Organisational issues

Organisational barriers to accessing services for people experiencing COMHAD may include remote locations, lack of flexible opening times, discharge policies for nonattendance, minimal adaptation to provide outreach or afterwork services and high diagnostic entry thresholds. Historically, most mental health services in England have been commissioned by NHS England, while substance use services are usually commissioned by local authorities. This creates multiple access points across services within a geographical region (Hamilton 2014, Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group 2017). As an example, at the time of writing there were two mental health providers and five different substance use providers in the ten local boroughs across one of England’s largest cities. For service users with COMHAD who may move around a region due to being homeless, it can be daunting to achieve timely access to services.

In addition, communication between services can vary. For example, some areas have shared IT systems which can benefit inter-service communication, others may only have information-sharing agreements, and some may have no formal arrangements. Similarly, staff taking up roles in another region or service can take time to learn how local services work. Overall, there is no ‘one system model’ for people experiencing COMHAD, which can adversely affect care pathways and the way service users navigate services (Hamilton 2014).

Philosophy of care

The philosophy of care in some services can present a challenge for service users experiencing COMHAD. For example, historically it is the responsibility of the individual service user to seek out substance use services (unless mandated by a court). This means that, in general, the person is required to recognise that they have an alcohol and/or drug use issue and show a desire to address it. The same applies in primary care level mental health services such as NHS Talking Therapies (NHS 2022), whereas staff in tier two mental health services, such as community mental health teams or social care, can explore a person’s mental capacity and, if necessary, use legislation such as the Mental Capacity Act 2005 or the Mental Health Act 1983 (as amended 2007) to safeguard them.

Interactions between staff from different services, who must attempt to determine which person should be in receipt of which service and for which risks, can increase the challenge of accessing services for people experiencing COMHAD. Similarly, discrepancies between staff members’ perceptions of who should be involved in a service user’s case can at best create delays to treatment and at worst create exclusionary factors; for example, where an individual without a defined mental health diagnosis might not be accepted into mental health services because of their substance use (NCISH 2022).

Staff knowledge, negative attitudes and stigma

Mental health nurses may encounter a significant number of people who use drugs or alcohol during their career, yet their undergraduate nursing degree programme may only have included a limited amount of study on substance use. Similarly, frontline staff in substance use services, for example recovery coordinators, may not be trained in caring for people with mental health issues. This lack of knowledge, alongside limited access to training and inadequate resources, can result in staff in drug and alcohol services developing negative attitudes towards people experiencing COMHAD (Hamilton 2014).

People with COMHAD are also known to experience stigma in a number of ways (Lloyd 2010, Krausz et al 2014). For example, Alcohol Change UK (2019) emphasised how frontline practitioners’ perceptions of alcohol consumption as a ‘lifestyle choice’ negatively affected their readiness to explore service users’ issues fully. This reluctance on the part of practitioners could negatively affect service users’ attitude towards attending or accessing services.

Additionally, service users may experience ‘othering’, which can be described as the act of treating someone as though they are not part of a recognised group or as ‘different’ in some way. This can apply to people with COMHAD, with some healthcare staff regarding alcohol-related issues as ‘self-inflicted’ and beyond their remit of care delivery. Any assumption that alcohol use is an example of a person exercising ‘free choice’ is unhelpful and should be challenged by nurses who encounter it in their colleagues (Alcohol Change UK 2019).

Navigating change

In health and social care settings people experience turbulence in their life because of change. This may be a change in their mental health (often relapse and remitting conditions), or changes in substance use. Where both conditions co-occur, a person may have found equilibrium. At the same time a person’s life situation is dynamic. One way of understanding change is to explore a person’s feelings, thoughts and attitudes about it. This is a shift away (but not a complete divergence) from a medical perspective, one which can be understood by Prochaska and DiClemente’s (1984) transtheoretical model of change. Whether a person is pre-contemplative towards change (unaware of a problem and/or not wishing to change), contemplative to change (in ‘two minds’), determined (taking steps) or maintaining a change, rather than passing through these stages sequentially, any change experienced by a person with COMHAD is likely to be non-linear because of the multifaceted determinants. Therefore, the nurse should seek to engage with the person on their terms, or in other words ‘where they are’ in terms of change.

A common trope in services is that staff should meet people ‘where they are at’. Attempting to understand the thoughts, feelings and values of a person experiencing COMHAD through compassion and empathy can guide the nurse’s clinical practice, which may include the use of techniques such as motivational interviewing (NICE 2011, Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group 2017). Ahn and Wampold (2001) reported that the effectiveness of any specific psychological intervention is probably due to general factors, such as the therapeutic alliance, rather than treatment specificity. To draw on motivational interviewing, Miller and Rollnick (2013) explained that this is a style and set of skills for tackling diverse challenges through the development of a partnership or alliance with a person.

Motivational interviewing

Motivational interviewing is a way to have a conversation about change which seeks to strengthen a person’s own motivation and commitment to change. Motivational interviewing is an intentional move away from a ‘righting style’, or well-meaning advice, deliberate correction, or judgement of a person’s choices and subsequent behaviours. It relies on partnership through collaboration, acceptance through empathic listening and a demonstration of non-judgemental attitudes. It is an active process of compassion and empowerment through ‘calling forward’ the wisdom and best advice from a person a nurse is supporting. It is the belief that resources to change lie with the person. The nurse’s desire to help, reflexivity to fix and ‘make people better’ though well intended can remove a sense of autonomy from a person seeking support (Miller and Rollnick 2013).

Meeting people where they are at requires a responsiveness to the changes observed. To draw on a metaphor of guiding or walking alongside a person is to reflect – does this person even wish to walk with us? Where are we going? Why are we going there and how may we get there? The first question here fits with the model of change. Until there is a desire, ability, reason or need to change, how can we know the direction of care to provide. A person may not be ‘lacking in motivation’ to stop using substances, rather they are more motivated to use substances than stop. There is tremendous value in understanding what this motivation is. To reduce this to a simple dichotomy of ‘motivation’ or ‘unwise decisions’ and ‘lifestyle choice’ does not meet people where they are at, or account for the complexity of a person’s ambivalence. There are a multitude of interventions that nurses can adopt for those who may not be considering change and at any stage. ‘They didn’t want to engage’ cannot effectively be stated unless a trauma-informed approach considering harm reduction, pre-engagement style development of trust, outreach, brief advice, longitudinal assessment of capacity, safeguarding and consistency in approach has been explored in the first instance.

Motivational interviewing provides not only the approach and attitudes essential in developing an alliance with people, but also a way to put this into practice. It is common to hear staff talk in an empathic manner about people they have supported. It is the active communication to the person being supported of these thoughts and considerations that shows there is a willingness to ‘meet them where they are’. This takes a degree of curiosity which emerges from an ability to see the world from that person’s perspective (empathy). This is demonstrated through open questions; enquiry that draws on a narrative, an exploration of strengths, challenges, resources, barriers (‘Help me understand what this has been like for you?’). By responding to the strengths the nurse hears, a person’s resources are affirmed, which can help identify strengths as a positive attribute that can now be used to help them on their journey (‘You’ve overcome challenges in the past’). The nurse can develop their active listening skills to be reflective to what they are hearing. A desire to understand a person’s meaning from what they communicate is a demonstration of compassion and empathy (‘You’re frustrated you find yourself in hospital again’) and often a deeper meaning can be found as a result. Reflective listening is a skill that takes a short time to understand but lots of practice to feel at ease with. Motivational interviewing supports listeners to summarise where a person is – their hopes, fears, challenges, strengths and a richer understanding of their experience. It is only then nurses can start to claim to have met someone where they are at (Miller and Rollnick 2013).

The nurse can then move forward (and sometimes step backwards) together with people, with permission, with agreement, with a sense of trust and collaboration. Through neutral and non-judgemental enquiry, the nurse can evoke reasons and hopes and resources for change and weigh these against fears and concerns of not changing. The nurse can provide options or choices and explain what the next turns may look like at a person’s own pace. Training models for all staff should focus on the importance of interviewing skills, establishment of a therapeutic relationship and common factors as the bedrock of skills to become an effective practitioner (Ahn and Wampold 2001).

A capability framework for working effectively with people experiencing COMHAD describes the values, knowledge and skills required and may be useful for nurses as a skills development tool (Hughes et al 2019). The capability framework includes a reflective self-assessment for healthcare professionals in areas such as (Hughes et al 2019):

Collision of complexity

At the beginning of this article, the author referred to a collision of complexity between people experiencing COMHAD and service provision. To begin to address this, the author would argue that nurses and other health and social care staff should challenge the idea that service users’ COMHAD issues are incomprehensible; additionally, the author would suggest that these services should ‘hold’ cases until agreement is reached on the most appropriate service for that person at that point in their care journey. In the author’s view, the real complexities lie not with individual service users but with health and social care services’ collective inability to respond accordingly. Understanding this complexity may involve these services reflecting on the challenges they have experienced in the past in delivering effective, multiservice, person-centred care and support to this patient group.