Development and validation of the Meaningful Engagement Evaluation Tool (MEET) for dual diagnosis peer-led programs: a co-designed approach

Will the Australian Government's response to its 'National Ice Taskforce' deliver more treatment as promised?

Background: 'Dual diagnosis' is the term of choice in many countries to describe clients with co-occurring mental health and alcohol and other drug (AOD) issues. However, it is not known if its meaning is consistently represented within and across health care services. This uncertainty has significant implications for referral, consultation and research. Aim: To obtain information about the way that different health care professionals understand the term 'dual diagnosis'. Method: Twenty-nine health care workers across five service types (medical, mental health, AOD, dual diagnosis and community health) in Victoria, Australia were interviewed about their understanding of the term 'dual diagnosis'. Results: The findings indicated that service providers working in AOD and Mental Health had a shared general understanding of what was meant by 'dual diagnosis', despite uncertainties about more specific inclusion criteria. In contrast, medical and community health staff lacked a similar shared understanding, and were more likely to recommend change, but offered no consensus on alternatives. Conclusion: The results indicate that while the term 'dual diagnosis' has value in efficiently directing attention to the complexity of treatment issues, health practitioners cannot assume it will convey the intended meaning outside mental health or AOD services. Clear articulation of the intended definition may be a necessary requirement in wider health care communication.

Two very different approaches can be employed to promote recovery from psychiatric disorders. One approach is grounded in an understanding of individual psychopathology, and it is clearly central to contemporary care. The second approach to recovery, which is based on group psychology and the support derived from participation in a group, can also be valuable in promoting recovery. In examining this second approach, I consider Alcoholics Anonymous (AA) and other movements that operate through social and ideologically grounded support. The term “spiritual recovery movement” (1) can be applied to them. On the basis of studies that I and my colleagues have conducted, I describe a psychological model to clarify the operation of such groups. Charismatic groups Social and spiritual recovery can be considered from the perspective of naturally occurring, highly cohesive, and religiously oriented cultic groups, two of which I have studied. One was the Divine Light Mission, headed by a guru who began preaching at the age of six in his native India. Members’ responses to a research questionnaire indicated a reduction in their symptoms of psychological distress after they joined the group, and the extent of the reduction was significantly correlated with the intensity of the social cohesiveness a member felt toward the group (2). Further clarification of the psychology of cultic groups emerged from our studies of the Unification Church, the “Moonies.” Using two scales I found that the stronger an individual’s affiliative feelings toward the group, the greater his or her psychological wellbeing (3). A study of long-term members who were matched to their future spouses by the Reverend Moon

Religious organisations have been involved in delivering alcohol and other drug (AOD) services since Australian colonial times and are a familiar presence in the AOD sector. However, there is concern in some sectors that AOD services delivered by religious organisations might be influenced by religious ideology, at the expense of evidence-based service provision. A national, cross-sectional survey of non-government AOD agencies was undertaken using a mailed questionnaire. All non-government AOD agencies in Australia, providing at least one face-to-face specialist AOD service, were invited to participate. Agency goals and activities were assessed using the Drug and Alcohol Program Treatment Inventory, which has eight distinct treatment orientations: 12-step, therapeutic community, cognitive behavioural therapy, psychodynamic, family, rehabilitation, dual diagnosis and medical. There was a high degree of uniformity in treatment orientations with religiously affiliated agencies having similar goals and activities to non-religiously affiliated agencies. Cognitive behavioural therapy was most commonly provided and 12-step the least provided. Religiously affiliated agencies were significantly more likely to favour the 12-step orientation in both goals and activities. Concerns that the religious affiliation of non-government organisations might influence AOD service delivery in Australia appear to be overstated. Factors contributing to the observed uniformity of care may include a more strategic, federal approach; and an increasing emphasis on best practice within the sector. The lack of discernable differentiation between religiously affiliated and non-religiously affiliated non-government organisations may also be attributable to changes in the way services are delivered by many religious organisations.

Mental health service users (MHSUs) have elevated rates of cardiometabolic disturbance. Improvements occur with physical activity (PA) programs. We report the development and evaluation of three innovative peer-developed and peer-led PA programs: 1) walking; 2) fitness; and 3) yoga. Qualitative evaluation with 33 MHSUs in British Columbia, Canada, occurred. These programs yielded improvements for participants, highlighted by powerful narratives of health improvement, and improved social connections. The feasibility and acceptability of innovative peer-developed and peer-led programs were shown. Analyses revealed concepts related to engagement and change. Relating core categories, we theorize effective engagement of MHSUs requires accessibility on three levels (geographic, cost, and program flexibility) and health behavior change occurs within co-constituent relationships (to self, to peers, and to the wider community). This study highlights the benefits of peer involvement in developing and implementing PA programs and provides a theoretical framework of understanding engagement and behavior change in health programs for MHSUs.

Comorbidity between mental health and alcohol and other drug (AOD) disorders is common. This study aimed to identify and describe all of the local government and non-government (NGO) mental health and AOD services in a socially disadvantaged urban region in Adelaide, South Australia. Services were identified using telephone directories and the internet, and via information from workers employed by a wide range of mental health and AOD services. Local mental health and AOD services were difficult to locate, but eventually we identified a total of 70 services. Soon after this, reorganisation of the mental health services and a new NGO funding round changed the service configuration, with a decrease in the number of services. The available services were fragmented, and rarely addressed comorbidity specifically. Our real-world study demonstrates the lack of a clear pathway for people to access existing services. Further, changes occur frequently as government funded services generally reorganise every couple of years, and NGO services come and go according to funding. There is a need for a central, widely available database for mental health and AOD services. More services addressing comorbid mental health and AOD disorders are required.

Patient-reported measures that assess satisfaction and experience are increasingly utilised in healthcare sectors, including the alcohol and other drug (AOD) sector. This scoping review identifies how and to what extent people accessing AOD services have been involved in the development of satisfaction and experience measures to date. PubMed, EMBASE, CINAHL, Scopus, ProQuest, Google and Google Scholar were searched. Included papers described the development and/or implementation of a multiple-item measure of patient-reported experience or satisfaction specifically for people accessing AOD treatment and/or harm reduction programmes. If there was more than one paper, key papers were chosen that described each measure. The method of development, including service user involvement, was assessed against a framework generated for this review. Two reviewers were involved at each stage. Thirty measures-23 satisfaction and 7 experience-were identified. Sixteen measures reported some level of involvement by people accessing AOD services in their development, although, for most measures, at a relatively low level. This involvement increased over the time span of the review becoming more frequent in later years. Only four measures were developed for use in harm reduction-specific settings, and fewer than half reported undertaking analysis of underlying scale structure and constructs. Several gaps could be addressed to enhance the measurement of patient-centred care in the AOD sector, including: developing experience measures for use in harm reduction settings and across various AOD settings in a service system; improved reporting of psychometric properties of these measures and increasing commitment to the meaningful involvement of AOD service users in measure development. This scoping review is part of a broader codesign project that involves a partnership between the peak organisation for AOD services and the peer-based AOD consumer organisation in the Australian Capital Territory, Australia. These organisations are working closely together to engage with AOD service users, service providers and policy makers in this codesign project. As such, the Executive Director of the peer-based AOD consumer organisation is involved as a co-author of this scoping review.

BackgroundPeople seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC.MethodsSeven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann–Whitney U tests.ResultsRates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC.ConclusionsWhile those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

A history of trauma exposure is almost universal among clients of alcohol and other drug (AOD) treatment settings. In Australia, more than 80% of entrants to treatment report having experienced a traumatic event in their lifetime, most commonly having been physically or sexually assaulted, witnessing serious injury or death, being threatened with a weapon, held captive or kidnapped 1, 2. The vast majority have experienced multiple traumas. It is therefore not surprising that up to two-thirds of AOD clients have also been found to suffer from post-traumatic stress disorder (PTSD), a chronic and debilitating psychiatric disorder 1. The significance of these figures for AOD treatment providers cannot be understated. Traumatic events are often defining, life-changing moments, regardless of whether a person goes on to develop PTSD or any other trauma-related disorder. Whether it be a one-off event or more prolonged, trauma can shape or redefine a person's views about themselves (e.g. I am weak, bad, worthless), the world around them (e.g. the world is not safe) and how they relate to it (e.g. people cannot be trusted). For those who are unfortunate enough to have experienced trauma during childhood 3, 4, these beliefs may be particularly well entrenched. Knowledge and awareness of a client's trauma history is, therefore, a crucial piece of the puzzle needed to understand the cause and nature of their presenting problems and inform the development of the most suitable treatment approach. Self-medication of PTSD symptoms plays a significant role in the development and maintenance of AOD use disorders 5. The onset of trauma exposure and the development of PTSD symptoms predates the onset of an AOD use disorders in at least half of cases 6, 7. Improvements in PTSD symptoms are associated with subsequent improvements in AOD use, a relationship demonstrated by Lopez-Castro et al. 8 in this issue. The authors conduct a secondary analysis of data from the 'Women and Trauma Study' 9, the largest randomised clinical trial of co-occurring AOD and PTSD to date. Improvements in PTSD symptom severity were associated with a reduced likelihood of substance use 1-year post treatment. Although treating PTSD symptoms may lead to improved AOD outcomes, the reciprocal relationship is not observed 10-12: PTSD symptoms do not remit following improvements in substance use. On the contrary, PTSD symptoms may worsen in the absence of substance use 13, making it difficult for patients to sustain abstinence and increasing their risk of relapse to AOD use 12, 14, 15. This situation has led experts to advocate for a 'trauma-informed' approach to providing care 16. As outlined by Killeen et al. 17 in their article on the implementation of integrated therapies for PTSD and substance use disorders (SUD), trauma-informed care is 'a service delivery approach whereby programs: (i) recognise the high rates of exposure to trauma in the patient populations they serve; and (ii) provide a safe environment and services that accommodate the needs of patients presenting with a history of significant trauma' 17. It is about understanding the potential impact of trauma on AOD treatment so as to 'create treatment environments that are more healing and less retraumatising' 17. Despite its intuitive appeal, this recommended approach has not been adopted in the vast majority of AOD services. There are several reasons for this as outlined below. First, despite the pervasiveness of trauma exposure and PTSD among AOD clients and their potential to impact on treatment, both go largely unrecognised at the service level. Very few services systematically assess for a history of trauma exposure among their clients, with most preferring to put the onus on the client to raise the issue. However, for a multitude of reasons (e.g. shame, issues relating to trust), most clients are unlikely to volunteer information about their past trauma experiences unless specifically asked 18. Hence, the scale of the problem is often underestimated, and providers are missing a crucial piece of information that may fundamentally alter a person's treatment plan. This reluctance to assess for trauma is in large part related to concerns regarding client safety; specifically, fears regarding AOD clients' ability to cope with the emotions that may be elicited. Rather than risk client safety, services prefer to err on side of doing nothing at all. Although well intentioned, this practice is likely to be doing more harm than good. Whether or not clients' trauma is openly acknowledged, services are dealing with its consequences. Furthermore, research has demonstrated that while some people may become upset when talking about these events, talking about the trauma does not overwhelm or retraumatise the majority of people. On the contrary, most people describe the process as a positive experience 19. Second, service providers are understandably concerned about their capacity to respond. Trauma training is not a core feature of most certification courses. In their survey of Australian AOD workers, Ewer et al. 20 found that close to two-thirds of respondents had undergone trauma training; however, the type and content of that training was unclear. At a minimum, all members of the AOD workforce should: (i) have an awareness of the extent of trauma exposure among their clientele; (ii) understand the consequences of trauma exposure and its potential to impact on a recovery; (iii) be able to recognise the signs and symptoms of PTSD and other trauma-related disorders; and (iv) integrate that knowledge into their practice. However, trauma-informed practices can only be effective if organisational policies and procedures operate within a trauma-informed framework, such as that proposed by the US Substance Abuse and Mental Health Services Administration 21. Third, until recently, there was very little empirical evidence to guide treatment responses. There is, however, a growing body of evidence that supports the use of integrated treatments for PTSD and SUD; that is, treatment of both disorders at the same time by the same clinician 22, 23. Killeen et al. provide an overview of these treatments and discuss factors that may need to be considered when deciding which to implement. It should be noted, however, that although the ability of services to provide integrated trauma-focused treatment is desirable, it is not necessary for the provision of trauma-informed care. Until such time as training in the treatment of trauma responses becomes more widespread, the provision of trauma-focused treatment is likely to remain in the realm of specialist providers. A final reason that trauma has largely been ignored relates specifically to the focus of Ewer et al.'s article in this issue: concerns regarding the well-being of AOD workers themselves 20. How trauma is managed within a service not only impacts upon the clients but also the staff of that service. In this issue, Ewer et al. 20 report findings from a survey of Australian AOD workers that examined the impact of working with traumatised clients on their well-being. Close to 20% met criteria for secondary traumatic stress as a result of working with clients with a history of trauma. The findings highlight the crucial importance of adequate and appropriate training and support for AOD workers. In sum, there is a clear need trauma-informed care within AOD services. A history of trauma exposure is more common than not among clients of these services, and for many clients, this exposure is integrally linked to their substance use. The reluctance of services to address trauma among their clients stems from valid concerns regarding client and worker safety and a lack of evidence-based treatments to guide best practice. However, research in this area has grown substantially in recent years, highlighting the importance of addressing trauma among AOD clients and demonstrating the efficacy of trauma-focused treatments. By providing a supportive trauma-informed model of care, the outcomes for clients, and health of the AOD workforce, may be improved. A/Prof Mills currently receives funding for research from the Australian National Health and Medical Research Council (NHMRC), the Australian Government Department of Health and NSW Health.

There is growing interest in the role of the non-government sector in the alcohol and other drug (AOD) service delivery system. This study examined the demographic profile of AOD workers in the non-government (NGO) compared to government sector, to ascertain their professional development needs, job satisfaction, retention and turnover. This study utilised cross-sectional data from an Australian AOD workforce online survey that assessed participants' demographics, employment profile, professional development needs and barriers. The sample comprised 888 workers in direct client service roles. Binomial logistic regression analysis indicated that NGO workers were more likely to be younger (<35 years), have AOD lived experience and have an AOD vocational qualification. NGO workers were more likely to earn below the national average salary and report job insecurity; but nonetheless were more likely to feel respected and supported at work, believe their work was meaningful and be satisfied working in the AOD sector. Their top professional development barrier was personal financial cost. NGO workers were more likely to report employer financial costs as a professional development barrier, whereas government workers were more likely to report staff shortages. AOD services in Australia rely increasingly on the NGO sector. Quality services and care pivot on the size, capability and maturity of the workforce. This study highlights the need for systemic interventions addressing structural issues, and the professional development and ongoing support needs of the NGO AOD workforce. Without such support, Australia's AOD services will be potentially jeopardised.

Aims: The comorbidity of substance use and mental health problems poses a significant challenge for alcohol and other drug (AOD) treatment services. In many cases, AOD practitioners do not have experience or training in identifying or managing mental health conditions.Methods: This project examined the implementation of screening and intervention practices for mental health disorders among AOD clients. Training and supervision was provided to 20 AOD practitioners across five sites in four agencies with a focus on enhancing skills in detection of, and intervention for, mental health conditions among their clients. A package developed for this purpose, known as PsyCheck, was used. A random file audit was undertaken to examine changes in detection of mental health conditions.Findings: There were significant improvements in detection after training and supervision, with detection rates almost doubling in this time.Conclusions: Training and supervision using the PsyCheck package appears to have the potential to improve mental health detection and intervention in AOD services. This study shows promise for the implementation of mental health intervention in AOD services.

High prevalence mental health (HPMH) comorbidity is common in clients seeking alcohol and other drug (AOD) treatment yet can remain undetected. Although research has reported on the introduction of screening into AOD services, little research has reported on the processes surrounding the introduction or evaluated its effectiveness. This study reports on the implementation and evaluation of brief anxiety and depression screening within a specialised, publicly funded AOD service in South-East Victoria. Study one examined the implementation of standardised HPMH screening with 114 adult clients (Mean age=35.49, SD=9.53; 64% male) telephoning an AOD service over a 5week period. Measures included severity of HPMH problems, AOD use, care plans and referrals. Study two used semistructured interviews with nine staff/managers to evaluate the effectiveness of screening and its impact on service delivery. Ninety-four per cent of clients were identified at risk of anxiety or depression. Most care plans incorporated counselling, and concurrent referrals commonly involved a general practitioner. Staff and management found systematic screening increased identification and understanding of comorbid issues and enhanced client interaction but impacted on resource requirements. Most AOD treatment seekers were identified HPMH comorbid and care plans generally included counselling. Adjunctive referrals were more common for severely depressed clients. Screening was effective and enhanced client rapport. Evaluations revealed low confidence in treating HPMH issues in-house. Training may increase worker confidence in managing mental health interventions with subclinical cases, enhancing services' ability to move towards dual diagnosis capability.

Alcohol and other drug (AoD) use is an important health and community issue and may be positively affected by collaborative care programs between specialist AoD services and general practice. This paper describes the feasibility, model of care and patient outcomes of a pilot general practice and specialist AoD (GP-AoD) collaborative care program, in Sydney, Australia, based on usual care data, the minimum data set, service utilisation information and the Australian Treatment Outcome Profile (ATOP), a patient-reported outcome measure. There were 367 referrals to the collaborative care program. GPs referred 210 patients, whereas the AoD service referred 157 patients. Most GP referrals (91.9%) were for AoD problems, whereas nearly half the AoD service referrals were for other issues. The primary drugs of concern in the GP group were either opioids or non-opioids (mostly alcohol). The AoD service-referred patients were primarily using opioids. An ATOP was completed for 152 patients. At the time of referral, those in the GP-referred non-opioid group were significantly less likely to be abstinent, used their primary drug of concern more days and were more likely to be employed (all P < 0.001). A second ATOP was completed for 93 patients. These data showed a significant improvement in the number of days the primary drug of concern was used (P = 0.026) and trends towards abstinence, improved quality of life and physical and psychological well-being for patients in the program. There are few studies of GP-AoD collaborative care programs and nothing in the Australian context. This study suggests that GP-AoD collaborative care programs in Australia are feasible and improve drug use.

The treatment of nicotine dependence in individuals with substance use disorders has been an area of neglect and contributes to morbidity and mortality. Lack of staff training and education is the most frequently reported barrier to providing smoking cessation treatment in alcohol and other drug (AOD) treatment services. This study assessed the effectiveness of brief intervention training for smoking cessation for staff in AOD treatment services. Participants were recruited from one residential AOD Therapeutic Community, which received the intervention, and the results were compared with participants from two other centres, where no intervention was delivered. Results demonstrated that intervention training increased confidence and willingness to intervene, which are predictive of adopting tobacco interventions in AOD treatment services. This is important as providing more smoking cessation intervention in AOD centres is needed in order to decrease mortality and morbidity related to smoking in AOD clients. Findings indicated however that training did not increase motivation to intervene, and future research is required to determine effective ways to increase staff motivation to address smoking cessation in AOD services.

Cultural inclusion and competence are understood at the most basic level to be the practice of considering culture so as to provide effective services to people of different cultural backgrounds. In order to work better with clients from diverse backgrounds, alcohol and other drug (AOD) services need to offer a service that is designed to be accessible to all people, where systems in place operate in a way that considers different cultural needs. This research aimed to assess the extent to which non-government AOD services in New South Wales are positioned to support cultural inclusion as well as to evaluate the acceptability of a cultural inclusion audit across four AOD sites. The research adopted a mixed methods approach comprising of a pre-audit online survey (n = 85) designed to assess AOD services' attitudes and practices towards cultural inclusion, and in-depth interviews that were conducted with nine AOD service staff and four cultural auditors to explore the acceptability of a cultural inclusion audit process. Findings from the survey indicate cultural inclusion practices are limited. Interview data highlight that while staff are not fully aware of what appropriate cultural inclusions entails, they are receptive to and want a cultural inclusion program. The study illustrates the benefits of implementing a cultural inclusion audit process aimed at raising awareness of what cultural inclusion entails. Including a cultural inclusion service audit is likely to enhance AOD service provision to culturally and linguistically diverse groups and thereby improve treatment outcomes.