1. Dual Diagnosis
HEA 3126
17th October 2011

2. Learning objectives
To gain an understanding of what dual diagnosis means
To become more familiar with the multiple factors that may
contribute to substance/drugs use in this client group
Establish facts and myths surrounding the links and relationships
between drug/substance use/misuse and mental health
Reflect on your own use of legal drugs/substances
To be aware of the approaches/interventions that may best help
this client group

3. What is ‘dual diagnosis?’
Exercise 1.
For 5 minutes- in groups- identify what the term ‘dual
diagnosis’ means to you and also consider:
How helpful is the term?
How unhelpful is the term?
Are there any other terms that could be used?
Nominate a spokesperson to feedback

4. What is ‘dual diagnosis?’
‘The co-existence of psychiatric disorder and substance
misuse’ (Crome et al. 2004)
‘…a broad spectrum of mental health and substance
misuse problems that an individual might experience
concurrently’ (DOH 2002).
‘Dual diagnosis is a label they give you, but even at my
most buoyant I think I’ve got more than two problems’
(Quote from a Service user taken from Rethink 2007)

5. Is the term ‘dual diagnosis’ helpful?
Some points to consider
A professional term.
A broad term, at best, promotes an understanding of two interwoven complex
conditions.
Provides a conceptualisation of the phenomenon of substance misuse and
mental health
Too narrow a focus? More than just 2 problems?
Medicalised?
Misleading?
A vague and yet stigmatising label?

6. How common is ‘dual diagnosis?’
‘Substance misuse is usual rather than exceptional amongst people with
mental health problems’ (DOH 2002)
May affect between 30 to 70% of those presenting to health and social care
settings (Crome et al. 2009).
At the same time, approximately 50% of patients in drug & alcohol services
have a mental health problem (Rethink 2007).
First-episode psychosis: A sample of 168 young people showed that 37% of
the sample reported drug use, drug misuse and alcohol misuse (Cantwell
et al. 1999).

7. Why do people with mental health problems
use or misuse drugs/substances?
Exercise 2.
In groups- Explore the various reasons as to why people with
mental health problems may use/misuse substances/drugs.
Consider the following areas:
Social/environmental/cultural factors
Mental state
Effects of prescribed medication(s)
Physical factors
Feedback in 10 minutes- nominate a spokesperson

8. Why do people with mental health problems
use or misuse drugs/substances? (1)
As varied as the individuals themselves
Socially excluded, may find a sense of belonging and community with other
drug users
Counteract the unpleasant side-effects of prescribed psychiatric medication
such as limb stiffness, involuntary movements, sexual dysfunction.
Increase energy levels and motivation by stimulating nervous system
Numb or mask painful thoughts and feelings
Alleviate intensity and distress from auditory hallucinations
Aid sleep

9. Why do people with mental health problems
use or misuse drugs/substances? (2)
Shorted-lived sense of euphoria and confidence
Vulnerability: may be a ‘soft’ target for drug dealers
Boredom/unemployment
‘Anti-depressants not always enough’
‘Living on the streets-to keep a lid on it’
Enjoyment
Availability-
Peer pressure
To reduce marked periods of mania/excitability

10. Which came first?

11. Do substances/drugs cause mental
health problems?
Exercise 3.
In groups- discuss whether substances/drugs cause
mental health problems or whether mental health
problems lead to substance/drug use?
Feedback in 5 minutes- once again, nominate a spokesperson

12. Do substances/drugs cause mental
health problems?
There remains on-going debate about the extent to which substance/drug use
causes mental health problems?
More agreement reached that drug/substance misuse can ‘enhance’,
‘exacerbate’ or ‘trigger’ in individuals who are pre-disposed to mental health
problems.
Substance/drug use can also mask a mental health problem which is later
revealed when use is ceased.
Earlier age of onset of first-episode psychosis is proposed in young people
with a vulnerability to schizophrenia and who misuse substances (Addington
& Addington 1998). May act as a trigger.

13. What ‘dual diagnosis’ may mean for services &
carers/families
Pessimistic attitudes and values: could be viewed as ‘criminal’,
‘manipulative’, ‘aggressive’, ‘intoxicated’, ‘bringing it on themselves’.
May be viewed by services as ‘problematic’ or ‘revolving door’.
Preoccupations with ‘what came first’- whose responsibility is it?
Restrictive ‘gate-keeping’ practices
In a climate of finite resources, may be removed from caseload list for
poor or non-engagement with appointments

14. What may dual diagnosis mean for
service users?
‘ I was pushed around like a tennis ball. The alcohol people said I
had a mental illness and the mental illness group said I had a drink
problem. Neither of them did very much for me’ (Rorstad &
Chesinski 1996).
‘Passing the book’
May not be ready to address their substance misuse problems,
when their carers and professionals believe they should.
May perceive their issues differently and may not view their
substance use or mental ill-health as a problem
Previous contact with services may have been negative and
consequently, there may be poor engagement or mistrust.

15. You Tube clip
‘Integrated treatment’
http://youtu.be/2kwtcADn-yM

16. Exercise 4: Types of use
In groups- think about licit/illicit substances/drugs that might be used:
To numb or mask mental distress
To increase mood and motivation
To improve sleep
To reduce marked periods of mania or restlessness
Feedback in 10 minutes- nominate a spokesperson

17. Thinking about you own use of legal
drugs/substances
Do you enjoy a drink of beer, wine or spirits?
Do you smoke?
Do you like caffeinated drinks such as tea and coffee?
Does your own use of the above drugs/substances ever
exceed ‘healthy limits?’
Would you be willing to give up these ‘pleasures’ if
someone else told you to? Why?

18. How can we respond?
A few guiding principles to consider:
Co-morbid mental illness and substance misuse is commonplace, therefore:
Be inclusive rather than excluding: on the basis of health needs NOT on ill-defined
or ill-judged causes.
Cast a wide-net: ‘Err on the side of caution’ and ‘maintain a high index of suspicion’ –
It is better practice to misidentify a service user not experiencing dual diagnosis
than to miss others who do (Holland & Midson 2004).
Mainstreaming: Should be delivered within mental health services but working
closely with specialist substance misuse services (DOH 2002).
Working alongside the individual ‘holistically’ (although don’t exclude
families/carers)

19. Ask the service user
Best way to detect substance use/misuse is to ask users in an open
and frank way
Ask sympathetically and reassure that negative consequences will
not automatically follow
Might be important to initially consider asking service users on their
own (although don’t wholly exclude families, carers or friends).
Slang terms can vary across the country- Be clear about
misunderstandings or misuse of drug-using terminology.

20. Interventions
Establishing a therapeutic alliance
Focus on ‘engaging’ with the service user – be flexible in your
approach
Maintain an holistic focus
Consider that ‘reduction’ may be more realistic than ‘abstinence’
Provide advice and information
Accept that ‘setbacks’ can occur- that drug/substance reduction does
not always move along in an linear mode

21. Four guiding principles to aid engagement
Known as R.U.L.E ( Rollnick, Miller & Butler 2008).
Resist the Righting Reflex
Understanding the Service User’s Motivations
Listen to the Service User
Empower the Service User

22. DVD- ‘Pillar to post’- a film about dual diagnosis
(MIND 2011)
For the next 20 minutes, watch this short film
documentary and consider:
Why people use street drugs?
How supported do service users feel?
What types of interventions/approaches might help?

23. Thank you
Any further questions?
Feedback

24. References
Addington, J. & Addington, D. (1998). Effect of substance misuse in early psychosis. British Journal of Psychiatry, 172, (suppl.
33), 134-136.
Cantwell, R. et al. (1999). Prevalance of substance use in first-episode psychosis. British Journal of Psychiatry, 174, 150-153.
Crome, I., Ghodse, H., Gilvarry, E. & McArdle, P. (2004). Young People and Substance Misuse. London: Gaskell.
Crome, I. Chambers, P., Frischer, M. et al. (2009). The relationship between dual diagnosis: substance misuse and dealing with
mental health issues. Social Care Institute for Excellence, 30, 1-23.
DOH (2002). Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. London: The Stationary Office.
Holland, M. & Midson, V. (2004). Substance Misuse and Mental Health . Chapter 16 IN Ryan, T. & Pritchard, J. (2004). Good
Practice in Adult Mental Health. London: Jessica Kingsley Publishers.
MIND (2011). Pillar to Post- a film about dual diagnosis. www.mindincroydon.org.uk
Rethink (2007). Dual diagnosis toolkit: Mental health and substance misuse: A practical guide for professionals and practitioners
(online) last accessed 13 March 2008 at www.rethink.org.uk
Rollnick. S., Miller, W.R. & Butler, C. (2008). Motivational interviewing in health care: helping patients change behavior. New York:
Guildford Press.
Rorstad, P. & Chesinski, K. (1996). Dual Diagnosis: Facing the Challenge. Kenley: Wynne Howard Publishing