The long-awaited National Clinical Programme for Dual Diagnosis was published last week. This piece will take a look at it from the point of view of the new paradigm that Mad in Ireland advocates for.
It might seem strange that Mad in Ireland is writing about mainstream psychiatric services policy guidelines, given our remit is to give voice to the new paradigm contemporary mental health practice. To be clear, this is not a review or a critique of the newly launched model of care, others will happily take on that task. It is an informed opinion piece. Perhaps even a tentative exploration of how those involved in contemporary responses to mental health and substance use issues might find it informative or dare I say useful in the pursuit of effective care.
I have a vested interest and indeed a conflict of interest. For my sins I have been at the forefront of research, education, practice and service development in relation to Dual Diagnosis (yes, the term itself other than as a political tool is at best unhelpful, and at worst double stigmatising) in Ireland since 2004. Along with practitioners, people with self experience, family members, community organisations and a few services; we have been identifying what needs to occur in any arena of mental health and substance use if conservatively 50% of people trying to access those services are to have their complex needs met. We now have our own Irish grown research that is context specific and in the main commensurable with international evidence for effective service provision (Connolly et al. 2015; Minyard et al. 2019; Proudfoot et al. 2019; Mental Health Reform 20220). Many practitioners have embarked on academic and professional journeys seeking to improve service response to dual diagnosis; people with lived experience have identified their needs; and there have been many innovative Dual Diagnosis services developed across the country, yet to date not really endorsed by HSE. Ironically, two of the three pilot sites (CHO3 & CHO4) for the new National Dual Diagnosis Model of Care have already established evidence based Dual Diagnosis services. Unfortunately, whilst effective and developed by communities in communities, they were not official HSE speak and were perhaps too economical and effective to warrant funding. CARMHA in North Tipperary provided an integrated community dual diagnosis service based in Nenagh and after four years of operations and struggling for funding, it was forced to close in 2022. In Cork South Lee, a five year participatory action research service development resulted in an effective dual diagnosis service (Connelly et al. 2015). The proof of concept service was not endorsed by Mental Health, Primary Care or Addictions services senior management and lost its’s impetus in or around 2019. This is not new in service evolution, often the vanguards of good practice become collateral damage as bureaucratic systematised changes take over.
My conflict of interest is that I was involved in the development of this programme/model of care as a lesser mortal on the capacity building and evaluation subgroups reporting to the national working group. Needless to say, I never saw the final product until it was launched on 23rd May 2023. None the less I have been party to aspects of the evolution and final words on the pages of the long awaited model of care for dual diagnosis. So, I feel beholden to explore the potential, if any of this model to enhance the healing experience of people with interrelated mental health and substance use issues and aid the response by practitioners and services to improve those people’s lives.
There is no need here to critique the model of care, see for yourself. It is what it is and purports to be unashamedly a medical model, a psychiatrically dominated model and a model controlled and answerable to psychiatry. There is no ambiguity. If you are waiting for a summary of the model of care, you will find it in the above link, it is not a feature of this piece.
I do feel the need to offer a few observations (micro summary) on what has been published and what was presented at the programme launch.
The clinical programme is like any other predecessor, just that, it is the ‘clinical’. In this case a clinical response to Dual Diagnosis. The personal and social does not need to feature within this framework, nor does it and those hoping that after 20 years since the seminal and to date only national study on Dual Diagnosis (Mac Gabhann et al. 2004); that we would finally have a systemic response to Dual Diagnosis, will be disappointed. But like all of the international evidence for good practice there is a place for such a model. Generally, as a subsection of a systemic model of care for a small minority of people with dual diagnosis, though not for the broader population of people with complex needs associated with dual diagnosis.
We start with the medicalisation of mental health and substance use issues in the up front definition underpinning the model of care:
The definition of Dual Diagnosis for this Model of Care is: ‘the co-morbid disorders due to substance use and/ or addictive behaviours along with the presence of mental disorder(s)’. The disorders of substance use include disorders of alcohol use.
Interestingly the national working group ignored the definition of dual diagnosis set out by contemporary mental health policy Sharing the Vision (2020): the coexistence of mental health problems and significant substance – drug and alcohol – misuse problems in an individual; which is in keeping with international evidence enabling a broader perspective, beyond medical diagnosis, on what constitutes dual diagnosis (Department of Health, 2020, P53.).
Twelve adult specialist Dual Diagnosis multidisciplinary teams and four adolescent ‘Hub’ teams will now take responsibility for 50% (as per the published literature review within) of existing clients of mental health, substance use and homeless services throughout Ireland. Or at least they will have the power to determine if those 50% warrant dual diagnosis specialist care or can be declined care and passed back to non mental health services. Continuing with the math’s, there is a four quadrant model for the dual diagnosis experience. 1 and 2 includes those people with serious mental illness and significant substance use disorders and it is only those that will be actively received and treated by the specialist teams. A conservative research estimate suggests that at best 25% of people with Dual Diagnosis will get a look in with the specialist teams. 75% of people with dual diagnosis will receive at best an onward referral back to where they came from.
The Vision for Change mental health policy document (DOH&C, 2006) recommended the development of 14 specialist dual diagnosis medically led teams to address the unmet need of the 50% of people in mental health and addictions services. By the by, this recommendation was completely at odds with international best practice and homegrown national research. Well after 20 years these recommendations have finally been implemented, hurray! Okay 12 adult dual diagnosis teams instead of 14. Though hey, there has been an updated policy in 2020, Sharing the Vision?
The model purports to be a trauma-informed care model. Those proponents of trauma-informed care, myself being one, know that a model that is entrenched in medical diagnosis and medical control, by definition and perspective cannot be trauma-informed.
A major faux pax in the articulated model of care is the stated intention that specialist teams will not engage in family work, leaving this role to other agencies, a decision completely at odds with contemporary evidence on dual diagnosis service provision.
Of note is the inclusion of Peer Support Workers on the specialist dual diagnosis teams, though there is little other mention of the importance of lived experience. I suppose, in fairness there is little other mention of anything other than the specialist teams in the documented model.
There is complete incongruence between the selective literature review, the Irish research into dual diagnosis, Slainte Care, the Service User scoping review, and the then articulation of what is planned. I think I understand why. The clue is in the aims of the Clinical Programme. It is to develop a model of care to support individuals with a dual diagnosis though a multidisciplinary, specialist dual diagnosis service: That is what we have, 12 and 4 specialist dual diagnosis services, not a model of care. So, let’s celebrate, some people, maybe up to 25% of those with Dual Diagnosis will benefit from these specialist services, when they eventually come onto being. Just saying, the envisaged 14 specialist teams from 2006 have not yet materialised?
And as I move from cynical observation mode into positive mode and reflection on potential benefits of this refocusing on an age old problem, I have some hope. This is grounded in my work with many of those who have sought to bring the model to fruition, in my experience of practitioners and community workers nationwide who are already working effectively with Dual Diagnosis and hopefully can capitalise in some way on this model of care towards meeting longstanding unmet needs of people with dual diagnosis.
The document chronicles a service user and family member scoping exercise that is to inform the model of care. Whilst the articulated specialist service orientation does not explicitly incorporate the findings of this review, none the less they are party to the published model and worthy of replication here:
Review of the feedback from people with a lived experience (and family members), plus additional input from practitioners, revealed a number of consistent messages for the National Working Group (NWG) for Dual Diagnosis to consider in developing the Model of Care.
- Those who accessed a dedicated DD practitioner/service had a more positive experience of care. There is a clear rationale for the development of the MoC and specialist DD teams from the outset.
- As the DD teams are unlikely to be in every CHO in the near future, a clear focus on building the capacity of existing services needs to be considered so that they are better equipped to provide appropriate interventions.
- Capacity-building within existing substance-use and mental health services in relation to DD is required. This should extend to all healthcare and social care professionals who are likely to come into contact with people with a DD. This will be important in ensuring informed referrals to the new DD teams when established.
- The level of training/capacity-building should be aimed at all tiers, from basic training/capacity-building to more comprehensive training depending on the role of the practitioner and to what extent they are likely to engage with people with a DD (e.g., members of the mental health teams will require more intensive training/capacity-building than the voluntary agencies). The feedback indicates clearly that there is a capacity/information gap about even fundamental elements of DD among many practitioners both within and outside the HSE.
- The DD services need to include an aspect of family support. These can be provided through existing resources in the mental health services and referral to appropriate community-based family supports.
- The MoC needs to include a case management function in line with the NDRF approach to coordinate care and navigate the shared care that is required, particularly in complex cases.
7. Subject to agreement by the service user, family members/carers need to be included both as agents of change in recovery and as service users requiring support in their own right.
- People with a lived experience or ‘experts by experience’ need to be involved meaningfully in the service delivery as it rolls out through co-production.
9. Policies that do not meet the complex needs of an individual are to be identified and modified so as not to lead to disadvantage, e.g., non-dispensing of methadone in some residential services, or non-residential treatment of people taking mental health medications.
- There need to be trauma-informed integrated care pathways.
This is a powerful message and in keeping with prevailing contemporary evidence on provision of an effective response to Dual Diagnosis. We are mandated (Sharing the Vision, 2020) to listen to and respond to the voice and needs of service users. My suggestion is that we respond and focus this response as mandated by the voice of experience within the published model of care. If this becomes a declaration of required actions and intent, then the model has a broader scope than presently articulated.
There is an intention to take a PPI (public and patient involvement) approach to evaluating the model of care. I know this process is already underway and see it as a very positive move. Albeit as it stands, it is aimed at the activities of the specialist Dual Diagnosis teams and specifically the qualitative experience of users of this service. There are three pilot sites and if people with lived experience are to influence the questions asked and ask those questions, then there are possibilities that real lessons will occur, providing the role of PPI remains front and center of the evaluation.
Approximately 75% of people with Dual Diagnosis will be in the 3rd and 4th quadrant of dual diagnosis experience and continue to be provided with services that are not specifically mental health. Those people in those services may ask, so what has changed. Good question! Well 25% of people who hitherto had no specialist treatment might now get it, so you may have support with helping those people. Now it is explicitly stated who these services will be providing for. This will for the first time offer a mandate and a platform to secure support and resources to help meet the needs of those 75% of people with Dual Diagnosis. It is no longer a hidden burden and can no longer be ignored because it was not previously acknowledged in policy directives.
Together with the articulated objective of creating communities of trained practitioners – ‘practice communities’ there is the scope for better preparedness of organisations to be able to respond to dual diagnosis. Not surprisingly as a clinical programme there is a blind side to ‘community’. This is not new and a feature of all medically dominated models and approaches, despite the call of recovery orientated models (I am sure somewhere there is mention of this model being recovery orientated) to move away from service provision wrapping to reconnection with community.
Not to worry, the model by articulation specifies that all of those people with dual diagnosis in quadrants 3 and 4 (75%) will be dispersed back to the ‘community’ for their care. Once more this is explicit and non statutory organisations (e.g. sec 39) are frequently referred to as the responsible organisational responders (about 10 iterations of this in the publication). I believe there is sufficient reference to community service provision to open up avenues for community capacity building and we know (outside of this articulated model) that effective care for people with complex needs (as with dual diagnosis) requires a whole systems approach. Recovery is not individual, it is systemic and in order for people to feel they can recover, there needs to be a reciprocal recovery community where recovery capital and social capital become indicators of effective dual recovery.
As part of the process of developing this model of care there was a training needs analysis conducted with statutory mental health and addictions services. We now have a wish list of training for practitioners working in dual diagnosis, although it appears (this is not clear) that not all people working with dual diagnosis will have the same opportunities. I cannot in good faith support the final published piece on training. Within my conflict of interest position, it does not reflect all of what is needed to prepare practitioners and services to respond effectively to Dual Diagnosis. We do have a list of existing training, i.e., it already exists. So why then do we all not feel adept at responding to dual diagnosis? Specific dual diagnosis training is a foot note in the list. Unidirectional approach to education and training, already criticised in the literature review for this documented model seems to now be supported. I hope this is a misconception on my part. Because of cultural differences between professional groups and service orientations, not to mention turf wars on who ‘should’ be delivering what interventions, the list of training (and trainers) needs to undergo a dual diagnosis competency assessment before been taken as workable. I use the example of Cognitive Behavioural Therapy (CBT) to illustrate the dangers of applying same as usual training for a nuanced dual diagnosis competency. In the 90’s and still for some dogmatic training bodies, CBT was taught in an exclusionary way towards people with psychosis, i.e., ‘don’t use it’. Thankfully with interdisciplinary discourse and practice it is now mainstream for psychosis (this is not an endorsement). My point being the listed trainings are not necessarily culturally attuned to Dual Diagnosis. The relative diluted reference to Dual Diagnosis awareness and skills enhancement, as articulated in the international literature needs to be a priority and include those who are presently providing training from one cultural perspective. There is a bizarre ranking of training under certain disciplines, again contrary to effective systemic response. Psychology gets all the cool interventions, despite for decades, every other one of the cited disciplines have engaged in these trainings and interventions. For some strange reason ‘Nursing’ has a list drawn from bygone days, with a few of the approaches long dismissed as ineffective interventions. Let’s stick with the articulated findings of the literature review and all international evidence on training for dual diagnosis – interdisciplinary education and training!
The model espouses a trauma informed care approach. By definition this is unlikely in the specialist teams, though possible for remainder of service providers carrying the care burden for 75% of people and needs to be resourced and supported.
I have read the model of care document three times, with the intention of finding elements of the published model that can give hope for people with a dual diagnosis. And for services and practitioners who operate from a contemporary perspective on effective care to find resource and motivation to keep going. Whilst the model of care is archaic, I believe there are some contemporary aspirations that offer a peg to support us claiming our space in providing effective care. Not least the recommendations of the service user scoping study.
Those of us in practitioner roles, in community worker roles, in dual diagnosis spaces, find ourselves being hope carriers. After reading this document again, I am reminded of an old proverb – its better to light a candle than to curse the darkness – Confucius (Date unknown)
References:
Department of Health & Children (2006) ‘A vision for change’ report of the expert group on mental health policy’. Dublin: Stationery Office.
Connolly, J Mac Gabhann, L McKeown, O (2015) ‘Developing a dual diagnosis service in Cork, Ireland by way of Participatory Action Research (PAR)’. ADVANCES IN DUAL DIAGNOSIS, 8 :29-41
Minyard K, Manteuffel B, Smith CM, Attell BK, Landers G, Schlanger M and Dore E (2019) Treatment Services for people with co-occurring substance use and mental health problems. A rapid realist synthesis. HRB Drug and Alcohol Evidence Review 6. Dublin: Health Research Board
Proudfoot D., M MacGabhann L., & Phelan D. (2019) Dual Diagnosis: A community perspective. School of Nursing, Psychotherapy and Community Health, Dublin City University.
Department of Health. (2020) Sharing the vision: a mental health policy for everyone. Dublin: Government of Ireland
Mental Health Reform (2022) DUAL RECOVERY: A qualitative exploration of the views of stakeholders working in mental health, substance use and homelessness in Ireland on the barriers to recovery for individuals with a dual diagnosis.