Download Dual Diagnosis PPT

Dual Diagnosis
Substance Use
to
Mental Health Workers
Training Session
Active, inclusive , positive training.
• Participants should take responsibility for themselves
and the role they play in the group
• Acknowledge individual differences and avoid
stereotyping of individual groups
• Be aware of the language and terminology used within
the training setting
• Accept that each participant will have varying levels of
knowledge and expertise
• Accept we may have different learning styles
• Adhere to the practise of confidentiality
Objectives for the day
• To increase knowledge of substances and their effects
• To explore attitudes to substance use in society and
service users
• To improve confidence in working with substance users
• To introduce techniques for working with substance
users
• Services available / Refferal Process
In short , an individuals needs
are often multiple rather than
dual , and include social as well
as medical needs.
( LEHMAN ET AL 1989 )
Good practise guide
Primary responsibility for treatment of severe and enduring illness lies
within mental health services ( mainstreaming ) .
Substance misuse agencies should provide specialist support /
consultancy / training to mental health teams.
Where clients have less severe mental health problems, mental health
services should provide similar support to substance misuse services .
Clear pathways of working and treatment should be developed in dual
diagnosis strategic planning.
Dept of health.
Lincoln University
Severe Mental Illness
Bipolar/Schizophrenia
Cannabis use twice weekly
Minor Substance use
Minor Mental Illness
Depression
Alcohol dependence
Severe Substance Use
Severe Anxiety
Depression
Occasional cocaine use
Heroin dependency
Evidence base/Consistency
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Important based on factual evidence.
Need for consistency in response of information
Leading to informed choice
The individual has a responsability as well as the
professional
Nutt-Blakemore rank of problems:
Physical, dependence and social
Sufficient evidence on risks
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Homelessness
Poor / non compliance with medication
Pronounced psychotic symptoms
Aggression
Violence
(soyka 2000)
• Well documented evidence from many studies.
Acknowledge!
• Reduce: Supply Demand Harm
– Interventions in society
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function/ benefits
Links with managing symptoms
Your own experiences
Street terms,important to clarify!
Harm minimisation=bbv screening/needle exchange/information
on limiting risks
Acknowledge!
• Substance use is a human constant across time and
place
• Substance production, sale and use of interest to
chemists, economists, anthropologists…
• Substance use even if not ‘dual diagnosis’ very
common in client group
• Common in society,not just mental health!
• There is now a body of research that has
shown that the attitudes of professionals
towards substance misuse in the mentally ill
are generally suboptimal and this has an
impact on the quality of nursing care provided
(Foster 2003)
• Negative and ill informed beliefs about drugs
can be expected to translate into negative and
ill informed reactions to users (Griffiths 1988)
Different views
• Mental illness external force over which
client has no control (Medical model)
• Substance use consequence of client’s
own conscious choices (Work in client’s
frame of reference)
• Moral overtone. Blame. Responsibility.
Crome 1999 - Chicken
and egg
• 1+ SU, Harmful SU, Withdrawal leads to psychiatric
syndrome/symptoms
• Dependence, Intoxication, Withdrawal leads to
psychological symptoms
• SU exacerbates pre-existing psychiatric d
• Psychological morbidity precipitates SUd
• Primary psychiatric d leads to SUd
• Primary psychiatric d leads to SUd leading to
psychiatric syndromes
Dual diagnosis: theories
1 Self-medication hypothesis (Khantzian)
2 Alleviation of Dysphoria (Birchwood)
– feeling bad rather than coping with voices
3 Multiple risk factor model (Meuser) – isolation, social
skills, cog skills, educational failure, poverty, few
roles, peers, availability (social drift)
– 2 and 3 parallels with general population?
4 Supersensitivity (Meuser)
Theories
• There are many theories seeking to explain
problematic use focussing on different levels
including:
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Neurochemical
Psychological
Sociological
Spiritual
Examples
• Social learning: from TV, parents, peers
• Learning theory: classical and operant
conditioning
• Disease model: genetic, powerless over use
• Symptomatic theory – symptom of other
medical disorder
• Social theory – response to poverty,
hopelessness etc
The Biopsychosocial Model
• Problematic substance use embraces a variety of syndromes
• Problematic substance use lies upon a continuum of severity
• The development of problems follows a variable pattern and may
not progress to a fatal stage
• The population of substance users is heterogeneous and defy
stereotyping
• Treatment is contingent upon full, accurate needs driven
assessments
• Recovery may or may not require abstinence
Awareness of interactions
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Substance use
Psychological robustness/effects on illness
Interaction with medications
Social functioning
• E.g. anxiety, relationship problems, alcohol use; what
caused what?
• All important factors in assesment
Frank Cannabis video
Frank Cocaine video
Frank Ecstasy video
Frank LSD video
Frank Heroin video
Environment
• Risk factors
• Availability of
substance
• Poverty
• Social change
• Occupation
• Cultural norms/
attitudes
• Protective factors
• Good economic
situation
• Situational control
• Social support
• Social integration
• Positive life events
Individual
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Risk factors
Genetic disposition
Victim of child abuse
Personality disorders
Family disruption/ substance
problems
• Poor performance at school
• Social deprivation
• Depression/ suicidal
behaviour
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Protective factors
Good coping skills
Self-efficacy
Risk perception
Optimism
Ability to resist social
pressure
• General health behaviour
Classical Conditioning
• Probably the primary process by which environmental cues come to
elicit urges or cravings to use psychoactive substances.
– Siegel (1982) tolerant rats more likely to die from heroin when
receive in unfamiliar environment
– Wikler (1965, 1973) individuals being treated for heroin addiction
experienced withdrawal symptoms from the mere sight of the
paraphernalia associated with heroin use
– When given the opportunity to use what they thought was heroin
(but was actually an inert substance) they often experienced a
“high”
Behavioural change
Norcross and Vangerelli 1989
• 200 subjects – New Year resolutions
• Given up giving up:
– 1 month 45%
– 6 months 60%
– 2 years 81%
• ‘Resolution decay curve’ identical to relapse curves for
substance problems
From NTA ‘Addiction Careers’
o Idea of natural recovery
• Miller (1996) found that disease beliefs about
alcoholism were associated with higher risk of relapse
• Can be seen as absolving responsibility if feel ‘it’s out
of my control’
• Important ‘addict’ not full ‘identity’, rather a ‘phase in
the life course’ (Stall 1986)
• Refusal to adopt ‘addict identity’ protective
• Most substance users (and offenders) do ‘mature out’/
desist without assistance
Principles of Effective Treatment
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No single treatment is appropriate for all individuals
Treatment needs to be readily available (on demand, timely)
Effective treatment attends to the biopsychosocial needs, not
just the substance use
An individual’s treatment plan must be assessed and modified
continually to match the changing needs
Treatment is goal and time specific
Treatment has multiple entry and exit points
Treatment modalities must be evidence based
Relapse prevention
• This is a programme designed to teach
individuals who are trying to change their
behaviour how to anticipate and cope with the
problem of relapse.
• Forewarned is forearmed
ognitive-Behavioural Model of Relapse
Effective
coping
response
Increased
self-efficacy
Decreased probability
of relapse
High risk
Situation
Ineffective
coping
response
Decreased
self-efficacy
+
Positive
outcome
expectancies
Initial use
of
substance
Abstinence
violation
effect
+
Perceived
effects of
substance
Increased
probability of
relapse
Intervention
• Knowledge from worker combined with experience
of user
• Strategies for preventing initial “lapse”
• Awareness of / prevent acting on a “Seemingly
Irrelevant Decision”
• Identify / avoid high risk situations
• Develop coping strategies for high risk situations,
emotions, thoughts
• How to stop the “Abstinence Violation Effect”
following a lapse
Drake et al (2002)
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Psychosocial recovery relies on:
New relationships
New activities
New coping strategies
New identities
- all interact with ‘bio’ of biopsychosocial
ALCOHOL
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Central nervous system depressant
Widely used / acceptable
Approx 30,000 related deaths annually (uk)
14 x units weekly= 2/3 units daily, Drink free
days
• Body eliminates 1x unit per hour (approx)
• Volume (mls) x strength (abv) ÷1000=units
• 1x unit = 10mls / 8 grams alcohol ( ethanol )
ALCOHOL
• 4 x more likely to consume alcohol if diagnosed
with severe mental illness.
• Documented risks linked with anxiety /
depressive type illness
• Assessment of need to include risks with
physical dependency ! = S.A.D.Q
• Never advise abrupt cessation (daily drinkers +)
• Korsakoff s syndrome- alcohol misuse
The Transtheoretical Model
PRECONTEMPLATION
RELAPSE
EXIT
EXIT:
CONTEMPLATION
MAINTENANCE
PREPARATION
Permanent
Permanent
Lifestyle
Lifestyle
Change
Change
ACTION
The Stages of Change
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Pre-contemplation; is the stage at which there is no intention to change
behaviour in the foreseeable future. Many individuals in this stage are
unaware or under-aware of their problems
Contemplation; is the stage in which people are aware that a problem
exists and are seriously thinking about overcoming it but have not yet made
a commitment to take action
Preparation; is a stage that combines intention and behavioural criteria.
Individuals in this stage are intending to take action in the next month and
have unsuccessfully taken action in the past year
Action; is the stage in which individuals modify their behaviour,
experiences, or environment in order to overcome their problems. Action
involves the most overt behavioural changes and requires considerable
commitment of time and energy
Maintenance; is the stage in which people work to prevent relapse and
consolidate the gains attained during action. This stage might extend from
six months to an indeterminate period past the initial action
Precontemplation
Increase awareness of need to change
Contemplation
Motivate and increase confidence
in ability to change
Relapse
Assist in Coping
Maintenance
Encourage active
problem-solving
Termination
Matching
interventions
Preparation
Negotiate a plan
Action
Reaffirm commitment
and follow-up
Socratic questioning involves asking
questions that:
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The client has the knowledge to answer
Draw the client’s attention to information that is
relevant to the issue but which may be outside their
current focus
Generally move from the concrete to the more
abstract
Encourage the client to apply the new information
either to re-evaluate a previous conclusion or
construct a new idea
Self-motivational statements
‘Change Talk’
A. Recognising disadvantages of the status quo
(Problem Recognition)
B. Recognising advantages of change
C. Expressing optimism about change
D. Expressing intention to change
E. Confidence ruler 0-10
Evoking Change Talk
3 Decisional balance
4 Ask client to elaborate – when, how much
5 Query extremes
6 Look back
7 Look forward
8 Explore goals and values
Motivational Interviewing
– Miller and Rollnick
• “A directive, client-centred style for helping clients
explore and resolve ambivalence about behaviour
change”
• Purpose is for the patient to increase their motivation
for change
1: Express Empathy
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Acceptance facilitates change
Skilful reflective listening is fundamental
Ambivalence is normal
Human nature
Change is psychologically uncomfortable
2: Develop Discrepancy
• Awareness of consequences is important
• Discrepancy between present behaviour and
important goals will motivate change
• The client should present the arguments for change
3: Roll With Resistance
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‘What you resist persists’
Energy of momentum can be used to good advantage
New perspectives invited, not imposed
The client is a primary resource in finding answers and
solutions
• Arguing is counter productive
• Never risk engagement
• Resistance means change strategies
4: Support Self-efficacy
• Extent person believes they can make a change is a good
predictor of how likely it will be made
• Belief in the possibility of change is an important motivator
• The client is responsible for choosing and carrying out personal
change
• The worker’s own belief in the person's ability to change
becomes a self-fulfilling prophecy
• There is hope in the range of approaches available
Ask open-ended questions
• Closed: “Did you smoke cannabis?”
• Open: “What did you enjoy about smoking
cannabis?”
• Explanatory: “How did your cannabis use change
over time?”
A Framework for Interventions
Osher and Kofoed 1989
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Engagement
Persuasion
Active Treatment
Relapse Prevention
o Fits with transtheoretical model
Motivational therapy
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Feedback – substance use, mental illness
Responsibility – the service user’s
Advice – on how to change
Menu – of change options
Empathic - understanding
Self-efficacy – capable of positive change
Frank Cannabis video
Frank Cocaine video
Frank Ecstasy video
Frank LSD video
Frank Heroin video