DUAL DIAGNOSIS TRAINING AND
PILOT PROJECT Spring 2007
WHOLE TEAM PORTFOLIO
COMMISSIONED BY CSIP DUAL DIAGNOSIS NATIONAL PRGRAMME
DEVELOPED BY CSIP EASTERN REGIONAL OFFICE AND THE CENTRE FOR CLINICAL AND ACADEMIC WORKFORCE INNOVATION
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The Dual Diagnosis Good Practice Guide (Dh, 2002) and the National Service Framework – 5 Years On review (DH,2004) have highlighted the central role of existing Assertive Outreach (AO) teams in England in the delivery of „Dual Diagnosis‟ services to those who have a co-existing diagnosis of mental health
problems and substance misuse. Most teams have a significant percentage of clients who experience substance misuse problems (around 30-50%) (Graham et al, 2001; Fakhoury et al, 2006)
AO teams have recently been reporting a reduction in the number of specialist practitioners within teams who have expertise in working with people with a „Dual Diagnosis‟. Therefore there is a need to increase capacity. In order to do this there needs to be a „whole-team‟ approach to working with dual diagnosis, in a multidisciplinary context, with a focus on severe mental illness.
The aims of this project are therefore as follows:-
; To develop a team training resource for Assertive Outreach Teams
focused on service improvement processes and the delivery of equitable,
accessible and sensitive services for those who experience both mental
health problems and substance misuse difficulties, and their
families/carers. This team training will focus on increasing the capabilities
of the team as a whole, and of individuals within the team.
; To pilot the resource with identified teams and evaluate effectiveness.
A Dual Diagnosis training resource has been commissioned and produced which will form the basis of the training to be delivered. Three methods of delivering this training will be evaluated:
1. The first method will involve the team manager (or other appropriately
experienced member of the team) delivering the training using the
training Support for this will be provided by CSIP in the form of supervision
and the provision of a short “train the trainer” programme. CSIP will play
no specific role in delivering the training in these teams.
2. The second method of training will involve CSIP Eastern Programme Leads
delivering the training to specific AOT‟s.
3. The third method will be training delivered to a forum of key individuals
from AOT‟s within the West Midlands, and they will then be responsible for
cascading the training within their teams (with support from the regional
Assertive Outreach network).
An evaluation schedule will be established which will measure before and after ratings.
It is envisaged that the evaluation will consider the following outcomes;
; Ratings of confidence by staff
; Before/after measure of knowledge of key DD interventions
; Attitudes of staff towards DD users
; Changes in practice
Philosophy of the training resource
The philosophy of the training is based heavily on a recovery model of mental health (NIMHE, 2005). This places the service user (and their carers) at the centre of their care, they are valued as an individual and their strengths as well as their needs are recognised. Service users and carers are active partners in care as opposed to passive recipients. The service will endeavour to provide an atmosphere of care that enables the service user (and their carers) to make their own choices about their lifestyle and treatment. The aim of treatment is to assist the person to make choices that enable them to achieve an optimum quality of
life based on their abilities and strengths as well as taking into account the realities of their situation.
Department of Health (2001) Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. DH, London
Department of Health (2004) the National Service Framework- 5 years on. DH, London
Fakhoury, W.K.H.; Priebe, S. and the PLAO group (2006) An Unholy Alliance: substance abuse and social exclusion among assertive outreach patients. Acta Psychiatria Scandinavica. 114, 124-131
Graham, H.; Maslin, J; Copello, A et al (2001) Drug and alcohol problems amongst individuals with severe mental health problems in an inner city area in the UK. Social Psychiatry and Psychiatric Epidemiology. 36, 448-455
National Institute for Mental Health in England (2005) NIMHE Guiding Statement on Recovery www.nimhe.csip.org.uk
Capabilities for Dual Diagnosis
Competence: This is a measure of practice in terms of the person‟s ability to perform it.
Capability: encompasses competency but is wider in its scope as it covers attitude, application of theory to practice and reflection on that practice. It is the individuals‟ ability to apply a competence in practice.
The training is based on a values and evidence base to dual diagnosis and the content is designed to develop team capabilities based on “Closing the Gap” a capability framework for dual diagnosis (Hughes, 2006). This framework was developed in consultation with NHS, Higher Education , non-statutory agencies and service users. It is developed from the Ten Essential Shared Capabilities for Mental Health. The Ten Essential Shared Capabilities (ESC) lay out the core practice standards that all mental health practitioners (regardless of role) are expected to achieve. These capabilities were developed through a major consultation exercise with Service Users and carers and led by the Sainsbury Centre for Mental Health. The ESC are deliberately focused on the expectations of Service User and Carers when considering the type of care they would like to receive. We believe the ESC also describe the expectations of mental health practitioners on the standards of care they aspire to deliver. Therefore the ESC have the potential to set a common and consistent foundation on which to develop high quality Service User and carer centred mental health.
Reference will be made throughout the training to both the Dual diagnosis capabilities and the ESCs.
The Ten Essential Shared Capabilities (DH, 2004)
1. Working in Partnership. Developing and maintaining constructive working relationships
with service users, carers, families, colleagues, lay people and wider community
networks. Working positively with any tensions created by conflict of interest or aspiration
that may arise between the partners in care.
2. Respecting Diversity. Working in partnership with service users, carers, families and
colleagues to provide care and interventions that not only make a positive difference but
also do so in ways that respect and value diversity including age, race, culture, disability,
gender, spirituality and sexuality.
3. Practising Ethically. Recognising the rights and aspirations of service users and their
families, acknowledging power differentials and minimising them whenever possible.
Providing treatment and care that is accountable to service users and carers within the
boundaries prescribed by national (professional), legal and local codes of ethical practice. 4. Challenging Inequality. Addressing the causes and consequences of stigma,
discrimination, social inequality and exclusion on service users, carers and mental health
services. Creating, developing or maintaining valued social roles for people in the
communities they come from.
5. Promoting Recovery. Working in partnership to provide care and treatment that enables
service users and carers to tackle mental health problems with hope and optimism and to
work towards a valued lifestyle within and beyond the limits of any mental health problem. 6. Identifying People’s Needs and Strengths. Working in partnership to gather
information to agree health and social care needs in the context of the preferred lifestyle
and aspirations of service users, their families, carers and friends.
7. Providing Service User Centred Care. Negotiating achievable and meaningful goals;
primarily from the perspective of service users and their families. Influencing and seeking
the means to achieve these goals and clarifying the responsibilities of the people who will
provide any help that is needed, including systematically evaluating outcomes and
8. Making a Difference. Facilitating access to and delivering the best quality, evidence-
based, values-based health and social care interventions to meet the needs and
aspirations of service users and their families and carers.
9. Promoting Safety and Positive Risk Taking. Empowering the person to decide the
level of risk they are prepared to take with their health and safety. This includes working
with the tension between promoting safety and positive risk taking, including assessing
and dealing with possible risks for service users, carers, family members, and the wider
10. Personal Development and Learning. Keeping up to date with changes in practice and
participating in life-long learning, personal and professional development for one‟s self
and colleagues through supervision, appraisal and reflective practice.
Mapping Closing the Gap to the Ten Essential Shared Capabilities
Dual Diagnosis Capability (Closing the 10 Essential Shared
1 Role legitimacy Challenging Inequality;
making a difference;
working in partnership
2 Therapeutic Optimism Promoting Recovery
3 Acceptance of the uniqueness of each Respect diversity;
individual promoting recovery
4 Non-judgemental attitude Practicing ethically
5 Demonstrate Empathy Respect Diversity; Promote
UTILISING KNOWLEDGE AND SKILLS
6 Engagement Making a difference;
working in partnership;
respect diversity; promote
recovery; promoting safety
and positive risk taking
7 Interpersonal skills Providing service user led
services; making a
8 Education and Health promotion Promoting safety and
positive risk taking
9 Recognise Needs (assessment) Working in partnership;
identifying peoples‟ needs
10 Risk Management and Assessment Promoting safety and
11 Ethical, legal and confidentiality issues Practicing ethically;
promoting safety and
positive risk taking
12 Care planning in partnership with service Providing service user-led
user care; working in
13 Delivering evidence and values-based Making a difference;
care Promoting Recovery;
14 Evaluate care Providing service user-led
15 Help people access care from other Making a difference;
services challenging Inequalities
16 Multi-agency/professional working Working in partnership
17 Learning needs Practice development and
18 Seek out and use supervision both formal Practice development and
and peer learning
19 Life-long learning Practice development and
Department of Health (2004) The Ten Essential Shared Capabilities: A Framework
for the whole of the mental health workforce. DH, London
Hughes (2006) Closing the Gap. A capability framework for working effectively
with people with combined mental health and substance use problems (dual