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Wednesday, 12 August 2009

It's official: 30-50 % of your clients have substance misuse problems!

The UK National Statistics Information Centre has indicated that "30-50% of clients with mental health problems have current drug or alcohol issues". This would suggest that up to every one in two clients we work with on a daily basis, have an additional substance misuse issue.
This has enormous implications:
Firstly is the simple question of do we know who these clients are? How do we find out?
Secondly, we know that this will have implications for the work we do with them. These range most obviously from the impact of the substance(s) on mood through to clients' ability to remember what we say to them.
There are of course numerous other issues ranging from the impact on client motivation through to knowing which to work with first.
I've raised this issue because there is still a great tendency to divorce substance misuse from the other problems clients present with. Even in the field of anger management, where the connection between substance use and the problem is very obvious, this is so. Kassuinove and Taffrate's otherwise excellent "Anger Management: A Complete Treatment Guidebook" has only two and a half pages (out of three hundred) on substance misuse — and those are right at the end before the index! Take a brief look through the indexes of the books you have relating to your field of work. Are they any different?
This separation is also reflected in services. Clients with "substance misuse problems" usually go to a "substance misuse service" (with the possible exception of those working with offenders). But this assumes that substance misuse is the presenting problem and that the client sees themselves as having a difficulty with substances. What do you do if the don't? How do you work out which of your clients use which substances? Do you know the effects of substances on the client? How do you manage the issue within your work? Do you refuse to work with people if they use? Refuse when they are intoxicated? Refuse when they are withdrawing?Ignore the problem altogether?
As always, we are interested in how you approach this whole topic and what your thoughts are on it.

Paul Grantham


  1. In response to your question about dual diagnosis, I can state as a team we are very aware of this issue, and in fact include it in our initial assessment to the team. We monitor and reflect this issue to our clients and as we get to know them can use examples of where their drug/alcohol use has led them into vulnerable or difficult situations, and even exacerbated their mental health problems.

    We work jointly with Ad action or similar services for the benefit of our clients, and promote understanding of the financial, emotional, social and physical effects this can have on them. Naturally as a recovery team we consider this to be our 'bread and butter', and use a holistic approach, supporting with a variety of issues. Developing a good relationship and having time to work with someone longer term means we are often best placed to be aware of and address such issues. Fortunately our caseloads are reduced to @15 per wte. I acknowledge caseloads such as a community mental health team may have means their opportunity to do so work can be very limited.

    We find it incredibly rewarding to work with 'the whole person'. We work hard to remain engaged with people and to support them both practically and emotionally to make changes. We do not refuse to work with people simply because they have a dual diagnosis, and understand that often the use of drugs/alcohol can be ways in which a client may self medicate. We aim to help them to learn more healthy ways in which to manage their problems so that they can reduce their need for drugs/alcohol. We provide education on a variety of subjects that can impact, including medication, diet, structure of activities to name but a few. This in itself makes our work more rewarding, and the prospect of recovery more possible for our clients.

    I hope this is of use to you, and hope to attend your courses in the future.

    N. S., CPN

  2. Thank you for this — I always wondered how many of the people I worked with had hidden difficulties.

    Generally, I asked at the outset, if there were any other problems, or whether they were drinking more than usual, smoking more etc, and mostly people were fairly honest.

    Women seemed to find it easy to tell me if they were using non prescribed medication — men found it harder, but were easier if the problem was alcohol. I tended to work with people and accept the way they were when they came in — only occasionally did I ask someone to leave and gradually people seemed to stop of their own accord. I really didn't do anything in particular — just helped with the bits I could and hoped they would help them to sort the other bits. I tended to find that good listening and acceptance were good tools.

    It seemed to work and I was well supported by a voluntary organisation, where I did most of my work.

    L. D.

  3. Let me ask you another question: how many of your friends drink more than 3-4 pints every Friday night? The same statistics say that 1 in 4 people in the UK have a mental health problem. The chances are that at least one of your friends has a mental health issue with an additional substance misuse. What do you do?

    I haven't read that book. I can recommend another: John Booth Davies (1997) The Myth of Addiction. It has a few more pages on substance misuse.

    My biggest problem now is funding rather than counting pages. You talk about "substance misuse service", well, the small charity that I work for faces closure because the government and BCC Children in Need think that young people have no problem with substance misuse.

    M. J.

  4. Very interesting topic. I wonder if food misuse would come under the heading of substance misuse. I am increasingly seeing clients who binge eat, vomit or starve themselves to varying degrees in order to deal with their emotions/situations. Also the use of exercise? When does "healthy eating practice" become unhelpful coping strategy, and how as a dietician can I best help these clients?

    E. S., Dietician

  5. Thanks for the email very interesting and good to have some factual information that supports our experience. Working with people who have mental health issues we struggle with the whole "Dual diagnosis" thing. Chicken or egg the nature of the situation makes it difficult? My own view is it doesn't matter what came first our clients are in need. As an organization, however, EDAMH has to pay attention to the use of resources and we are not set up as substance abuse specialists and therefore have to try and work with addiction services and agencies who don't necessarily share our philosophy.

    As a SMHFA instructor one of the issues that we try to get across is the connection between substance abuse and mental ill health and we point out that the correlation between the two is complex.

    In short we do not turn clients away who abuse substances but we do try and work out what the first response should be, addictions work or mental health work. If we judge that it is the former then we have to refer on while this is dealt with; for the reasons already stated. On the other hand there are times when we judge things to be the other way around and will engage to find that the substance abuse subsides when the mental health issues are being dealt with.

    As part of the voluntary sector we have flexibility in our approach in a way the statutory sector don't seem to. Restrictions that we face are around resources, however, your "official" figures may help in the debate and what we try to achieve when we approach those who fund us.

    I hope this gives you a taste of what we do and if you would like further clarification please contact me. I would also be interested on your own reflections on this matter and something of the work that you do in this area.

    D. L., Snr. Support Worker/Counsellor

  6. I have worked with many client's who's presenting problems was not substance misuse, but as the time has gone on discovered that there was a dependency. I have worked with DV clients for H. Police, and I would say at least 50% of the client's had drug or alcohol issues, but was only disclosed further into our sessions together, changing the direction of our work.

    I am now working with substance misuse, so would be interested to come to the workshops. Also, enjoyed the positive therapy seminar in March.

    J. McG., Dip. Integrative Counselling MBACP

  7. I’m presently doing a BSc Honours in Substance Use Studies and felt that the timing for your Depression course couldn’t have been better; it fits in well with my Dual Diagnosis study.

    I’ve worked in AA for 20 odd years so have experienced persons with affective depression and substance misuse symptoms. I’m very open minded and at present I’m studying working with dual diagnosis which I feel is one condition, depression and substance abuse need not be separated. I feel we just need to get on with counselling the person with a compassionate approach from the onset making hopefully an improvement and give some symptom relief from the low mood experiences. This can only be done by regular structured counselling sessions.

    C. D., Counsellor

  8. I am a qualified counsellor with a psychology degree. I ran a one man alcohol services in York for a year for an umbrella voluntary service organisation.

    Initial thoughts… Many alcohol workers are not trained in counselling/psychology theory and techniques and use CBT measuring continuously. What works well? Looking for the underlying triggers… They are nearly always there. Also having been to one of your seminars on brief work… Asking the client how they have coped until now and asking them to envisage themselves as a non drinker… The positive feelings this would bring… I have also had other clients with alcohol/drug issues… Social anxiety crops up a lot… but was it there already or did the alcohol/drugs cause it/make it worse… have also had one or two close friends with alcohol problems so have seen it second hand… all for now… but probably have more to offer… I wouldn't say that in a year my clients when running alcohol service had a high rate of recovery but those who did and there were several looked healthier and were happier without alcohol… those who succeeded addressed underlying problems and wanted to give up 100%… very rewarding when it worked… obviously slow with need to gradually reduce intake to avoid withdrawal.

    A. M.

  9. In our counselling service here part of our client assessment for therapy asks this question. If the answer is ‘no’ — that’s one thing. If it comes out during the sessions as it often does we support them to be referred to a statutory service in our borough for practical assistance around drug & alcohol issues.

    If it is flagged up at assessment we get the background and say we can't offer therapy unless they are already attending the service just mentioned. If they're not attending there we suggest/refer them and if this is forthcoming we agree to work with them then. If the addiction is not too bad and/or the client is able to commit to not drinking/taking their substance on the day they will be attending here we will work with them. A contract is agreed between therapist/client regarding the drink/substance abuse. If a client attends and the therapist sees he/she has been drinking the client is asked to go home and return the following week if they are clean/sober on that day.

    M. G.

  10. At our university students complete a Student Life Questionnaire along with a CORE questionnaire before their counselling assessment. This has two relevant questions:

    My use of alcohol is getting in the way of my studies (scaled from 0 = Not at all to 4 = Very much);

    My use of drugs is getting in the way of my studies.

    There are always limitations to questionnaire completion, but we find a striking level of honesty in completion and scores on there questions give us an opportunity to bring the subject up at assessment. Sometimes it arises out of discussion of a problem area like anger, stress or depression.

    If it seems an important issue, we would explore why, when, where etc and start to explore other coping strategies that might be more positive.

    We would normally work with the underlying issue unless the substance misuse was clearly the major issue and clouding everything else. Sometime clients do utilise the local Drugs and Alcohol Service for a one off session before or during our counselling work. They are also a point of contact for us if we wished to speak to a worker there. I have tended to have one ground rule about not being 'not being under the influence' at the time of the counselling appointments. Motivational Interviewing knowledge and approaches are useful here. With pre-contemplators you can ask 'What if' type questions and there can start to be a feeling that it is having an impact on an important other such as a boy/girl friend. Psycho-education can also help such as how substance misuse can add to the effects of depression. With contemplators it is usually starting to impact on study (hence the value of the above questions) and budgets! You can then start to look at the pros and cons of change.

    T. B., Counsellor

  11. I fully agree with you that we tend to miss the boat with this fairly obvious connection of mental health and substance use. I run a programme of multi-agency training days and 2-day courses around sexual health, mental health and substance use and I try to make the links between all three areas explicit in every training event I run since sexual health is another 'out on a limb' subject that, in real people's lives, is inextricably linked with mental health, emotional well-being and substance use and misuse. Like you, I tend to find texts separate the subjects out and ignore the links that exist in people's lives and that services still have a tendency to stick with their own speciality too - so sexual health services may not always assess or even ask about substance use; mental health services VERY seldom ask about sexual activity and sexual health etc. It is getting better in Swindon, where I work, and that is in small part due to the linked training we offer. If I keep bashing on about it the message will get through eventually :-)

    M. C., Multi-agency Training Coordinator


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