Dual diagnosis discourse and narratives in the State of Victoria, 1985-2012
2017-05-24T06:35:50Z (GMT) by
Health services are more effective if they are coordinated around the person, family or community. Frequently they operate in silos determined by diagnosis. Many people with mental health problems also have problems with alcohol and other drug (AOD) use, and vice versa. The coexistence of such problems has been variously termed ‘dual diagnosis’, ‘co-occurring disorders’ or ‘comorbidity’. In recent decades attention has been drawn to the problem of fragmented services for people considered to have a ‘dual diagnosis’. A dual diagnosis discourse has developed around the proposition that there should be ‘no wrong door’ when people seek treatment or support. Services specialising in either mental health or drug and alcohol treatment should recognise assess and respond to co-occurring problems. Little research attention has been paid to the historical and cultural impediments to the ‘no wrong door’ approach. The thesis asks: Why did dual diagnosis discourse emerge? How did it evolve in the two specialist sectors? What are the implications for service users/consumers, services, professions and governments? How has the discourse played out in the context of an espoused vision of person-centred care, rather than care organised around disciplinary and service structures? The research, focusing on the State of Victoria since 1985, involved a qualitative exploration comprising six stages: a review of research literatures; collection and analysis of government policy documents; in-depth interviews with key informants, purposively selected to offer varied perspectives from the level of policy development and service leadership; feedback of findings to these informants for validation and further comment; synthesis of findings into papers for peer review; and final refinement of conclusions in the submitted thesis. I found that dual diagnosis discourse emerged in Victoria at a time of greater differentiation between services. Deinstitutionalisation was a part of this but further contributors were greater managerialism, the allocation of funds according to diagnosis, professional turf issues and a broadening of the scope of mental health and AOD strategies to encompass mild and moderate as well as severe conditions. ‘Capacity-building’ characterised the discourse and strategies through the 1990s and 2000s, entailing top down and bottom up change management that challenged over-specialisation and offered leadership, networks and a focus for achievement. The mental health and AOD sectors both made at best incremental progress towards a ‘no wrong door’ service culture. Still to be resolved are enduring therapeutic pessimism, particularly in the acute mental health sector, cultural clashes between sectors, and enduring social stigma. The thesis contributes to the body of qualitative research on the history and course of efforts to develop appropriate care for patients who are considered to have alcohol and drug problems and other mental health disorders. More broadly, the thesis illuminates the development and implications of a medical construct over time in a particular context. It adds to the evidence for improving quality control and interdisciplinary, intersectoral workforce development with a focus on patient strengths and recovery within an integrated health and social support system.