Models of dual diagnosis services

The first joint mental retardation and mental health services established in the United States were outpatient clinics. They included the Langley Porter Institute in San Francisco, the Developmental Evaluation Clinic of the Children's Hospital Medical Centre in Boston, the ENCOR community services in Nebraska, the University of California and Los Angeles services, and the University of Illinois mental retardation-mental health clinic. In the last 20 years, there has been an expansion of specialized community-based services for people with dual diagnoses as the growing need was recognized.

This period has also been marked by the founding of two professional membership organizations dedicated to improved understanding of and service provision in the area of dual diagnosis, the National Association for the Dually Diagnosed (founded in the United States) and the European Association for Mental Health in Mental Retardation.

In 1999, Davidson et al.(9) described the development and operation of 12 models of community-based dual diagnosis service that had been published by that time in the English speaking literature (nine in the United States, one in Canada, one in Australia, and one in the United Kingdom). These models offered a variety of services including crisis intervention to people with mental retardation and psychiatric disorders and/or challenging behaviour problems.

In most of the models described in the United States there were both conceptual and operational problems between mental health and mental retardation service systems. As a result, inter-agency communication was not well established and access to services across systems was limited. Among the several barriers to services for people with challenging behaviours identified in the United States were a lack of community commitment to establishing special services, attributed to limited consumer advocacy, and a dearth of momentum-generating support from professional organizations, lack of fiscal resources, and organizational resistance to change. A number of models emphasized the need for consensus among providers, consumers, and purchasers in establishing a comprehensive service network for those with a dual diagnosis. Facilitating this can be achieved by bringing all stakeholders together to sanction the need for and the characteristics of the service programme before it is established.

In the United Kingdom services have developed differently. One of the main reasons being that in the United Kingdom there has been a strong specialist group of psychiatrists (who form one of the Faculties of the Royal College of Psychiatrists) specializing in the psychiatric aspects of people with mental retardation (known as 'learning disability' in the United Kingdom).

In the 1980s they initiated with others the development of services for people with mental retardation and psychiatric disorders. In the United States clinical psychologists led them, with a few notable exceptions such as Menolascino, Szymanski, and Sovner. In the United Kingdom, clinical psychologists were mainly involved with the development of services for people with severe mental retardation and 'challenging behaviour'. Psychiatrists concentrated on services for people with mild/moderate levels of mental retardation and psychiatric illnesses including forensic problems, without overlooking those with severe mental retardation.

The publication of the Mansell Report on Services for People with Learning Disabilities and Challenging Behaviour or Mental Health Needs in the United Kingdom in 1993 offered impetus for the development of specialist services for people with severe mental retardation and severe challenging behaviours. Emphasis was given to community-based and locally based services to support good mainstream practice.

The Royal College of Psychiatrists Council Report Meeting the Mental Health Needs of People with Learning Disability in 1996 addressed the issues of people with mild mental retardation and dual diagnosis. It recommended the development of specialist mental health teams to ensure co-ordinated services, and effective liaison and integration with other agencies. These teams should have expertise in both mental retardation and mental health, and provide direct services to patients and carers, and training and advice to other agencies. They should be based locally and provide inpatient care as well as outpatient and community-based interventions.

Dual diagnosis services in the United Kingdom can be broadly divided into residential and non-residential models. There is considerable variation within each model, and some services have features of both.

Residential services

In this model, inpatient and outpatient facilities are concentrated within a hospital setting with outreach work. The suggested advantages of this approach include the provision of a comprehensive range of services, the ability to develop staff expertise, high levels of nursing staff support, sharing of on-site occupational, training, and recreational facilities for clients, and a secure environment for those who need it. (1°>

The difficulty with such units is that they are linked with long-stay hospitals. These are rapidly being closed. They also tend to be separate from generic mental health services. Nevertheless, this model is well established in parts of the United Kingdom, usually where there are still long-stay hospitals. They offer a wide range of specialist mental health services for people with mental retardation, including treatment for forensic cases.

A number of new residential units for people with dual diagnosis have opened in recent years, varying in their size and system of working. Most are in the private sector. They are used for different reasons such as short-term admissions or respite care, and some operate as medium secure units specializing in the care of people with mental retardation and forensic problems. Many are attached to hospital settings but some are in the community. There are also some residential units specializing in the care of people with challenging behaviour with or without mental retardation.

Non-residential services

In this model specialist mental health services for people with mental retardation provide their input in the community. Such services may be linked with mental retardation services only or in addition may also be linked with generic mental health services.

The first model has been the most common in the United Kingdom. A multidisciplinary (interdisciplinary) team offers assessment and specialist services to people with mental retardation. Initially, most of these teams were involved with deinstitutionalization, carrying out tasks such as identifying houses, matching clients to live together, assessing health and social needs, and so on. Most of them have input from clinical psychologists and a psychiatrist specializing in people with mental retardation. Some teams have developed innovative ways of working with people with challenging behaviour often with severe mental retardation. Members specializing in functional analysis and/or behavioural treatments strengthen such teams.

One considerable problem with this model has been the lack of links with generic mental health services. Despite the input of a psychiatrist, such services may experience difficulties in meeting the mental health needs of people with mild mental retardation and mental illness. The closure of institutions for people with mental retardation means that such clients cannot be admitted there, and people with mild/borderline retardation may fall between the criteria of both mental retardation services and mental health services. The care programme approach and supervision register have drawn attention to this deficiency.

The second non-residential model is linked with mental retardation services but is also integrated with generic mental health services. It has overcome most of the problems mentioned above. An example is the Community Specialist Mental Health Service for People with Mental Retardation. This uses all the facilities of the generic mental health service, including acute and medium-stay inpatient beds and a variety of community resources. (!1 The strong clinical interaction between clinical psychologists, psychiatrists, community psychiatric nurses, and specialists in functional analysis enables a wide range of mental health needs and/or challenging behaviours to be addressed in people with severe to mild mental retardation using different approaches and therapeutic interventions. These methods can be applied in various settings, including the individual's home or usual environment, or the outpatient clinic, and if necessary as an inpatient.

This model has many of the advantages of the residential units without being tied to buildings. It also has limitations. Generic services have experienced increasing pressure on beds for acute admissions, so that their facilities may offer a hostile environment for vulnerable people. In particular they are unsuitable for people with severe mental retardation, and those who require a long period of admission or secure accommodation.

To address these issues the Community Specialist Mental Health Service has been strengthened by the development of a specialist inpatient admission unit (as an extension of the generic mental health admission service), community houses with specialist support, and a centre providing training, research, and development in dual diagnosis.

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