Mental health & substance use: building a recovery community

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It is difficult to be interested in, or involved with, either mental health or addiction/substance use communities without having an opinion on dual diagnosis. That’s why an 11 month project set out to raise awareness of the prevalence of mental health and substance use issues (dual diagnosis) to build one Dublin community’s capacity to respond to the issue in a trauma informed way. 

The final report from this project, Capacity Building- A Community Response to Dual Diagnosis in North East Inner City, Dublin, is an in depth evaluation of the work that was done by the community development team comprising of the Dublin North, North East Recovery College and the Recovery Academy Ireland alongside the wider community. The evaluation proves that by using a community development approach, people can be brought together to create the change needed to respond to an issue such as dual diagnosis.

Context 

For those new to the ongoing saga, and what at least seems to be a now systemic attempt to finally respond to dual diagnosis in Ireland in a meaningful way, a recent Dublin North, North East Recovery College podcast featured on Mad In Ireland and a review of the 2023 clinical programme for dual diagnosis may also offer a contextual preamble to this report. Previous Irish research on this top, Dual Diagnosis project working definition: “Coexistence of both Mental Health and Substance Misuse Problems for an individual” is still the only long-term research nationally on this topic in Ireland.

Across Irish society, communities such as the North East Inner City of Dublin have been known as areas of high social deprivation that have been left decimated by poverty, drug use and in recent decades gangland criminality. The heroin epidemic of the 80’s/ 90’s left a lasting mark on the residents of the area and left behind a community devastated. Families were and still are destroyed by drug related deaths leaving the community in a continuous cycle of suffering. 

Up until the last decade, areas like the North East Inner City have been excluded in terms of investment and regeneration initiatives. Due to the growth in population and need for more social housing, families migrated from inner city accommodation to the suburbs of Dublin, leaving a torn and fractured community behind.  The above sequence of events enabled unemployment and idleness to permeate throughout the community creating an environment that lacks meaningful connection which ultimately has resulted in negative effects on the mental health of individuals. Old flat complexes that appear vacant and derelict, on closer look are still providing overcrowded housing to families, again contributing to feelings of low self-esteem and self-worth. There are streets in and around the area that are home to numerous homeless hostels and PEAs (Private emergency accommodation) which are housing people with complex issues including mental health and substance use. On top of that, the area has been disproportionately used to home refugees and asylum seekers without any consideration given to how these new communities would be integrated into the existing community, one that is quite clearly battling with a multitude of complex social issues without the added overcrowding and strain on already stretched resources. 

As a result of years of neglect, the community has been left collectively traumatised which has added to high levels of mental health issues and high levels of self-medicating with drugs and alcohol, both of which are normalised ways of coping in the area. 

Participative process

However, despite the adversity experienced in this area, the sense of community has not been lost. In a society that could be perceived as favouring a move in the direction of individualism and turning its back on the collective community experience, the north inner city has managed to maintain a strong sense of community amongst many of its residents. It holds tight its identity as an authentic working class community that strives to looks out for one another. It was this sense of community that was tapped into by the Dublin North, North East Recovery College and Recovery Academy Community Development Team with the community development project and subsequent report.

The project was funded by the NEIC initiative, one that was created after the publication of the Mulvey Report 2017. The Mulvey Report was written in response to the underlying socio-economic problems in the area and the gangland feud that was gripping the community. Gang related deaths were escalating at an increasing rate and the government at the time had to intervene and so the North East Inner City initiative was set up. The NEIC consists of a programme implementation board which is broken up into several different targeted interest areas including a group that looks at projects working on tackling substance use, misuse and inclusion health.

The project itself was a participative process that required linking in with as many community stakeholders as possible. The community development team were able to identify the needs of the community and recognise that dual diagnosis is a very real issue and that almost all professions are faced with and often perceive themselves as lacking the awareness and skills to respond to people experiencing the effects. Based on this, the team brought together the community, engaging with people from as many different backgrounds as possible. The intention was to create a space for transformation so that the community could reach a common understanding of dual diagnosis and what would be needed in order for the community to create a collective response. The specific objectives of this community intervention were to:

  1. Establish an open dialogue community forum, comprising all stakeholders that have a vested interest or are affected by dual diagnosis in the community
  • Stakeholders will include people with lived experience, family members, statutory services, community services, ancillary services, peripherally involved services
  • The community forum will provide the vehicle (as a participatory network) for action orientated activities and engagement between stakeholders;

2. Establish rules of engagement between stakeholders, underpinned by an ecological view of trauma in personal and community contexts;

3. Explore existing capacity for service providers to respond to dual diagnosis and what they need to develop, so that they can enhance capacity

  • This will include further training, personal and practice development and inter agency capacity;

4.Develop an integrated care pathway within the community for people who are affected by dual diagnosis.

Open dialogue approach

Key to the project was the creation of the open dialogue community forum, which provided the space for multiple perspectives, identifying needs and responses, and ultimately giving a community evaluation on the extent this project was successful. A recognised community development evaluation framework LEAP was utilised to implement, monitor and ensure optimum participation in this community endeavour. 

Open Dialogue as a form of open communications; a therapeutic process; and as a process for organisational/community development has a long-standing tradition. One of the crucial strengths of Open Dialogue is the capacity for people engaged in this process to take on board multiple perspectives, to internalise these and to work with whoever they are engaged with to form mutual realities and possibilities (Piippo & MacGabhann, 2018).

The level of engagement at the open dialogues was unexpected. People from different perspectives attended, mainly professionals but with their own lived experience of living in the area or having they themselves experienced mental health and or substance use issues. The space created reach discussion and conversation, it opened different channels for communication and on a very basic level it allowed the opportunity for different organisations to get to know each other and what they do in terms of addressing mental health and or substance use.

It would be fair to say that most agreed on one thing, and that was that the current pathway for people experiencing complex issues such as dual diagnosis was not effective in providing sustainable support. Most stories shared involved people falling through the cracks of mental health and addiction services, only to enter into a cycle of revolving doors which ultimately ended in extreme negative outcomes for not only individuals but family members too.

The project provided a process of capacity building for the people in the community. There were awareness courses on trauma, an attempt at creating a more trauma aware community which could support a person on their recovery journey with empathy and compassion. With such a dense area like the north inner city and a high number of people experiencing complex issues, the atmosphere can feel tense and hostile. Not a space that fosters recovery. By providing basic information on how to be aware of the presence of trauma and how to change our interactions, we could offer a supportive community instead of an adverse one. As the community began to recognise their established expertise and organisational practice with dual diagnosis, a subgroup of participatory network developed and delivered two dual diagnosis skills enhancement courses that capitalised on the emerging capacity within the community itself. 

Investment and political will 

The impact of this process is demonstrated in several ways. Community organisations are now aware of what each provides in relation to dual diagnosis, what the deficits are per organisation and how to link with other organisations to address these deficits. There is an active dual diagnosis network established with a significant enhancement of skills amongst practitioners to respond effectively to dual diagnosis in this community. Moreover there is a clear integrated pathway for youth and adult services that do and can respond to dual diagnosis in an integrated way.

In short space of time, 11 months, this project connected the jots of the community supports that are working with mental health and or substance use. With the community it created a potential pathway for people experiencing dual diagnosis. The community got on board with the events that were held, and each training session was booked out with waiting lists – proving that they are invested and motivated to work towards building a recovery community. Steps have been taken to maintain sustainability within this community, though it remains to be seen if the relevant supports, resources and evolving practices will be forthcoming. Without investment and resources to continue with coordination work of the project, the pathway may ultimately remain that of a potential one. We remain hopeful that political will regarding dual diagnosis will continue to increase and considering the recent model of care has been launched, that further investment is on the way. Meanwhile, the project has demonstrated that an effective all community response to complex issues is possible and with collective action of all relevant stakeholders, probable.

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