Dual Diagnosis A Particular Challenge To The Treatment Of Serious Mental

Dual Diagnosis
A particular challenge to the treatment of serious mental illness in prisons is dual diagnosis. Dual diagnosis describes a patient who has both a mental illness as well as having a substance abuse disorder. Singleton, Meltzer & Gatward (1998), in examining co-morbidity in prisoners, found that while only one in ten were free of any mental disorders, only two in ten only had one disorder. This means that the large majority of prisoners would be considered to have a dual diagnosis. O'Grady (2001) makes the point that these kinds of prisoners, with dual diagnosis, face even greater problems to getting the right treatment, partly because of the system, and partly because of the difficulties in treating dual diagnosis.
One part of the The Models of Care (DoH, 2002b) document that is relevant for dual diagnosis patients is the Counselling Assessment Referral Advice and Throughcare (CARAT) services. This service is aimed at the treatment of those with substance misuse disorders, from which many dually diagnosed prisoners suffer. These services are to be provided by specialists external to the prison system who work on identifying needs, talking to a variety of agencies and using counselling as a therapeutic intervention with the prisoner. While this step forward is better than nothing, there are two reasons for the inadequacy of this programme. As O'Grady (2001) points out, one of the most significant omissions is the abuse of alcohol, perhaps unsurprisingly, a very common substance misuse disorder amongst prisoners. The second flaw is that the Department of Health (2002a) calls for the use of integrated care pathways - a single clinician dealing with a patient's dual diagnosis - the CARAT scheme is failing to address this, and in fact working in the opposite direction. O'Grady (2001) cites Drake, Mercer-McFadden, Mueser, McHugo & Bond (1998) who argue that while the evidence is not yet strong for integrated care pathways, the evidence, such as it is, suggests that this will provide the best outcomes in the long term.
The other main type of rehabilitation going on in prisons, as described by O'Grady (2003), is that aimed at reducing re-offending. The advantages of these sort of programmes are clear, if they are effective, but the problem is that, as can be clearly seen from the evidence here, many of the prisoners have quite severe mental health problems and are probably unable to benefit effectively from these programmes. O'Grady (2003) provides some examples of those groups: those with personality disorder make up a large percentage of those with mental health problems, and this can limit the group work that can be carried out. Similar problems - social, cognitive and learning disabilities - will also limit the benefits of these programmes to many other prisoners.