Text is taken from an interview with DDN Magazine - DDN May2021 May 2021 (joomag.com)
People working in substance misuse manage people with mental health issues really well whether they realise it or not,’ she says, and we should be building on these strong skills. An experienced psychologist, she talks of the ‘whole person’ arriving in treatment with various issues to address and is very keen to move away from the label ‘dual diagnosis’. Mental health needs were identified in 60 per cent of people admitted into Phoenix’s residential services – 66 per cent were found to have depression and/or anxiety, 7 per cent had PTSD and 12 per cent were diagnosed with a personality disorder/affective disorder.
People with mental health needs are ‘our bread and butter, this is who we’ve always treated’, says Epstein, but it’s not always straightforward. ‘Some substances are very good at masking the positive signs of mental illness… So heroin for example is quite good at dulling down the psychotic symptoms of schizophrenia, which is sometimes why people use it. If the substances are masking the symptoms, when you detox they will emerge.’
Many diagnoses were identified by GPs and mental health services before admission, but other people had mental health needs that had not been formally diagnosed. With a system of ‘dynamic assessment’ in place, their needs are reviewed regularly and the treatment plan adjusted to bring in the relevant expertise. Referrals are made swiftly and incorporated into risk assessment and care planning – an approach that’s working. Data on completion shows that those with a mental health issue are as successful as anyone else in completing the rehab programme.
The registered mental health nurse (RMN) is an important member of the team and a key to keeping the door open between substance misuse and mental health. Training for the entire team includes a full set of skills to recognise and manage mental health issues, and some of the nurses are dual qualified as CBT therapists. Everyone is switched on to helping people engage in treatment, explains Epstein, and that might mean clinical supervision, medical interventions or cognitive behavioural therapy (CBT) at different points in their journey. Anxiety, for example, ‘yields very well and relatively quickly to CBT interventions’ and a few sessions usually enable the person to engage in treatment.
The other major part of staff training is in trauma-informed care, because, says Epstein, ‘we know that nearly everyone who comes into residential treatment has an experience of trauma’. This has to include supporting staff to recognise their own triggers, as well as being fully aware of the risks of retraumatising people in their care.
The team is looking at some very promising (and cost-effective) interventions such as eye movement desensitisation and reprocessing (EMDR) – ‘evidence based and economical, because it’s a brief intervention with very good outcomes’, according to Epstein. While the intervention itself is brief, she adds, there’s a ‘long preparation period where people have to be stabilised enough to be able to engage in it’, which once again shows the need for close-knit working within the multi-disciplinary team and beyond.
The community mental health team form another essential link in the chain of care, and Epstein is hopeful that changes within the Department of Health and Social Care will give greater capacity for the multi-disciplinary team approach, including joint case conferences that support residents beyond discharge from rehab. It makes all-round (including financial) sense, she says. ‘People who come into residential treatment may have had frequent contact with the police and be frequent flyers with A&E. But we know that if you’re successful with your treatment and continue with your aftercare, those presentations to A&E will decrease and there’s an overall cost benefit to the health system.’ DDN