Avoid situations, which could lead to alcohol abuse. Explore the dynamics between divorce-related depression and alcohol abuse. Achieve one week with no alcohol abuse. The second goal will be an improved mood. This will be achieved by the following behaviours and cognitions: 1. Go one week without crying. Complete three tasks every day. Avoid sleeping to escape from negative feelings. Call a crisis hotline if experiencing suicidal thoughts. Celebrate daily success at mood improvement by noting it in a journal.
The process should be monitored and evaluated by the therapist weekly Winyard, This can be done each time the client comes for psychotherapy. Unfortunately, there has been little progress made toward establishing service models and standards for treating many of these patients.
One of the more striking messages sent by the Dual Diagnosis Good Practice Guide is that individuals suffering from severe mental illness are highly likely to have a substance abuse disorder Day, It also describes why there is a need for integrated and comprehensive care of high quality to treat individuals with the dual diagnosis Thornicroft, The publication of this guide and the complementary guide provided by the National Treatment Agency for Substance Misuse can be seen as progress in the UK toward assisting individuals suffering from a dual diagnosis such as the one being experienced by Jane in the case study Winyard, Conclusion This paper reported on a case study of a client suffering from alcohol abuse and depression.
There was a discussion of the epidemiological issues Winyard, , assessment process, areas of risk, model of intervention, care plan, and associated national policies and guidelines in the United Kingdom in relation to this type of dual diagnosis. It was pointed out that the Dual Diagnosis Good Practice Guide, and the complementary guide developed by the National Treatment Agency for Substance Misuse represent progress made in the United Kingdom toward helping individuals with these difficult problems Thornicroft, References Thornicroft, G.
Oxford textbook of community mental health. Oxford: Oxford University Press. Cooper, D. Developing services in mental health-substance use. Oxford: Radcliffe Pub.. Phillips, P. Dual Diagnosis Practice in Context.. Day, E. Clinical topics in addiction. London: RCPsych. Boardman, J. Social inclusion and mental health.
London: Royal College of Psychiatrists. Stickley, T. Learning about mental health practice. Chichester, England: Wiley. Rassool, G. Alcohol and drug misuse a handbook for students and health professionals.
London: Routledge. Brooker, C. Mental health: from policy to practice. Edinburgh: Churchill Livingstone Elsevier. Winyard, R. Substance misuse in primary care: a multi-disciplinary approach. Oxford: Radcliffe Pub. Stein, G. Database search results Initially, articles met the criteria through electronic database searching, with an additional 3 articles sourced through searching reference lists of eligible articles. The screening process was carried out by removing 2 duplicate articles and examining 34 article abstracts to remove further irrelevant articles.
Following this process, 20 articles met the eligibility criteria. Of these articles, following a full review of the text of the articles, 11 were included in this review due to their discussion on staff training with relation to dual diagnosis in adult service users.
The articles included after the screening process ranged from behavioural studies, pilot studies and longitudinal studies with both qualitative and quantitative results. Themes that emerged from the articles were supervision, staff training and education, training programs and tools, organisational changes, and changes to policy and mission statement. Supervision Within the dual diagnosis training literature, there is little research regarding the role of supervision. The minimal evidence however suggests that it is necessary.
Supervision led by qualified and competent staff in a helping environment has been found to support staff in difficult situations, allowing the opportunity to reflect on the process that is occurring Cookson et al. The article by Brunette et al. They researched 13 community agencies within the USA over a 2-year period that had a new dual diagnosis training treatment program.
They applied both a quantitative and qualitative approach to their research. Program data was collected using a quantitative fidelity scale to see the degree to which the new service adhered to established principles for integrated dual disorders treatment.
The qualitative approach involved interviews, meetings and ethnographic observations to elicit responses regarding facilitators and barriers to implantation of the training program Brunette et al.
Barriers to implementation of the program were researched. A major barrier to successful delivery was the lack of staff supervision.
It was found that supervision played a key role in the success of the integrated dual disorder treatment teams in other, successful, agencies. The absence of high-quality clinical supervision was a common barrier observed in organisations with moderate or low fidelity Brunette et al. Sacks et al. This research reported on the capability of New York State outpatient programs to provide integrated services for dual diagnosis.
This criterion includes the element of staff supervision. Within these programs supervisory sessions with staff were not routinely scheduled; instead, supervision was conducted primarily on an as needed basis, which tended to narrow its focus or concentrated on specific problems that staff members were having.
However the instrument validity in this study has to be reviewed. It has been suggested that even though considerable effort has been put into developing both the DDCAT and DDCHMT indices, further study is needed to determine, among other things, the importance and proper weighting of each of the dimensions included, which in return may skew the findings in the study by Sacks and colleagues Sacks et al.
Schulte, Meier, Stirling, and Berry also found that clinical supervision is a major element that needs to be in place to ensure careful monitoring of staff who work with dual diagnosis service users.
Schulte et al. The staff expertise had been measured against the retention rates of these service users in treatment over a three-month period. The key finding of this study was that service users who were treated by staff with lower levels of self-rated dual diagnosis competency were significantly more likely to drop out of treatment. Among external factors that were found to reduce dual diagnosis competency in self-assessment included the chance to debrief in supervision with a clinical leader Schulte et al.
This study was limited due to the small sample size; a number of staff self-assessments also remained incomplete despite numerous reminders.
It has to be noted that this study was one of the few studies that interviewed dual diagnosis service users alongside the practitioners. The inclusion of the service users in this research is likely to enable a more accurate overview of practitioner competence. Staff training and education The way staff training is implemented into the organisation has also been associated with successful dual diagnosis competency by staff.
Matthews et al. The DDCAT suggests that to be defined as competent in dual diagnosis treatment, staff training should be a priority, however most organisations found this to be a low priority within their organisation. These findings closely correlate to the findings of Padwa and colleagues. They found that the majority of programs did not have staff members with competency to provide dual diagnosis services other than to provide medication treatment on site.
The highest scoring sites for dual diagnosis competency were found to have onsite staff with expertise in mental health alongside staff who had advanced training in specialised treatment approaches for dual diagnosis Padwa et al. The need to complete further training, and be able to put knowledge into practice, may help enhance competency. Both studies, however, are limited in their sample size, and the use of the DDCAT scale as its validity has not yet been established. It shows the need for suitably qualified staff to ensure the best outcome for the service users.
A quantitative tool, the Recovery Knowledge Inventory RKI , was created by Bedregal and colleagues, in which the staff responses were ranked and used to assess the staff's views on recovery of a dual diagnosis service user Bedregal et al.
Even though specific to recovery, this study was incorporated as the findings have implications on dual diagnosis training and the needs for tailoring staff training to better prepare them to offer recovery-oriented care. Bedregal et al. Implications could result in dual diagnosis service users not receiving the best treatment.
They determined that further training was necessary to enhance service user care Bedregal et al. Limitations of this study were that the training undertaken was specific to the Connecticut area, therefore data found may be specific to the attributes of the area, and replication may not be possible.
Instrument validity of the RKI is also not known; Bedregal and colleagues determined the use of a larger sample size was needed to reevaluate stability of components and reliability of the instrument Bedregal et al. In another USA study, this time in Texas, Mangrum and Spence focused on the education of staff and the implications this has upon the competency of staff. Mangrum and Spence researched co-occurring disorder COPSD programs in mental health MH settings versus substance abuse SA settings to analyse if education made a difference to staff dual diagnosis capability.
All respondents to the study had undergone 15 h dual diagnosis training independent of occupation in which they were employed. With the use of a 5-point self-rating scale, ranging from Poor to Outstanding, mental health and substance abuse workers rated their understanding and ability to demonstrate each of the competencies described by the items on the scale. It was concluded that both MH and SA staff needed further training, which suited their area of expertise, irrespective of their qualification or work experience.
The key findings demonstrated that service users who were treated by staff with higher levels of self-rated dual diagnosis competency were significantly less likely to drop out of treatment.
Those with seven years or more of work experience in the dual diagnosis area ranked themselves highly and retained service users in treatment longer than those who rated their competency as lower Schulte et al. However while this research is promising, it is also limited because it did not assess other variables for the service user retention, such as increased staff training.
An additional limitation is that minimal numbers of participants were included in this study due to time constraints of the practitioners. Furthermore, the use of a self-rating scale could also hold social-desirability bias as participants have a tendency to give socially desirable responses instead of choosing responses that are reflective of their true feelings Grimm, , p. Training program and tools Hughes explored the need for dual diagnosis training to be standardised across all agencies and occupations to ensure that care is more service user oriented.
Hughes undertook a scoping study for the National Health Service in which an electronic survey was emailed to all lead clinicians or service managers within the North West region of England. Hughes explained that integration between mental health and alcohol and drug workers through standardised assessments would offer a better quality service for dual diagnosis service users. The study was limited in its small sample size of only 12 individuals. Selection bias may also have been present as organisations that do not have contact details for their management online were excluded and no attempt to find contact details apart from via the internet was used.
Sacks and colleagues found, similar to Hughes, that standardised assessments should be used. The Sacks et al. It was concluded that a standardised screening tool should be administered in a separate procedure prior to, and distinct from, the bio-psychosocial assessment to enrich dual diagnosis programs already in place Sacks et al. On the other hand, standardised scales are not always the most utilised tool of assessment for clinicians.
McCabe, Staiger, Thomas, Cross, and Ricciardelli found that a standardised scale presented some challenges to clinicians who generally worked with a more open style of assessment. McCabe et al. Dual diagnosis service users were monitored over 4 weeks and 7 clinicians undertook a focus group to discuss findings. The full two-part screening that was used in the research was thought to be cumbersome or difficult for service users to understand. Clinicians also found using the standardised scales in isolation created difficulties in recording important contextual detail around the dual diagnosis problems McCabe et al.
It should be noted that the study was specific to an emergency department of a hospital, where some questions may need to be more succinct than in other departments. Service users were also surveyed who had undertaken the questionnaire and found that it was at times confusing to answer; therefore more user-friendly questions would be beneficial. So research shows that a structured tool is important in gaining vital information; the knowledge that every department is different and that every dual diagnosis service user is different may make using a standardised questionnaire difficult to work with.
Organisational changes The organisation itself plays a role in supporting staff to be competent in dual diagnosis work. Organisations that allowed for training to be introduced and sought further learning were more successful than those organisations that didn't allow for change Schulte et al. Roberts and Jones conducted a qualitative study that used a narrative approach. Participants were purposively sampled and from an initial 60 participants enough data was available to reach saturation after 19 interviews.
Being able to implement change toward being an organisation that views the general wellbeing of service users to be of the upmost importance is necessary. However, these narratives may be limited due to their small sample size; and the narrative approach is dependent on participants narrating their lives and experiences without being overly guided.
A strength of this study though is that they did include several occupational groups who support dual diagnosis service users: service user-researchers, nurses, occupational therapists, psychiatrists, psychologists, and social workers. This allowed for perspectives from several professional occupation groups, creating a more holistic view of dual diagnosis service user care. Brunette et al. Both chronic staff turnover and employers not supporting employee's time to train have been found to be limiting factors.
In addition, some of these teams were short-staffed for long periods, resulting in high caseloads and overworked employees not being afforded time to train in dual diagnosis competency Brunette et al. Hughes also suggested that an organisation being willing to change is key to provide a successful dual diagnosis organisation.
Hughes' research displayed that those organisations that were willing to implement change by improving attitudes and challenging stigma, as well as joint training and more collaborative work with service users, had the highest rates of competency Hughes, p. However, only similar agencies were contacted in this research.
Those contacted were all part of the National Health Service, therefore findings are restricted to this service and may not confer to other agencies in other countries. A total of 66 staff were questioned in the study, both in rural and urban settings, in the USA. Findings showed that the size of an agency can denote competency of staff. Smaller agency size was associated with greater change in capability, and single-service agencies showed greater improvement than multiple-service agencies.
Paradoxically, larger programs might therefore face greater challenges in initiating change despite the greater resources they have at hand Gotham et al. It may be that smaller agencies and agencies that have one main treatment focus are more able to quickly implement significant program change when they decide to do so, because there is less bureaucracy.One of these centres was at Middlesex University, London, England. Therefore, simply asking Jane if she is planning on harming herself is likely to be an effective method of assessing her for this risk. The key finding of this study was that service users who were treated by staff with lower levels of self-rated dual diagnosis competency were significantly more likely to drop out of treatment.
The key findings demonstrated that service users who were treated by staff with higher levels of self-rated dual diagnosis competency were significantly less likely to drop out of treatment. The process should be monitored and evaluated by the therapist weekly Winyard, I worked hard to cultivate a strong therapeutic relationship with Jessica. Clinicians also found using the standardised scales in isolation created difficulties in recording important contextual detail around the dual diagnosis problems McCabe et al.
An additional manual search of reference lists was conducted to ensure relevant articles were not overlooked.
Avoid situations, which could lead to alcohol abuse. The inclusion of the service users in this research is likely to enable a more accurate overview of practitioner competence.
Matthews et al. This is both an action oriented and problem-focused approach. Articles were also excluded if they were not in English language, or if the article lacked sufficient detail to be clearly relevant. Staff training and education The way staff training is implemented into the organisation has also been associated with successful dual diagnosis competency by staff. However, limitations are present in implications from this research, as it would be a generalisation to infer applicability across a range of organisations and training packages, especially those carrying out different functions in their work with service users. They applied both a quantitative and qualitative approach to their research.
This is both an action oriented and problem-focused approach. This improved service user-physician communication and enhanced shared decision making Moerenhout et al.