Doubling Down

‘Mental health co-morbidity is the rule, rather than the exception,’ EUDA scientific analyst João Vian told the Understanding dual disorders webinar. ‘And these patients fall through the cracks in the systems of care.’ 

People with dual disorders also tended to have worse prognoses, both clinical and social, said Francina Fonseca of the Parc de Salut Mar hospital in Barcelona. They were more likely to relapse, experienced higher suicide rates, and had more medical co-morbidities, including hep C and HIV. They were also more likely to be unemployed and experienced more social exclusion, she added, facing stigma from both their drug use and mental health issues.

Substance use and severe mental health problems were very often combined with factors like unstable housing, social isolation, trauma and violence, said post-doctoral researcher at Ghent University, Clara de Ruysscher. ‘These are not separate boxes – they interact and reinforce each other.’ People could end up in self-reinforcing cycles of instability and exclusion, she said, and it was not so much that these people were ‘hard to reach’ – more that they were often easy for systems to ignore.

So what worked? Recovery wasn’t just something that ‘happens inside an individual or inside a treatment programme’, de Ruysscher said – ‘it’s also something that’s made possible through places, relationships and everyday practices’. One place doing very good work in this area was Villa Voortman, a low-threshold, community-orientated meeting place for people with co-occurring substance use and severe mental health issues who had often lost contact with traditional services. Established in 2012, it was based in a previously derelict villa in Ghent. 

The villa was open Monday to Saturday, with around 25 people visiting each day. ‘They come voluntarily, which is important to mention, and they may stay for a short time or the whole day,’ she said. ‘Rather than patients or clients, we call them visitors – they can take part in activities, or just be there. Human encounter is really at the heart of the practice. I’m not trying to say that nothing professional or therapeutic happens, but not every encounter is conditional on a treatment goal.’ 

Staff helped with issues like housing and building broader networks for the visitors, while creative activities like music, theatre, writing, art and cooking were woven through the villa’s daily life. Many of these were instigated or run by the visitors themselves, with some of the theatre productions even making it to major festivals. ‘These are not just “nice” activities on top of the real care, they’re among the central ways in which people meet and become visible beyond their diagnostic identity.’ This meant that Villa Voortman was not just a place to be, she said, but a ‘place to be me’.

No one was required to follow a pre-determined therapeutic programme, she stressed. ‘They can take part, withdraw, return – they can choose what matters to them.’ Contributing to the daily life of the place meant people could become more than ‘a diagnosis or collection of risks’, and reveal parts of themselves that had previously been obscured by stigmatising labels or negative treatment experiences. Half of the visitors were homeless or in unstable housing, while a third had a history of incarceration, she added.

When interviewed, the visitors repeatedly said how much they felt welcome and that they belonged, she said, with certain areas of the house becoming ‘real hot spots’ where rituals like cooking, making coffee or washing the dishes together helped to provide rhythm and familiarity and foster a genuine sense of community. 

‘But of course hospitality hasn’t made those complex needs disappear,’ she stated. People frequently brought very urgent problems to the villa – housing crises, severe psychological distress, physical illness, legal problems – which the staff of course did not ignore. But her analysis had shown that the ‘homely rituals of the villa could act as a counterweight to the survival rituals of the street’, where daily life was often organised around finding shelter, avoiding danger, managing withdrawal or obtaining substances. 

‘The cooking, the eating, the talking, the music making don’t magically remove poverty, homelessness, psychosis,’ she told the webinar. ‘But they temporarily interrupt survival mode and make room for another rhythm, another way of being. It’s a soft effect, but a significant one.’  

Continuity was vital, she stressed. People with dual diagnosis and complex needs needed places and relationships they could return to, including during relapse, in a crisis, or after disengagement. Villa Voortman was not a model to copy into every service, she stated. ‘It’s not that every treatment team should become an arts collective – I see it more as an invitation to open up space within our existing systems of support.’

When dealing with people with dual diagnosis, it was vital to ensure that everything was in place before any planned admissions, said Prof Narayanan Subramanian, national clinical lead for the Irish Health Service Executive’s (HSE) dual diagnosis national clinical programme – the ethos of which was all partners working closely together to ensure the best integrated care. 

The programme used a ‘full quadrant’ model – making sure that its referral pathways were not so narrow that they excluded people who had substance use issues but not the most serious levels of mental illness. ‘So we’re not ignoring anyone.’ The programme had already established adolescent dual diagnosis teams and was also hoping to implement a pilot service in prisons – where there was a ‘significant need’ – before the end of the year, he said. 

Referrals to the programme came from both mental health and substance services, with many people having been under the care of both for some time. If someone was admitted in a crisis overnight, for example, ‘we will get the referral. The patient will still be under the care of the community mental health team, but we’ll provide tertiary support – detox, stabilisation, signposting to residential rehabilitation, and if they need funding we’ll support with that.’ It wasn’t about one team dealing with one person, but different teams working together, he stressed.

‘We all know that one service cannot provide everything,’ he said. ‘We can only provide the best care if we work together,’ and the programme worked closely with voluntary bodies, community mental health teams, maternity services and more to always ensure the best achievable care. There were obviously challenges, however. ‘We’re so used to working in a silo nature, but we are breaking down the barriers as we progress. We’re moving forward with the support of everyone, and we’re hoping this could be a model for across Europe in how to develop integrated care with all the stakeholders and provide the best possible service for our patients.’ 

The Irish government had also been ‘excellent’ in providing resources, he said, while Villa Voortman received money from a linked psychiatric hospital and Ghent’s city council, alongside donor funding and subsidies for its arts projects. ‘It’s important that we campaign for governments to realise the importance of dual diagnosis services, and the need to fund them properly,’ Subramanian urged – having seen many services that were doing excellent work ultimately fail through lack of money. 

‘We’re often not very good at doing this, but we need to sell ourselves. And sell the huge cost benefits to the whole system.’  DDN