DUAL DIAGNOSIS POLICY

DUAL DIAGNOSIS POLICY 1. POLICY PURPOSE AND RATIONALE Anglicare Victoria provides services to individuals, young people and families in crisis, including individuals experiencing mental health and alcohol and other drug issues. Individuals experiencing co-occurring mental health (MH) and alcohol and other drug (AOD) issues, also known as dual diagnosis, and their families have multiple and complex needs that require a high level of responsiveness across all Anglicare Victoria services. Mental health and alcohol and other drug services delivered by Anglicare Victoria are, in particular, expected to work closely with people with dual diagnosis as a matter of core business. However, working effectively with people with co-occurring conditions is important, irrespective of service type. This policy document outlines contemporary policy and practice principles that must inform all Anglicare Victoria service provision. 2. DEFINITIONS Dual diagnosis or co-occurring conditions are defined as the co-occurrence of two or more disorders or issues, at least one of which is a mental health issue and at least one of which relates to the use of alcohol and other drugs. The severity and complexity of MH and AOD issues is determined by the range and impact of a client s presenting symptoms on their level of functioning, rather than diagnosis alone. Screening is the initial step in the process of identifying possible cases of co-occurring mental health conditions. This process is not diagnostic (i.e. it cannot establish whether a disorder actually exists); rather, it identifies the presence of symptoms which may indicate the presence of a disorder. Integration is defined as the coordination of interactions and relationships within and across MH and AOD services in order to secure the best possible service system response for an individual with dual diagnosis. Integrated care, at a service level, refers to the provision of treatment for both MH and AOD issues by a single clinician or treatment team and, where this is not possible, the provision of treatment by two or more clinicians working within a network of linked services. At the systems level, integrated care means developing clinical pathways between and across a range of agencies and building capacity to provide holistic and coordinated responses to consumers of services. Ultimately, the required outcome is that integrated services appear seamless to the person accessing them. 3. PRINCIPLES The twelve principles of good practice outlined below are based on evidence- and consensus-based research and clinical practice with people with dual diagnosis. These Page 1 of 6 Supporting families, building

principles have been articulated and validated across both the mental health and alcohol and other drug treatment fields (COCE, 2006 1 ; Minkoff, 2001 2 ). 1. To enable an adequate response to individuals with co-occurring mental health and alcohol and other drug issues, the National Drug Strategy 2004 2009 identifies the need to build strong partnerships between MH and AOD services which can enhance responses for people with co-occurring conditions. Partnerships between MH and AOD services should be supplemented by strong collaboration, cooperation and effective working relationships between the MH and AOD service sectors and the broader network of social welfare services, including professionals in primary care, social services, housing, criminal justice, education and related fields. Partnerships are required among service providers across the government, nongovernment and private sectors. Note that coordinating interactions and relationships within and across agencies does not imply the structural realignment of service systems. 2. Individuals with dual diagnosis are the expectation not the exception. Planning, management and the delivery of treatment and care must address the need to provide services for people with co-occurring mental health and alcohol and other drug issues. 3. An integrated care approach that ensures continuity and quality between mental health and alcohol and other drug services, and across other service sectors, must be used in the provision of treatment for individuals with a dual diagnosis. High levels of care must be provided throughout all phases of recovery including engagement, screening, assessment, treatment, rehabilitation, discharge planning and aftercare. Services must facilitate the seamless delivery of comprehensive mental health and substance use treatment services through a variety of agencies across all health and welfare settings. 4. A no wrong door approach provides people with, or links them to, appropriate services regardless of where they enter the system of care. Services must be accessible from multiple points of entry and be perceived as caring and accepting by the consumer. 5. Effective services rely on the provision of holistic, person-centred interventions and care. The development and maintenance of a therapeutic alliance, or quality treatment relationship based on mutual respect, is an essential component of effective treatment for individuals with a dual diagnosis. Empathy, respect and belief in the individual s capacity for recovery are fundamental service provider attitudes and values. 6. Integrated service provision involves a bio-psycho-social approach comprising an array of physical, psychological and social service interventions in the provision of engagement, assessment, treatment and care. These interventions must be outlined in an integrated and comprehensive treatment plan based on an assessment of individual needs and preferences, matched to appropriate levels of care, and coordinated within a broad range of provider networks and social services. 1 COCE (2006). Overarching principles to address the needs of persons with co-occurring disorders, Overview Paper 3, Co-occurring Centre for Excellence, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services. www.coce.samhsa.gov 2 Minkoff, K. (2001) Behavioural health recovery management service planning guidelines co-occurring psychiatric and substance use disorders. Illinois Department of Human Services Office of Alcoholism and Substance Abuse. Page 2 of 6

7. A commitment to harm minimisation must inform the treatment of people with dual diagnosis. This approach recognises that people with substance use issues have a wide range of treatment goals that range from the reduction of harms related to use through to abstinence, and that interventions need to be realistic and achievable. 8. A holistic, recovery-based approach must be used in the provision of assessment, treatment and care, involving direct service provision for mental health and alcohol and other drug issues and effective linkages with the broader social service network. 9. Within the treatment context, both mental health and alcohol and other drug issues are simultaneously considered of primary importance to the clinical presentation. As mental health symptoms and alcohol and other drug use can vary over time and interact in dynamic ways, both mental health symptoms and alcohol and other drug use must be given equal priority in treatment. Both issues must be continually assessed and treatment plans adjusted accordingly. The complexity of the interdependence of mental health and alcohol and other drug issues must be reflected in the treatment plan. 10. The needs of special populations must be acknowledged in the provision of integrated care. Special populations include young people, Aboriginal and Torres Strait Islanders, culturally and linguistically diverse populations, and older people. 11. The active participation of the person, primary carers, family or significant others in the treatment and care of people with dual diagnosis must be prioritised wherever possible. 12. The contribution of the community to the course of recovery for people with dual diagnosis and the contribution of people with dual diagnosis to the community must be explicitly recognised and supported in treatment planning and consumer advocacy. 4. PROCEDURES Anglicare Victoria staff are responsible for putting into practice the principles outlined in this document. This means implementing evidence- and consensus-based practice when working with people with dual diagnosis, as follows: Screening 1. Anglicare Victoria AOD services will screen all people on their initial presentation for AOD and MH issues respectively, and the detection of AOD and MH issues will be recorded and addressed in the person s treatment plan and other relevant information systems. Screening and assessment of dual diagnosis will involve examination of symptom multiplicity and severity using a bio-psycho-social approach, and will focus on the impact of symptoms on level of functioning, rather than on specific diagnoses. Screening will include the identification of risks for cooccurring problems as well as opportunities to interrupt the potential development of an entrenched diagnosis. Engagement and Assessment 2. Anglicare Victoria AOD services will ensure that all people who present with cooccurring MH and AOD conditions are eligible to receive ongoing dual diagnosis screening, assessment, and care coordination services. The presence of a co-existing MH or AOD condition does not constitute criteria for service exclusion or denial. Page 3 of 6

3. Anglicare Victoria AOD services will treat people with a dual diagnosis with a welcoming attitude and professional, non-judgemental approach. Staff will be proactive in engaging and retaining people in treatment and work towards the development and maintenance of a therapeutic alliance based on dignity and mutual respect. 4. Where MH or AOD issues or disorders of mild-moderate severity are detected, Anglicare Victoria AOD services will provide AOD and MH brief interventions, respectively. Reassessment of MH and AOD issues and disorders will occur on an ongoing basis. 5. Where either the MH or AOD issue or disorder is of moderate-high level severity or complexity, and the other (MH or AOD) issue or disorder is of mild-moderate severity or complexity, it is expected that both a comprehensive assessment and specialised dual diagnosis intervention will be provided by the Anglicare Victoria AOD service where the person first presented. If this is not possible due to the requirement for a more specialised expertise (e.g. eating disorders, prodromal psychotic symptoms, chroming, psychedelics), then linkage with MH services or other health services (eg. general practitioners, psychologists, psychiatrists) via agreed clinical pathways will be coordinated by the Anglicare Victoria service. The coordinating service will remain involved until the new service provider and consumer (and primary carers if appropriate) agree that the new service will provide more specialised MH or AOD interventions and coordinate care according to need. 6. Where MH and AOD disorders are both of moderate-high level severity or complexity, it is expected that comprehensive assessments, specialised AOD interventions and ongoing reviews will be coordinated by Anglicare Victoria AOD services. Linkage with MH services will occur via agreed clinical pathways. Co-case management or shared care with linked service providers must be provided via regular communication and clinical review meetings in order to ensure consistent and integrated treatment. Treatment The MH service will continue to hold primary clinical responsibility for the ongoing management and review of such individuals. However, the participation of providers of other health and social services, including Anglicare Victoria AOD services involved in the person s care will be actively encouraged. 7. Anglicare Victoria AOD services will provide interventions that are matched to a client s presenting needs including consideration of acuity and severity of each condition, phase of recovery, stage of treatment and stage of change. This involves the delivery of treatment using a an outline of the stepped care approach (eg. engagement, persuasion, active treatment, relapse prevention), stage-specific treatment within the context of a client s stage of change and phase of recovery (acute stabilisation, motivational enhancement, prolonged stabilisation, rehabilitation and recovery). 8. Treatment plans and service delivery arrangements will also take into account a client s general health and social welfare needs. This means giving appropriate attention to family, relationships, accommodation, employment, financial, and legal needs along with the presenting AOD and MH needs. Plans to address identified needs will be incorporated into a comprehensive treatment plan, including regular review of the treatment plan and will involve the client s active participation whenever possible. Where consent is provided, primary carers, family or significant others involved in a client s care will be actively involved in decisions about treatment and care. Page 4 of 6

Collaborative Work 9. Where a client is linked with a more specialised service for treatment of MH or AOD use issues, co-case management or shared care arrangements will be provided. The initial service provider will retain active involvement in treatment and care coordination to ensure the person s needs are met and to facilitate a positive outcome. 10. Linking individuals with severe and complex needs to other health and welfare services involves an assertive case management approach whereby staff proactively coordinate and negotiate services on behalf of a client to ensure service continuity across service sectors and to ensure that people do not fall between service systems. Professional Development 11. Anglicare Victoria staff will be afforded appropriate professional development opportunities. It is a priority to ensure that all relevant staff are provided with education and skills in AOD and MH screening and brief interventions, treatment plan development and care coordination services to enable the delivery of fundamental services for people with dual diagnosis in all phases of their recovery. Special Need Groups 12. AOD staff will provide integrated care in accordance with the unique needs of special populations such as young people, Aboriginal and Torres Strait islanders, culturally and linguistically diverse populations and older people. 13. AOD staff will provide screening, assessment and treatment planning to those adult clients who are parents and facilitate a discussion of the relationship between their health issues and capacity to provide care and protection for their child/ren. If required, referral to child-centred services will be considered in the interests of enhancing the well-being of children in the care of adult clients. 5. OTHER RELATED DOCUMENTS A New Blueprint for Alcohol and Other Drug Treatment Services 2009-2013, Victoria State Government 2009. Because Mental Health Matters: Victorian Mental Health Reform Strategy 2009-2013. Victoria State Government 2009. Ministerial Council on Drug Strategy (2004) The National Drug Strategy. Australia s integrated framework 2004-2009, Commonwealth of Australia. Canberra. NSW Health Drug and Alcohol Psychosocial Interventions Professional Practice Guidelines. National Drug and Alcohol Research Centre and University of New South Wales Sydney, Australia, 2009. Queensland Health Policy: Service Delivery for people with dual diagnosis (co-occurring mental health and alcohol and other drug issues), September 2008. The PsyCheck Screening Tool, PsyCheck is funded by the Australian Government Department of Health and Ageing under the National Comorbidity Initiative. Victoria s Alcohol Action Plan 2008-2013,Victoria State Government 2008. Page 5 of 6

This policy becomes effective as at: January 2010 This policy was last amended: February 2010 This policy is due to be reviewed: July 2011 Queries about this policy should be directed to: Peter Thompson, General Manager Community and Regional Programs Page 6 of 6