The Theory Underpinning One Intervention With A Dually Diagnosed Client Nursing Essay

The hypothesis Underpinning One Intervention With A du bothy Diagnosed Client Nursing EssayDual diagnosis has been described as one of the most significant problems veneer the health services (Phillips et al 2010). The enclosure was first exercised in America in the 1980s and in its most basic elements describes psyche who has a combination of a aff adequate distemper and stub maltreat problem. Dually diagnosed patients argon often frequent practice sessionrs of emergency services and of in-patient care (Bartels et al 1993). There is likewise a much racyer rate of anger and imprisonment amongst this gathering (Yesavage and Zarcone 1983 cited in Menezes et al (1996). Yesvage and Zarcone cited in Menezes (1996) believe that inebriantic beverage and drug step interact with the symptoms of psychotic illness to produce a to a greater extent flagitious acute illness. Due to the complication of preaching court retrieval is often slower than a psychotic episode bumpkinl y by core group ab theatrical role. This places a great burden on resources and stave (Drake et al 1993), which is corroborated by the London survey (Menezes et al 1996) discovering on second-rate that this group of patients spends almost twice as much time in hospital than those with turn up a substance misuse problem.Clients with the most severe psychiatric disorders tend to urinate the highest rates of co-occurring substance use disorders (Drake 2007). It has been well at running played that the co-existence of severe psychical health and substance misuse problems are universal (Regier et al 1990 Krausz et al 1996 Menezes et al 1996 cited in graham flour 2003). Prevalence figures commute across studies however the latest study by Weldon and Ritchie (2010) estimate the life history prevalence rate of substance abuse amongst persons with severe mental illness at 50%, which is 4.6 times higher than that of the general population (Blanchard et al 2000). One of the quarrels o f mental health providers is how beaver to meet the require of this group of lymph glands (whole wheat flour 2003).The most re centime government guidance is one of integrated sermon whereby the word for drug and alcohol problems are provided primarily within mental health services, integrating this with the intercession of mental health problems (DoH 2002). This is to be provided by one squad and involves a flexible combination of sermons targeting the specific bespeaks of those diagnosed with co-morbid severe mental illness and substance misuse (Horsfall 2009). Researchers and clinicians have confirming a number of interventions that combine, or integrate mental health and substance abuse interventions (Drake et al 2007). An example of one element of integrated handling is Cognitive- behavioral Integrated Treatment (Graham and Carnwath 2004). C-bit incorporates an integrated cash advance with personalised planning to deliver improved treatment outcomes to triple d iagnosis patients.The focus of this hear pull up stakes be on the use of C-bit (Graham and Carnwath 2004) and its application with a guest who has been has been diagnosed with schizophrenia and alcohol problems. For the purpose of this essay and confidentiality his name has been de violated to David. C-bit can be split into 4 perspicuous phases, Engagement and Building motive, Negotiating some doings metamorphose, Early relapse prevention Relapse management. The essay will put up on negotiating behavioural dislodge and what this entails. The author will therefore correspond its loadiveness with an selection speak to.An introduction to C-BitHermine Graham (2004) describes C-bit as a psychological multi-purpose lance designed specifically for people with both a mental illness and a problematic substance misuse. It was developed from CBT which had a firm evidence base for mental health (Grant et al 2004) and substance use problems (Conrod and Stewart 2005). The evidence base of CBIT in dual diagnosis remains pathetic as studies have tended to focus on engagement and building motivation as appose to the nutriment of veer that CBIT encompasses (Callaghan and Jones 2010). However early studies would call down that the skilful use of analysis, disputing cognitions and home meet assignments improve the skills required to promote abstention including self-efficacy in finding, establishing and maintaining appropriate sustain profitss (Rassool 2002).CBIT follows the cognitive model and treatment cash advance (Graham 1998, 2003). A invitees beliefs intimately substance misuse are often relate to their own get a line of mental health problems. David would often say in therapy that the side set up of his anti-psychotic medication made him feel over sedated and this had a knock on effect in mixer situations. He comprise that alcohol improved this and allowed him to integrate better in social situations. By continuing to use alcohol it was maintai ning a detrimental maintenance cycle.Graham (2004) identifies three key aims of CBIT with dual diagnosis patients. The first concentrates on knob and therapist severalizeing and challenging unrealistic beliefs about substance misuse and interchange them with alternatives that aim to break ostracize maintenance cycles. The second facilitates an understanding of the relate amidst substance misuse and mental health problems and thirdly CBIT aims to divide in the customer the power to self-manage substance misuse and recognise the early signs of relapse. Although thither are 4 distinct step in treatment plan of attack the flexibility of the treatment means a client does not need to progress through them all. The harm reduction philosophy that underpins the intervention (Heather et al 1993) puts more emphasis on a client setting more realistic remainders and achieving these. Although flexibility is a key asset of CBIT it would be vilify to assume there was no structure to t herapy sessions. In later sessions especially, in the beginning commencing a session client and therapist must set an order of business to discuss which ensures key areas are discussed (Graham 2004).In practice, teams trained in the use of CBIT tend to use the general principle of the approach rather than the distinct components or techniques (Graham et al 2006). The author believes this shows the flexibility of the therapy and therapists and clients find what proves useful to them . Graham et al (2006) also discovered that when trained members of the team utilize unhomogeneous assets of CBIT, engagement increased, alcohol intake was reduced and a reduction in alcohol-related beliefs. The study however noticed similar findings when the client had been seen by teams that had not yet received CBIT training suggesting that CBIT alone was not responsible for the change in behaviour and belief. However, qualitative in straination recorded from the teams staff suggested that treatment integration increased over the course of the study, and that CBIT was a useful spear for integrating planning substance misuse treatment. Qualitative information from the team managers suggested that CBIT training improved the magnate of teams to address substance use by themselves, rather than avoiding substance issues referring clients to specialists.Achievable Goal settingFollowing treatment phase one the client will be able to identify some of the prejudicious effects of substance misuse. David could recognise the negative effect that alcohol use had on his ability to find any form of employment and how he had no real condenseive social ne devilrk besides drinking companions. Graham (2004) set offs that in treatment phase two it is probably too early for a client to consider have a go at it abstention. David was beginning to fabricate links with the amount he drank and the negative effects he was having. Due to this he negotiated with the therapist that he would reduce his alcohol input by stopping all spirits but remain on his strong lager. This follows the harm reduction philosophy that there are several levels in which change can occur that would reduce the negative trespass it causes to the client. David set his ache-term goal as eventually acquiring some form of employment. Following treatment phase one David was able to see the impact excessive impact alcohol was having on his ability to make appointments on time (if at all), and how this would have a negative effect on any chance of employment. Graham (2004) suggests that for a client to get to this long-term goal a series of short term harm reducing steps need to be identify by the client in therapy that will in-turn have a positive impact upon his life. David had already agreed to stop drinking spirits but make headway steps included reducing contact with fellow drinkers, attending all appointments on time, getting his body back into a work routine. These steps would move David clos er to the eventual long term goal and give him the belief that this was achievable. The therapist found that the use of the recovery star was a useful tool with aiding the client identify and plan how to achieve these goals. The recovery star helps both client and therapist measure change and visually see progress made. At times when David struggled to achieve goals it provided an opportunity for parole on how to change the approach. David found the tool useful in between sessions where he could refer back to past successes to give him the confidence to continue. On reflective sessions what proved important for David was to identify and discuss possible obstacles that he may cognize in trying to achieve his goals and to recognise that if things do not go as planned it should not be automatically assumed to be a failure. Simmons and Griffith (2009) believe that there is never a failure but an opportunity to learn and do things differently.Behavioural ExperimentsBy treatment phase two of CBIT the client will have identified an unhelpful thought, the nature of which will be maintaining a negative maintenance cycle. David had begun to plan harm reduction goals to reduce the negative aspects of his substance misuse however there was clearly some situations he was avoiding, and some vestigial nonadaptive thoughts there were perpetuating his problems. To address this the therapist and David discussed and designed a Behavioural Experiment. Beck (1995) believes that BEs strengthen an intellectual belief by helping the client test out alternative beliefs and thoughts in practice in order to authorize evidence to discover the validity of a belief . Beck (1979) believed through reparation behaviour a cognitive change occurs. BEs are significant as a means of explicitly targeting belief change through experience and as such cleft prime opportunities for sustained therapeutic change (Padesky 2004). David held the belief that if he did not drink alcohol he would step up boring and no-one would have any time for him. For this reason when David was going to be in the company of anyone he would drink excessively, therefore getting inebriated became a safety behaviour. By allowing a client to see what will happen if they drop safety behaviour and then testing out what actually happens in that situation proves to be a powerful challenge to unhelpful assumptions (Whitfield and Davidson 2007). Sloan and Telch (2002) support this view adding that experiments target safety behaviours result in significantly greater changes than exposure alone. Safety behaviour may be helpful and protective to a client but can crown to maintenance cycles of maladaptive processes perpetuating the initial belief. If a threat is not disconfirmed the maladaptive cognition continues (Salkovskis 1991, Sloan and Telch 2000, Clark 1989, Salkovski et al 1998). The notion of experimentation, derived from scientific principles, can be utilise to the patients experience of th e therapeutic process and it is this active experience which can be so meaningful the validity of a new cognition beingness generally more memorable when followed through from conceptualisation to active experience (Westbrook 2007). Once the evidence contradicts the initial belief it allows the client and therapist to spirit the validity of new more adaptive beliefs (Westbrook et al 2007). David and the therapist designed an experiment in which he would limit his alcohol approach and would then engage in general conversation in his local pub. sign experiments gave David the confidence to build on further experiment supporting the work of Bennett-levy (2004) who believe early experiments increase confidence and independence BEs can be active, where the patient takes the lead role in either real or simulated situations to test the validity of thoughts, or observational, where data is gathered. Lewin and Kolb propose a learning cycle in which it suggests that for learning and reten tion to be deepen the client must build upon knowledge and understanding gained through the experiment which in turn forms a foundation for the next step of the experiment. (Lewin 1946 Kolb 1984). The vanadium key aspects of this learning cycle, Experience, Observation, Reflection, Planning and then further experiment underpins BE work.Establishing supportive social communicatesIn the field of substance misuse social factors are seen as important in the onset, aetiology and maintenance of substance misuse (Graham 2004). David recognised that as his alcohol intake increased the friends he associated with were also using alcohol regularly. This supports the work of Drake (2004) who identified that clients with both severe mental health problems and substance misuse problems would have social networks of only fellow substance users. David felt increasingly set-apart from anyone outside of this network as his behaviour would draw attention towards himself. Trumbetta et al (1999) su ggest that for anyone to make changes in substance misuse they need to reduce contact with such peers. Healthier networks need to be formed which provide positive support where there is excessive substance misuse is not the norm (Drake 1993a). David identified his sister as someone who was willing to and who he would like as a supportive person away from mental health services. In crisis David could contact his sister who could give him some level of support. Graham (2004) emphasises the richness of working closely with family members as they often know very teentsy about dual diagnosis problems. David was only close with his sister. The rest of his family had isolated him cod to his substance misuse. Ideally psycho-education information is often given in the group setting as family members may benefit from the experience and support of fellow members (Graham 2004). Davids sister became a key figure in Davids recovery and was encouraged to attend sessions on psycoeducation so she could best understand the problems associated with dual diagnosis clients and how best she could support David.Limitations of its useProchaska and DiClemente (1992) recognised certain barriers to treatment for dual diagnosis patients in regards to therapeutic engagement, treatment continuance and goal setting. In the case of CBIT it makes assumptions of a certain level of coping skills and ability to facilitate cognitive change. Symptoms of schizophrenia can inhibit a clients movement to change behaviour (Horsfall et al 2009). Negative symptoms which have a negative effect on motivation and energy affects individuals internal drive to nurture the complex behavioural routines needed for abstinence (Ballack and DiClemente 1999). An integrated treatment approach incorporating CBIT does not make dramatic changes in the short term, it is a long term therapy. Evidence based studies are always plagued by contrition rates as clients relapse or do not wages to the study. This may sugges t that CBIT may suffer from the same poor treatment compliance/attendance. For clients who complete a full programme of treatment 10-20 per cent achieves a stable remission of their substance use problems per year (Graham 2004). This seems a low figure for the intensive input required on the part of the therapist and client. Bellack and Gearon (1998) believe the therapist must become tolerant of this client group dropping in and out of therapy and abstaining then relapsing. Davids attendance was at times sporadic but the therapist never criticised him for this but used it as a platform for discussing problems experienced through the week. Drake et al (2001) suggests the greatness of assertive outreach teams in retaining clients within programmes. Hellerstein et al (1995) cited in Philips et al (2010) highlight that without this input dropout rates may be high, especially amongst those identified as having unvoicedies participating in treatment.Alternative approachesThe evidence ba se for dual diagnosis is still in its infancy. Those studies completed have limited generalisation due to methodological issues such as heterogeneous samples, equivocal descriptions of treatment components and high attrition rates (Weldon and Richie 2010). Horsfall et al (2009) recognises that due to a lack of longitudinal studies long term outcomes have yet to be determined. It also proves difficult to compare C-Bit with alternative interventions as C-Bit is not used in a vacuum it is often used in conjunction with other therapies such as pharmaceuticals of motivational interviewing. Kemp et al (2007) found a significant advancement in substance use in dual diagnosis patients when CBT and MI principle were combined. For the purpose of this essay the author will briefly look at one main alternative approach to dual diagnosis, that of motivational interviewing.Motivational interviewingTreasure (2004) describes MI as a patient centred counselor-at-law approach that facilitates the p atient in resolve and explore ambivalence about behaviour change. The theory of MI centres on the cycle of change and its half dozen components, precontemplation, contemplation, decision, action, maintenance of change and relapse. Miller and Rollnick (1994) describes motivation as something that one does as appose to something that one has. Empathy is vital in the therapeutic relationship and the use of MI. If the client believes the therapist has no appreciation of their experience they are believably to dis-engage or not fully commit to therapy. Rassool (2002) believes active listening also has an important role in MI. Reflecting back to the client their thoughts, fears, hopes and doubts give a feeling of genuineness, trust and empathy. In MI it is important not to offer advice , give judgement or attempt to question. The reason for behavioural change should be acknowledged and stated by the client. MI proves an effective therapy in dual diagnosis if delivered effectively. The t herapist needs to avoid confrontation as this will lead to client denial, the role of the therapist as intellectual proves counter-productive and structured answer formats will inhibit the client in recognising the effects of their substance misuse. Motivational styles that guide a client in discovering alternative ways of thinking about their problems results in positive change (Miller and Rollnick 1991). By combining elements of style and technique MI has proven successful in dual diagnosis patients and has a developing evidence base.It proves difficult to pedigree MI with CBIT as both complement each other so well and have similar approaches. Both are based on a collaborative relationship with clients, both incorporate a non-judgemental approach and both are approaches are built on empathy, warmth, trust and positive regard (Rogers, 1991). Both approaches also incorporate socratic questioning techniques back up the client to discover alternative meanings of their experience (P adesky and Greenberger 1995). One of the key differences is when it is best to use either technique. Those following a transtheoretical model of change may use MI when the client remains undecided about change in the precontemplation and contemplation stage whereas CBIT can be adopted when the client is more committed to change (Treasure 2004). This would support the work of Drake et al (2001) who subsequently studying the work of a number of researchers believe that to enhance attendance and utilisation of treatment motivation interventions are important.ConclusionThe research on the impact of CBIT as a therapeutic intervention is still in its infancy. Some anecdotal evidence would suggest it provides the skills necessary to promote abstinence (Rassool 2002). Qualitative information gained from Grahams (2006) study suggests CBIT proved a useful tool for integrating and planning substance misuse.Due to the complex nature of dual diagnosis it seems unlikely that a single interventio n will have the desired effect of meeting all the clients needs. Kemp (2007) supports this finding an improvement in substance misuse when MI and CBIT were combined. Due to this there has been a teddy towards the integration of interventions delivered by mainstream mental health services (DOH 2002, 2006Rassool 2002 Ziedonis et al. 2005). Some of the strongest treatment effects have come from combining a number of approaches (Barrowclough et al 2001 Bellacket et al. 2006).