients including:
- Meeting the needs of women and of black and minority ethnic patients
- Searching patients and taking samples
- Observation and security
- Restriction or exclusion of visitors
- Incident management
- Destruction and disposal of drugs
- Buildings and environment
- Discharge and rapid follow-up
- Involving other agencies
It also makes the following observations
- Patient focused strategies to prevent substance misuse can also militate against therapeutic collaboration.
- The withdrawal of leave and confinement to the ward is stressful for patients, and the resulting boredom and frustration may make substance misuse more attractive.
- The use of contracts with patients, where discharge from the ward is presented as a sanction in the instance of substance misuse can also be counter-productive, resulting in patients perceiving staff as being unaware of their concerns and difficulties.
- If discharge is used as a sanction, this can result in the withdrawal of services from needy and vulnerable individuals. Often discharge is found to be an empty threat, as the statutory frameworks prevent the unplanned discharge of patients with complex needs.
- Where they exist, specialist teams of dual diagnosis workers should provide support to mainstream mental health services
- All clients must be on the Care Programme Approach
Because addictions are very hard (but still possible!) to overcome, patients need to be connected with their GP, local substance misuse services and/or voluntary organisations before they leave. Many wards ensure that patients with a dual diagnosis leave:
- With a date in their diary for a support group meeting or appointment with a specialist worker
- Having had a chance to go to a support group meeting while they’re still an inpatient
Video: ‘Pillar to Post’
‘Pillar to post’ features people with a dual diagnosis and a range of experts who describe the difficulties faced both by services and service users. A model of good practice is presented, which shows how by working flexibly and with the service user’s agenda, progress can be made with people who once felt they had been written off by services.