Dual Diagnosis and Substance Misuse | Providence Centered Care

What it is

The people who fall down the gap between two services

Dual diagnosis means a mental health condition and problematic substance use at the same time. It is extremely common and it is one of the hardest things in the system to get support for, because of how services are arranged.

The familiar pattern is that mental health services say they cannot work with somebody until the substance use is stabilised, and substance services say they cannot work with somebody whose mental health is unmanaged. Both positions are defensible on their own and together they mean nobody does anything. The person cycles through crisis presentations while two waiting lists refuse each other.

We hold both. Not as a clinical treatment service, we are not that, but as a support service that does not require one problem to be solved before it will engage with the other.

We also do not require abstinence as a condition of support. That is a deliberate position. Making sobriety the entry requirement for the support that would help somebody get sober is a circle nobody can get out of. We work with people where they are, including on the days that go badly.

The practical work is much like our other outreach: housing, benefits, appointments, structure, routine, keeping a tenancy, staying connected to the clinical services that do the treatment. What changes is the tolerance and the expectations, and the refusal to hand somebody back because they had a difficult fortnight.

We are a support service rather than a treatment service. Detoxification, prescribing and psychiatric treatment stay with the clinical teams. We work alongside them.

This is likely right if

Someone has a mental health condition and problematic substance use together
A person has been declined or discharged for not fitting one service or the other
A tenancy or a placement is at risk and the pattern keeps repeating
Repeated crisis presentations without anything changing in between
Support is needed that will not end at the first setback

Something else may fit better if

Somebody needs medical detoxification, which is a clinical service
A person is in crisis right now, where the crisis team or emergency services come first

In practice

How we work with people here

Patiently, and without the conditions that usually make this group unsupportable.

Both at once

The mental health and the substance use are treated as one situation, because for the person they are one situation.

No abstinence gate

Support does not depend on somebody being clean first. Requiring that is how people are locked out of the help that would get them there.

Keeping the tenancy

Housing is where dual diagnosis most often falls apart. Arrears, complaints, neighbours, breaches. Getting on top of it early prevents the eviction.

Getting to appointments

Reminders, accompaniment, and picking up the pieces after a missed one so that somebody is not discharged for non attendance.

Structure

Meals, sleep, something in the day. Empty days are the highest risk hours and structure is genuinely protective.

Staying through setbacks

A relapse does not end the support. That continuity is the thing most of these people have never had.

The detail

What is included, and what is not

Set out plainly so there is nothing to discover later. Anything not listed here can still be discussed, and often arranged.

Included as standard

A named worker who holds both parts of the situation
A support plan written with the person, at a realistic pace
Practical support with housing, benefits, debt and appointments
Joint working with mental health, drug and alcohol and probation services
Support continuing through relapse and setback
Support within our accommodation or out in the community

Arranged separately

Detoxification, prescribing and substitute prescribing
Psychiatric treatment and therapy
Crisis response, which is the crisis team or emergency services

Getting started

From first call to first visit

Referrals come from mental health teams, drug and alcohol services, probation, housing and hospitals, and directly from individuals and families.

01

Referral

Tell us the full picture including whatever has gone wrong before. We would rather know than find out.

02

Meeting the person

On their terms. First contact is about whether they want anything from us at all, because forced support in this group does not hold.

03

Agreeing where to start

Usually with whatever is most urgent to them, which is very often housing or money rather than the substance use.

04

Regular contact

Reliable, and it continues through the difficult stretches rather than pausing during them.

Cost

How this is paid for

Usually commissioned by a local authority or an NHS service. Section 117 aftercare may apply where somebody has been detained under the Mental Health Act, which makes support free of charge, and this is frequently missed.

Direct Payments and Personal Health Budgets can also be used. Where accommodation is part of the support, housing benefit usually covers the accommodation element.

Read the full guide to funding

Questions

What families ask us about this

Do you require someone to be clean first?

No. Requiring abstinence before providing the support that helps somebody achieve it is a circle people cannot get out of, and it is the main reason this group goes unsupported. We work with people where they are.

Is this treatment?

No. Detoxification, prescribing and psychiatric treatment are clinical services and stay with the clinical teams. We are the support around them, which is often what determines whether the treatment can work.

What happens after a relapse?

We carry on. Relapse is part of this and support that ends at the first one was never going to help. Continuity through the bad weeks is the entire value of the service.

Will you take somebody other services have discharged?

Yes, and we frequently do. Being discharged for missed appointments or for not fitting a service criteria is exactly the pattern this service exists to interrupt.

Do you work with probation?

Yes, and with drug and alcohol services and mental health teams. Joint working is not optional in this area, it is the only thing that stops people falling between services.

Can you provide accommodation as well?

Yes, within our supported living properties, with staff on site around the clock and a structured route towards independence.

Also worth reading

Services that often go together

Community Mental Health Outreach

Practical support to stay well, stay housed and stay out of hospital, delivered where the person actually is.

If two services have both said no

That is precisely the referral we want. Tell us what has happened so far and we will tell you honestly whether we can help.

Make a referral Talk to someone first

Emergency placements are answered 24 hours a day, seven days a week.