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Chapter 4: Service Provider Perspectives on Co-morbid Mental Health and Substance Misuse

Introduction

This chapter examines the priorities, practices and challenges for service providers in relation to co-morbid mental health and substance misuse. Researchers carried out a series of focus groups with a cross-section of service providers from the seven research localities. The aim of this exercise was to help draw up a contextualised, summative account of the nature of current practice and service provision for co-morbid mental health and substance misuse in Scotland.

Two case vignettes associated with mental health and substance misuse issues were given to each focus group. The vignettes were used to:

• explore actions in context
• let participants define the situation in their own terms
• provide a less personal and less threatening way of exploring potentially challenging topics in a group environment.

The focus groups were organised around topics such as practice and policy, access and assessment, intervention and organisational facets. A summary of the focus groups' discussions follows each vignette.

Summary: 'Gordon'

The majority of the participants focused on the immediacy of the situation and pointed out the possibility of incorrect hospitalisation. They also discussed the need for alternative contributions, such as anger management or cognitive techniques including motivational interviewing, and the need to have a long-term perspective of the case.

All focus groups were concerned about the diagnosis and some questioned whether the psychoses were actually drug-induced. This issue was considered important because inappropriate prescriptions could have extremely bad effects especially when taken with other non-prescribed substances. It was also thought that this could partly explain the reason for Gordon's non-compliance with his medication.

Service providers were aware of many pressing accommodation issues which went some way to explain the apparent lack of focus on the needs of Gordon's family in the case study.

Many focus groups expressed concern that a difficult situation had to become a crisis before appropriate support was provided. They examined the possibility of other requirements and asked whether other services had been involved in the past.

This led to discussions regarding a more holistic approach and identifying wider psycho-social issues that might be affecting Gordon. Services that were considered important for inclusion in Gordon's care plan included occupational therapy, community psychiatric nursing, specialist psychiatrist input, voluntary day and residential services. This showed that interagency working was high on the participants' agenda, in principle, if not in practice.

The focus groups suggested that statutory substance misuse services would not engage with Gordon because cannabis use was not seen as a priority. They also agreed that service provision would depend more on Gordon's effect on others rather than on his own requirements

Many thought it was important to establish Gordon's views on his own goals and ways of reaching them. This focus on self-determination could be part of a method to engage and motivate Gordon into treatment compliance.

More specialist services concentrated on long-term goals. They emphasised the importance of ongoing consistent support and in particular the need for support that went beyond crisis management.

The creation of a support network was believed to be vital in helping Gordon to gain independence and control over his life. Striving for stability was a common theme running throughout the discussions.

Family stability in particular was considered fundamental for Gordon's successful rehabilitation. The focus groups were ambivalent regarding the long-term need for Gordon to be housed elsewhere and the overriding consensus was that this decision depended on the outcome of family meetings and negotiations. The support needs of the family were clearly recognised.

Most participants thought that a multi-agency meeting leading to inter-agency co-ordination would constitute the most obvious initial step toward better care but in reality felt that this was unlikely to happen. They all approved of taking a holistic approach to Gordon's care but were concerned that this practice was not in general use.

Stabilising Gordon, both in regard to his medication and in his cannabis consumption, was thought to be most appropriate move toward a much needed harm reduction strategy.

Other goals identified included the introduction of an advocate to help Gordon with practical issues and find accommodation. Overall, participants recognised that suggesting small bite-size goals to Gordon would be more beneficial than trying to get him to engage in longer-term commitments.

Low motivation and the failure to perceive substance misuse as a significant problem to his health might preclude Gordon from service provision. The focus groups acknowledged that while in principle the development and maintenance of a therapeutic alliance between worker and service user could strengthen a service user's motivation to change, in practice engagement would in all likelihood be halted because of apparent non-compliance and a lack of motivation. This, coupled with lengthy waiting times, was seen as compounding the problem of receiving appropriate and effective service input.

Discussions in many focus groups touched on the issue of staff attitudes and how these might affect entry to treatment. They agreed that Gordon was the type of case that could slip through the net, and few people held out much hope for change.

Throughout the discussions, participants emphasised the need for joined-up working and the identification of a key worker to reduce the number of services who may be involved with someone who already had a chaotic lifestyle.

Summary: 'Joanna'

There was general agreement that Joanna presented as a complex case with many needs. The focus groups acknowledged that dealing with her problems would not be a simple process, either for her for her or the services she was likely to engage with.

Many queried the possible reasons for Joanna's extensive alcohol use, and some suggested that she might be using alcohol as a coping mechanism for an underlying problem, such as the sexual abuse she had experienced. All agreed that it would be difficult to unravel Joanna's problems. It would be particularly hard to determine whether the depression was purely alcohol-related or a separate mental health problem.

All focus groups were concerned about Joanna's willingness but inability to change. Less specialised services tended to focus on aspects of Joanna's personality, such as low self-esteem and feelings of insecurity, as a possible explanation for her reluctance or inability to engage with services. In contrast, the more specialist services considered that limitations on Joanna's intellectual capacity to engage with services and understand the processes were the consequences of her extensive alcohol abuse. External demographic factors, such as her occupation and early life experiences, had also played a part.

A number of participants highlighted the importance of identifying the most appropriate services at each point along Joanna's care pathway. Given the complexity of her case, they felt this would be a struggle. Many commented that the timing of service involvement was more important than the actual services that were provided.

Participants focused heavily on the consequences of extensive alcohol abuse on Joanna's physical health. All agreed that the severity of her alcohol problem had a major impact on her physical well-being as well as her mental health, and that this should be a priority issue for her (and services) to address.

Similarly, all participants agreed that Joanna's 'cry for help' or attempted suicide would be another personal issue in need of attention.

Given the complexity of Joanna's case and corresponding complex needs, most participants suggested that their service would probably be involved with Joanna's treatment. They recommended joint working with other services across both statutory and voluntary sectors that would address Joanna's needs concurrently rather than consecutively. In reality, they admitted that this would be unlikely to happen

The inadequacy of service provision for cases like Joanna was highlighted along with the evident lack of available specialist knowledge. Other issues raised as sources of concern included the limited availability of ethnocentric services, lengthy waiting lists for specialist services and a general reluctance to deal with service users who continue to misuse.

Specialist statutory services discussed the importance of inter-agency involvement. The role of non-statutory services within Joanna's care plan, however, was unclear. Participants felt that the complexity of this case would require specialist input from competent, trained addictions staff, and did not think that this would be found within the non-statutory sector.

There were some doubts about multi-agency involvement. Participants thought that Joanna might not be able to cope with a possible service overload and suggested a key worker should be allocated to help her deal with her care package. This approach would help to prevent Joanna from slipping through the service gaps, assist in correctly identifying services and reduce the number of appointments to a more manageable level.

The role of a key worker would also help to encourage rapport-building and allow Joanna to engage equitably with services. As with 'Gordon', consistency and continuity of care was viewed as crucial to long-term development and positive change.

Participants agreed that a multi-agency approach for treatment would be most favourable, with the primary aim of stopping Joanna's continued misuse of alcohol. This was primarily dictated by the obvious physical complications Joanna was currently experiencing. Any mental health problems could then be investigated more specifically at a later stage.

All participants agreed that Joanna's goals should be made manageable and achievable. Her treatment plan needed to be built in steps, so that any accomplishment she made would help to boost her confidence and self-esteem.

Joanna's accommodation problems could be solved by re-housing. Engaging an 'advocate' could help her with practical issues such as identifying suitable accommodation.

Joanna's continual alcohol abuse was perceived by all as a major barrier. It was felt that services would either have no contact with her while she drank, considering her too uncooperative and non-compliant, or that they would simply grow tired of her presenting to their service.

Joanna's ethnicity also raised concerns. The focus groups considered that the lack of resources available for ethnic minorities, coupled with ethnicity per se limiting access to existing services, could prevent her from engaging with any services at all.

Conclusions

• Substance misuse services and mental health services held different philosophies. Substance misuse services would mainly treat those willing to be helped, whereas mental health services would have an obligation to try and treat everyone with a mental disorder.
• The types of problems services dealt with were limited in scope. Representatives of most services saw the need to widen their focus, but it was felt most strongly that substance misuse services needed to deal with mental health issues and mental health services needed to identify and tackle substance misuse.
• Lack of communication between services seemed to be a major perceived problem. Some focus group participants felt that meetings between different services were taking place at too low a level. Other participants believed it was more important for there to be good communication between professionals and services at grassroots level where contact with service users actually took place.
• There was a high level of consensus regarding the issue of training need. Staff training was an issue that arose repeatedly. It was viewed as imperative that mental health professionals should be skilled in dealing with substance misuse and that those working in substances services should have knowledge of mental health. Voluntary service providers and non-specialist workers were also viewed to need training in both areas.
• Mental health and substance problems could not be isolated from other disadvantages and hardships such as homelessness and unemployment. Although there was a degree of liaison, not enough communication took place between substance misuse and mental health agencies, the voluntary sector and other services such as housing, criminal justice, leisure and employment. The question of which service would take overall control remained unresolved.
• It was suggested that relevant non-statutory sector services and mental health and substance misuse community services work together. It was also recommended that workers from relevant specialist agencies be seconded to other, different specialist agencies. Training manuals would also prove extremely useful. These would let staff assess clients at any level of intervention as well as understand the effects of different substances and treatment combinations.
• The large numbers of co-morbid people who had also experienced sexual and/or physical abuse were not adequately catered for. There were not enough psychology and other specialist services and waiting times were lengthy.
• There was strong demand for more assertive outreach teams made up of people from many sectors. It was also pointed out, however, that these teams would require secure support systems when working in the community with what could be an unpredictable client group.
• While holistic care was seen as important in terms of service user treatment gains, continuity of care and access was considered to be crucial. The focus group participants observed that most services do not provide 24-hour access and many do not operate during evenings or weekends. This finding has been noted elsewhere in this report.
• It was generally recognised that only a very small proportion of people with problems with drug dependency or misuse were actually engaged in treatment or self-help groups. Given the magnitude of the untreated population, finding a way to reach these people was vital. Procedures were needed that could reach substance misusers and facilitate their induction into treatment or self-help groups. Outreach efforts might facilitate the direct engagement of a certain number of substance abusers. These would help to make users more aware of what is available and give them hope of recovery.
• Mental health services placed a strong emphasis on medical treatment whereas substance misuse services tended to favour a more psychotherapeutic approach. As entrance to treatment was often based on the level of motivation displayed by the service user, simply combining the two core treatment options might not be sufficient to address co-morbid problems. Motivation would need to be encouraged, possibly through motivational therapy or interviewing.
• Although some co-morbid people were involved with the criminal justice system, there was no link between services and services in prisons to help these people and to continue the support needed following release. Investment in this area might be on grounds of strengthening community safety.
• Wider family needs could often not be addressed, especially in rural areas where few services exist and were sometimes difficult to reach with public transport.
• Although work would not be appropriate for everybody, many people with longstanding experience of mental health problems retained an ambition to do meaningful work. Opportunities for vocational training were lacking.
• There was a wide range of specialist and mainstream services providing support for adults with mental health and substance misuse problems, but these continued to be ineffectively co-ordinated and/or were not configured around the needs of individuals.

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