Dual Diagnosis: Stopping the merry-go-round
Prepared for the ACT Department of Health and Community Care April 1999
by Leigh Cupitt, Elizabeth Morgan and Marilyn Chalkley
Final report on dual diagnosis* treatment options for the ACT
(*mental illness and alcohol or drug issues)
The provision of high quality services to people with a dual diagnosis of mental illness and alcohol and substance abuse is a major challenge for policy makers and providers across the world. The literature indicates that many modern health systems are engaged in activities to rethink their service approach to people experiencing co-existing mental illness and substance abuse. The separate administration and delivery of mental health and alcohol and other drugs services poses major problems for a co-ordinated and integrated system of care, able to address the functional needs of a very vulnerable group of citizens.
The prevalence of co-existing mental illness and substance abuse is well documented in international research. It is estimated that in the vicinity of up to 80% of people with a diagnosed mental illness also has a diagnosis of problematic substance use. In alcohol and drug services, up to 20% of people presenting, are estimated to have a co-existing mental illness. Many studies assert that people with a dual diagnosis are not a separate population group, rather they are represented in the current client base of existing services, are receiving poor services and are generally seen as too hard by many professionals.
This project found that the ACT demonstrates many of the same issues and problems identified in the international literature on the management of dual diagnosis or dual disorders. Some of these issues and problems included:
- access barriers to services from both ACT Mental Health Services (ACTMHS) and Alcohol and Drug Program (ADP) for both consumers and their families;
- the absence of a co-ordinated and shared case management approach with people being shunted between services;
- significant professional differences between the two fields, underpinned by different professional orientations to treatment and support and a limited understanding of the respective diagnoses by the other service area;
- the absence of mechanisms to involve consumers and families in service planning and evaluation;
- a lack of respect for consumers;
- a failure to understand the need for a commitment to engagement and long-term interventions;
- limited understanding of and active involvement with other sectors including NGOs and the private sector services;
- a poor understanding of dual diagnosis and a lack of adequate and ongoing training.
However despite these problems the ACT also exhibits considerable goodwill between sectors and evidence of several existing initiatives to improve services. These include joint initiatives between ACTMHS and ADP, between government and non-government sectors and between consumers and carers and providers. The goodwill between the two government services in the ACT is not a feature of the relationship between services in other states. Thus the nature of relationships in the ACT is a significant and positive indicator for the potential to improve services.
- This project is also occurring in the context of national strategies to improve mental health and alcohol and substance abuse services. The first stage of the National Mental Health Strategy was completed in June 1998 and a Second Plan commenced in July 1998. The Second Plan identified two areas requiring attention to address need; definitional issues which lead to exclusions in service delivery, and, targeting particular needs, including people with a dual diagnosis.
The National Drug Strategic Framework 199899 to 200203 Building Partnerships, is underpinned by a commitment to harm minimisation as the basis for a national approach to the strategy. The strategy identifies links with the National Mental Health Strategy and the National Youth Suicide Prevention Strategy as two of the key areas where overlapping issues can be addressed including improving services to clients with co-existing mental health and drug problems.
There are unique opportunities in the ACT which will assist agencies to implement a creative response to the development of services. These include the size of the ACT population, which is the equivalent of a small region in other states, the compact geographic location and the nature of overall, good relationships between services and sectors. These are not features of many other states and territories which have been grappling with finding appropriate and manageable responses for the past few years.
Throughout this project the consultancy team aimed to build and utilise the knowledge and understanding of providers, consumers and carers to develop a service approach which would work in the ACT. The project drew on the experiences of ACT based and interstate consumers and families, providers and trainers to increase understandings of dual diagnosis and to identify opportunities for the advancement of initiatives already underway.
Future service development in the ACT
The proposals contained in this report have been tested extensively with all stakeholders. There is widespread support for the proposed approach. This support is moderated by a degree of skepticism and concern that a political preoccupation with a quick fix has driven the public debate regarding mental health and alcohol and drug policy and service development. The willingness to recognise that assisting recovery for people with dual diagnosis is a long and often frustrating experience for the consumer, their families and for services is seen as an important first step in service reform.
Participants in the consultation process identified the principles which must underpin a new system and what would need to change for consumers and their families to receive improved services.
The project explored several potential approaches to the development of services, including the establishment of a new stand-alone specialist service. It drew extensively on the experiences of Victoria and NSW and on recent research from the United States. There is considerable evidence that specialist, stand-alone services are neither the best service response nor the most effective or efficient. The international evidence suggests that a comprehensive, integrated service system which brings together mental health and alcohol and drug services, working collaboratively with consumers, families and non-government services, delivers the best outcomes for consumers and their families.
This report proposes a change management approach as the most appropriate and timely model for the ACT, commencing with ACTMHS and ADP. This approach includes the urgent need to build relationships and links with NGOs. The change strategy would have a commitment to actively work with consumers and families and carers in the development of services. The initial Change Management Team will be small, and needs the involvement of different staffing levels within both services. It would be resourced by a full time project manager, located initially with ACTMHS.
The Change Management Team members would not have a direct service delivery role except back in their respective service. Their function would be to facilitate a major change strategy which leads to an improvement in both agencies in the provision of services to people with dual diagnosis and to their families and carers. A key outcome would be to build a comprehensive, integrated service approach in the ACT which strives to achieve the principles outlined in the vision for the dual diagnosis services contained in the report.
The strategy will need to include priority attention to developing relationships with indigenous workers to ensure the needs of indigenous communities are addressed.
The tasks of the Change Management Team are clearly articulated and will be monitored by a committee of senior executives and managers and involve external participants from the non-government and private sectors.
To achieve any sustainable change there must be a commitment to a training strategy which is long term and draws on existing best practice and the experiences of other states. This report includes an extensive training strategy which accesses the highly respected training offered through the University of Wollongong and the SUMITT service in Melbourne.
The report contains the following recommendations:
Recommendation 1
That ACTMHS and ADP agree to establish a joint Change Management Team to work towards achieving a comprehensive, integrated service approach to the provision of dual diagnosis services.
Recommendation 2
That the joint team comprises six members with three selected from each service, one senior manager, a middle manager or team leader, and a field worker at the clinical level.
Recommendation 3
That the team be appointed for an initial period of 18 months to two years with regular reviews of progress and the possibility of an extension beyond this time if required.
Recommendation 4
That a Monitoring Committee - comprising the Director of ACTMHS, the Chief Executive Officer of ACT Community Care, the respective managers of the policy units for mental health and alcohol and drugs, and representatives of non-government organisations, including consumer and carer groups, and the private sector - be established to monitor progress within both services and the achievements of the Change Management Team.
Recommendation 5
That the key tasks of the Change Management Team would be to:
- identify strategies for the development of joint approaches to the provision of services, including diagnostic and assessment approaches, case management, treatment, outreach services, rehabilitation, withdrawal services, and ongoing consumer and family support;
- work with consumers and families and carers to identify ways of involving them in the planning and development of services;
- develop relationships and links with non-government organisations, hospitals, GPs and other services including Family and Community Services and police;
- oversee the implementation of a survey of worker attitudes in both services to assist in the development of the broad training strategy;
- ensure the implementation of the training strategy;
- develop an appropriate evaluation plan for the strategy;
- provide progress reports to the Monitoring Committee on a six monthly basis.
Recommendation 6
That the change strategy be evaluated against the following outcomes:
- ACTMHS and ADP are able to demonstrate improved skills for all staff in the management of dual diagnosis.
- Consumers and carers report that they receive improved services.
- Consumers and carers are involved in service planning and evaluation of services.
- Joint strategies and approaches exist between ACTMHS and ADP, in particular related to diagnosis, case management, ongoing treatment, support and outreach services.
Strong working relationships exist between ACTMHS and ADP, and non-government organisations and other private providers.
- Appropriate training is provided on a regular and ongoing basis to government and non-government providers.
- Consumers and carers are involved in training.
Recommendation 7
That funds be allocated for a dedicated full time project manager at the level of Senior Officer, Grade C, to work with the Change Management Team.
Recommendation 8
That the project manager works to the direction of the Change Management Team, supports the work of that team and provides reports to both agencies through the Change Management Team.
Recommendation 9
That negotiations occur with both services regarding the need for funding to back-fill a portion of staff time, such funds will be provided on the basis of an outcomes agreement with each service.
Recommendation 10
That improved resourcing for non-government organisations be addressed in the allocation of future funding for broad-banded public health funds and the Second National Mental Health Plan for the ACT.
Recommendation 11
The ACT Council of Social Service Mental Health Provider network be encouraged to initiate discussions between non-government organisations with a view to building strong linkages with the Change Management Team.
Recommendation 12
That the Change Management Team works with non-government organisations to establish strategies which build stronger links between non-government organisations and government providers.
Recommendation 13
That the team builds immediate links with the indigenous worker in ACTMHS and the mental health worker at Winnunga Nimmityjah to address issues of services for indigenous communities.
Recommendation 14
That the Change Management Team builds links with the ACT Transcultural Mental Health Network to consider ways of addressing issues of the cultural appropriateness of services.
Recommendation 15
That, in the development of the project, the team must take account of the wide range of issues including issues of gender, age, cultural appropriateness and location of services.
Recommendation 16
That the Change Management Team works with the ACT Division of General Practitioners and Calvary Hospital to build partnerships and to identify other ways of incorporating these services into an integrated service system.
Recommendation 17
That any training conducted adheres to the following principles:
- An integrated approach with people jointly trained should be used as much as possible.
- Consumers or advocates for consumers should contribute to the training process.
- Carers of people with a dual diagnosis should contribute to the training process.
- Course facilitators should aim to build respect for consumers and carers and between agencies so that a joint working relationship can be developed.
Recommendation 18
That high quality and extensive training at a number of different levels be recognised as an essential ingredient of developing an integrated approach to dual diagnosis.
That training be consistent with competency levels for mental health and drug and alcohol workers about to be published by Community Services and Health Training, Australia.
That as many people in the field as possible attend module 1, a 45-minute training session in the workplace.
That the plan is structured in a series of building block modules, which can be studied independently but overall contribute to staff development reaching a certain level of expertise in dual diagnosis.
Recommendation 19
That a survey be conducted of staff in mental health, alcohol and drug services and the non-government sector to review attitudes and knowledge to dual diagnosis, and that this survey is seen as part of the training program, and contributes to development of training approaches in the long term.
That the existing surveys used by NSW and Victorian services be adapted for this purpose.
Recommendation 20
That the Illawarra training program be brought to the ACT to train approximately 20 change agents.
That all of the joint Change Management Team members attend the Illawarra training program as a matter of priority.
That Women's Information Resources and Education on Drugs of Dependency be subcontracted to address gender and cultural issues as part of the Illawarra course.
That the Illawarra course trains a combination of clinicians and others in approximately this ratio:
- seven from ACTMHS (one should be the new indigenous worker)
- five from ADP
- two from ADDINC (one from Arcadia House)
- one from each of the following:
- Karralika
- Calvary Hospital
- Samaritan House
- CentaCare
- Winnunga Nimmityjah
- Inanna
The course providers will include the involvement of consumers and carers as trainers and participants. This should include discussions with Canberra Schizophrenia Fellowship and the ACT Carers' Network regarding carer involvement.
Recommendation 21
That the links and discussions on training between ADP and Women's Information Resources and Education on Drugs of Dependency should be further explored.
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