Working with Dual Diagnosis: A Psychosocial Perspective

186 Pages·2016·1.941 MB·English

by  Darren Hill, William J. Penson, Divine Charura

Working with
Dual Diagnosis
A Psychosocial Perspective
Darren Hill, William J. Penson
and Divine Charura
WORKING WITH DUAL DIAGNOSIS
FOUNDATIONS OF MENTAL HEALTH PRACTICE
The Foundations of Mental Health Practice series offers a fresh approach to the field of
mental health by exploring key areas and issues in mental health from a social, psycho-
logical and a biological perspective. Taking a multidisciplinary approach, the series is aimed
at students and practitioners across the people professions, including student nurses, social
workers, occupational therapists, psychiatrists, counsellors and psychologists.
Series editors:
Thurstine Basset worked as a community worker and social worker before becoming involved
in mental health training and education in the 1980s. He is Director of Basset Consultancy
Ltd and has experience of working with a number of universities, statutory and voluntary
mental health organisations, service user and carer groups. He has published widely across
the fields of mental health training and education. In collaboration with Theo Stickley, he is a
co-editor of Learning about Mental Health Practice (2008). He is also an editor of the Journal
of Mental Health Training, Education and Practice. 
Theo Stickley is Associate Professor of Mental Health Nursing at the University of Nottingham.
He has authored and edited many books and journal articles about mental health. Each repre-
sents his interest in promoting a fair, just and genuinely caring way in which to think about
and deliver mental health care. His area of research is promoting mental health through
participatory arts and he advocates a creative approach to care delivery.
Available now:
Working with Dual Diagnosis: A Psychosocial Perspective by Darren Hill, William J Penson
and Divine Charura
From Psychiatric Patient to Citizen Revisited by Liz Sayce
Models of Mental Health by Gavin Davidson, Jim Campbell, Ciarán Shannon and Ciaran
Mulholland
Values and Ethics in Mental Health: An Exploration for Practice by Alastair Morgan, Anne
Felton, Bill Fulford, Jayasree Kalathil and Gemma Stacey
WORKING WITH DUAL
DIAGNOSIS
A Psychosocial Perspective
DARREN HILL
WILLIAM J. PENSON
AND
DIVINE CHARURA
© Darren Hill, William J. Penson and Divine Charura 2016
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permitting limited copying issued by the Copyright Licensing Agency,
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Any person who does any unauthorized act in relation to this publication
may be liable to criminal prosecution and civil claims for damages.
The authors have asserted their rights to be identified as the authors of this
work in accordance with the Copyright, Designs and Patents Act 1988.
First published 2016 by
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ISBN 978-1-137-33766-5 ISBN 978-1-137-33767-2 (eBook)
DOI 10.1007/978-1-137-33767-2
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Contents
List of tables and figures viii
Introduction ix
PART I HISTORY, POLITICS AND CONCEPTS
1 THE HISTORICAL CONTEXT OF SUBSTANCE USE,
MENTAL HEALTH AND DUAL DIAGNOSIS 3
Dual diagnosis: a ‘contested’ term and a ‘real’ issue 4
Why do substances and mental health go together? 7
What comes first, mental health symptom or substance use effect? 9
Stimulants 9
Depressants 10
Hallucinogens 10
The global is the local: economic liberalization and the normalization
of substance consumption 14
References 16
2 THE SOCIO-POLITICS OF DUAL DIAGNOSIS:
PSYCHIATRY, LAW AND ECONOMICS 19
The social and political construction of dual diagnosis: understanding
the context of mental health and substance use policy 20
Moral–medical 21
Medical–criminal justice 26
Psychiatric–criminal justice 32
Economic–criminal justice 37
References 50
3 KEY MODELS FOR UNDERSTANDING DUAL DIAGNOSIS 53
Introduction 54
Critical accounts 54
The main models 57
Psychosocial perspectives 59
v
vi Contents
The social model of disability in dual diagnosis 61
References 62
PART II WORKING IN PRACTICE
4 WORKING WITH INDIVIDUALS: THE BROADER PICTURE
AND GETTING STARTED 67
Introduction 68
The varied and complex nature of the relationship between substance misuse
and mental health problems 69
Values-based practice 70
Importance of acknowledging issues of difference and diversity
and their impact on treatment 72
The Care Programme Approach – case management 73
Strengths-based models in mental health 74
Strengths-based models for substance use 76
Risk 77
Physical and mental health factors affecting motivation to change 81
Key factors in assessment when working with dual diagnosis 84
Assessing clients and formulation 88
The problem list – a tool for getting started 89
Problem formulation and conceptualization in dual diagnosis 90
Relapse prevention 92
Homework in relapse prevention 93
Relapse prevention in mental health 95
Harm reduction 95
References 96
5 PSYCHOSOCIAL INTERVENTIONS 100
Motivational interventions (MI) 102
Importance of facilitative conditions 103
What is motivational interviewing? 103
Stages in motivational interviewing 103
Brief interventions and self-help 105
Guided self-help 106
Contingency management 107
Cognitive behavioural therapy (CBT) and formulation 109
Structure in CBT 113
Psychodynamic therapy 114
Psychodynamic understanding of addiction 114
Addiction as transitional phase fixation 115
Medication as transitional objects 115
Self-regulation difficulties 116
Contents vii
Substance use as self-medication 116
Understanding substance use from an attachment theory perspective 117
Repetition compulsion 118
Psychodynamic therapy and what it says about the practitioner in
the therapeutic relationship 121
Inpatient, residential settings and the criminal justice system 123
Mindfulness and technology-based interventions 123
Technology-based interventions 124
References 126
6 WORKING WITH GROUPS AND FAMILIES 130
Introduction 131
Group work modes 132
What is the 12-step programme? 132
Dual diagnosis and 12-step programmes 133
Group interventions and psychotherapy 134
Resistance and challenges to the curative process in group interventions 135
Group ending, separation and focus on relapse prevention 136
Key protocols informing family work perspectives 138
Involving families and carers 140
A five-step approach 141
Behavioural family therapy (BFT) and cognitive behavioural (CB) interventions 142
Behavioural couples therapy 143
Basic family and systemic therapy concepts 143
NICE guidelines (2007) – supporting families and carers 146
Social behaviour and network therapy (SBNT) 147
SBNT stages 148
References 151
7 WORKING IN COMMUNITY SETTINGS: DUAL DIAGNOSIS AND
THE RECOVERY MOVEMENT IN A COMMUNITY CONTEXT 154
The lived experience of challenges faced by professionals working
in the community 155
Recovery movement within the community 157
Therapeutic communities 160
Integration of harm reduction and recovery-oriented practices 161
The social model of disability: rights of access 162
References 164
Conclusion 165
Glossary 169
Index 171
List of Tables and Figures
TABLES
2.1 Home Office Notifications for Drug Treatment 1959–1964 38
3.1 The main models in contemporary mental health
and substance user practice 58
3.2 The main models and their areas of intervention 58
4.1 Substance use and related health impacts 82
4.2 Working out what boundaries are needed and when they apply 86
4.3 Assessment template for dual diagnosis 87
5.1 CBT case conceptualization and formulation 112
6.1 Different group practices offered in working with dual diagnoses 137
6.2 Possible impacts of a dual diagnosis on the family 140
6.3 Summary of the Think Family, Work Family approach 145
FIGURES
I.1 The Scope of Coexistent Psychiatric & Substance Misuse Disorders, Source:
DoH (2002) x
4.1 The LUV Triangle (Echterling et al. 2005) 72
4.2 The case management model (Thanks to Neil Bottomley for
this adapted version of Onyett’s (1998) model) 75
4.3 The transtheoretical model adapted from Prochaska and DiClemente (1983) 80
4.4 The zone of helpfulness in professional boundaries 86
4.5 A simple functional formulation, drawing links and cycles 92
5.1 CBT longitudinal case conceptualization and formulation 111
6.1 Wider factors impacting on individuals 139
6.2 A holistic view of the client, considering family 140
6.3 A five-step model for working with families 141
6.4 Eliciting appropriate social network members for SBNT work 148
6.5 James’s network map 149
viii
introduction
Hallucinogenic drugs have been used by humans for as long as we can determine
to provide novel insights into the mind and enhance social bonding. For moral
reasons, hidden behind spurious concerns about health harms, modern day society
has attempted to deny the value and importance of the use of these drugs and
the study of this altered state of consciousness.
(David Nutt, Professor of Neuropsychopharmacology at Imperial College, London, and
former British Government advisor, in a special issue of The Psychologist devoted to
hallucinogenic drugs (Nutt, 2014:658))
This textbook takes a bold position on dual diagnosis, and by doing so it embraces the ideas
that this is a challenging area of practice and ‘dual diagnosis’ is a much-contested term
and concept. Despite this, and in acknowledging that critical positions may not always feel
very helpful to the practitioner in contemporary services, this text will also give some clear
practice and clinical guidance. So it is a book of two halves – the first being a social, political
and historical critique of dual diagnosis, and the second a practice guide based on our own
practice ‘wisdom’ and experience, current best practice guidance and evidence. As David
Nutt (2014) suggests in the quote above, concerns and thinking about substance use is as
much driven by non-clinical issues such as politics and morals, as it is by health concerns.
As a starting point, we need to have at least a provisional definition of ‘dual diagnosis’.
There are different definitions which include ‘severe mental illness’ with either substance
misuse, alcohol problems and/or learning difficulty. The Department of Health (DoH) (2002)
suggests the relationship between mental illness and substance misuse is complex, and may
include:
• a primary mental health problem leading to substance misuse;
• substance misuse worsening, perhaps altering the course of a mental health problem;
• intoxication/substance dependence leading to psychological problems;
• substance misuse/withdrawal leading to mental health symptoms/illness.
The DoH goes on to provide a chart (see below) showing the relationship between mental
ill-health and substance use, and it notes the upper right quadrant as being of greatest
concern. These are likely to be familiar terms and ideas to the practitioner, but with a little
critical thinking we begin to entertain the idea that even a simple chart has within it ideas
of normal substance use, rationing of services, risk management and risk aversion, and given
that it is a graph, the user experience can be located in any of the quadrants to varying
degrees. This implies a broad norming of the user experience because we are invited to locate
the person in the quadrant.
ix