DUAL DIAGNOSIS

Walsingham House is committed to offering an equity of service regardless of previous or current psychiatric diagnosis.

Dual diagnosis is the occurrence of substance misuse and mental illness in the same person at the same time[1].  The diagnosis can incorporate more than problematic drug use or a mental health problem and includes personality disorder.  The severity of the illness is not an issue for Walsingham House although the cognitive ability to participate in a therapeutic treatment programme is essential.

 

 

 

 

 

 

 

 

Brendan Georgeson, Treatment Co-ordinator, & Cliff Hoyle, Dual Diagnosis specialist, discuss a referral.

 

BOTH PRESENTED A  DUAL DIAGNOSIS  WORKSHOP AT THE UKESAD CONFERENCE  IN MAY 2008  http://ukesad.org/conference

 

 

 

 

 

Protocols for the treatment of dual diagnosed clients

 

What we offer>

 

1                   Integrated treatment approach via user-focused treatment plan for dual diagnosed clients.

2                  Regular mental state monitoring via qualified specialist.

3                    Crisis planning, including referral for mental health act assessment, in the unlikely event that deterioration of mental health state occurs.

4                    Non-medicalised approach.  We understand the need for medication but also that our clients come from very complex and often disadvantaged backgrounds.  The social context of the persons presentation must be acknowledged.  The psychological impact of life events are recognised implicitly throughout the treatment process. 

5                   Walsingham House advocates a bio/psycho/social approach to the treatment of dual disorders.

6                    Walsingham House values the diverse experiences of dual diagnosed clients whilst acknowledging we may not share those experiences.

7                    The philosophy of Walsingham House is abstinence based with regard to substance misuse.  We understand the use of mood altering medication is a separate issue for dual diagnosed clients.

8                    A Cognitive Behavioural Therapy (CBT) and Motivational Interview (MI) approach is used with dual diagnosed clients to enable them to re-contextualise their experience of mood altering chemicals and other treatment options to achieve long term stability.

9               Regular communication with community teams and facilities for care plan review.

 

What we aim for>

1                    To enable the client to understand that medication and drug misuse are separate events.

2                    With agreement of the client and community team (if relevant), to introduce medication holidays to assess the clients true mental state once

 stability in the treatment environment is achieved.  This may not be practical in all cases.  We recognise that a personís mental health diagnosis may have been influenced by lifestyle choices and substance misuse and diagnosis needs review in abstinence.

3                    If a previously unknown co-morbidity is realised throughout the treatment process then appropriate discharge planning and continued care planning will be incorporated into the treatment plan.

4                    Equity in the treatment of dual diagnosed clients alongside primary substance mis-users.

 

 Dual Diagnosis Service Model>

 

1                    A 3 Stage treatment pathway within the established 12 week abstinence drug/alcohol treatment programme

2                       Stage one for stabilisation of mental disorder during first period of abstinence- first 4 weeks.

3                       Stage two for review of disorder and confirmation or reframing of known diagnosis and treatment- weeks 4 to 8.

4                       Stage 3 for continued review and throughcare planning to maintain stability.

 

What we ask for>

 

1              If subject to CPA (care programme approach)[1][2]

a             For clients to enter treatment with an up to date care plan including crisis management planning.

b        Core assessment, risk assessment and contact sheet to be made available to Walsingham House.

c             Psychiatric to be maintained with the community team and for the psychiatrist to be available for medication reviews/advice if required.

d        Care co-ordinator to be contactable and to attend at least one CPA review whilst the client is in Walsingham House to include discharge planning of client from Walsingham House.

e             Mental health services and referring/commissioning agency (if different) to maintain joined-up service approach especially with regard to early discharge of client (either self or therapeutic discharge).

f         Client remains the responsibility of the community team to enable continuity of care in the event of early discharge.

 

2              If client unknown or discharged from locality mental health services.

a             Referrer to provide as much background information as possible with regard to mental health history and need.

b        Referrer to inform Walsingham House of last known contacts within psychiatric services.

c        Prior to admission (during motivational phase of the referring agency), clients to be registered with a GP in their home locality.  GP to review medication prior to treatment. 

          Note:  GP registration is a requirement for locality service provision and onward referral to community services post treatment can be hindered without such links.

d        For clients coming from prison not registered with a GP, alternative arrangements with regard to onward referral will be made on a client by client basis.

 

Restrictions to Service>

 

Walsingham House will assess each person on an individual basis.  We like to maintain a balance of resident mix (gender, treatment order, dual diagnosis etc) and may have to restrict admission dates in order to maintain that balance.

 

These are some of the restrictions that may affect a personís suitability for Walsingham House;

  1. current suicidal ideation/intent
  2. current self harming behaviours
  3. active severe eating disorders
  4. dangerous and severe personality disorder
  5. unacceptable risk of harm to others
  6. severe inappropriate sexualised behaviour

 

Skills base of service

 

Walsingham House has 4 qualified addiction counsellors plus one qualified support worker.

 

To enable us to work with the complex nature of dual disorder we consult a dual diagnosis specialist who attends on a sessional basis. He is governed by the rules and regulations of BASW (British Association of Social Workers), which covers indemnity.

 

We also have clinical input from a psychiatrist who has a special interest in dual diagnosis.

 

Psychiatry protocol

 

There is a need for Walsingham House to hold the temporary clinical (psychiatric) management for clients with a dual diagnosis.  This is especially relevant for out-of-area clients.

 

Clinical Management for this service is:

  • Diagnosis and treatment of mental disorder.
    • It is likely that the client has come to Walsingham House with a diagnosed mental disorder complicated by substance misuse.  Treatment of the disorder will need review.
  • Review of treatment (medication).
  • Review of diagnosis once client is abstinent from illicit substances.
  • Introduction of carefully monitored medication Ďholidaysí to assess efficacy of existing treatment (if appropriate).
  • Crisis/urgent response to unforeseen circumstance.
  • Liaison with GP service for prescribing.

The clinical responsibility is held by Walsingham House only whilst the client is resident.  Responsibility will revert to referring locality once client is not resident.  If the client is known to a community mental health team and has a psychiatrist, it is expected that partnership arrangements be set-up between the RMO and the psychiatrist at Walsingham House.

 

Service Protocol:

  • Psychiatrist will provide sessional input and have capacity for a crisis/urgent response.
  • Psychiatrist will be involved in initial dual diagnosis assessment once client is resident and input into the continued care arrangements.
  • Psychiatric review will occur 5 to 6 weeks following admission for review of diagnosis and treatment.  Introduction of medication holidays will occur at this time, if appropriate.
  • Further psychiatric review will be determined if appropriate.
  • There will be close working arrangements between the psychiatrist and dual diagnosis specialist to monitor changes to the presentation and treatment of mental disorder.
  • The psychiatrist and dual diagnosis specialist will share appropriate information with the locality team and the receiving agency regarding management of disorder for after care planning considerations.

 

Service Considerations

  • Arrangements with the Walsingham House GP practice to be established with agreements for prescribing informed by the recommendations of the psychiatrist.
  • Need to be aware of the cost of private prescriptions in the rare event of out off hour crisis prescribing need.

 

Outcome Monitoring

Outcome measures for dual diagnosed clients will be defined at each point of the 3 stage pathway.  Longitudinal outcomes will be monitored through personal feedback and referrer reporting. 

 

Costs of Contracts

  • The cost of dual diagnosis treatment at Walsingham House is charged at the enhanced rate of £712 per week for clients maintaining tenancies elsewhere or £675 for clients eligible for a housing benefit claim whilst at Walsingham House.


[1] Anon (2000) Drug Misuse and Mental Health: Learning Lessons on Dual Diagnosis. Report to the All Parliamentary Drug Misuse Group

[2] Department of Health (1999) National Service Framework for Mental Health London DH


 

See Article in DDN Publication :http://www.drinkanddrugs.net/features/sept2506/dual_challenge.pdf

 

See www.turning-point.co.uk - DUAL DIAGNOSIS Good Practice Handbook. Page 13

Download a PDF copy from Publications on their web site.

 
 
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