1.
This is hard work, you are going to have to deal with it! This is probably not what you want to hear but this is the way it is.
There will be no magic bullet, no rescue squad.
No one will swoop down and take your client off your hands.
Even if there are mental health services that recognise that your client has a psychiatric problem, what do you genuinely think they can do? The first step to working with a DD client is accepting that your intervention, done properly, is probably the best and most significant intervention your client will get.
You may feel that you lack the skills but the truth is so does everyone else - there is no super-magical skill set for working with chaotic clients, psychiatric services rarely have any greater expertise in working with these kinds of clients than you do (and they most likely will have less experience than your common or garden outreach worker or drugs worker).
So, knowing that there is no rescue (and when it comes to DD clients most of us would like to be rescued from what seems an impossible task) it's time to steel yourself for this extra work you will be doing.
Get good supervision in place, you will need it.
If it isn't forthcoming, find it - the most important thing is that you don't burn out, so do what you have to do (in dialogue with your line manager), take breaks if you need to, go for coffee with colleagues, anything that works.
The client needs a consistent worker and for the time being just accept that that worker is you.
2.
Know what you are talking about.
The DD label is bandied around a lot.
But let's be clear that we are dealing with two different categories: (1) Clients that have formal diagnoses who also use substances, and (2) Clients who use drugs who just seem that extra bit difficult to work with because their baseline mental capacities (though there is no easy way of judging this) seem more inhibited or affected than their peers.
The former tend not to worry us too much, the care pathways seem fairly clear, the latter are the real meat of our anxiety as workers.
Be careful not to overuse the term dual diagnosis or knowingly equivocate between lower level DD and more concerning DD.
If your substance using client has mental health issues but your capacity to communicate with them and their capacity to understand and relate to the world seems by and large intact then only in certain clear circumstances is it useful to employ the term DD.
We could quite easily make the point that all substance misusers have mental health issues but that won't help us.
Save the term DD for clients that illicit genuine concern, for whom the prognosis seems particularly bleak and your capacity to communicate effectively with them is genuinely hampered.
3.
Know what matters.
If you are working to get additional support for your client from psychiatric services then what matters is not what your client feels or even their level of distress.
Of course these things are deeply important (obviously to your client) but what matters when making assessments of need is what your client is prevented from doing because of their mental illness.
Mental illness is a barrier and you should be clear about what it is a barrier to.
It is one thing to say a client is schizophrenic, but much more powerful to be able to say that the client's schizophrenia means they are unable to feed themselves, or care for themselves - these are the things that count in mental health assessments.
Someone can be unwell but be judged to be coping, no noticeable deterioration in their circumstances over a given period, whilst the most concerning clients will stop being able to look after themselves.
If you are making a referral to psychiatric services this is what you must be able to detail.
4.
Pull everyone in.
A lot of workers feel quite junior as compared doctors, nurses and social workers.
It is time to snap out of this thinking.
It is perfectly legitimate for a worker to seek to coordinate the actions of professionals to best meet the needs of the client (they'll thank you for it if it works!).
It is a sad truth that everyone is busy, no one is working very efficiently and most workers and agencies are better at fire fighting that working pre-emptively.
Approaching the client's situation with vigour will be surprising and refreshing to most workers and when you do this it is not that hard to inject bit of energy into the system.
So, draw a map of your client's contact with services, often with DD it will be massive but erratic, then get everyone around the table (if someone says they can't come then ask if they can send a representative).
If you haven't done this before, this is a 'case conference' and because you called it you'll chair it.
Keep the chatter down and the specific actions up.
Coming away from the conference everyone should know the plan and how they fit into the next step even if it isn't specifically in their remit (if your client needs benefits then everyone, even the GP, should know this and be fixed towards sorting it out, arranging all manner of concurrent interventions is pointless, agree the priority and get everyone fixed on it).
Keep the conferences regular, keep the emails flowing.
Lastly, invite the police, they have a place at the table.
Those that are cagey about sharing info with the police shouldn't be (by law you can share any info you want with a view to preventing crime, data protection is second to this (crime and disorder act1998) - anyone that has contact with your client should be there and if your client is given to acts of self-harm or public acting-out then it is the police that will be sectioning them.
5.
Build a relationship.
In the great scheme of things, how you develop relationships with an easy-to-work-with clients is fairly trivial compared to building relationships with complex, exhausting clients.
When you die and go to the great supervisor in the sky, you'll be judged on this.
An outcome with a difficult client is worth five outcomes with easy clients.
It is worth the extra effort on every level (both because their plight is more concerning and because their impact on the community and services is more demanding).
The skills involved here could probably fill a book that amazingly has never yet been written but we do know that you'll need to be friendly, consistent, and constant.
Use humour, be funny.
Most importantly, get things done and be seen to be getting them done.
Nothing breeds a better worker/client relationship like the sense that the worker can make things happen.
In conversations hunt all the little things that you can get done (especially if there is no chance that you can get the big things done!) - ID, benefits, phonecalls, form filling, taking them to the doctor etc.
Seek out these actions so that the client knows that time with you is useful.
If at any stage there is nothing you can think of then consider little tokens like a cup of tea or a sandwich.
The more disordered your client, the more substance-affected, the more clear emotional and practical waypoints are required.
If your client is very chaotic (imagine having schizophrenia and a crack addiction), they'll process actions more readily than words and remember them.
6.
Recognise that your counselling skills will sometimes go out of the window.
Counselling skills are universally useful but all of the existing therapeutic modalities have been born to work in fairly similar therapist/client scenarios.
They all take place in safe, calm environments and even though the client might have behaviours they are seeking to address through talk therapy most are at least cognitively capable and able to engage in conversation.
This is very different to assertive social intervention and the contact we call 'assertive engagement'.
So, even though it might not fit comfortably into the skill set of recognised therapeutic modalities be prepared to raise your voice, be paternalistic or maternalistic, withdraw when the client is being demanding, say that you disapprove of opinions or actions (a very un-counselling thing to do) etc.
I don't suggest these things lightly - these are powerful actions - but the more pressing the need, the more we will need to step out of our comfort zone (note I said comfort zone, not safety zone!).
In the case conference you set end goals and you might need to privilege achieving those above your fear about being outside of your comfort zone.
The rule is that workers can work out of their comfort zone only so far as they are able to explain their goal at every stage - supervision should be geared to exploring this.
Imagine for example that a client would profit from going to the GP, the skill set learnt in motivational interviewing or solution focused therapy training would be useful for you as a worker in raising motivation, exploring barriers etc.
But if you are in the position of convincing a client to go to the hospital because there is genuine danger of harm there is little in these modalities that you can draw on - you have to get out of your therapeutic comfort zone, roll up your sleeves and try something a bit more pushy a bit more didactic.
Be prepared for this.
7.
Deal with the substance use.
Many workers will ask: 'how can my client address their substance use when they have underlying issues that drive them to use substances?' It's a fine question but the truth is so does everyone else, the DD client's issues are just deeper and more all-engulfing.
Substance use work is all about underlying issues (whether dwelling on them or trying to move past them).
The increased severity of someone's needs means that interventions must improve quantitively not necessarily qualitatively.
There are probably no other treatment approaches available to your client so even if the ones available (substitute prescribing, group work, counselling) are only of limited use they are the tools you have so you have to use them.
There is simply no good way of addressing underlying mental health issues without first accessing substance treatment.
If your client has chronic substance dependence, making substance treatment successful has to be the goal over accessing mental health services.
8.
The GP is the most underused God-like resource on the planet, use them.
One of the great anxieties that workers have is that psychiatric services don't take their concerns seriously.
Getting services to take things seriously is the job of your client's GP (who is actually the only person properly mandated to look after your client).
The first stage of client work in DD has to be establishing who the GP is and getting contact with them.
This is not easy, they are cautious and surround themselves with a labyrinthine collective of receptionists and early closing hours that you will have to cleverly navigate.
Some GPs are excellent at communicating, most are awful.
Invite them to the case conference, if they don't come then email or post them the minutes, highlight actions.
Chances are they know your client very well (are likely prescribing anti-depressants and other goodies) and are quite concerned for their well-being.
Reiterate how important it is that they buy into your plan.
When used to working with you they will appreciate the extra pair of hands (often in the past they will have referred their patients to appointments they haven't made - make it clear that you can help with this).
The best route of referral into psychiatric services is through the GP.
9.
Seek stability.
The pragmatics of working with someone who is dually diagnosed are no different to someone who is only substance dependent.
ID is still needed, benefits, housing, probably there'll be poor self-care, poor daily living skills, troubled relationships, acquisitive or violent crime, malnourishment etc.
Even if your heroin-using client has severe schizophrenia that impairs most cognitive and affective functioning these issues remain the nuts and bolts of intervention.
If handed over to a psychiatric nurse to keywork these things would still need doing.
10.
Look to other successes.
A simple one this one, surprising then how infrequently it's done.
There must be, or have been, clients with similar issues to the client you are working with at the moment.
Whether the intervention they received was successful or unsuccessful there must be some learning to be gained from it.
Talk to colleagues and ask them what they did, how well it worked (talk to the other client if this is viable).
If a worker managed to get a client assessed and onto CPA (Care Programme Approach - meaning that psychiatric services have a care plan for a client - even if it doesn't always work) ask them how they did it.
We are often not curious enough and don't ask enough questions.
11.
It all comes down to personalities not systems.
Care pathways are necessary and can be the mechanism which will guarantee your client a service, be it within substance misuse services, housing or psychiatric services.
However, the truth is that even the most watertight care pathways can be sunk by disinterested or undynamic workers.
It doesn't really matter for the most part how good the pathway is, or the protocol, what matters is that you are able to find co-workers that carry the same level of conviction and determination that you carry (give me a good worker over a good pathway any day).
Get a mental list of workers that get things done - forget the ones that you like working with, or find pleasant, find the ones that get successes, they're the ones you want to turn to when things get tricky.
12.
Say what you see, don't go making cod diagnoses.
Workers borrow terms they hear and read being used by doctors and researchers partly because these words are the tools of the trade and partly to seem more professional.
It is important to learn the terms but there is a great danger in workers making diagnoses they do not understand.
It is okay, for example, to ascribe low mood to a client because that is what you have witnessed but a very different thing to start talking about bi-polar disorder - about which you have no means of diagnosing.
Borderline Personality Disorder, Anti-Social Personality Disorder, schizophrenia and others are all term workers are happy to bandy about.
Rather than making communication clearer, it muddies up the water: if you tell people you are working with someone with a personality disorder then they will assume that it is a formal diagnosis not your own assessment.
It is less scientific but much clearer to talk about clients being chaotic or expressing strange ideas, or disturbed thinking - at least then professionals know you are describing what you've seen.
Another danger is that the client's self-testimony gets taken at face-value.
This is difficult because we should listen closely and sympathetically to our client's experiences and record them accurately but I have seen several times a client's description of having, say, schizophrenia written down by one agency and then passed onto another without the qualification of it being self-described until the tag of schizophrenia follows the client around everywhere without any formal diagnosis.
13.
Reframe your notion of success.
Now the difficult bit - your client may not change in your time as a worker.
Or they may change and then relapse back into a chaotic lifestyle.
You may have to watch your client slowly kill themselves through behaviours that seem fairly trivial and avoidable.
Your client will probably find ways of sabotaging things you have worked hard to put in place (like accommodation) and even if an intervention is successful you probably will get no thanks.
The only way to cope with this thankless task is to reframe what you accept as a successful intervention.
So, for example, referral into supported accommodation becomes a success because at least they went in, even if they came out a week later.
4 days in a detox is better than 3 etc.
Make the successes smaller, get everyone to recognise that they are successes and keep them rolling in.
Break each small action down into two components: agreeing to do something/ doing something - both are successes.
Then break down large actions into component parts - accessing drug treatment for example involves: having conversations about drugs, the client disclosing information, the client agreeing to be referred for treatment, the client completing the form, the client agreeing to attend an appointment, the client attending the appointment, the client agreeing to start a programme, the client agreeing to turn up on the first day, the client turning up on the first day, the client deciding to turn up the next day, the client turning up the next day etc.
Each small stage is a success, if we have our eyes only on the big goal we'll get frustrated.
14.
Judge by actions not assessments of thinking.
The more disordered your client, the more severe mental health issues are compounded by the varying effects of substance use, the more you can't count on your everyday means for judging the motivation and thinking of others.
Most engagements are informed by our intuition of other's thoughts.
This intuition has to be switched off - it can't help you.
Judge engagements by the things you see and know have happened.
If your task is to complete a form then judge the engagement on the progress of the form - expressions of elation or low mood, tangential thinking, vaguely threatening or threatened behaviour and all kinds of loaded interpersonal communications from a client can fog sight of the goal.
Your job is not to ignore them (that would be plain rude) but to take account of them with the end goal of still getting the form done.
It is a skill to be developed by all workers, the capacity to put yourself in a place of communication overload (try working with a group of street drinkers!), appear attuned to the overloading communication yet pushing through it to achieve a clear goal.
Don't get lost in: 'what did he mean by that?' and 'Do you think that means this?' Think always of what got done.
15.
Don't let anyone ever say it's hopeless.
If someone says: 'Well it looks like we're back to square one.
' You reply: 'I think you'll find we're at square one and a half.
' Even psychiatrists can get defeated by patients and sometimes need someone (even lowly old you earning a quarter of their wage) to reaffirm the potential for small successes.
Kick a cat if you have to, punch a wall when things go wrong but keep you ballast set at optimism so that when the cat is kicked and you're over your frustration you are back to believing that a difference can be made.