The term dual diagnosis has been used to refer to the co-occurrence of mental health disorders and problematic substance use. The term has been linked with efforts to improve the interfaces between service delivery systems that have different philosophies, models of treatment and resource bases. This thesis employed the Social Ecological Model in a project that investigated community-wide issues relating to improving service delivery to people living with dual diagnosis across Southern Victoria.
Over a period of twenty-eight months, 226 representatives from service providing agencies, carers and consumers participated in the development and implementation of this community project. The project took place over three phases. The Phase 1 study involved Participatory
Action Research (PAR) that engaged stakeholders in the generation of an explanatory model concerning the state of service delivery to the target population encompassing multiple levels of social ecological analysis. A series of focus groups produced 108 statements describing what can be done to improve the system’s capacity for working with complexity generally and dual diagnosis specifically. The Phase 2 study then focused on developing an ecologically relevant program to improve system responses. The resulting program involved three elements: (a) training and education, (b) consultation and mentoring, and (c) system and program development. The Phase 3 study then evaluated the effectiveness of the resulting interventions using a combination of a three (treatment groups—brief training, multi-session training and multi-session plus mentoring) by three (times of testing—pre-training, post training and three month
follow-up) quasi-experimental design and systematic community observations.
Qualitative themes analysis of statements generated in Phase 2 yielded four core priority areas for intervention. These were: (a) reducing system fragmentation, (b) improving integrative case management practices, (c) improving community attitudes, and (d) addressing the lack of money and resources. Evaluation of the training intervention showed that, consistent with previous research, a three-day training program enhanced workers attitudes and self-efficacy for working with dual diagnosis. This improvement was maintained at the three-month follow-up, whereas a control group that received a more standard one-day training workshop had returned to baseline levels. The inclusion of supportive follow-up and mentoring was not found to produce additional benefits. Improved attitudes and self-efficacy did not result in improvements in
collaborative work practices of individual training participants. At the broader systems level, agencies that participated in the training and mentoring were found to have made considerable progress towards developing structures and processes for improving inter-sectorial linkages in the interest of delivering a more comprehensive continuum of care. The number of service initiatives targeting complex needs was found to have grown considerably through the life of the project. As the number of programs increased, the ratio of collaborative interconnections was found to have declined. This and other structural factors were identified as major targets for future evaluation cycles of the project.