The Scottish Government

« Previous | Contents | Next »

Listen

MIND THE GAPS
Meeting the needs of people with co-occurring substance misuse and mental health problems

CHAPTER 5: ASSESSMENT, INTERVENTION AND SUPPORT

This Chapter:

• sets out the principles for the assessment of, and continuing support for those with co-occurring mental health and substance misuse problems, in line with the Joint Future Agenda and Integrated Care for Drug Users; and

• provides further information on the stages of intervention and appropriate approaches to treatment and care.

Basic principles and historical context

5.1 The provision of care for both substance misuse and mental health problems has long been recognised as requiring a broad range of participants. If a smooth passage through services for the client is to be achieved, not only must the providers share a broadly similar understanding of what types and sequences of care are appropriate, but they must also to be able to apply these flexibly and jointly across professional and organisational boundaries.

5.2 This aspiration is obviously compatible with, and a driver for, the implementation of both the Joint Future Agenda and Integrated Care for Drug Users. There are many examples of effective joint working or shared and integrated care in both substance misuse and mental health services. However few areas, if any, have managed to apply the process fully. The language of care and of strategy differs markedly between local authority, health and voluntary sector services, often leading to misunderstanding and subsequent difficulty in service provision. Those forms of working that depend upon professional or organisational identity are likely to result in a pathway of care which is less effective than those which work jointly.

5.3 If this is true of both mental health services and substance misuse services individually, then the problems are increased significantly when a further specialism is added into the mixture. These problems include the following:

• within NHS mental services, many of those staff concerned with treating adult mental illness are unhappy at the prospect of dealing with substance misusers ;

• there has traditionally been a separation at operational and planning levels between the two services, with the result that both services, and those who need the services, are at risk of failing;

• skill deficits in substance misuse services when treating mental illness can lead, at the very least, to inadequate identification of problems and to misinformed interventions;

• the same deficits in the opposite direction are seen in mental health services, with the same consequences;

• both areas therefore become frustrated and irritated at the apparent difficulty that the other is having in providing what would be perceived as a good service, which in turn may further divide services; and

• the voice of service users rarely seem to be heard or heeded.

Resolving these difficulties will require:

• putting the clients' needs at the centre of care;

• joint service planning;

• systems of care delivery;

• workforce training; and

• governance;

before there can be any opportunity of developing truly integrated pathways of care.

5.4 As already outlined in Chapter 4, different areas are addressing this problem in different ways. Some are developing specialist teams; some are targeting training and development at generic teams; others are developing integrated care pathways for substance misusers in the expectation that this will better serve those with more complex needs. These are valid local responses aimed at adapting existing situations, but they highlight the need for a national framework of practice based on evidence. This should allow decisions to be taken at local level as to which combination of responses will best suit a particular area in light of identified need, existing services and the related resource. The mechanisms now exist, deriving from Joint Future, Partnership for Care and Integrated Care for Drug Users to facilitate this process. Key to the success of this will be a new willingness to work across and through existing service boundaries, which is fundamental when dealing with this particular client group.

5.5 A wide range of health and social services should be readily available to this group. Sometimes this may need to be delivered in sequences which are not currently accepted or which may not, at first sight, appear to be entirely logical. In particular it may not always be possible in a community setting, where the majority of interventions will occur, to allow the theoretical debate of whether care for mental health issues and care for substance misuse issues should be parallel, sequential or integrated. Inevitably initial clinical and risk assessment will determine what can or cannot be done within that person's current circumstances. For instance the usually accepted principle that detoxification from alcohol should precede assessment and treatment for depression might not be appropriate if the person is unwilling to be detoxified (given the common perception by clients that alcohol is the only thing that helps lift mood). Similarly the person may be unwilling to accept residential care despite exhibiting alarming levels of risky behaviour as a result of low mood. Care sequences need to be constructed in a pragmatic way which gives most hope of a successful outcome for the client, rather than being driven by theory or practice deriving from a group with less complex care needs.

5.6 Local services therefore require:

• a sufficiently diverse skills mix to allow ready access to appropriate specialist and generic services as a client's needs becomes apparent;

• to be staffed by workers who are sufficiently confident of their own abilities to construct practical care plans in the face of a complexity of rapidly shifting problems;

• to be well enough understood by generic workers so that they can contribute to tackling the less complex issues, partnering the specialist service;

• to be understood and accepted by other potential providers, as well as care funders and commissioners; and

• to have significant presence and the capacity for a prompt response in those parts of the community where significant numbers of the client group will be found, often in crisis, and therefore possibly more amenable to accepting help - A & E departments, in psychiatric crises/emergency/out of hours services and in parts of the criminal justice system.

These principles should be built into any national framework as basic good practice.

ASSESSMENT

Why is assessment important?

5.7 An effective assessment process is at the core of effective and co-ordinated delivery. Assessment aims to establish with the individual as complete a picture as possible of all their needs - care for health, physical and mental, social needs, housing and occupation - and their state of readiness to change, in order to identify and provide the most appropriate service/services likely to promote a positive outcome. Without this information, the individual may be offered support that does not match their needs and aspirations, leading to disillusion and dropout from services.

Protecting the welfare of children cared for by service users

5.8 In addition to assessing the needs of the individual, all agencies and professional staff working with individuals who misuse substances have a responsibility to protect the welfare of any children cared for by their service users. Hidden Harm: A Report of the Working Group of the Advisory Council on the Misuse of Drugs, published in 2003, highlights the problems of children whose parents misuse drugs.

5.9 Getting Our Priorities Right: Good Practice Guidance for Working With Children and Families Affected by Substance Misuse published by the Scottish Executive in February 2003 highlights good practice in working with substance misusing parents/carers. It clarifies expectations in terms of information sharing and confidentiality and provides guidance on deciding when children need help.

Single Shared Assessment

5.10 A key element of the Joint Future Agenda is the establishment of locally agreed, single shared assessment procedures for all groups within the remit of community care. Full implementation of single shared assessment for all community care groups, including those with mental health problems and those with substance use problems is due by 1 April 2004. However, as each care group is developing their own single shared assessment, there is risk that those with both substance misuse and mental health problems could be subject to assessment from both. There needs to be some proper co-ordination to ensure consistency.

5.11 In November 2001, the Joint Future Unit of the Scottish Executive issued guidance on single shared assessment. Within this guidance a minimum standards checklist was provided in order to ensure that local single shared assessment tools meet a number of specific criteria. The guidance notes, which accompanied this document, confirmed that the minimum standards checklist for single shared assessment would apply to all care groups.

5.12 The core data set in use is currently divided into 4 sub-sets, as follows:

• personal information core data set;

• assessed need core data set (components of need);

• care plan core data set; and

• important medical conditions guide.

5.13 Single Shared Assessment creates a single point of entry to community care services and will lead to better use of resources and more effective outcomes for people in need. It:

• ensures that agencies adopt a holistic approach to assessing and meeting people's needs, reducing bureaucracy and duplication in assessment and planning care;

• should be person-centered and needs-led and be seen as a continuing process reflecting changing levels of need throughout a person's care;

• is a shared process that supports joint working by seeking information once, co-ordinating all contributions from service providers, clients and people close to them

• has an identified lead professional who co-ordinates documents and shares appropriate information;

• actively involves people who use services and their carers; and

• provides results which are acceptable to all agencies.

5.14 The Joint Future Unit states that in order to achieve this:

'Agencies should put in place single shared assessment processes and a single shared assessment tool. This should be done through the development of joint protocols to ensure agreement locally in the systems for and ownership of assessments and the provision of joint training for staff in assessment practice'.

5.15 Given the breadth of agencies with which initial contact may be made, it is likely that three levels of assessment are appropriate, in line with Joint Future guidance. These are:

• simple assessment (or screening);

• comprehensive assessment; and

• specialist assessment.

5.16 The EIU has collaborated with the Joint Future Unit to agree definitions of simple, comprehensive and specialist assessment relevant to drug users. They also collaborated in identifying the key items for two draft core data sets: the personal information data set and the assessed need core data set. Guidance is contained in Integrated Care for Drug Users: Principles and Practice. In addition the Unit has recently produced a digest of Assessment tools which have been shown to be appropriate and valid. This is also available on-line.

5.17 In addition there are two specialist instruments which are considered appropriate in screening for substance misuse in those with co-occurring problems:

• DALI - Dartmouth Assessment of Lifestyle Instrument (18 item interviewer administered);

• SATS - Substance Abuse Treatment Scale (measures progress); and

• CUAD - The Chemical Use, Abuse and Dependence Scale (measures substance misuse in those with co-morbid problems).

5.18 However, these assessment tools focus on health-related problems and take little account of socio-economic difficulties, which may often be just as important to the service user. The results should be interpreted cautiously taking account of their limitations.

5.19 Assessment involves several related elements. These are:

• Detection - to determine the nature and degree of substance use and psychological distress. This may initially involve the targeting of groups known to be at particular risk of developing co-morbid problems, such as those suffering from severe and/or relapsing mental health problems.

• Formulation - to determine the relationship between substance misuse, psychological distress and other relevant medical problems, taking into account the socio-economic context in which they occur. This may require a number of interviews and information from friends, family, other professionals and the use of drug tests.

• Risk assessment - to identify a hierarchy of need based on ensuring safety, accommodation, treatment and care. Key to risk assessment is the nature of the behaviour that is causing concern, the frequency and intensity of thoughts pertaining to it, how much planning has been developed to deal with it and whether or not there is the opportunity to carry out the plan. There may be a history of the same or similar behaviour and note should be made of the reasons why previous plans have not been carried out and of any strategies that have been developed to help reduce the risk. There are a number of clear predictors of risk which should be borne in mind.

• Goal development - to agree goals with the client which should be sequentially achievable within a harm reduction framework, and be flexible and adaptable in order to maximise opportunities for effective engagement and retention. If denial is thought to be an issue, tactics for approaching it should be factored into goal setting.

• The planning of delivery of care - to agree goals with other agencies. Inevitably this will depend on the resilience of the available network. A flow chart of care, including responses to failed or unexpected outcomes, can be useful as a way of minimising the likelihood of disengagement or of system failure.

• Monitoring - to provide a baseline to measure progress.

• Communication - with the client, their family, their carers, their close friends should be as transparent as possible to reduce the chance of failure.

• Diversity - to be sensitive to the interactions of need, prejudice and stigma amongst ethnic minorities, young people, disabled people, older people, and young mothers.

INTERVENTIONS

5.20 It is not the aim of this document to provide detailed guidance on clinical or social interventions for the treatment of those with either substance misuse or mental health problems or co-occurring mental health and substance misuse problems. These are well documented elsewhere. Guidance includes:

• Drug Misuse and Dependence: Guidelines on Clinical Management (UK Health Departments 1999)

• Drug Treatment Services for Young People: A Systematic Review of Effectiveness and the Legal Framework (EIU June 2002)

• Drug Treatment Services for Young People: A Research Review (EIU June 2002)

• The Effectiveness of Treatment for Opiate Dependent Drug Users: An International Systematic Review of the Evidence (EIU July 2002)

• A Survey of NHS Services for Opiate Dependents in Scotland (EIU July 2002)

• Psychostimulant Working Group Report (Scottish Advisory Committee on Drug Misuse August 2002)

• Psychostimulants: A Practical Guide (EIU September 2002)

• Services for Young People with Problematic Drug Misuse: A Guide to Principles and Practice (EIU January 2003)

• Prevention of Relapse in Alcohol Dependence (Health Technology Assessment Report No 3)

5.21 It is clear from the above publications that many different treatments and approaches work for this client group. Although the evidence of effectiveness is substantial and growing as the research base develops, there is no single approach that is universally effective for such a complex mix of conditions. It should be recognised also, that clients are likely to have particular difficulty in co-operating because of the influence of substances, the effect of mental disorder or the effects of previous trauma. Individuals may be particularly chaotic and unwilling, or unable, to self-advocate, when not offered the right types and levels of support they need.

5.22 There are some general principles which should be applied.

• Interventions should be presented in as simple and as understandable a way as is possible.

• Service providers need to be working in effective partnership with each other and with the client.

• Mutually agreed interventions need to be adaptable, flexible and to be attached to realistic goals - as true for workers as for clients.

• Interventions should take account of the degree of commitment to change, the readiness to change and the various factors which underpin this process.

• Staff who are not used to working with this group will need to recognise that, on occasion, they are having to deal with a set of behaviours which might not normally be tolerated and which might induce fear and anger. Staff should resist the temptation to attribute this sort of behaviour to a diagnosis of personality disorder. Many other influences are probably at work.

• Expectations of staff to the degree to which they are personally responsible for the process of intervention may need to be reduced.

• Changing working conditions for staff needs to be carefully managed. Staff need to feel fully supported in their work. Adequate training, supervision, career and personal development opportunities are critical to success.

• Given the high risk inherent within severe, enduring and relapsing mental illness and substance misuse, there needs to be a full understanding of, and a commitment to, the long-term nature of the work.

Stages of intervention

There are a number of identifiable stages of intervention.

Engagement

5.23 Establishing a therapeutic relationship can be long and drawn out, but begins from the point of first contact. The inequality implicit in the relationship and sense of disempowerment on the part of the client must be understood along with its potential for creating misunderstanding. Initial aims may be very different and to proceed adequately requires that a mutually acceptable middle ground be found. Attentive listening, courtesy and respect are the foundation of this. The use of normal referral routines may fail because of difficulty of understanding or fitting routine appointments into a chaotic lifestyle. The process of assertive outreach is often a useful way of making the initial contacts.

Meeting basic needs

5.24 From the complex range of needs generated by assessment, the basic needs of safety, accommodation and food come first. Support for benefit claims is important as well as providing alternatives to violent or dangerous environments.

Persuasion

5.25 There is a point at which the client's perceptions about the reasons for their problems can be discussed and better understood and at which a more accurate understanding of their motivation for change can be assessed. Gentle debate as to alternative explanations can then begin, and the client can be introduced to other perceptions of what is happening to them. The aim is initially to understand the problem from the client's perspective and then, by beginning to use techniques such as motivational interviewing and concepts such as the cycle of change, to influence motivation and encourage the belief in a positive outcome. This is best accomplished by using techniques that are empathic, client-centred, and non-judgemental whilst avoiding argument, facilitating accurate debate, gently feeding back discrepant statements and encouraging an awareness that change is possible after all.

Active intervention

5.26 Most interventions are carried out collaboratively in the community. The diversity and complexity of difficulties may sometimes be best met by using the Care Programme Approach, but whether or not this is formalised, it is essential that care systems are properly planned and integrated in a way which is client-centred and which is fully understandable by everyone involved.

5.27 Allowance should be made for the most likely contingencies and exit strategies planned for those parts of the system which become redundant or prove to be ineffective.

5.28 The client should be fully aware of, and involved in, the construction of the plan and should have a clear mechanism by which they can rapidly access.

5.29 Services such as the police, local A & E department, doctor on call service, or the local Mental Health Officer may need to be aware of some of the situation, normally with the client's understanding and involvement.

5.30 A care co-ordinator should be identified and be responsible for updating the plan and keeping the appropriate people informed.

5.31 The plan should include all those interventions used in both the mental health and substance misuse arenas that are felt to be appropriate. They should be sequenced in a way that is acceptable to the client, rather than a way that neurobiological theory might dictate. For instance motivational interviewing, relapse prevention techniques and substitute prescribing might be tied in with anti-psychotic prescribing, anger management and cognitive hallucinatory control techniques.

Early intervention

5.32 Ideally early intervention should be the basis of the treatment system, tied into broader prevention work. Access to services should be rapid, flexible and appropriate to the individual's need. Existing points of contact eg through the criminal justice system and A & E departments should be more fully recognised and utilised as gateways to care for this client group. There should be clear referral pathways to services appropriate to the individuals needs.

« Previous | Contents | Next »