Southern District Health Board (DHB) is improving the way it supports people with co-existing mental health and addiction problems.
The DHB is implementing the Ministry of Health’s co-existing problems (CEP) initiative, which supports services to provide more integrated care and improve the CEP capability of staff.
David Jaggard, unit manager of Ward 11 and Adult Packages of Care Service at Wakari Hospital, has been leading the initiative within the DHB since 2010.
|David Jaggard and Bernie Thijssen|
Bernie Thijssen, a registered nurse and clinician at Dunedin Community Alcohol and Drugs Service (CADS), is working alongside David as co-leader of the initiative.
“We decided to concentrate first on workforce development rather than service integration,” says David.
“The main tools we’ve used are one-day workshops and monthly one-hour forums about mental health and addiction. Often mental health workers don’t feel they have the knowledge or confidence to address substance use issues, so we’ve looked at things like motivational interviewing, brief intervention, the history behind CEP and how to approach it with clients.”
David Jaggard, unit manager of Ward 11 and Adult Packages of Care Service, Wakari Hospital
David and Bernie have deliberately taken a gentle approach.
“It’s not about telling people they’re doing something wrong or that they have to do something completely different; that can be insulting,” says Bernie. “It’s strengths-based. It’s about highlighting the skills they already have – and the idea that with a little extra learning and support, even better results might be possible.”
She says an example is that mental health workers often already have good relationships with the people they work with. These relationships can form a useful basis for screening for substance use issues, and to develop strategies to fit with their treatment plans.
In their training, David and Bernie rely on a transdiagnostic formulation matrix championed by Southern DHB CADS psychologist Dr David Mellor, a proponent of Acceptance and Commitment Therapy (ACT).
Bernie says, “The matrix is really useful because it asks important questions, for example, ‘What matters to you – such as a job, a better relationship or a happy home?’ It also asks people why they are using alcohol and/or other drugs, for example to move away from depression, anxiety or low self-esteem, and what they could do instead to address those problems and achieve what’s important to them.”
David says this approach fits well with CEP being person-centred, behaviour-focused, and much less reliant on diagnosis.
“When people have really complex CEP problems, they can end up with many diagnoses. Someone may end up with several concurrent diagnoses and there can be a lot of disagreement about which ones are the most correct.
“This may result in people being excluded from services, so we much prefer to concentrate on people’s needs, behaviours and strengths.”
Bernie and David are convinced the initiative has gained traction because they individually represent the mental health or addiction workforce. They role model shared decision making and problem solving that collaboratively makes best use of their individual areas of skill and experience.
Over the last few years referrals to CADS from mental health services have risen, and David says most mental health and addiction staff now have at least a basic understanding of CEP.
A mandatory screening tool should be in place across Southland mental health services by April 2015. More training and evaluations are planned for staff.
By June 2015, the DHB aims to have 75 percent of mental health and addiction staff CEP-capable. All job descriptions will require staff to work towards this capability. Bernie and David are preparing a business case to create a full-time CEP position at a DHB level to support further development and maintain momentum.
Registered nurse James Mather sees incredible value in this work. “CEP is just so relevant,” he says.
James works with the Regional Forensic Psychiatry Service in Dunedin. He supports people whose mental health may be a factor in their offending or in their ability to understand the court process.
He also works on Ward 9A, a medium-secure forensic unit at Wakari Hospital, where he champions CEP and raises its profile with the team.
James says “The vast majority of the people I work with have substance use issues, which are directly related to their offending. Substance use is almost symbiotic with mental health problems, and we simply can’t ignore it.”
James attends the forums and regularly talks with David and Bernie about issues on the ward and how to approach people who experience CEP. He says it’s almost like a mentoring relationship, but not as formal: “They take a very non-forceful approach. It’s all about working with the strengths of the person and helping them get to how they want to be living. That’s something I now try to do consistently.”
James uses the matrix to help people discover their values and think about what to do next.
“The matrix enables people to raise the ideas themselves. They can see cause and effect drawn on a piece of paper. It’s a lot more powerful, and they can take that visual away with them. It’s much better than a health professional who doesn’t know them, telling them what to do. I’ve never found that approach particularly useful.”
James Mather, registered nurse, Regional Forensic Psychiatry Service and Ward 9A, Wakari Hospital
Johnnie Potiki feels CEP is an incredibly important issue. Johnnie is consumer advisor for Southern DHB mental health services. Johnnie has experienced mental health and addiction problems, and recovery, and has accessed both mental health and addiction services.
In his role as consumer advisor he provides direction, leadership and advice to support improvements in service development and delivery. He also serves as a point of contact for people using mental health services at Wakari Hospital.
“For eight years I was running round in a form of hell. I was drinking a lot and that’s all people could see. In 1990 I got treatment for alcohol dependency, and five years later it was discovered I also had bi-polar. That discovery would never have been made if I hadn’t stopped drinking. I could have been treated for it much earlier, but the screening measures just weren’t in place.”
Johnnie Potiki, consumer advisor, Southern DHB mental health services
Johnnie says the groundwork by David and Bernie should soon start having excellent results.
“I think we’ll see acute ward staff referring a lot more people to CADS and I think this will save lives. People with mental health problems are dying because they’re not getting help with their substance use. If they are being referred, they often don’t attend, and this isn’t always followed up because there’s not yet enough co-ordination between services.”
Johnnie looks forward to the implementation of the mandatory screening tool: “I think the tool will help provide enough information to get to the root of the problem. Many psychiatrists may prefer having an in-depth discussion with the person, but they are not always readily available. So this is the most effective way of supporting staff to become capable of screening.”