Residential and vocational programmes for people with dual diagnosis

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Successful community living opportunities for people with mental retardation require a comprehensive and collaborative service structure, including appropriate residential and vocational facilities. However, whilst these have been developed for many people, services to meet the needs of those with dual diagnosis have lagged behind.

Housing for people with dual diagnosis must be compatible with all the main principles of 'ordinary housing'. It should be located in an acceptable community setting that offers opportunities for community integration (access), be designed to provide services and supports to meet the needs and desires of the person residing in the setting (appropriate), and provide an affordable, safe, and comfortable setting (accountable). (15> This requires that staff have the necessary skills and service structures to meet client need.

Current policy trends in both the United States and the United Kingdom direct towards the development of smaller, supported living settings as an alternative to the larger group living models. In addition to empowering individuals with dual diagnosis, smaller settings, organized to respond to a wide range of needs particular to one or a few people, appear to offer the best environment for prevention of behavioural difficulties that have previously jeopardized community living situations. However, no one model will necessarily meet the needs of all individuals with dual diagnosis. Some people may become isolated and lonely in one- or two-person settings, or have difficulties that cannot be managed in housing where additional staff or clinical support is not readily available. Some people may simply prefer to live in a supervised group living situation rather than supported living and should be given the opportunity to live in a place they prefer.

Residential services should include a full range of alternatives to enhance an individual's capacity for community living. The individual receiving residential services should be allowed to have as much comfort, ownership, and autonomy as possible. Housing can offer a wide range of options, and maximize opportunities for community integration and personal independence. Specialist mental health services for people with mental retardation should work in collaboration with residential providers, to provide clinical support and a safety net when difficulties arise. Delivery of services in this manner represents one of the most important organizational challenges for services for people with dual diagnosis.

Vocational services should also offer work in integrated settings in a person's community (access), opportunities and supports that are manageable and productive for the worker and the workplace (appropriate), and adequate salary compensation (accountable).

During the past 10 years, there have been significant changes in employment and vocational services for people with disabilities in the United States. Many people with disabilities have moved from traditional workshop settings to integrated supported employment. The majority of placements have been in the service sector consistent with shifts towards entry and low skills jobs in the national employment market. Individual placement (as opposed to work group participation) has had the greatest positive effect on wages. Supported employment enhances the quality of life of people with mental retardation. Although there is an acceptance in society that people with mild levels of disabilities can be meaningfully employed, traditional views of the capabilities of people with severe disabilities continue to be major obstacles to their access to the most progressive contemporary, educational, and rehabilitation practices. People with dual diagnosis may be under-represented in both the sheltered and supported employment workforces.

Similar initiatives have occurred in the United Kingdom, but are less widespread. Staffing issues and training

The availability of specialist training varies markedly between countries, and not surprisingly bears a close relationship to the level of service development.

In the United Kingdom the need for specialist mental health services for people with mental retardation and mental health disorders was recognized in the early 1970s. A comprehensive network of specialist training programmes for psychiatrists, nurses, and other health-care professionals including family doctors, community nurses, and direct care staff has been developed.(!6)

Attention has focused in recent years on the training needs of first level care workers in community day and residential facilities. Currently, in the United Kingdom and elsewhere, they often receive little or no training in the psychiatric aspects of mental retardation with the consequence that psychiatric illness amongst their clients frequently goes unrecognized and untreated.

Staff find working with people with mental retardation and mental health problems stressful. Giving them skills in this area so that they can manage, with support, people with challenging behaviour and mental illness enables them to find this work more rewarding. The most basic and vital role of support staff in this context is the awareness that a person with mental retardation may suffer a mental illness, as we all may. They need to be aware of the range of therapeutic options that might be helpful, including environmental changes, behavioural strategies, psychotherapeutic techniques, drugs, and so on. A fuller knowledge and consideration of this topic will help to dispel myths and prejudices, for example that medication is to be avoided at all costs, or that its use signifies that staff have in some way failed the client. Specific knowledge about some disorders will provide insights into why and how interventions must be tailored around someone's strengths and needs, for example someone with autistic spectrum disorder may hit himself when his routine is changed. The intervention chosen may be to provide a timetable which the staff and client follow. This may need to be in pictorial form to meet the client's communication needs, and small and durable enough for him to carry at all times.

Flexible training materials, which can be used by staff groups in their own settings, are now available. It is often useful to design training around particular clients, for instance a morning spent considering various aspects of autistic spectrum disorders followed by an afternoon working with a staff team developing ways together as to how to work with a specific individual with this diagnosis. The Training Package in the Mental Health of Learning Disabilities (!Z.) has been developed along these lines, with materials provided to run a series of workshops with lots of active participation in individual and group activities, some based on information provided and some based on participants' experience. A handbook(!8) for reference and further reading accompanies the Package for use by the workshop facilitators, and others. A video, Making Links,{13 complements the Package.

Training should be part of the culture of an organization. Including managers in training activities is helpful. It allows them to share a knowledge base with their staff, and to set up processes, which facilitate the continued development of issues identified by the training. For instance, each client's mental health might be considered in their individual planning meeting. Actions agreed can then be regularly discussed in individual staff supervision, at staff groups, and at meetings with the mental health and multidisciplinary teams. Interventions may need to be made in working practices at different levels. At an individual level, for instance, a particular member of staff can develop a life book with a client, interventions can be made at the staff level (e.g. where a staff group responds to a client's challenging behaviour in an agreed consistent manner), or at an organizational level interventions can be made such as altering staff rotas to ensure maximum cover at particularly demanding times, or enabling staff to work in other parts of the service if they are finding a particular placement too difficult. Without the constant reinforcement of and building on training, its effects on practice are likely to be minimal.

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