Policy, Service or Practice Development Issues

This section is divided into the two distinct areas of information and services. Information relates to material designed for service users and carers about their condition, treatment and about the services that provide the treatment. Treatment in the context of this section is used as a ‘catch-all’ term for any provision or intervention from hospital admission, through medication to social and network support. The analysis of service issues revealed views related to service configuration that held policy and procedure implications. Properties such as collaboration and communication that aided joint working and encouraged integrated practice were revealed as highly important. Integration in this sense was defined by services integrating their efforts at the point of client care. In other words joint or parallel working.

Information

The CAT (Community Alcohol Team) proved and validated my concerns about alcohol therefore I was convinced of the need to change after receiving the information from them – the concrete, tangible truth about the use of alcohol… I had panics, sweats, I was experiencing dependency. Services saved my life – give you hope, a sense of identity - a problem shared is a problem halved. (Mathew)

In the quotation above Mathew displays a level of insight and readiness to change that coincided with the community alcohol team’s intervention. The information they provided was timely. He states he was convinced of the need to change after receiving the “concrete” and “tangible” information. This suggests he was open to evidence that alcohol was damaging; the information may also have reinforced the significance of his physical symptoms (panic and sweats). Information in this example was effective and reinforced the validity of my goal to construct education or information materials.

Becoming aware of sources of help was significant too. Asking for help when impeded by social inhibitions or shame was overcome by services advertising such as on flyers and in leaflet form. I asked;

Were there any major difficulties to getting help?

Embarrassment of owning up and the stigma was stopping me for a while until I saw poster. (Substance Misuse Day Treatment Centre Focus Group)

Information for Mathew that helped him was factual and appealed to him because it was consistent with his experiences and circumstances. Obtaining the information for some was necessarily preceded with direction or advice about services in the form of a prompt from a carer or a practitioner. A conclusion drawn from this was that information had to be widespread. It had to appear in a range of settings (advertising a service or providing brief advice). As the analysis progressed and theory development grew the issue of access to information, its form and appeal were noted.

Strands of information across a range of circumstances and experiences and possessing a variety of characteristics have been revealed in the previous categories. Margaret emphasised that cultural diversity within the general population required diversity within service provision and professional practice. This aspect of information relates less to specific conditions, such as Mathew and alcohol dependency, and more to the concept of collaboration and inclusion. Having identified social isolation as a barrier to engagement the diversity of certain groups emerged as a further potential barrier.

A low level of awareness within South Asian communities of mental health and substance misuse issues was one such factor. It was reinforced by taboo and stigma. Reaching those communities may be a challenge as Margaret suggested however given the diversity within the participant sample it seemed conceivable that the represented views within the data would possess a cultural significance and appeal.

Yes. But it would mean finding out from the faith leaders what, how they can support the clients but equally how they can support you to deliver the service to the client, to your clients. They need to know where you are coming from and what support you can give, so it’s collaboratively working together. (Margaret Practitioner Participant)

Diversity was a characteristic of the study sample. Their behaviour and adherence to British social convention was apparent in their appearance and values.

You know younger, younger generation as well as older generation are more fashion consciousness and you know, labelled clothes and labelled shoes and all that, and children get marginalised at school if they aren’t equal to everybody else. (Margaret Practitioner Participant)

This point of convention within diversity was salient when considering the production of information or educational material. There was an emerging cultural theme derived from general observation of participants and the analysis of transcripts from the specialist diversity practitioner (Margaret). Sample population diversity existed but in terms of the studies’ information materials it became apparent that specifically tailored content need not be necessary. An information product and theory that possessed resonating features for a diverse range of people was feasible. This theme within the subcategory of information linked with other categories closely. For example the experiences of drug use on symptoms, the issues of blood borne viruses, opiate overdose, and feeling socially included spanned the majority of participants regardless of their background or culture.

The issue of information and its cultural sensitivity was solved by matching the participants’ pattern of experiences. That is drug effects generally do not discriminate and therefore the essence of the data should be construed as relevant to all groups. Consequences such as isolation cross cut all and endeavouring to find things that helped was the major concern – the major category.

Yes, yes its (health problems) not particular to dual diagnosis its right across the field and right across the field is taboos, you know the South Asian communities have lots of taboos like all other cultures in the world, you know they have their own belief systems about issues, you know, especially health issues.

But children are growing up, going to universities, or going where the jobs are. So they are actually in the same boat as everybody else, yeah, yeah, they maybe more sort of westernised as you may call them even though that needs to be defined (laugh) erm, that break up is making them feel more isolated, there isn’t the family and community.

(Margaret Practitioner Participant)

In this section the subcategory ‘Information’ has been presented as three dimensional. Firstly, the importance of it being accurate and timely was shown; secondly, an emphasis was placed on awareness and availability of services, and thirdly cross cultural issues in this context were considered. The latter aspect suggested that information could reach a diverse audience, without being culturally tailored, by virtue of the common themes (of dual diagnosis) being shared by all.

Services

The analysis of data pertaining to the later category ‘Things that Helped / Might have Helped’ showed a substantial number of themes related to the treatment approaches provided by services, see Table 16, ‘Properties of Help’, Page 148. The themes were explored and their nature revealed in order to interpret how participants’ experiences could inform the development of information materials. The properties of ‘Help’ therefore provided individual treatment issues of value rather than matter concerning the organisation of services.

In this section however treatments are more global in nature. The framework for practice rather than the nuts and bolts of intervention is described. For instance daily support groups may provide an extended family (Mathew) however they are peer intervention based and subsequently signal the power of peer intervention programmes in a range of recovery settings (Allott 2004; Rowe et al 2007). Peer intervention therefore constituted a valid theme that services could potentially facilitate.

Having group sessions was really healthy and then, these people you say look down upon, invite you to these groups where’s there’s other people themselves and they all discuss their experiences and then theories and some practical advice. That’s what the group sessions are all about isn’t it? So you’re not on your own. (Sid)

Collaborative working and efforts to integrate practice and services appeared important to practitioner participants.

….this is talking about a systemic approach to dual diagnosis, of the idea that you … you may develop integrated services but probably what is going to develop is the capacity for both services to enhance their ability to deal with these patients. (Ranjeev Practitioner Participant)

Here what became clear was that practitioners appeared to hold an over-arching view of what was required from services in terms of the way they were organised, whilst service user participants’ were more likely to view service issues on a personal level.

If we can’t access health services or drugs services or any of the services that are needed to provide a support network for people then it’s going to have a knock on effect elsewhere.

I think because mental health care services are so big we don’t actually know who to go to all the time. It would be really helpful to us if we had just one focal point that we could refer to. (Vanessa Practitioner Participant)

The framework for effective treatment was therefore viewed as collaborative and communicative; two qualities that emerged on an individual basis and surfaced frequently throughout the analysis. Here collaboration and communication were portrayed on a service provision level with clear implications for services in their efforts to joint work.

The CPA, whilst not referenced or labelled as such by most participants, is a valid framework for organising and implementing care which encompasses the criticisms emergent in my research. For instance Vanessa cites the size of mainstream psychiatry as being problematic. The imposing positional power psychiatry emits in care provision matches its volume and often goes unaddressed. An example of such a

assessment of need within the CPA did not include substance misuse workers, housing workers or practitioners from criminal justice. These failures invariably undermine the consistent policy message of joint working and may indicate the power imbalance between mainstream mental health and previously non psychiatric areas of need such as those associated with social care or substance misuse. Indeed the diagnostic criteria for severe mental illness, medically orientated and adopted for the implementation of the original CPA, could conceivably exclude volitional based disorders or issues such as substance misuse or homelessness.

A harm reduction or damage limitation understanding appeared as a frequently occurring manner or model of work. Participants described examples whereby services worked with them whilst they continued to use substances. Goals therefore were focused on limiting the damage drug use created. Complementing this position however were those who promoted abstinence opportunities for service users.

There’s been potentially an over emphasis on harm reduction at the loss of patients potentially being abstinent from substances as well. So I think what we need to think about if we are going to develop services is a range of potential places that patients could go, so for instance you may take a harm minimisation approach in general psychiatry in the main but there should also be facilities where you can look at patients from an abstinence perspective as well so that you aren’t just a one trick pony. (Ranjeev Practitioner Participant)

What became apparent during analysis was that a substantial range of responses (treatment approaches and models) would be required to accommodate the variety of views on what constituted an effective approach. Furthermore different approaches were clearly defined as useful by the stage of change a person was in (DiClemente & Prochaska 1985). The conclusion in this respect is two fold. Services adopted principles, or held a philosophy, that informed practice; harm reduction, abstinence, peer intervention or social networks for example, but regardless of the service type inter service collaboration was a prerequisite. Such collaboration integrated care and enhanced efforts to include people with a dual diagnosis. In addition, by services working together, the process of exposure to new forms of practice encouraged their own capability to develop in both philosophical and practice domains.

Whilst the issues this section presents were conveyed with passion, the incident count was modest with only a minority of participants overall having contributed. It is remarkable that this section contains comments mainly from practitioner participants. This may indicate that policy, service and practice development issues are less easily conceptualised by service user participants than for example concrete examples of their individual experiences. Alternatively, the unstructured manner in which data was collected may have been responsible for eliciting personal experiences rather than wider views on service issues.

In summary this section demonstrates that participants made constructive comments about the need for information and education related to dual diagnosis. Participants elaborated on this by suggesting the sources and types of information that should be available. Furthermore the need for services to work together and incorporate both substance misuse and mental health interventions into their repertoire of skills was reinforced.