Transcript Pilot Dual Diagnosis Training: London Prison Service 2005-2006

Pilot Dual Diagnosis Training:
London Prison Service 2005-2006
Liz Hughes
Centre for Clinical and Academic Workforce
Innovation (CCAWI), University of Lincoln
Timetable
•
•
•
•
•
•
•
•
•
•
•
9.30 Introductions
10.00 background to course
10.30 break
10.45 Capabilities
11.15 your experiences
12.00 overview of dual diagnosis
12.30 lunch
1.30 groups- drug/alcohol and mental health awareness
3.00 coffee
3.15 back to main group; summary
4.00 close
Outline of presentation
•
•
•
•
Background to project
Methodology
Outcomes
Discussion and recommendations
Dual diagnosis
• The co-occurrence of two or more “diagnosable” disorders
(according to diagnostic criteria such as ICD10)
• Each disorder usually exerts an influence on the course of
the other (thus complicating the clinical picture)
• This term has been increasingly used to represent a group
of people who have mental health and substance use
disorders (although in reality it is more than two problems:
they usually have complex needs including physical, legal,
financial and social needs)
Background
•
•
•
•
Significant developments in prison health care including development and
expansion of mental health and substance use services
Despite this, reports suggest that frontline staff are lacking capabilities to
deliver on the policy targets (SCMH 2006; DH 2005)
Lack of integration between substance use and mental health services
In order for prison services to provide equivalence; substance use and
mental health services will need to work more closely together, and have
clear strategy for providing care for prisoners with dual diagnosis
Prevalence
• No research into dual diagnosis specifically in prison.
• Psychiatric morbidity research suggests that rates of mental
disorders is much higher than general population
• 90% have substance use, mental health problem or both.
• Research has demonstrated that people with co-morbid mental
health and substance use problems have poorer outcomes when
compared to those with single diagnoses
• Re-offending rates are likely to be higher
• 32% of people who committed suicide in prison had co-morbid
disorders.
Training project
• Funded by DH for development and piloting of training package for
prison mental health and substance use staff
• Consisted of training needs, development of training package,
implementation of training, evaluation
• 5 prisons acted as pilot sites across London: HMP Wandsworth, HMP
Wormwood Scrubs, HMP/ YOI Feltham, HMP Belmarsh, and HMP
Highdown
Training needs
• 80 questionnaires given to mental health and substance use staff at all
sites (29% returned)
• People were aware of the capabilities that were important for working
with this group, but most common response to what they actually do
was “referral”
• Barriers to care included lack of time, poor communication between
services, and security issues
• They lacked a theoretical framework for working with dual diagnosis
• Very few people had relevant training and experience (26%)
• None of the addictions staff reported any mental health training.
• They were unsure of their training needs.
Service user consultation
• Service user consultant group (n=4)
• Drawn from London mental health trust
• One had previous experience of criminal justice
system; all had experienced both mental health
and substance use issues
• Most important issue for them was staff attitudes,
giving people space and time to talk, and working
at different levels of motivation
Training Manual
• Series of modules: each related to 2hours of
classroom teaching or self-directed learning.
• 17 modules covering range of topics related
to dual diagnosis.
• Combination of theory, exercises and
clinical skills
Manual/training Content
• Introduction
• Drug and alcohol
awareness
• Mental health awareness
• Interaction of drugs and
alcohol and mental health
• Assessment
• Physical health
•
•
•
•
•
•
•
•
•
Risk
Treatment models
Engagement
Persuasion (MI)
Resistance
Active treatment
Relapse prevention
Multi agency working
Practice development
Training methods
• 5 day training:
• one day per week for 5 weeks
• On site; classroom based
• manual
• Blended learning
• Manual
• 3 x 2 hour group supervision sessions on site every two weeks.
Outcomes
• 70% of participants returned follow-up questionnaire on
attitude, confidence and knowledge about dual diagnosis
• There was significant improvement on attitudes and
confidence across all participants irrespective of training
method)
• There were no differences between the training methods in
scores.
• The manual was evaluated slightly higher in the 5 day
training group
Qualitative feedback
•
•
•
•
•
•
•
Manual was identified as one of the most useful things
People also liked the skills practice (role-play)
People wanted more on mental health
The 5 day training seemed to be the preferred mode of training delivery.
People in the blended learning had not been able to complete the exercises
in the manual within their working day.
Service user feedback for manual was very positive.
People felt that getting together with workers from other services was very
useful (both modes of training did this)
Skills for Health Demonstration Project:
Dual Diagnosis Training for criminal
justice staff
• Collaboration between Thames Valley, University of
Lincoln, DH (offender health), and West London Life-long
Learning Network
–
–
–
–
–
Review materials
Training needs assessment
Mapping competancies based on job descriptions
Revise materials and HEI accreditation
Pilot the course in London area March 2009
Challenges
• Number of different types of workers involved
–
–
–
–
Prison service
Health (primary health, mental health inreach)
Drugs (CARATs)
Offender managers
• Release for training
– No backfill monies
– Lack of suitable venues within prisons
• Implementation after training
– Ongoing supervision?
– Booster sessions
Challenges continued
• Access to prisoners for interventions
– Movement of prisoners- lack of consistency of care
– Access for face to face contact
– Lack of privacy
• Different competence frameworks
– Mental health NOS
– DANOS etc
Some possible solutions
• London- we will be training outside prison
walls using central location
• Engagement of all stakeholders to ensure
training is given priority (getting managers
sign-up)
• Screening applicants for suitability
(including motivation)
The Future
• Accreditation of course at levels relevant to
various participants (individualised)
• Educational pathway mapped
• Regional roll-out using regional HEIs and
central team will control quality
• Punctuality
Expectations
• Is essential for the learning experience for all
• If you are more than 5 minutes late, you will have to wait till next break to come in
• We start promptly at 9.30 and after all breaks
• Participation
•
•
•
•
Role-play
Discussion
Homework
assignment
• Respect
• Healthy debate
• Agree to differ
•
•
•
•
Confidentiality
Switch off mobiles
No sleeping in class!
Behaviour is only what is expected at workplace- it’s the same here
Overview of Course
Day 1 introduction to dual diagnosis, drugs
and alcohol
Day 2: models of treatment, motivation to
change
Day 3: assessment and risk
Day 4: ambivalence, resistance goal setting
Day 5 Relapse prevention
Assignments
• Multiple choice questionnaire
• Workbook assignments
• Case presentation (during course)
• Plus: all formative homework- evidence
must be provided
• Attendance is 80% or more (this equates to
0.5 day)
Background
• Modernisation of the NHS
• National Service Framework for mental health sets out
standards for care
• Shift from hospital to community
• New roles and ways of working
• Service user focused
• Values and evidence based practice
• Mental health services delivered in partnership with social
care
The KSF
• Covers all workers in the NHS
• Not mental health specific
• Single explicit framework by which all NHS workers can be reviewed
and developed=Agenda for Change
• Describes the knowledge and skills the individual needs to apply in a
specific role
• It is about application of knowledge and skills not the knowledge and
skills the individual may possess
• The MHNOS describes the knowledge and skills more precisely
The Structure of the KSF
• Based on 6 core dimensions relevant to
every post in the NHS:
–
–
–
–
–
–
Communication
Personal and people development
Health safety and security
Service improvement
Quality
Equality and diversity
• The remaining dimensions are more specific-they apply to
some but not all
• Divided into groups:
– Health and well-being
• E.g. HWB1 promotion of health and well-being and prevention of adverse
effects to health and well-being
– Estates and facilities
• E.g. EF1 systems, vehicles and equipment
– Information and knowledge
• IK1 Information processing
– General
• G1 Learning and Development
What is a Capability?
1. A performance component (what people need to
possess
2. A ethical component (integrating a knowledge of
culture, values, and social awareness into
practice)
3. Reflective Practice
4. Capability to effectively implement evidence
based practice
5. Commitment to working with new models of
professional practice and responsibility for lifelong learning.
(SCMH 2001)
Using Capability and Competency
Frameworks
The MHNOS is mapped to the KSF
MH_23 Plan and
review effectiveness of
therapeutic
interventions with
individuals with
mental health needs
KSF HWB7 level 2
Interventions and
Treatments
Contribute to planning
delivering and
monitoring
interventions and/or
treatments
DANOS mapped to the KSF
DANOS AF3: Carry
out comprehensive
substance misuse
assessment
KSF HWB2 level 3
Assessment and care
planning to meet
peoples’ health and
well-being needs
Level 3: assess health
and well-being needs
and develop, monitor
and review care plans
to meet specific needs
Dual Diagnosis Policy and Research
• 2002 Good Practice guide: “mainstreaming”
• Workforce need to be equipped with capabilty to
deliver effective care for dual diagnosis
BUT Problem: workforce lack skills, knowledge and
attitudes
SO: training in dual diagnosis interventions to be
developed and made available to mental health
and substance use staff.
The problems with training
• Lots of training delivered; little formal evaluation
beyond trainee satisfaction
• From research, there is limited evidence that
training in dual diagnosis interventions has
significant effect on service user outcomes
(COMO, CODA, COMPASS)
• Trainees demonstrate some gains on attitude,
knowledge and self-rated skills, but capabilities
not measured
Capabilities Framework for Dual
Diagnosis
• Level 1 CORE
– Aimed at all workers in contact with this service user group
e.g. primary care workers, A & E staff, non-statutory
agency workers
• Level 2 Generalist
– Generic post-qualification workers in non-specialist roles
(secondary and tertiary care) e.g. community mental health
workers, substance misuse workers
• Level 3 Specialist
– those people in senior roles that have specific experience or
qualifications, a special interest, or specific role in dual
diagnosis, and who have a practice development, and/or
training remit related to dual diagnosis
The Framework
Values
• Role legitimacy
• Therapeutic optimism
• Acceptance of the uniqueness of each individual
• Non-judgemental attitude
• Demonstrate empathy
Utilising Knowledge and Skills
• Engagement
• Interpersonal skills
• Education and health
promotion
• Recognise needs
(assessment)
• Risk assessment and
managment
• Ethical legal and confidentiality
issues
• Care planning in partnership
with service user
• Delivering evidence and values
based interventions
• Evaluate care
• Help people access help from
other services
• Multi-agency/professional
working
Practice Development
• Learning Needs
• Seek out and use supervision
• Commitment to life-long learning
Using the Framework
• Training
• Assessment in workplace
• Devising job descriptions
• Aim to produce consistency and fidelity of
dual diagnosis capabilities.
DD Framework is mapped to the
NOS and KSF
• Recognise need
– Assessment (3 levels)
– DANOS AF2
– MHNOS_14
– KSF HWB2
Future Developments
• Dual Diagnosis training package- advanced
module of the 10 ESCs (April 2007)
• Development of a tool to measure dual
diagnosis capabilities
• Develop effective methods of
implementation of dual diagnosis
interventions in routine care (following
training)
Competences
•
•
•
•
Describe good practice
To measure performance
The coverage and focus of a service
The structure and content of educational
and training and related qualifications
How it all fits!
Objectives
•
•
•
•
Define and understand “dual diagnosis”
Be aware of the prevalence rates
Be able to list associated consequences of
having combined mental health and
substance use problems.
To be aware of the different models of
service delivery
Definitions
• The term “dual diagnosis” is generally applied to
people who have two disorders
• Combined mental health and substance use
problems
• More than “dual problems”- likely to have
complex health and social needs
• Wide range of people with varying degrees of
need- need individualised treatment
Discussion 1
What have been your experiences of
working with people with dual diagnosis
within your work setting?
Think about issues concerning:
–
–
–
–
the individual
the carer
yourselves
the service that you work for.
What have been your experiences of
working with people with dual diagnosis
within your work setting?
• Within the prison services
– Duplication of work
• Inreach
• Healthcare
• SMS
– But who co-ordinates
– Falls through gap
• Separate targets
Think about issues concerning:
the individual
the carer
yourselves
the service that you work for.
• Short time to work with them – custody
suite
• Prison releases on Fridays – unscripted for
the weekend
• Engagement barrier if in “uniform” –
custody
• Vulnerability of SU – dealers etc
What have been your experiences of
working with people with dual diagnosis
within your work setting?
• Integrated treatment – who takes
responsibility
• Lack of information sharing
• Have “specialists” in the team
• Frustration of aftercare facilities
– Boroughs refusing to asses those in prison
• Medication concordance
– Both MH, SM and effects of MH drug side effects
Think about issues concerning:
the individual
the carer
yourselves
the service that you work for.
• Assumptions and stereotypes
– Creates barriers to access of services
• New IDTS
– Short time to work with SU
– Where does primary care fit?
• SU and staff lack confidence in the services
ability – because no info sent on with the
SU
What have been your experiences of
working with people with dual diagnosis
within your work setting?
• Time and target driven culture (National)
– SU group need longer term interventions which
is prevented by these targets
– Loses the SU
• IDTS
– Conflict about perception of SU problems
– SMS feel someone has MH problem, MH
services disagree
Think about issues concerning:
the individual
the carer
yourselves
the service that you work for.
• Treatment confirmation
– People go without medication
• Security problems/reasons prevent
discussion/feedback to carers
UK Prevalence Studies (see manual for
more details)
• Duke (1995) Community services 37% (1 year)
• Menezes 1996 Inner London MH services 36% (1 year)
• Cantwell (1999) Nottingham first episode psychosis 37%
(1 year)
• Weaver (2001) Inner London Community mental health
and substance use services 24% (recent-last 30 days)
• Phillips 2003 Inner 49% (last 6 months)
Prevalence
• 1/3 people with psychosis have concurrent
substance use problem (alcohol, cannabis,
stimulants)
• ½ people in substance use treatment also
have mental health problems (depression,
anxiety, PD)
• Higher rates to be found in inpatient,
forensic and prison population
Consequences
•
•
•
•
•
•
•
Young, single, male, homeless
lower educational and employment attainment
higher rates of relapse
longer inpatient stays (twice as long- Menezes et al, 1996)
non-adherence to medication
higher rates of violence and suicide,
higher likelihood of involvement with the criminal justice
system,
• higher rates of HIV and other substance use related
physical problems
• family problems.
Alcohol and mental health
• Most commonly used drug by those with mental health
problems
• Depression
• Anxiety and paranoia
• Morbid jealousy
• Delerium Tremens (confusion and psychosis)
• Organic brain damage
• For people with schizophrenia
– May increase psychotic symptoms
– Reduces effectiveness of psychiatric medication
Cannabis and Mental Health
• Second most commonly used drug by those with mental health
problems.
• In any user cannabis use can cause anxiety, panic attacks, and extreme,
but short lived paranoia.
• Temporary cannabis psychosis
• Some evidence that regular cannabis use is a contributing factor to the
onset of schizophrenia:
– cannabis use in teenage years is a predictor of future mental illness.
– The earlier a person begins smoking and the heavier they smoke, the
greater the risk of future development of schizophrenia.
– This effect seems to be stronger in individuals who have other
vulnerability factors (Arseneault et al, 2004).
• People with schizophrenia who smoked cannabis were more likely to
relapse quicker and have worse symptoms than those who didn’t use
cannabis. (Linszen et al 1994)
Cocaine and Mental Health
• Less commonly used, mostly urban areas.
• Cocaine increases levels of dopamine in the brain.
(Dopamine-chemical messenger in the brain; high levels
have been associated with psychotic symptoms).
• Even people without a history of psychosis can experience
a transient but severe psychosis (“drug-induced
psychosis”).
• Cocaine use in people with schizophrenia seems to
increase both severity of symptoms and likelihood of
psychiatric relapse when compared to non-drug using
people.
• Can exacerbate or induce a depressive illness as it may
deplete natural serotonin levels over time. (Serotonin is the
chemical messenger in the brain that is reduced in people
with depression)
Opiates and Mental Health
• Less than 10% of people with schizophrenia use opiates:
– relapse of psychotic symptoms commonly occurs during or
immediately after withdrawal of opiate or substitute (methadone).
– Opiates have mild antipsychotic effects, and therefore use may
mask psychosis.
– People with acute psychosis should not undergo a rapid
detoxification of opiates; the focus of care should be on the
stabilisation of their mental state and substitute opioid prescribing
(Royal College of Psychiatrists, 2002).
• Opiates: more commonly used by people who also have
depression, anxiety, and/or personality disorders rather
than psychotic illness.
Possible links between mental health
and substance use
• Common Causal factor: An underlying factor that increases likelihood
of developing both a substance use disorder and mental illness e.g. past
trauma or a genetic predisposition.
• Mental Illness leads to substance use. People with mental illness are
more likely to develop substance use problem than those in general
population. For example, mental illness may lead to the use of
substances as a coping strategy or self-medication.
• Substance use causes mental illness. Heavy substance use clearly
leads to temporary states that mimic psychosis (drug induced
psychosis) and/or lead to problems such as depression.
• Bi-Directional Theory. Mental health symptoms and substance use
affect the course of each other in a constantly evolving spiral.
Serious mental illness
E.g. someone with
bipolar affective disorder
who smokes cannabis
twice per week
E.g. Someone with
schizophrenia
and alcohol dependence
Table 1
Minor substance use
E.G. Someone with anxiety who
snorts cocaine occasionally
Minor mental illness
Severe substance use
E.g. someone with heroin
dependency and depression
“Mainstreaming”
DH (2002) Good Practice Guide:
• Doesn’t advocate a separate specialist service for dual
diagnosis
• Mental health services should take primary responsibility
for those with serious mental health problems (like
schizophrenia) and substance use
• Substance use services should take primary responsibility
for those with primary substance problems and common
mental health problems (anxiety, depression)
• However mental health and substance use services should
work together and support each other