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The University of Dublin
Trinity College Dublin
School of Social Work and Social Policy
Major Project
“The Management of Dual Diagnosis in Ireland, Perceptions and
Views of the Professionals”
Claire Marie Forrest
Submitted as partial fulfilment of the
Requirements for the
Diploma in Addiction Studies
May 2008
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The University of Dublin
Trinity College Dublin
School of Social Work and Social Policy
“The Management of Dual Diagnosis in Ireland, Perceptions and
Views of the Professionals”
Claire Marie Forrest
I declare that the content of this assignment is all my own work.
Where the work of others has been used to augment my assignment it
has been referenced accordingly.
Signed_______________________________
Date_____________
Word count:_________________
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Acknowledgements
I would like to take this opportunity to acknowledge the following people for their support throughout
this study.
Firstly I would like to thank the participants for sharing their experiences with me.
My tutor Vivienne O’Brien for providing support, patience and guidance throughout the course of this
research.
The Director and Assistant Directors of Nursing for allowing me to conduct the research and for the
opportunity of undertaking the course.
The course co-ordinator Marguerite Woods for her support and assistance.
My family and friends for their encouragement and patience throughout the course of my studies.
My parents for their ongoing loyalty and support throughout my life.
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Abstract
The increasingly high rates of dual diagnosis in Ireland reflect the high level of
substance misuse and mental health co-morbidity in the population. Although studies
have explored the management of dual diagnosis at an international level there is a
dearth of research which has explored the experiences in the Irish context.
The study aimed to gain an understanding of the perceptions and views of
professionals from both the addiction and mental health services.
A qualitative
approach was undertaken. The sample consisted of four professionals, two addiction
counselors and two registered mental health nurses working as clinical nurse
specialists in the Health Service Executive. Data was collected using semi-structured
interviews and analyzed using content analysis.
Analysis of the data identified that all professionals possessed a diverse awareness of
the problematic issues surrounding the management of dual diagnosis and open to
adopting change to their own service and their professional development.
Five
themes emerged; knowledge of current policies/recommendations, assessment of
clients, difficulties in the provision of services, recommendations on the future
management of services and existing communication between the mental health and
addiction services.
It is advocated that policy recommendations need to be implemented as a matter of
urgency; guidelines and frameworks need to be developed between the two services in
order to provide an effective and collaborative relationship. Both services need to be
provided with training to inform professionals of relevant evidence based practice in
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working with dual diagnosis. The effectiveness of assessing clients with a co-existing
substance misuse and mental health issues need to be evaluated. In order to provide
high standards of care both services need to be supported and in order to effectively
manage dual diagnosis specialist teams must be executed to bridge the gap between
the mental health and addiction services.
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Table of Contents
Page no
Declaration of own work………………………………………………….2
Acknowledgements………………………………………………………...3
Abstract…………………………………………………………………….4
Table of contents…………………………………………………………..6
Chapter 1.Introduction and Aims of the Study
1.0
Introduction ……………………………………………………….9
1.1
Aims of the study……………………………………………………9
Chapter 2.Literature Review
2.0
Introduction ………………………………………………………..11
2.1
What is dual diagnosis?.....................................................................12
2.2
Relationship between Mental Health and Substance Misuse…….13
2.3
Prevalence of dual diagnosis………………………………………..17
2.4
Models of Care………………………………………………………19
2.5
Conclusion……………………………………………………………21
Chapter 3.Methodology
3.0
Introduction ………………………………………………………..22
3.1
Research Design……………………………………………………..23
3.2
Sampling……………………………………………………………..24
3.3
Ethical Considerations……………………………………………...25
3.4
Access ………………………………………………………………..25
3.5
Limitations…………………………………………………………..26
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3.6
Data Analysis ……………………………………………………….27
3.7
Conclusion………………………………………………………….28
Chapter 4.Findings
4.0
Introduction………………………………………………………..29
4.1
Policies……………………………………………………………...29
4.2
Assessments………………………………………………………...30
4.3
Difficulties………………………………………………………….32
4.3.1 Communication……………………………………………………32
4.3.2 Structures between services ………………………………………33
4.3.3 Conceptions of the professionals………………………………….33
4.4
Recommendations on the management of dual diagnosis ………34
4.5
Existing communication between services ………………………36
4.6
Summary…………………………………………………………...37
Chapter 5.Discussion and Recommendations of the Study
5.0
Introduction……………………………………………………….39
5.1
Discussion………………………………………………………….40
5.2
Recommendations for practice…………………………………...43
5.3
Recommendations for education…………………………………43
5.4
Recommendations for future research…………………………...44
5.5
Study limitations…………………………………………………...44
5.6
Personal reflections………………………………………………...44
5.7
Conclusion…………………………………………………………..45
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Chapter Six. Conclusion
6.1
Conclusion…………………………………………………………46
Appendices
Appendix 1 Glossary of terms…………………………………………….48
Appendix 2 Informed consent form………………………………………50
Appendix 3 Interview Guide………………………………………………51
References…………………………………………………………………..53
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Chapter One Introduction and Aims of the Study
1.0 Introduction to the Study
The motivation for this research arose from my interest in working with clients with
co-existing mental health and substance misuse problems. Working in a Psychiatric
Intensive Care Unit (P.I.C.U), I have noticed an increase in the number of patients
being admitted with a dual diagnosis. The difficulties in the management of these
clients and the lack of follow up or after care in place became evident to me. This
chapter will outline the aims of the study. Chapter two will examine, explore and
present the available literature on dual diagnosis. Chapter three will describe the
methodological approach adopted and present the rationale for the chosen
methodology. Chapter four will present findings resulting from the study. Chapter
five will incorporate the discussion and recommendations resulting from the study
and chapter six will conclude the study.
1.1 Aims of the Study
The aim of the study is to gain an understanding of professionals’ experiences of
working with clients with a dual diagnosis. The study provides an opportunity to
explore, examine and enhance practices, to improve service management, to identify
training needs and to improve the quality of care people with a dual diagnosis receive.
The intention of the study is to identify current experiences including opinions,
attitudes and practices of the professionals in the delivery of services. It is recognized
that these experiences may be positive or negative.
It is envisaged that an
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understanding of their experiences may influence professional development through
education and training. As a result of this study the professionals’ experience of the
management of dual diagnosis may become clearer, which may lead to an
improvement in the management of clients with a dual diagnosis accessing these
services and mark a recognizable need for change.
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Chapter Two Literature Review
2.0 Introduction
The purpose of the study is to examine the management of dual diagnosis services in
place in Ireland. Dual Diagnosis is a relatively new phenomenon with its existence
being accepted by service providers in the past two decades as a condition requiring
treatment. This taken into account it should be recognised that little research has been
carried out in Ireland in relation to dual diagnosis and was only recognized by the
Irish governments 2006 document ‘A Vision for Change’ prior to this little
recognition exists in the Irish context. A research study carried out by the National
Advisory Committee on Drugs in 2004 “Mental Health and Addiction Services in
Ireland and the Management of Dual Diagnosis” provided a basis for the recognition
of dual diagnosis in Irish policies and the need for further research in the area. Mental
illness and addiction frequently occur together but have traditionally been treated
separately, often in isolation and with an unsuccessful history (MacGabhann et al
2004 p15). MacGabhann et al 2004 (p50) also highlight that successful treatment of
either substance disorders or mental illness is extremely challenging if treated
separately as complex interactions between the two can have serious consequences for
the health and well being of the client.
Both disorders are chronic, relapsing,
stigmatizing and potentially disabling.
To examine the management of dual diagnosis, the following review will focus on the
following themes; what is dual diagnosis, the relationship between mental health and
substance misuse, prevalence of dual diagnosis and treatment models of care bearing
in mind that the NACD 2004 (p11) highlight that there is a dearth of research on dual
diagnosis in the Irish context.
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2.1 What is Dual Diagnosis?
Varcarolis 2000 (p256) describes dual diagnosis as the co-occurrence of a substance
use disorder with a psychiatric disorder. A Vision for Change Report on the Expert
Group on Mental Health Policy states that dual diagnosis is a condition where an
individual presents with a mental health disorder and concurrently a substance abuse
problem. However in 2004 in a report on the management of dual diagnosis in
Ireland commissioned by the National Advisory Committee on Drugs MacGabhann et
al stated that no consensus exists on what dual diagnosis is and making a dual
diagnosis ranges from explicitly identifying two or more classified disorders to
establishing problematic substance use with the manifestation of some psychological
symptoms (p11).
The phrase dual diagnosis has been internationally adopted in order to present a wide
range of clinical presentations by those who have both mental health and substance
misuse problems. In more recent times dual diagnosis has become common in mental
health practice describing the relationship between severe mental illness (mainly
psychotic disorders) and substance misuse (NACD 2004 p23). Tyrer 1996 promotes
the concept of co-morbidity which is used for the illustration of the presence of more
than two concurrent ailments’, this description of dual diagnosis entails various
behaviours and consequent problems of two defined components in a clearly defined
presentation.
Common co-morbid psychiatric disorders include personality disorders (borderline
and antisocial), major depression, bipolar disorder and schizophrenia. Varcarolis
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2000 (p257) dual diagnosis must always be identified and the co morbid disorder
treated simultaneously if any change in drug related behaviour is to occur. In the Irish
context outlined by the policy document A Vision for Change mental disorders are
three times as common among those with alcohol dependence in comparison with the
general population, 40% of service users managed by the Community Mental Health
Teams report to have drug or alcohol misuse problems (p146).
Research indicates that the rate of co-morbidity of substance abuse among individuals
with schizophrenia is rising at a higher rate than in non-psychiatric populations. In a
study carried out by Kamali et al 2006 of in-patients with a diagnosis of schizophrenia
39% fulfilled the criteria for a lifetime history of substance misuse. In this particular
study the main substances being misused were alcohol, cannabis or a combination of
both.
The presence of co-morbidity contributes to greater severity of addiction
therefore in turn to the severity of mental illness With this co-occurrence rates of
relapse are higher, service utilisation increased, inpatient treatment becomes frequent
and poor treatment results exist for both conditions (p146 A Vision for Change).
2.2 Relationship between Mental Health and Substance Misuse
The relationship between substance use and mental illness appears to be unique with
various possible relationships which lead to a dual diagnosis for the individual.
Gafoor and Rassool 1998 (NACD 2004 p25) believe this complex relationship gives
rise to a heterogeneous group with defining features of the dual diagnosis changing
over time. In 2002 the U.K. Department of Health described a more manageable and
clinically relevant interrelationship between psychiatric disorders and substance
misuse.
The Dual Diagnosis Good Practice Guide outlined these possible
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relationships as:

A primary psychiatric illness precipitating/leading to substance misuse.

Substance misuse worsening/altering the course of a psychiatric illness.

Intoxication and/or substance dependence leading to psychological symptoms.

Substance misuse and/or withdrawal leading to psychiatric symptoms or illnesses.
As the term dual diagnosis is multifaceted all of the above relationships outlined may
contribute to an individual being diagnosed with a dual diagnosis. Under the Mental
Treatment Act 2001 involuntary admission of a person to an approved centre by
reason that a person is addicted to drugs or alcohol is not liable (p11 MTA 2001).
The primary aim of the National Drugs Strategy 2001-2008: Building on Experience
outlined its strategic objective as to ‘significantly reduce the harm caused to
individuals and society by the misuse of drugs through a concerted focus on supply
reduction, prevention, treatment and research’ but there is no reference is made to the
management of dual diagnosis within the strategy. However the Strategy aims at
adopting a balanced approach within an integrated framework it endorses inter-agency
co-ordination, integration and community/voluntary sector participation as necessary
steps to effective implementation.
The Drug Treatment Centre Board (DTCB) on a study regarding Methadone
Maintenance Therapy suggests that a significant amount of evidence suggests that
poly-substance abuse seriously compromises treatment (DTCB 2004 p1). Results
obtained suggest that the effectiveness of psychosocial programmes associated with
MMT varies widely among clinics. The DTCB 2004 (p1) recognize early and more
frequent counselling contacts associated with lower rates of drug use by patients on
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MMT proved more beneficial whilst highlighting that clients with a co morbid mental
disorder and substance misuse problem have poorer treatment outcomes, limited
research exists on the impact of mental disorders on the treatment of opiate
dependence. The DTCB acknowledges that clients attending their service at Trinity
Court in Dublin have higher rates of psychiatric co morbidity, serious physical illness
and co-dependence on other substances. In their study a co-morbid psychotic illness
was present in 6% of clients and a co morbid affective disorder was present in 27% of
clients.
An unexpected finding of the study was that clients with a dual diagnosis engaged
well in terms of opiate abstinence. The DTCB believes this is due to the fact that
clients with a dual diagnosis were receiving more intensive treatment from adult
mental health teams.
Enhanced and multidimensional services have shown to
demonstrate increased effectiveness in substance misuse treatment (DTCB 2004 p5).
The Health Service Executive developed a Report on the Working Group on
Residential Treatment and Rehabilitation (Substance Abuse) acknowledging that
because those with co morbid substance dependence and psychiatric problems are
seen as a major target group particularly in need of in patient interventions, the level
of such dual diagnosis is important in assessing treatment needs (p18 HSE Report).
Both the National Drug Treatment Reporting System (NDTRS) and the National
Psychiatric Inpatient Reporting System (NPIRS) report the use of psychiatric services
for the treatment of drug and alcohol problems. However the implementation of the
recommendations of the Expert Group on Mental Health Policy A Vision for Change
2006 will see this practice discontinued as: “individuals whose primary problem is
substance abuse and who do not have (other) mental health problems will not fall
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within the remit of mental health services” (HSE Working Group Report p41). The
Report recommends that significant support is needed for the development of drug
and alcohol community based services, including the availability of local
detoxification. The Working Group continue to suggest that the treatment of dual
diagnosis requires the mental health teams care for adults with co morbid substance
misuse and mental health problems where the mental health problem is the primary
problem. Also suggesting specialist substance misuse mental health teams for adults
with complex severe substance abuse and mental disorders are established.
In terms of delivering services to drug users Cox and McVerry 2006 (p4) write that as
the number of problem drug users increased in Ireland in the last 25years, many
specialist services and agencies have advanced to meet the needs. However due to the
lack of an agreed service model for specialist drug treatment provision, and variation
in the scale and pattern of problem drug use from area to area, means that different
health services, cities and communities provide combinations of services often
possessing different theories on problem drug use and addiction (p4 DPAG Report).
The authors use the term ’complex needs’ to describe the inter-connected nature of
peoples needs rather than using overtly prescribed definitions such as “dual
diagnosis”. Turning Point 2005 defines people with ’complex needs’ as individuals
with “multiple interconnecting needs that span medical and social issues, individuals
with complex needs may have mental health issues combined with substance misuse
problems…”. People with complex needs are often seen as lying at one end of the
continuum; they are vulnerable people who have multiple and usually intractable
problems and seek their solution by attending a number of agencies. In addition the
DPAG believe high levels of mental health complaints among problem drug users and
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incidences of dual diagnosis mean that some do access mental health services.
However, it is recognised that a large proportion of problem drug users have mental
health problems which remain undiagnosed (p4 DPAG).
Drug workers, service
providers, researchers and policy makers are aware that the majority of problem drug
users in treatment have complex needs.
A high proportion of drug users have
multiple problems ranging from psychological (ADHD, depression) or serious mental
health problems (schizophrenia).
The DPAG 2006 (p5) states that in Ireland health and social care services were
designed to meet single, rather than multiple complex needs. Each specialist service
has developed a fixed idea of what constitutes their ‘core business’. The isolation of
services can cause individuals with complex needs to experience a sense of frustration
as the inability to respond adequately to needs beyond the remit of their organisational
structures often exists.
It is evident from the Report compiled by the DPAG that the separate specialist social
care model that currently exists in Ireland fails to provide for the complex nature of
drug users’ needs , due to the reality that services which are in place to address such
issues of dual diagnosis are often poorly co-coordinated.
2.3 Prevalence of Dual Diagnosis
Despite difficulties in establishing prevalence the literature indicate rates of dual
diagnosis are increasing over time. Smith and Hucker (1993) propose two factors
which may have contributed to this increase.
First as services move towards
community care individuals with a psychiatric illness may be increasingly exposed to
illicit drugs and secondly there is a general increase in the experimentation of illicit
drugs in the Irish population as a whole (p31 NACD).
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An Irish study carried out by Daly et al 2005 shows that 724 of 22,279 admissions to
psychiatric units and hospitals and units in 2004 were for drug disorders. This figure
however may underestimate the level of dual diagnosis as many of those with coexisting drug and mental health problems find it difficult to access treatment services
(HSE Working Group Report p18).
Alcoholic disorders continue to be the main cause of admissions to psychiatric
hospitals, particularly for males. In 1999, of all admissions to psychiatric hospitals
26% of male admissions and 11% of female accounted for were alcoholic disorders.
Furthermore, in an Irish general hospital it was reported that 30% of all male patients
and 8% of female admissions were identified as having underlying alcohol abuse or
substance dependency (Strategic Task Force on Alcohol-Interim Report).
At an international level the estimated prevalence of dual diagnosis ranges from 1560% of substance misusing clients (EMCDDA Annual Report 2004). The limited
Irish data ranges from 26% reported by the National Inpatient Psychiatric Reporting
System to 43% in a community sample (Condren et al 2001 p18). In 2006 Whitty and
O’Connor detail that 37% of patients attending the Drug Treatment Centre Board had
a Dual Diagnosis; of those 26% had been diagnosed with depression and 11% with
psychosis. A study conducted on the prevalence rates on illicit substances and alcohol
misuse in outpatients with a diagnosis of Schizophrenia showed that there was a
prevalence rate of 45% for illicit substances and 33% for alcohol (Condren et al
2001).
2.4 Models of Care
Three types of treatment models have been identified from reviewing the literature;
serial, parallel and integrated. The Serial treatment model is when one service first
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treats that aspect of dual diagnosis which is their specialty, then refers the client to
another service (NACD 2004 p73). Difficulties which have been encountered with
this model included exclusion which resulted in relapse, as the assumption that one
condition was more important when in actual fact both mental health and substance
abuse are more likely to co-exist in the same client.
MacGabhann et al 2004 (p73) describe the parallel model as involving both services
treating the clients simultaneously on the aspect of dual diagnosis which is their
specialty. Clients often find this treatment model difficult as over time their level of
motivation decreases to attend two different centres for treatment. Also a conflict of
interest may occur with the client attending two different services for simultaneous
treatment.
The final model identified by the NACD 2004 is the integrated model which involves
both aspects of dual diagnosis being dealt with simultaneously by one agency. The
integrated model has been established as producing the best treatment outcomes in
comparison to the other two models (p59).
A Vision for Change 2006 (p149) identifies that different models of intervention exist
for dealing with problems of co-morbidity.
Interventions may be offered
simultaneously that separately address the problems of mental illness and addiction or
services which exist to address these issues may be offered in succession. Within the
context of the specialist mental health teams the recommendation of the policy was to
provide a service to those with complex or severe substance abuse problems and
severe mental disorders. MacGabhann et al (2004) recommended that training and
education should be improved at all levels and that the introduction of a clinical nurse
specialist in addiction was desirable. Also included was the belief by the NACD that
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guidelines for managing dual diagnosis in Ireland should be developed by a specialist
committee representative of stakeholders including the NACD, substance misuse
psychiatry, general psychiatry, the Mental Health Commission, the Irish Psychiatric
Association and the Irish College of Psychiatrists (NACD 2004 p9).
Recommendations on Mental Health Services for Persons with co-morbid severe
mental illness and substance abuse problems as outlined in A Vision for Change
(2006 p149) included the following:

Mental health services for both adults and children are responsible for providing a
mental health service only to those who have co-morbid substance abuse and
mental health problems.

General adult Community Mental Health Teams should generally cater for adults
who meet these criteria, particularly when the primary problem is a mental health
problem.

The post of National Policy Co-coordinator should be established to deliver
national objectives and standards, pertaining to primary care and community
interventions for drug and alcohol abuse and their linkage to mental health
services.

Specialist adult teams should be developed in each catchment area of 300,000 to
manage complex, severe substance abuse and mental disorder.

These specialist teams should establish clear linkages with local community
mental health services and clarify pathways in and out of their services to service
users and referring adult CMHT’s.

Two additional adolescent multidisciplinary teams should be established outside
Dublin to provide expertise to care for adolescents with co-morbid addiction and
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mental health problems.
2.5 Conclusion
As evident throughout the review of literature on the management of dual diagnosis
the condition is not clearly understood or formally recognised neither in policy nor in
addiction or mental health services.
It is of utmost importance that clarity and
practice guidelines to provide frameworks for managing dual diagnosis are
implemented.
All of the above policies, reports and studies, using different methodologies and
allowing for various limitations tend towards similar conclusions that there is an ever
increasing need to establish effective services to deal with the management of clients
with a dual diagnosis. The purpose of the review was to identify the policies and
recommendations which have been established for dual diagnosis and by examining
these studies identify from the available literature the need for these services to be
implemented within the Irish Health Service. As regard this association it has been
observed throughout the review that the need for these specific services does exist but
have not as of yet been resourced or implemented. Various reports outline the need
for these specialist services however in the Irish context there has been limited
research into the topic and where statistics exist most can only be estimated. Many
areas identified in the review require further research if dual diagnosis is to be more
effectively managed.
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Chapter Three Methodology
3.0 Introduction
As previously stated the intention of this research study is to identify the current
practice in place for the management of dual diagnosis in the Irish mental health and
addiction services, to identify current treatment processes in place and to elicit views
of the health professionals working in the fields of mental health and addiction on the
current situation. Findings from the literature review suggest that within the Irish
context dual diagnosis is a relatively new phenomenon however even existing
recommendations on the management of dual diagnosis are not being implemented or
managed effectively.
This section will incorporate the research design, how the interviewees were selected
and how the access to same was obtained. The ethical considerations and limitations
will be identified, and the format of data analysis which the author adopted will be
outlined. The explanation of the methodology utilized will lay the foundation for how
the research was conducted.
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3.1 Research Design
For the purpose of the study the author decided to apply a qualitative approach to
engage with the interviewees as Gubrium and Holstein (2002) state that qualitative
methods offer researchers access to peoples thoughts and ideas in their own words
rather than in the description of the researcher.
Strubert and Carpenter (1995)
recommend the use of a qualitative approach when the knowledge base of a particular
subject is sparse.
The form of qualitative research which the author decided would
prove most beneficial to the study was semi structured interviews. This was due to a
variety of reasons, the most prevalent being the amount of flexibility offered whilst
conducting the interviews as Robson 2002 highlights that predetermined questions
can be modified based upon the researchers perception of what seems most
appropriate. Question wording can be changed and explanations given; particular
questions deemed inappropriate with one interviewee can be omitted and additional
ones included.
Through adopting a qualitative approach the author found that specific individual data
would be more suitable to the research. This approach provides an opportunity as
each person’s personal perspective and in depth understanding of the personal context
within which the research phenomenon is located. Qualitative descriptive studies
offer a comprehensive summary of an event in the everyday terms of those events.
Although a pattern on trends may emerge and possible links between variables can be
observed, the emphasis is on the description of the phenomena (Parahoo 1997).
Sandelowski (2000) goes on to argue that qualitative research is especially amenable
to obtaining straight and largely unadorned (i.e. minimally theorized) answers to
questions of a special relevance to practitioners. Therefore the study consisted of a
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series of one-to-one semi-structured interviews.
3.2 Sampling
Polit and Hungler (1995) describe a sample as “a subset of a population selected to
participate in a research study”.
Morse (1991) argues that sampling should be
appropriate in that the method fits the aim of the research and that the method will
generate relevant quality data. The sample size as outlined by Omery 1983 should be
no more than ten people. For the purpose of the study four professionals were
recruited to participate the author kept the sample size small due to the length and
content of the interview. All participants were purposively selected as the benefits of
this for the study were more than obvious. Parahoo (1998) writes that purposive
sampling is the researcher deliberately choosing a sample on the basis that the sample
are the best people available to provide the data on the issue being researched. The
sample identified enabled the researcher to satisfy the specific needs of the project
and to ensure the clearest and most accurate experiences are collected from the
participants.
The Research Participants
The interviewees were carefully chosen as the author wished to identify the
experiences of professionals from all across the continuum. All participants were
interviewed within their own working environment. Interviewee A has eight years
experience as a mental health nurse and currently works with prison liaison/ in reach
services. Interviewee B has seven years as a mental health nurse and is now a clinical
nurse specialist in forensic psychiatry.
Interviewee C is an addiction counsellor
working with a community addiction team for the past twelve years. Interviewee D is
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a trained mental health nurse but has worked as an addiction counsellor for the past
eight years.
The inclusion criteria for the professionals were;
1: Professionals working in the mental health or addiction services.
2: Professionals who agreed to participate in the study.
3: Professionals with a minimum of five years experience.
The exclusion criteria for the professionals were;
Mental health nurses working in acute psychiatric units or day hospitals.
3.3 Ethical Considerations
The issues of anonymity and confidentiality were ensured to all participants of the
study. Where appropriate all the names and identification of services have been
changed or not identified. Informed consent was gained from each participant prior to
conducting the interviews this was in order to audio record the interview and
reassurance was provided that on completion of the study all information and data
obtained for its purpose would be destroyed. Information regarding the purpose of the
study was explained to each participant and also how the data collected would be
utilized was also discussed.
3.4 Access
The author initially wished to include clients with a dual diagnosis for the purpose of
the study however on reflection the only available access was to clients in acute
psychiatric settings; but due to the vulnerability of the clients the author believed that
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interviewing them on the subject would be unethical.
The participants of the study were recruited from the Southern and Eastern region. In
order to gain access to conduct the study with the three Health Service Executive
employees access was sought by contacting the HSE Ethics Committee in order to
gain approval. Following ethical approval permission was sought and granted from
the relevant Director of Nursing and consent was obtained to carry out the interviews
within their catchment area. In order to gain access to the addiction counsellor in the
Eastern region the relevant Community Addiction Team was contacted and consent
was approved by the Project Co-coordinator.
Woods and Roberts (2003) acknowledge the necessity for planning, diplomacy and
negotiation in gaining access to research participants. Denscombe (2002) highlights
the importance of gaining the co-operation of key people known as “stakeholders”
who have the authority to grant or deny access. As the researcher had worked in the
relevant HSE catchment area a relationship of trust had been established. Therefore
the researcher was able to make contact with the key people (Director of Nursing,
Assistant Directors of Nursing) necessary to access participants.
3.5 Limitations
The researcher acknowledges that the study was not without limitations. The major
limitation encountered by the researcher as mentioned previously was the access to
clients with a dual diagnosis on an out patient basis. Due to the fact that the HSE
catchment area being used had only one addiction counsellor and was on leave at the
time of the study there was no access to these clients this proved problematic to the
study as the author had to re-arrange the emphasis and focus on only one aspect of
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interest which changed the original focal point the author wished to emphasize.
Another recognizable limitation is that with qualitative research having a small
sample and only four participants in this particular study it is difficult to generalize
the findings. However having participants from different regions the results will be
from a wider base and will be representative of a larger area. Finally the fact that little
research existed on the concept of dual diagnosis in Ireland, as it is a relatively new
phenomenon proved another limitation to the study. The concept is identified in
many policies and documents and recommendations on the implementation of the
management have been identified however this presented as a challenge to the
researcher as the basis of which to work from proved difficult.
3.6 Data Analysis
The purpose of data analysis is to impose some order on a large body of information
so that general conclusions can be reached and communicated in the research report.
According to Thorne (2000) data analysis is the most complex and mysterious of all
phases of qualitative research. Priest, Roberts and Woods (2002) state that the aim of
data analysis is to cast light on the experiences of participants and are one of the most
challenging aspects of conducting qualitative research.
The data was collected during the semi structured interviews which generally lasted
between forty five minutes and one hour fifteen minutes. The interviews were audio
recorded which proved extremely effective, the author believed this to be a valuable
way to analyze the data due to the fact that parallels such as the use of an interview
and arrangement of the recurring experiences were drawn upon during the study.
Prior to conducting the interviews informed consent was gained from all participants
ensuring confidentiality throughout. Blaxter et al 2001 identify the concept of data
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analysis as reducing the size and scope of the data so as to draw attention to what is
relevant and significant to the research study. The author chose to analyse the data by
using the five steps outlined in Omery (1983).
Firstly the researcher read the
interviews to obtain a sense of the whole topic. The interviews were then re read to
identify certain topics which recurred regularly.
The third step involved the
elimination of experiences which did not seem significant. Certain sentences outlined
by participants were classified into concrete language units, which is to summarize an
experience in a few sentences. Finally the author concluded the data analysis by
outlining all themes and the meaning was put to the experience.
3.7 Conclusion
A qualitative approach consisting of semi structured interviews was chosen for the
study. The author identified the advantages and benefits of the approach to this
particular study. The sample size was identified and the rationale for their selection
justified. Ethical issues and limitations encountered by the researcher were identified.
Consideration was also given to the method by which the data was analysed and the
same was discussed. In the following chapter the author will demonstrate how the
relevant methods were applied, identify the findings and discuss their outcome.
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Chapter Four Findings
4.0 Introduction
The rationale of the study was to identify the current management of dual diagnosis in
Ireland.
For the purpose of the research four professionals were interviewed the findings of the
study will be identified in following sections under the subheadings; knowledge of
current policies/recommendations on dual diagnosis in Ireland, assessment of clients,
difficulties identified in the provision of services, recommendations on the future
management of services for dual diagnosis and finally existing communication
between the Mental Health and Addiction Services.
After the findings have been presented they will then be discussed as to what the
results of the study identify.
4.1 Policies
The participants were asked to identify their knowledge of current policies and
recommendations in place for the management of dual diagnosis between the mental
health and addiction services at both a local and national level.
The general consensus on national policies and recommendations were that they have
been established but not implemented. All respondents outlined the major documents
published in recent years (A Vision for Change 2006, NACD 2004) however only
Interviewee D was able to elaborate on the documents and provide a detailed
description of what was entailed in the policies and major recommendations outlined.
Interviewees C and D described how they have experienced informal guidelines on
service delivery having established relationships with the other relevant services over
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a period of time.
Although all participants were aware of national policies and had a basic referral
protocol as a result of their experience in the field; it seems evident that no specific
policies on dual diagnosis exist instead guidelines that address the co-existing aspects
rather than addressing the problem inclusively.
4.2 Assessments
Of the four participants all acknowledged that no specific assessment tool was in
place in either service to assess for dual diagnosis. For the assessment of clients
accessing both the mental health and addiction services only three acknowledged that
both aspects of a dual diagnosis were addressed in the assessment. However all
recognized that the assessment utilized was less than adequate in dealing with the
clients needs.
Interviewee A reports that in her specific assessment tool areas focused on with
regard to substance misuse include “type of substance used, age of first use, duration
of use, amount used and expenditure per week” reference is also made to contact with
other agencies for treatment.
Interviewee B reports “when admitted to acute psychiatric units all clients are
routinely screened for traces of substances in their system”. No specific assessment
tool exists in this area nonetheless it was stated that that in their care plan and risk
plan; history of substance misuse and possible precipitating factors and triggers are
identified.
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Although substance misuse is assessed the participant accepts the fact that these needs
are rarely addressed while the client is an in-patient but on the rare occasion referral
or advice is given on treatment options available in the locality.
While both Interviewees assess for dual diagnosis at an informal level they recognize
that primarily the mental health issues were addressed and the assessment for
substance abuse was routine and very occasionally identified as a major problematic
area of the clients’ life and not dealt with effectively. As clients mental health needs
were addressed within the medical model.
Only Interviewee D admitted that she felt confident in addressing a dual diagnosis.
The remaining respondents felt they did not possess adequate knowledge or training
to manage clients’ complex needs with a dual diagnosis.
Interviewees A and B agreed that they had obtained the adequate skills over their
professional career to screen for a dual diagnosis but to plan or implement an effective
care plan for these clients would prove problematic.
Interviewee C indicated that due to the fact that the service for which she worked was
a voluntary body the clients were not obligated to give information regarding their
mental health. Also stating that they did not have the specialist training to assess a
client’s mental health but that “most clients accessing the service have had a
psychiatric assessment as at one stage or another have had contact with the mental
health services”.
Of the four Interviewees all agreed that screening for a dual diagnosis on admission to
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either the mental health or addiction services should be mandatory, none of the
Sample deemed this as unreasonable or were in disagreement with the
recommendation.
4.3 Difficulties in the Provision of Services
All Interviewees were requested to identify the difficulties they experienced in the
provision of services. The difficulties perceived surrounded a number of areas the
main three will be identified under the following subheadings which recurred
throughout the study; communication between the mental health and addiction
services, current structures in place and the professionals misconceptions on working
with a client with a dual diagnosis.
4.3.1 Communication
All participants associated the communication between services in the difficulty of
stipulation of providing effective management for clients with a dual diagnosis. All
Interviewees disclosed that they worked on the treatment basis of a serial model
(where one service deals with their aspect of dual diagnosis then refers to another
agency).
Interviewee C identifies the difficulties by observing the fact “Its back to who owns
the problem is it the addiction services or the mental health services”.
Interviewee D remarked on the complexity in the referral of clients to either service
as “neither service wishes to take responsibility for the issue which leads to a lack of
communication and in turn no integrated model of care exists”.
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4.3.2 Structures between services
Each service possesses its own difficulties on access to a relevant agency or service.
However Interviewee B highlighted another extremely remarkable fact being that
mental health day hospitals in her specific catchment area would not accept referrals
from clients with a co-existing mental health and substance misuse problem.
Interviewee C identified a similar feature that no-one wants to take the responsibility
leading to the management of clients being inconsistent.
Interviewee D recognized the lack of a “middle man” as a difficulty she perceived
which she identified was due to the “lack of resources and no-one taken general
responsibility for this group of clients, which she also believes contributes to a high
rate of relapse and re-admission to hospital”.
4.3.3 Conceptions of the Professionals
Participants from both services identified that the major obstacle in the provision of
the management of services was the lack of knowledge professionals possessed to
manage dual diagnosis.
Lack of education and training on dual diagnosis was identified by Interviewees A and
B with Interviewee B emphasizing the “general lack of knowledge on dual diagnosis
by those in thee mental health field leads to nurses or medical professionals
perceiving this as an area for which they don’t have the confidence to address”.
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From the addiction sector the perceptions noted by Interviewee C were that they did
not possess adequate knowledge or skills to address complex mental health issues and
that unless thy actively seek out training opportunities to educate themselves on issues
they don’t receive any training.
Interviewee A defines that all complications in service delivery could be overcome by
“closer and more open communication between addiction and mental health services
and a short term intervention to the problem could be established by providing
workshops to both sectors”.
4.4 Recommendations on the Management of Dual Diagnosis
Interviewees all agreed that the issue of dual diagnosis is a complex one and due to
the increasing needs interventions must be implemented. Participants all believed
they require further training in mental health and addiction to address clients’ needs
effectively.
Interviewee B reiterated by stating “treatment of the clients in not consistent with the
holistic model of care which we are aiming to achieve. The needs of theses clients are
not being adequately met”.
Interestingly both Interviewee A and B responded with a general view for acute
psychiatric units believing that ideally a certain number of beds for clients with a dual
diagnosis should be in every acute unit and in conjunction with these there should be
a team or alternatively a consultant and nurse available on each unit to implement
effective care plan for the individuals needs.
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The main proposal “specialist teams” was the overall consensus of the Interviewees.
Although neither service is dismissing the problem both taking a certain level of
responsibility but believe they have neither the knowledge nor resources to address
the issues.
“A dedicated service would be great or even channeled communication for the
immediate future” was perceived by Interviewee C. In the absence of a specialist
community based team as all the Interviewees recognized this would not be
implemented in the immediate future Interviewee A recognized that a “joint plan or
assessment should be devised when a client is attending both services as we could
work together to minimize the risk factors of relapse of mental illness which in turn
may prevent substance misuse or visa versa”.
However due to many addiction services being voluntary and presently “no-one in
place to bridge the gap”. Interviewee D suggests that adequate referral protocols must
be implemented to ensure continuity of care when clients have been or are currently in
need of accessing both services.
Interviewee B believes that within the mental health services Clinical Nurse
Specialist and Advanced Nurse Practitioner posts need to be developed as well as
specialist Community Mental Health Teams in dual diagnosis generally believing
“resources need to be put in place as a matter of urgency as not only would it ensure
all the clients needs are being met but would also decrease the likelihood of readmissions for the co-existing issues of mental health and substance misuse”.
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4.5 Existing Communication between the mental health and Addiction Services
Within this theme Interviewees described and acknowledged that no formal
communication exists between the services. As both services acted on the basis of a
serial or parallel treatment model of care communication and liaison between services
was seen as a fundamental issue. Two participants also identified lack of knowledge
on services in their locality and different services having different code of ethics
proved an obstacle.
No difference existed from the participants in both fields; all distinguished the lack of
formal communication as a barrier in the management of dual diagnosis.
Interviewee C refers to a difficulty she perceived “a lot of the time the treatment
depends on the individual consultant where with the approval of the client a joint
three way meeting will take place so we can ensure that all the clients’ needs are
being met, but then that’s a rare occurrence”.
When Interviewees were asked to comment on communication being an effective
treatment to manage clients, results indicated different theories.
Interviewee A maintains as a “brief intervention” this could be applied however
Interviewee B identified the difficulties with the “referral protocol being lengthy
clients mental health could deteriorate over this time if they are treated in an acute
unit their level of motivation could decrease and chances of them attending both
services on discharge are minimal”.
Interviewee D deemed the suggestion “unsuitable” as “clients’ health is top priority
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which in theses circumstances requires effective liaison or specialist case managers
for these clients”.
Another intricacy described was the fact that the services are often run under different
management (e.g. HSE, Voluntary bodies), a level of frustration was measured by
respondents as some agencies/services will take referrals and others won’t and even
with referrals no continuity of care is assured.
However acknowledging that no formal protocols existing and three participants
conforming in the level of informal communication which they currently experience
as being adequate but also associate the need for this to change as a matter of priority
due to reasons identified previously certain recommendations were made:

An addiction counselor attending acute units.

Joint assessments and case management.

Primary nurses in situ while the client is an in-patient.

A nurse who specializes in dual diagnosis to liaise with the CMHT’s and
Addiction Services.

Out patient clinics with both services involved in maintenance for the client.
4.6 Summary
In summary the participants’ theories on dual diagnosis vary as well as their
experience in the management of clients with complex needs.
A variety of
management approaches were identified by both services however a lack of
communication, education and policies were noted to be a major impediment. The
participants report that further education and training is needed to manage clients with
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a dual diagnosis. Structures and policies must be implemented by both services where
an effective dual relationship can be established and maintained. Lack of resources
were identified as a barrier to introduce specialist teams however all participants saw
the introduction of this recommendation as inevitable with neither service dismissing
the problem or the difficulty in its management.
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Chapter Five Discussion and Recommendations to the Study
5.0Introduction
This chapter draws final conclusions on the findings and discussion of the study.
Recommendations for practice, education and further research are made, furthermore
my personal reflections of the research process are described.
The aim of the study was to gain an understanding of professional’s experience from
the mental health and addiction sector and the management of clients with a dual
diagnosis.
The findings as described in the previous chapter suggest that the participants all have
knowledge of dual diagnosis through experience and education in the field. However,
they acknowledge that further education and training is required as well as the
implementation of specialist teams to provide effective management of these clients.
The participants value the role of specialist workers between the services as well as an
interest in further education to enhance their skills and knowledge to deal with these
clients.
The participants demonstrated knowledge of policies and assessment practices but all
addressed the need for formal structures to be put in place between the services
recognizing the effectiveness of open communication and liaison between services
was a vital implication.
Ongoing conceptions in the provision of services were noted by all participants;
communication, structures between services and impressions of the professionals.
Recognizing the need for change in these areas and an increase in resources were
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identified as they are additional stressors in the management of dual diagnosis.
Effective management of the service were recommended by all participants, but with
regard to international evidence on the treatment models of care, Ireland must
implement a model which services can implement effectively. The integrated model
appears to have the potential as the international evidence identifies, however with
communication, policies and structures in place participants recognize this as a
possible intervention in Ireland.
In summary, participants engaged in a number of informal practices in working with
dual diagnosis identified lack of education and training and expressed interest in
professional development in this area. They believe with more education and training
they would feel more skilled and knowledgeable which would lead to more improved
assessment and provide early intervention for these clients, decreasing hospital
admissions and ensuring a continuity of care is maintained. These findings have
implications for practice, education and research.
5.1 Discussion
The literature review discussed the following themes; the relationship between
substance misuse and mental illness, the prevalence of dual diagnosis and the existing
models of care.
The review explored a number of recommendations, however
acknowledges that dual diagnosis has not been formally recognized by the mental
health and addiction services nor in policy though the overall consensus of the review
was that of the utmost importance is the establishment of effective services to deal
with the management of dual diagnosis. Similarly the findings highlighted the need
for formal policies to be implemented, the formulation of effective assessments of
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clients attending mental health and addiction services, the difficulties the participants
perceived in the provision of services, recommendations for the delivery of these
services and the communication which exists between services.
The research identified that the assessment of dual diagnosis was inadequate with
three participants acknowledging they assess for dual diagnosis however for two of
the Interviewees to plan or implement an effective plan of care would be problematic
as they did not possess the knowledge or training, nor did the service provide a
specific dual diagnosis service. The assumption could be made that on the basis of
the results people with a dual diagnosis are being treated within existing non-specific
treatment and services. The general “lack of knowledge” was emphasized by one
Interviewee correspondingly in the literature review MacGabhann et al (2004) make
the recommendation that training and education should be improved at all levels.
People with dual diagnosis are generally treated within the serial and parallel models
of care which was identified by the study as requiring good communication between
services, however Interviewees acknowledged that informal levels of communication
between services were suitable. As in the long term treatment of care with “referral
protocol being lengthy clients mental health could deteriorate over this time if they
are treated in an acute unit their level of motivation could decrease and chances of
them attending both services on discharge are minimal”.
communications
between
services
respondents
acknowledged
Despite good
where
good
communication exists if liaison does not include all people involved effectiveness of
the treatment of clients may be compromised.
Dual diagnosis is currently being managed between the mental health and addiction
services however no formal guidelines exist which may suggest this is not according
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to best practice. From the study and literature many indications on how these services
could be developed were identified. Suggestions from the study included training for
professionals in mental health, substance misuse and a dedicated service for dual
diagnosis with implementation of specialist teams in the community and acute
psychiatric units; addition counselors attending acute units for the purpose of joint
assessments and case management; also specialist out patient clinics with both
services involved in the provision of care.
An integrated model was identified as the preferred treatment option in the study,
however little consistency appears to exist between services. It was identified in the
literature that for the implementation of these services effective collaboration,
communication and ideologies must exist. It was perceived by Interviewees that
services being run under different management proved to reflect how the issue of dual
diagnosis is approached and also manifested a level of frustration with professionals
as different protocols existed between services resulting in an inconsistent plan of care
within services.
Some of the participants of the study described that inter-agency and intra-agency
structures often exclude those with a dual diagnosis from attending services. Both
services acknowledged exclusion criteria within their locality, however all
Interviewees were involved at some level in providing care for people who have coexisting mental health and substance misuse problems but did recognize that all needs
of the clients were not being addressed.
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5.2 Recommendations for Practice
The findings of the study highlight the lack of support in the provision of services
varies within sectors whilst working with this client group and also a lack of resources
for developing their knowledge base on mental health and substance misuse exist. An
awareness of the level of frustration which occurs whilst managing dual diagnosis
must also be recognized and appropriate structures put in place for services to liaise
effectively. Structured assessment tools need to be prepared to guide practice which
could be devised by input from both services. Management of the services needs to
provide sufficient resources to ensure that staff has the opportunity to train in
addiction, mental health and dual diagnosis. Specialist teams need to be structured
liaising with both services and treating the client in the community where appropriate
thus enhancing the continuity of care.
5.3 Recommendations for Education
A considerable amount of work needs to be carried out in the area of education. The
study identified that professionals expressed a desire in gaining further knowledge on
dual diagnosis and the management of clients through obtaining adequate skills,
training on assessments and greater knowledge of service availability. This illustrates
that education in the mental health and addiction field should incorporate a broader
range of information relating to mental health and substance misuse. This would
address the lack of knowledge expressed by participants. Additionally, in service
training days should be provided on practices, services and policies in situ this may
occur jointly for services thus leading to formal relations being established and
leading to comprehensive holistic care.
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5.4 Recommendations for Future Research
It is recommended that this study is repeated and should incorporate service users and
their families in order to develop comprehensive continuity of care. This may yield a
broader representation of the demographic group, also enabling identification and
descriptions of variations in practice to be explored.
5.5 The Study Limitations
As the study was completed as part of the Diploma in Addiction Studies and due to a
limited time frame, this study would benefit from being replicated on a larger scale
and over a wider geographical area. The limited timeframe did not allow for more in
depth exploration of issues which emerged from the data analysis process. Due to a
large amount of data collected, the findings produced more research questions than
the questions identified when the study began.
Many issues were not addressed in the interviews resulting in a lack of depth to some
of the findings.
On reflection this could be addressed by conducting a second
interview with participants to follow up on any issues that were not addressed.
5.6 Personal Reflection
I found conducting this research study difficult.
Interviewing former colleagues
proved challenging as I found it problematic to separate myself as a researcher. Also
I did not prepare myself for researcher bias due to my former working relationship
with two of the participants.
Nevertheless, I believe I gave an accurate description of the participants’ experiences
of the management of dual diagnosis.
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5.7 Summary
This chapter provided the conclusion of the research study. The recommendations for
practice, education and research have been described based on the findings of the
study.
In summary this study has provided a description of the professionals’ experience of
the management of dual diagnosis from both the addiction and mental health sectors
as told by four professionals.
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Chapter six Conclusion
Dual diagnosis in Ireland remains to be formally recognized or clearly understood in
mental health and addiction services. It is evident from the literature review that the
recommendation for the establishment of specialist services is beginning to evolve.
The study shows that as of yet no effective implementation for the management of
dual diagnosis in these services has been inaugurated.
The increase in prevalence of dual diagnosis sees the needs for these services to be
implemented as a matter of urgency, as identified that with no specific interventions
in place continuity of care cannot be maintained. It can only be assumed that clients
accessing mental health and addiction services in Ireland perceive similar problems.
The aim of the study was to identify the thoughts and perceptions of the professionals
on the management of dual diagnosis. The topic was explored and a number of
themes emerged from the following: policies, assessment of clients, difficulties in the
provision of services, recommendations for future management and existing
communication between mental health and addiction services. Some issues identified
were recurrent within the study which suggests that by resolving some of these issues
a better approach to the management of dual diagnosis could be established. The
study also shows that services over time have adopted informal guidelines and
relationships to try and effectively manage clients with a dual diagnosis. However
with the introduction of specific guidelines, protocols and policies many of the
existing issues may be resolved.
The author initially wished to include service users in the study however with limited
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access and ethical issues arising, the merits of this could not be achieved. Therefore
the author’s focal point was the professionals from the addiction and mental health
services and their views and opinions on the management of dual diagnosis within
their services.
The findings from the study provided an overview of how dual diagnosis is currently
being managed in the Irish context, in mental health and addiction services.
Highlighted in the study was that strategies need to be applied to combat the
difficulties outlined. As the prevalence of dual diagnosis increases also does the need
for effective management structures to be introduced. Many challenges were outlined
throughout the literature review and similarly within the study, which proved
consistent within both services. Each service has adopted informal strategies to
manage dual diagnosis however problematic issues exist.
Considering a client
centered holistic approach is deemed as being the services primary aim the difficulties
perceived by professionals in this study should be surmountable.
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Glossary of Terms
Attention Deficit Hyperactivity Disorder: A neuron-behavioural disorder, which
interferes with a person’s ability to stay on task and to exercise age appropriate
inhibition (cognitive alone or both cognitive and behavioural). Some symptoms
include failure to listen to instructions, inability to organize oneself, fidgeting with
hands and feet, talking too much, leaving projects, chores and homework unfinished
and having trouble paying attention to and responding to details.
Bipolar Affective Disorder: A disturbance in mood, resulting in either depression or
elevation, which is often chronic and recurring in nature. Alterations in sleep, activity
and appetite often occur.
Dual Diagnosis: The co-occurrence of a substance use disorder with another
psychiatric disorder.
Co-morbidity: The simultaneous presence of two or more disorders often refers to
combinations of severe mental illness, substance misuse, learning difficulties and
personality disorder.
Major Depression: A severely depressed mood, usually recurrent, causes clinically
significant distress or impairment in social occupational or other important areas of
the person’s life.
Personality Disorder: Consist of personality traits that are maladaptive, persistent
and inflexible. The intensity and manifestation of presenting problems may vary
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widely among clients with personality disorders upon diagnosis an individual
characteristics.
However all personality disorders have four characteristics in
common:
(1) Inflexible and maladaptive response to stress
(2) Disability in working and loving
(3) Ability to evoke interpersonal conflict in family, friends and healthcare workers.
(4) Capacity to have an intense effect on others (often an unconscious process and
generally produces undesirable results)
(American Psychiatric Association, DSM 1994)
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Consent Form
Title of Study: The management of Dual Diagnosis in Ireland, Perceptions and Views
of the Professionals.
I agree to participate in the study and consent to be interviewed by Claire Forrest in
relation to the above study.
I have read the information leaflet and I understand that the interview will be treated
in the strictest confidence. I understand that my name or any reference to individual
cases referred to in the interview will not appear in any documentation or dissertation
resulting from this study. All data will be stored securely, and only those directly
associated in this study will have access to the data. I also understand that I am free
to withdraw from the study at any time I choose, without any need for explanation.
Name (please print)
_________________________
Signature
_________________________
Address
_________________________
Telephone number
_________________________
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Interview Guide
Interview Questions
Q1: For the purpose of the research can you state your current job title? Within your
specialist area of work in the addiction/mental health field do you come across
individuals with a dual diagnosis/co-existing mental health issues and substance
misuse problems?
Q2: Are you aware of current policies or structures in place for the management of
dual diagnosis at both a regional and national level?

A Vision for Change

NACD: Mental Health and Addiction Services and the Management of Dual
Diagnosis in Ireland 2004
Q3: Are you aware of available treatment for dual diagnosis in either the mental
health sector or addiction field?
Are you aware of available literature on these services?
Q4: In your assessment of clients are there specific areas for you to assess issues
regarding the clients’ mental health?
Do you have a copy of the assessment?
Q5: Within the area of addiction/mental health what difficulties can you identify in
the provision of services for those with a dual diagnosis?
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Q6: What recommendations could you make on how these services could be provided
and how the current difficulties may be overcome?
Q7: Can you describe your communication with the mental health/addiction services
and the specific protocols in which to access these services?
Q8: When treating a client with a dual diagnosis how do you deal with both issues?

Do you offer a specialist intervention?

Is there a specific treatment model you use e.g. serial, parallel or integrated? Are
you aware of these models?

In your specific field how do you think these clients may be managed more
effectively? What would be the way forward in providing care for these clients

Are you aware of specialist teams in place for those with a dual diagnosis? Would
you recommend that addiction workers be provided with training to work with
clients who have a co-existing mental health and substance misuse disorders?
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