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1 Available online at Drug and Alcohol Education for Consumer Workers and Caregivers: A Pilot Project Assessing Attitudes Toward Persons With Mental Illness and Problematic Substance Use Michelle Cleary, Glenn E. Hunt, Gillian Malins, Sandra Matheson, and Phil Escott With the development of peer support networks in the mental health system, formal training should be provided regarding the adverse effects of substance use. Four educational workshops were conducted with caregivers and consumer workers to increase their knowledge and confidence to support people with a dual diagnosis.workshops were evaluated through presurvey and postsurvey. The workshops were well received, and postworkshop, participants reported fewer negative attitudes toward people with a dual diagnosis and increased understanding and knowledge regarding substance misuse. This study highlights the effectiveness of targeted workshops for caregivers and consumer workers and advocates that nurses take a more active role in educational projects involving stakeholders. D 2009 Elsevier Inc. All rights reserved. OVER THE PAST two decades, there has been a growing awareness of the problem of cooccurring substance use in persons with a serious mental illness (Drake, McLaughlin, Pepper, & From the Faculty of Nursing and Midwifery, University of Sydney, New South Wales, Australia; Discipline of Psychological Medicine, University of Sydney, New South Wales, Australia; Research Unit, Sydney South West Area Mental Health Service, Rozelle, New South Wales, Australia; NSW Consumer Advisory Group - Mental Health Inc. Corresponding Author: Michelle Cleary, RN, PhD, Clinical Nurse Consultant, Research Unit, Sydney South West Area Mental Health Service, and Clinical Associate Professor Mental Health, Faculty of Nursing and Midwifery, University of Sydney. Level 1 Executive Unit and Administration Support, Concord Centre for Mental Health, Concord Hospital, Hospital Road, Concord, New South Wales, 2139, Australia. address: michelle.cleary@ .cs.nsw.gov.au n 2009 Elsevier Inc. All rights reserved / $34.00/0 doi: /j.apnu Minkoff, 1991; Mueser, Drake, Sigmon, & Brunette, 2005). Higher rates of substance use disorder are found in people with a mental illness compared with the general population (Kessler et al., 1997; Regier et al., 1990), and while prevalence rates vary, about half of all people with a serious mental illness misuse substances (Drake et al., 1990; Fowler, Carr, Carter, & Lewin, 1998; Gregg, Barrowclough, & Haddock, 2007). People with a diagnosed serious (and persistent) mental illness such as schizophrenia, psychotic illness, bipolar disorder, and major depression may not fulfill the diagnosis criteria for substance abuse or dependence, but the use of alcohol and other drugs may worsen their symptoms and/or interact dangerously with their medication (s). Mild use of alcohol or illicit drugs may be problematic for people with a serious mental illness, resulting in higher rates of adverse outcomes (Dixon, 1999; Green, Drake, Brunette, & Noordsy, 2007; Jane-Llopis & Matytsina, 2006). Thus, the 104 Archives of Psychiatric Nursing, Vol. 23, No. 2 (April), 2009: pp

2 DRUG AND ALCOHOL EDUCATION FOR CAREGIVERS 105 terms problematic substance use and substance misuse are used interchangeably in this article to refer to risky or harmful use of substances. Clients with mental illness who misuse substances are more difficult to engage in treatment (Carey, Purnine, Maisto, Carey, & Simons, 2000; Gafoor & Rassool, 1998) and are often poorly managed, with staff experiencing frustration and resentment as they endeavor to provide mental health care while the client continues to use substances (Deans & Soar, 2005; Todd, Sellman, & Robertson, 2002). Treatment programs that focus on strengthening the client's immediate environment (Drake, Essock, et al., 2001) and reinforce meaningful alternatives to substance misuse (Green et al., 2007) are important to foster healthy social and peer support networks. Peer support networks include consumer workers and informal caregivers. The former, consumer workers, are people with previous or existing mental health problems who are employed by mental health services to provide current clients with education, support, and advocacy (Cleary, Walter, & Escott, 2006; McAllister & Walsh, 2004; Middleton, Stanton, & Renouf, 2004). The latter, caregiver, refers to parents, siblings, partners, children, friends, or people significant to the client, essentially anyone who provides support or cares for the patient but is not a paid employee. The provisions of information and support to both consumer workers and caregivers is an essential aspect of any modern mental health service (Cleary, Freeman, & Walter, 2006; Noble & Douglas, 2004) so that symptoms and behaviors associated with substance misuse are not misinterpreted (Clark, 2001; Drake, Essock, et al., 2001; Drake, O'Neal, & Wallach, 2008; Mueser et al., 2005). Recent studies have highlighted the benefits of involving caregivers in treatment programs (Clark, 2001), particularly those providing up-to-date information regarding the adverse effects of substance use (Moore, 2005) to prevent the loss of support, which is relatively common for those who have an untreated co-occurring disorder. Clinical staff receive education and training about current treatment approaches, relapse prevention, and a range of other issues, which are rarely available to consumer workers and caregivers (Cleary, Freeman, Hunt, & Walter, 2005; Drake, Essock, et al., 2001; Middleton et al., 2004). Arguably, their training needs are similar, so that they can communicate timely and accurate information to their peers and the people they are caring for to facilitate service provision and improved client outcomes. Despite efforts to promote consumer worker participation in mental health settings, there are very few studies evaluating training and educational needs, even though the benefits of consumer workers are well documented (McCann, Baird, Clark, & Lu, 2006; Meehan, Bergen, Coveney, & Thornton, 2002). In view of the growing concern about the use of substances in people with a serious mental illness, it appeared timely to develop an educational program to support and educate consumer workers and caregivers about the adverse effects of drug use. The program included the provision of contemporary information about the impact of drug use and what a peer supporter's role would constitute. We also sought to ascertain their attitudes and beliefs toward people who use drugs and judgements about their deservingness for care before and after the session. METHOD Sample and Setting The target group was a convenience sample of consumer workers and informal caregivers (e.g., parent, partner, relative, or friend of consumers) in New South Wales, Australia. Expressions of interest were circulated through consumer and caregiver organizations, inviting people to register to attend a 5-hour workshop. Four workshops were held free of charge, with three staff facilitating proceedings. Workshops were carefully planned with structured presentations and activities to engage participants in interesting and educationally useful workshops (Horsfall & Cleary, in press). This approach, combined with a variety of presentation modes, provided opportunities for the participants to learn interactively and to connect general ideas to specific practical aspects of their workplace and/or circumstances (Horsfall & Cleary, in press). The workshop framework was adapted from a previous study assessing knowledge and attitudes of staff regarding psychosis and substance misuse (Siegfried, Ferguson, Cleary, Walter, & Rey, 1999; Siegfried & Sainsbury, 2001). At the commencement of each workshop, participants were asked to complete a survey and group rules were set down, including confidentiality of the

3 106 CLEARY ET AL Box 1 Group exercises Scenario 1. X is a friend or family member who has been hospitalized in the past for drug-induced psychosis. You have noticed lately that he/she has changed his/her behavior being more withdrawn than usual, alternating between being highly excitable and tired and rundown. You suspect he/ she may be taking amphetamine (speed or ice) again. What do you do? Confront him/her and tell him/her to stop using? Get angry and threaten to call the police? Tell him/her not to see his/her drug-using friends? Encourage him/her to see his/her case manager or doctor? Give him/her information regarding the adverse effects of using psychostimulants? Discussion points What obstacles can you foresee? Will your friend or relative be receptive to your advice? What is the best approach? How would your approach differ, depending on the person's relationship to you, his/her age, type of illness he/she has, whether he/she lives with you? What do you think are some of the reasons he/ she uses illicit substances? Scenario 2. A group of middle-aged, professional people are out for dinner to celebrate a workrelated success. Everyone is drinking. One man has a history of depression and knows that alcohol can contribute to a relapse but wants to let loose with his workmates. Is the advised drinking level of four drinks a day (two for women) applicable to him, or should he consume less or abstain completely? Is it OK for him to go more than four drinks on occasions such as this? Does it change if he has a history of alcohol misuse? Scenario 3. An 18-year-old girl is attending a party with her school friends to celebrate finishing her examinations. A friend passes her a joint, and having a family history of schizophrenia, she knows she should say no to cannabis. But how? No one knows of her family history and would not understand anyway. Are a couple of puffs OK? Will that lead to more regular use? Should she just say no and explain her family history (she feels embarrassed about it)? What reasons can she use to turn down the offer? Does the scenario change if she is offered Ecstasy or methamphetamine (ice)? content. Facilitators also asked some brief questions to assess participants' preworkshop knowledge for the proceeding course content, which included the effects of various substances on physical and mental health, guidelines for safe alcohol use, and others. Questions used were from the General Quiz on Alcohol HTML Version (Australian Government, Department of Health and Ageing, 2007) and the staff knowledge survey of Siegfried et al. (1999). Presenter topics included prevalence of substance misuse, reasons for substance misuse, symptoms that suggest a client may be misusing substances, major current therapeutic treatment approaches, referral services, and management strategies. Each workshop comprised a range of group exercises to facilitate in-depth discussion (see Box 1 for examples). At the end of the workshop, all participants were asked to complete a postworkshop survey and received an information package and certificate to acknowledge attendance. Instruments The Attitude Measurement: Brief Scales (National Centre for Education and Training on Addiction, 2006) was used preworkshop and postworkshop. This eight-item scale was developed to assess attitudes and beliefs toward people who use substances and the level of health care they are entitled to receive (see Table 1 for survey questions). This scale can be adapted for different training groups. In this study, four items were slightly modified for clarification. Items 3 and 4 were reworded to ask separate questions about how angry or disappointed participants felt toward people using alcohol or drugs, and health care was substituted for the term medical care (Items 7 and 8). These changes were unlikely to influence the reliability or validity of the survey. The postworkshop survey also included questions that covered demographics (consumer/caregiver gender, age, previous training), usefulness of the information provided, whether workshops increased knowledge and understanding, and their satisfaction rating of the workshop presentation (e.g., whether it was

4 DRUG AND ALCOHOL EDUCATION FOR CAREGIVERS 107 interesting, well organized, and would be recommended to others). Data Analysis Data were analyzed using the Statistical Package for Social Sciences, Version 13. Descriptive data are presented as response rates, percentages, and means (SD). Cronbach's α was used to test for reliability (internal consistency) of related survey items preworkshop and postworkshop. Paired t tests were used to determine if there were any differences between participants' attitudes preworkshop and postworkshop. A probability level of.05 was used to determine statistically significant differences. RESULTS A total of 32 participants attended the workshops. There were 12 (37%) consumer workers, 15 (47%) caregivers, and 5 (16%) who were both consumer workers and caregivers. There were 21 (66%) women and 11 men, and mean age was 43 years (SD =10.7 years). Thirteen (41%) had participated in drug and alcohol training of some kind in the past. Preworkshop Knowledge Regarding Substance Use The quick quiz questions pertaining to alcohol asked at the commencement of the workshops revealed that 29 (91%) participants recognized that drinking at risky levels in the long-term can cause liver disease; 28 (88%) identified that alcohol can have a negative effect on stress levels, sleep patterns, and sexual function; 27 (84%) said that you should count your drinks to help avoid short- and long-term health problems; and 25 (78%) correctly noted that women should not drink at the same rate as men do. However, only 9 (28%) participants correctly noted that all clients with alcohol dependence should take thiamine to protect against memory deficits, and only 4 (13%) participants correctly nominated the recommended two alcohol-free days a week (according to Australian National Health guidelines). Questions regarding cigarette smoking revealed that 22 (69%) participants knew that arsenic and carbon monoxide are products of tobacco smoke, and 17 (53%) identified that nicotine increases blood pressure. Twenty-two (69%) participants correctly identified that 3 out of every 10 individuals who are methamphetamine dependent will experience psychotic symptoms during a given year. Differences in Attitudes The internal consistency for the eight-item scale was.63 preworkshop and.57 postworkshop, which is an acceptable level of reliability (Nunnally, 1978). Participant attitudes changed for three questions postworkshop (Table 1), including that the extent of a person's adverse life circumstances was more responsible for that person's drug use (Q1: t = 2.53, df = 31, p =.017). Workshop participants also reported that they were more sympathetic to drug users (Q5: t = 2.27, df = 31, p =.030) and thought that drug users were entitled to higher levels of health care than were those who do not use drugs (Q8: t = 2.18, df = 31, p =.037). Feedback and Usefulness of the Program Thirty-one (97%) participants reported the program as interesting or very interesting, and 30 (94%) said that the program was useful or very useful to Table 1. Preworkshop and Postworkshop Attitudes Items Preworkshop, Mean (SD) Postworkshop, Mean (SD) p Value To what extent do you think that adverse life circumstances 3.34 (1.07) 3.81 (1.03).017 are likely to be responsible for a person's problematic drug use? To what extent is an individual personally responsible for their problematic drug use? 3.87 (0.94) 3.87 (0.97) To what extent do you feel angry/disappointed toward people using alcohol? 2.22 (1.07) 2.28 (0.99).488 To what extent do you feel angry/disappointed toward people using illegal drugs? 2.75 (1.16) 2.59 (1.13).231 To what extent do you feel sympathetic toward people using drugs? 3.34 (1.06) 3.59 (1.01).030 To what extent do you feel concern toward people using drugs? 4.12 (0.91) 4.00 (1.05).514 To what extent do people who use drugs deserve the same level of 4.59 (0.66) 4.47 (0.72).161 health care as people who do not use drugs? To what extent are people who use drugs entitled to a higher level of 3.12 (1.36) 3.41 (1.39).037 health care as people who do not use drugs? NOTE. Adapted from the Attitude Measurement: Brief Scales (National Centre for Education and Training on Addiction, 2006) based on a 5-point Likert scale, where 1 = not at all, 3=moderately, 5=very or definitely. Paired t tests, df = 31.

5 108 CLEARY ET AL them. Twenty-two (69%) participants reported that the program increased their knowledge and understanding of the subject matter. Eighteen (56%) participants noted that the program influenced the way they thought about people using substances. All of the participants said that the workshop was well organized, 28 (88%) said that they were satisfied or very satisfied with the program, and 31 (97%) said they would recommend the program to others and would attend future workshops on various topics. General comments made about the program included the following: case studies were very stimulating, useful, interesting and informative, facilitators did a great job, more information on motivational techniques, very practical session, great handout, referral information and like presenters style, and maybe include some pictures on the slide show of types of drugs eg tablets, leaves. DISCUSSION This drug and alcohol education workshop was well received by consumer workers and caregivers based on their positive feedback. Participants found the content interesting, useful, and well organized. There was strong interest in the program, with registrations outstripping available places, suggesting a continuing need for education on this topic. Participants were also interested in attending future workshops on a range of other topics. Participants reported fewer negative attitudes on three items postworkshop. They felt more sympathetic toward this client group, that adverse life circumstances were responsible for substance misuse, and that those who misuse drugs are entitled to a higher level of health care than are those who do not. Attitude changes may be related to an increased understanding of the difficulties that people experience when attempting to reduce or abstain from substance use. No changes in attitude were evident for five items on the attitude measurement scale that assessed an individual's responsibility for substance misuse, anger/disappointment and concern toward people misusing substances, and whether people misusing substances deserve the same level of health care as those who do not use drugs. The reason that these attitudes did not change over the session may be attributed, in part, to ceiling effects. Some had participated in previous education forums on this subject and demonstrated reasonable knowledge levels preworkshop. Even so, the majority indicated that the workshop increased their understanding and knowledge on this topic. This study provides some support for local education programs that are based on sound scientific and clinical evidence and that convey up-to-date information that is clinically useful and easily understood. As there were varying perspectives expressed, and at times personal information was shared, facilitators need to maintain a high degree of self-awareness and skilled facilitation when presenting the workshop material. For example, mixed perspectives were apparent on topics such as abstinence versus harm reduction, consistent with the diverse views expressed by expert clinicians (Carey et al., 2000). Workshop participants expressed the belief that people with a mental illness use substances for the same reasons as those without a mental illness (e.g., to escape, relax, and help alleviate social pressures, symptom management). Consistent with Barrowclough, Haddock, Fitzsimmons, and Johnson (2006), it was generally felt that people with a serious mental illness may find it difficult to develop and maintain the motivation to change their substance use. This lack of motivation and concern about the adverse effects of substances may contribute to clinical inattention (Barrowclough et al., 2006; Drake, Essock, et al., 2001; Gregg et al., 2007), and consumer workers identified themselves as a potential resource for assisting clients to find meaningful social networks and programs. They did raise, however, the concern that clients may prefer to view themselves as a drug user than a mentally ill client, although both stereotypes are negatively stigmatized in the community (Gafoor & Rassool, 1998). Peer education initiatives are important, and this approach has been adopted as a model for promoting health for those considered hard to reach, such as young people and the homeless (Hunter & Power, 2002). As consumer workers continue to develop their roles within the mental health service, it is important that they receive training in dual diagnosis treatments, and local educational programs should aim to meet this need to promote informed choices and ensure effective service provision (Drake, Goldman, et al., 2001). It is hoped that the information provided in the workshop will contribute to a more comprehensive and optimistic view regarding treatment options and resources. Education programs not only foster shared perspectives and supplement experiential backgrounds but also

6 DRUG AND ALCOHOL EDUCATION FOR CAREGIVERS 109 can encourage broader stakeholder involvement (Burnam & Watkins, 2006; Flynn & Brown, 2008). The involvement of a range of service providers in this peer-support project ensured that the project was inclusive and therefore representative of as many interested parties as possible. Other strengths of this pilot program were that it targeted consumer workers and caregivers, whose support needs are often overlooked. Interest was high from consumer workers, and given that they have regular clinical contact with clients, these pilot workshops achieved their aim of increasing their understanding and knowledge about substance misuse when working with consumers with a dual diagnosis. There is a further need for such programs, as evidenced by the overwhelming level of interest, especially from the nongovernment sector, with some organizations requesting places for up to 100 places for their staff. This study is not without limitations. The lack of generalizability imposed by the small convenience sample must be considered. Participants were motivated enough to want to increase their knowledge about the effect of substance misuse on mental health and general well-being and may or may not reflect most consumer workers and caregivers. The responses may contain some bias, and a control group was not used. The implications for nursing practice involve a need for the provision of continuing education on this important topic, especially with other stakeholders, given the demand for available places. The information packages provided at the conclusion of each workshop can be shared with others to more easily find services within their local area and help identify early symptoms of relapse and receive assistance with minimum delay. CONCLUSION These workshops were well received and showed that there is a clear-cut need to offer similar programs to consumer workers and caregivers to increase their education and knowledge regarding the effects of substance use by people with mental health problems. Furthermore, the results demonstrate that some negative attitudes toward this client population can be shifted. Future workshops targeting a wider audience, including individuals within nongovernment organizations, should also be considered to facilitate and strengthen collaborative links with consumer workers and caregivers. Responding to this need has the potential to reduce stigma and lead to better outcomes for clients with a dual diagnosis. Finally, this program contributes to a range of peer-support activities and provides a basis to develop further strategies to treat people with problematic substance use more effectively. ACKNOWLEDGMENT This study was funded by a Nursing and Midwifery innovation scholarship from NSW Health. We thank Dr Nandi Siegfried for permission to adapt parts of her drug and alcohol education package and Ms Rebecca Doyle for her assistance in facilitating the final workshop. REFERENCES Australian Government, Department of Health and Ageing. General Quiz on Alcohol. Retrieved June 4, 2007, from: publishing.nsf/content/quiz2-text. Barrowclough, C., Haddock, G., Fitzsimmons, M., & Johnson, R. (2006). Treatment development for psychosis and cooccurring substance misuse: A descriptive review. Journal of Mental Health, 15, Burnam, M. A., & Watkins, K. E. (2006). Substance abuse with mental disorders: Specialized public systems and integrated care. Health Affairs, 25, Carey, K. B., Purnine, D. M., Maisto, S. A., Carey, M. P., & Simons, J. S. (2000). Treating substance abuse in the context of severe and persistent mental illness Clinicians' perspectives. Journal of Substance Abuse and Treatment, 19, Clark, R. E. (2001). Family support and substance use outcomes for persons with mental illness and substance use disorders. Schizophrenia Bulletin, 27, Cleary, M., Freeman, A., Hunt, G. E., & Walter, G. (2005). What patients and carers want to know: An exploration of information and resource needs in adult mental health services. Australian and New Zealand Journal of Psychiatry, 39, Cleary, M., Freeman, A., & Walter, G. (2006). Carer participation in mental health service delivery. International Journal of Mental Health Nursing, 15, Cleary, M., Walter, G., & Escott, P. (2006). Consumer consultant : Expanding the role of consumers in modern mental health services. International Journal of Mental Health Nursing, 15, Deans, C., & Soar, R. (2005). Caring for clients with dual diagnosis in rural communities in Australia: The experience of mental health professionals. Journal of Psychiatric & Mental Health Nursing, 12, Dixon, L. (1999). Dual diagnosis of substance abuse in schizophrenia: Prevalence and impact on outcomes. Schizophrenia Research, 35, S93 S100. Drake, R. E., Essock, S. M., Shaner, A., Carey, R. B., Minkoff, K, Kola, L., et al. (2001). Implementing dual diagnosis

7 110 CLEARY ET AL services for clients with severe mental illness. Psychiatric Services, 52, Drake, R. E., Goldman, H. H., Leff, H. S., Lehman, A. F., Dixon, L, Mueser, K. T., et al. (2001). Implementing evidencebased practices in routine mental health service settings. Psychiatric Services, 52, Drake, R. E., McLaughlin, P., Pepper, P., & Minkoff, K. (1991). Dual diagnosis of major mental illness and substance disorder: An overview. New Directions for Mental Health Services, 50, Drake, R. E., O'Neal, E. L., & Wallach, M. A. (2008). A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse and Treatment, 34, Drake, R. E., Osher, F. C., Noordsy, D. L., Hurlbut, S. C., Teague, G., & Beaudett, M. S. (1990). Diagnosis of alcohol use disorders in schizophrenia. Schizophrenia Bulletin, 16, Flynn, P. M., & Brown, B. S. (2008). Co-occurring disorders in substance abuse treatment: Issues and prospects. Journal of Substance Abuse and Treatment, 34, Fowler, I. L., Carr, V. J., Carter, N. T., & Lewin, T. J. (1998). Patterns of current and lifetime substance use in schizophrenia. Schizophrenia Bulletin, 24, Gafoor, M., & Rassool, G. H. (1998). The co-existence of psychiatric disorders and substance misuse: Working with dual diagnosis patients. Journal of Advanced Nursing, 27, Green, A. I., Drake, R. E., Brunette, M. F., & Noordsy, D. L. (2007). Schizophrenia and co-occurring substance use disorder. American Journal of Psychiatry, 164, Gregg, L., Barrowclough, C., & Haddock, G. (2007). Reasons for increased substance use in psychosis. Clinical Psychology Review, 27, Horsfall, J. & Cleary, M. (in press). Planning and facilitating workshops. The Journal of Continuing Education in Nursing. Hunter, G., & Power, R. (2002). Involving Big Issue vendors in a peer education initiative to reduce drug-related harm: A feasibility study. Drugs: education, prevention and policy, 9, Jane-Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: A review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug & Alcohol Review, 25, Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B., Schulenberg, J., & Anthony, J. C. (1997). Lifetime cooccurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of General Psychiatry, 54, McAllister, M., & Walsh, K. (2004). Different voices: Reviewing and revising the politics of working with consumers in mental health. International Journal of Mental Health Nursing, 13, McCann, T. V., Baird, J., Clark, E., & Lu, S. (2006). Beliefs about using consumer consultants in inpatient psychiatric units. International Journal of Mental Health Nursing, 15, Meehan, T., Bergen, H., Coveney, C., & Thornton, R. (2002). Development and evaluation of a training program in peer support for former consumers. International Journal of Mental Health Nursing, 11, Middleton, P., Stanton, P., & Renouf, N. (2004). Consumer consultants in mental health services: Addressing the challenges. Journal of Mental Health, 13, Moore, B. C. (2005). Empirically supported family and peer interventions for dual disorders. Research on Social Work Practice, 15, Mueser, K., Drake, R., Sigmon, S., & Brunette, M. F. (2005). Psychosocial interventions for adults with severe mental illnesses and co-occurring substance use disorders: A review of specific interventions. Journal of Dual Diagnosis, 1, National Centre for Education and Training on Addiction. (2006). Health professionals' attitude towards licit and illicit drug users: A training resource. Adelaide, South Australia: National Centre for Education and Training on Addiction, Flinders University. Retrieved October 23, 2007, from attitudes_booklet_06.pdf. Noble, L. M., & Douglas, B. C. (2004). What users and relatives want from mental health services. Current Opinion in Psychiatry, 17, Nunnally, J. C. (1978). Psychometric theory. McGraw-Hill: New York. Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S., Judd, L. L., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiological Catchment Area (ECA) study. Journal of the American Medical Association, 264, Siegfried, N., Ferguson, J., Cleary, M., Walter, G., & Rey, J. M. (1999). Experience, knowledge and attitudes of mental health staff regarding patients' problematic drug and alcohol use. Australian and New Zealand Journal of Psychiatry, 33, Siegfried, N., & Sainsbury, P. (2001). Improving services for people with a psychotic disorder and problematic substance use: A multifaceted approach to project evaluation. Australian and New Zealand Journal of Psychiatry, 35, Todd, F. C., Sellman, J. D., & Robertson, P. J. (2002). Barriers to optimal care for patients with coexisting substance use and mental health disorders. Australian and New Zealand Journal of Psychiatry, 36,