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Dual diagnosis narratives and their implications for the alcohol and other drug sector in Australia.

The context of this article is a movement, during the last 20 years, towards better treatment and care, and a reduction in system-related barriers, for people with both substance use and mental health problems. This condition is variously known as "dual diagnosis," "co-occurring disorders" or "comorbidity," among other terms. Problems associated with dual diagnosis entail diverse and complex physical, psychological and social difficulties for a wide range of people (see, for example, Teesson, Slade, and Mills' report on the Australian National Survey of Mental Health and Wellbeing [2009]). Health systems that are designed to deal with one problem at a time struggle to provide coordinated, seamless services (Staiger, Long, & Baker, 2010). Jurisdictions in Australia, Canada, the United States, United Kingdom and elsewhere have developed specific policies and initiatives aiming to build dual diagnosis capacity across the mental health (MH) and alcohol and other drug (AOD) sectors, so that both can respond more effectively.

The conversations, stories and documents associated with such work form a discourse which invites analysis. This article, a case study of the State of Victoria, Australia, examines the implications for the AOD sector of the emergence of dual diagnosis discourse and its role in service system improvement. We draw on interviews with key professionals concerning their experience of the health system's response to dual diagnosis. Informants note that dual diagnosis discourse has influenced the general quality of service provision in the AOD sector but perceptions of its value differ. Through analysis of the informants' interviews we have identified three narratives of dual diagnosis and AOD service provision: a "progressive narrative," which provides an optimistic picture of major and continuing improvement; a "remedial narrative" has change of improvement from a low base; and a "radical narrative" in which dual diagnosis is a narrow, perhaps distracting, concept in the context of the need for fundamental structural change. We conclude that dual diagnosis discourse has added value to the AOD sector by providing a focus for quality improvement. The common implication of all three narratives is, however, that the initiatives so far taken are not enough in themselves to secure welcoming services and overcome the structural barriers to treatment, support, and social inclusion of people with dual diagnosis. The barriers for people with dual diagnosis are symptomatic of the challenge of providing person-centered care.

Background

The following contextualizes the history of dual diagnosis by introducing two key factors in contemporary discourse. First, we problematize the use of the term dual diagnosis. Second, we outline the context of policy development by tracing the history of the use of the term in dual diagnosis initiatives in Victoria, Australia.

"Dual diagnosis"

How "dual diagnosis" is understood in practice varies widely and rests on contested foundations. The body of epidemiological and clinical literature on dual diagnosis has burgeoned since the late 1980s. Few researchers have challenged its findings on prevalence and the need for the integration or better coordination of the specialist mental health and AOD treatment systems. Frederick Glaser (1993) in a commentary and Robin Room (1998) in a review of the evidence are among the few suggesting that greater (attempted) precision of diagnostic criteria and the intrinsic overlap in symptomatology between AOD and MH problems means that more co-occurrences of mental health and AOD problems are being identified. They therefore note the likelihood that some artefactuality is built into the measurement of dual diagnosis.

The issue of problem definition is not confined to psychiatric diagnosis. There is ongoing tension among moral, psychiatric, and general medical perspectives on AOD problems, which are variously conceptualized as psychiatric disorders, physical disorders, and personal choices. They appear, for example, in the Diagnostic and Statistical Manual of Mental Disorders (DSMV) (American Psychiatric Association, 2010) as a category of mental health disorder, and in the International Classification of Diseases (ICD-10) (World Health Organization, 1993) variously in mental and physical classifications. A recent survey of people living with psychosis in Australia (Morgan et al., 2011) reports on AOD use and problems entirely as part of "physical health and at-risk behavior" and not at all as a comorbid mental health problem. And while mental illness, particularly depression, has become somewhat less stigmatizing as a result of high profile campaigns, drinkers and drug users continue to be marginalized (Talmet, De Crespigny, Cusack, & Athanasos, 2009).

It is unsurprising that dual diagnosis is a vexed discourse, when there are multiple concepts of mental health and illness, of AOD use, misuse and harms, and, even within the hegemonic clinical discourse, dual diagnosis encompasses many possible combinations of mental, physical, and social problems.

The term also becomes synonymous with the structures and workforce specializing in dual diagnosis treatment.

Dual diagnosis in Victoria

The term dual diagnosis in its current usage in Victoria emerged during major developments in the public Victorian mental health and drug systems, which matched the international deinstitutionalization trend towards locally accessible services. Large psychiatric hospitals were closed between 1988 and 1998, and a range of community-based services took over (Gerrand, 2005; Meadows, Singh, & Grigg, 2007). The government also reorganized AOD services, contracting them out to nongovernment organizations and mainstreaming them with community and general health (Department of Human Services, 1997). Victoria differed somewhat from other Australian states in its less medicalized and wholly non-government specialist AOD workforce without funding for addiction medicine and addiction psychiatry support. Throughout the process of restructuring, mental health services and AOD services were (in Victoria as well as the rest of Australia) conceptualized as separate systems. It has often been claimed (e.g., Lubman, Hides, & Elkins, 2009) that the problem of dual diagnosis is essentially one of a dual system.

Dual diagnosis was not an apparent issue in the restructure, although warnings existed: Much seminal research was published in the late 1980s highlighting people's experience of dual diagnosis and the need for a more integrated response (e.g. Carey, 1989; Drake & Wallach, 1989; Minkoff, 1989) and there was a brief assertion in the 1994 framework for Victorian mental health services (Department of Health and Community Services, 1994) that services "should not engage in buck-passing" but build in work with AOD agencies. From the later 1990s, however, pilot dual diagnosis projects were funded, followed by longer-term capacity-building initiatives. The Victorian Dual Diagnosis Initiative (VDDI) focused on both sectors while the National Comorbidity Project (Teesson & Burns, 2001; Teesson et al., 2009) targeted the AOD sector alone. In 2007 the state government mandated mental health and AOD services to become "dual diagnosis capable" (Department of Human Services, 2007).

A large proportion of dual diagnosis capacity building was based on the view that the AOD sector in particular was in need of remediation. Yet the Victorian Auditor General (2011) recently found that, overall (and irrespective of co-occurring mental illness), the AOD treatment service system had not met its objectives of effective case management, continuity of care and consistent high quality services. It remained difficult for clients to access and navigate, and did not provide seamless pathways to other health and social support services. In the same year, independent evaluation of the VDDI (Australian Healthcare Associates, 2011) found that, while the initiative had had a dramatic impact with regard to building recognition that "dual diagnosis is everyone's business," there was far less progress on integrated care and collaborative practice. More capacity-building was required. On a more positive note, a 2009 evaluation (AIPC) of dual diagnosis treatment models in 17 Australian services (six of which were in Victoria) found that AOD staff were better qualified and had better links with MH services than was suggested in the research literature.

In summary, attention to the concept of dual diagnosis in Victoria has grown in the last 20 years from small beginnings in the aftermath of deinstitutionalization. Problem definition has been an enduring issue affecting the search for solutions. Today there are several separate streams of action: state-funded capacity building for both mental health and AOD sectors, and national funding allocations for AOD organizational improvement, for research and for training. According to audit and evaluation findings, however, improvements in service access and coordination were limited.

International qualitative literature on dual diagnosis is relatively sparse, compared with epidemiological and clinical studies. Consumer perspectives on service system responses to dual diagnosis agree that a positive, client-centered therapeutic relationship is key, and better service integration, communication and cross-training are required, to redress shortcomings in holistic care (Kavanagh et al., 2000; Russell, 2009; Staiger et al., 2010), although David Webb (2009) cautions that consumers may not trust an AOD service with close links to MH as there may be a greater risk of coercion into involuntary MH treatment. An Australian study with young service users with a dual diagnosis (Russell, 2009) noted that the AOD services were experienced as more supportive, more personal, and less formal than MH services. Kavanagh and colleagues (2000) found that intersectoral liaison was more difficult for AOD staff than for mental health staff. Service providers in American, United Kingdom, and Australian studies of clinicians highlight the emotional impact of working with complex problems for which solutions are unclear or unavailable: the words "frustrated," "helpless," "hopeless," and "powerless" recur (Coombes & Wratten, 2007; Deans & Soar, 2005; Mericle, Alvidrez, & Havassy, 2007; Rosedale & Strauss, 2010). Systemic negativity about people identified as having a dual diagnosis, who are seen as a low political priority, is consistently noted (Carey, Purnine, Maisto, Carey, & Simons, 2000).

These studies from several continents typically end with recommendations for routine screening and assessment, improved coordination or full integration of services, and a range of workforce development strategies. This article makes a distinctive contribution in critically inquiring into continuing tensions in the dual diagnosis discourse in a jurisdiction which has begun a number of these recommended improvements over recent years.

Approach

Our approach to examining the dual diagnosis phenomenon in the Victorian AOD service sector assumes that understanding and honoring the perspectives of "meso" level stakeholders will illuminate the space of dual diagnosis, inform the field, and help overcome unnecessary barriers to effective action. Stakeholders at the policy and service provision level tend to be overlooked in qualitative health research, where the voice of the patient/consumer/client experience is more often heard, and they are in some ways another "hidden population" (Berridge, 2000).

The contribution of qualitative research is, through a detailed description of a phenomenon placed in its social/cultural context--"thick description" (Geertz, 1973)--to illuminate the problems of system fragmentation as they are lived. We use discourse and narrative as analytic lenses. We understand dual diagnosis discourse to be the spoken and written language used in a variety of forms to create and develop the concept of dual diagnosis and to give it a distinct identity (Phillips & Hardy, 2002). We follow narrative analysts (Mishler, 2005; Riessman, 1993; Roe, 1994) in noticing narrative components (such as a structure with a plot, characters, and a beginning middle and end) and in paying close attention to the way in which explicit and implicit narratives in the discourse create contrasting realities. Another advantage of narrative analysis is that it encourages the researcher to avoid extracting disembodied content and to place in context the whole story (both the stated and the implied) that the participant is telling. Narrative analysis offers a navigational aid in the complexities of dual diagnosis, guiding a path between post structuralism and the prevailing essentialism of the dominant clinical research literature. As Eliot Mishler (2005) (citing Charles Briggs) reminds us, differing narratives create, sustain, and mediate conflict, without eliding or suppressing it. Applying narrative analysis to the study of complex, uncertain and polarized policy problems, Emery Roe (1994) recommends extracting a "metanarrative" from stories and counter-stories which can be, even temporarily, a stabilizing influence on decision making and can combat "weary pessimism" about solutions.

Method

This article, part of a larger case study of the evolution of dual diagnosis policy and practice in Victoria, Australia 1985-2010, draws on interviews with 19 key informants. Participants were purposively sampled (Patton, 1990) to enable the research to tap into narratives of experience from different subsectors of the field and thus to document diversity. Based on knowledge of the field the first author developed a list of 60 potential participants, cross-referenced by gender, discipline, experience in one or more relevant roles, and by degree of involvement with specific dual diagnosis initiatives. She ranked them in order of priority for interviewing based on their involvement with dual diagnosis work and to maximize diversity of well-informed perspectives. Seventeen interviews were conducted and a further two as a result of recommendations by participants. Answers to a "snowballing" question at the end of each interview confirmed that the sample was basically well founded. After preliminary analysis of 19 interviews the first author determined that saturation had been reached: the transcripts contained enough varied insights to enable interpretation and illuminate answers to the research questions, and little new material was emerging.

The informants had experience in mental health service provision (MH), psychiatric disability rehabilitation and support, or alcohol and drug (ADD) treatment. They included consumer-researchers, nurses, occupational therapists, psychiatrists, psychologists, and social workers, with their main roles defined as current or former state government policy executives (three), consumer advocates/researchers (two), or service managers and clinicians (fourteen). All the service managers had a background in a health profession.

Semistructured interviews (lasting between half an hour and 2 hours) sought narratives of relevant experience over recent decades. Topics included key turning points, the interrelationships of relevant service sectors, and views on the "winners and losers" in dual diagnosis discourse. The interviewees read and validated the transcripts of their interviews. Through analysis of themes and narrative threads (using manual data management techniques and QSR NVivo computer software), we developed key propositions relating to the reasons for and consequences of the emergence of dual diagnosis discourse, and invited the informants to respond to these in writing. Thirteen (68%) responded. This article presents and discusses all responses as they relate to the AdD sector. The research was approved by Monash University Human Research Ethics Committee.

Results: Informants' views of the consequences of 20 years of talking about dual diagnosis

This section will describe and illustrate major threads in informants' contributions. It begins with informants' perspectives on the problem of the unstable ground beneath conversations about dual diagnosis before identifying three narratives, here labeled progressive, remedial and radical.

The problem of definition

Definitions of dual diagnosis vary and each tends to be situation specific. Informants demonstrated this in their narratives and many, as in the following example, recognized the multiplicity of definitions as a problem:

The two service systems think of things quite differently. If you talk about dual diagnosis and you're sitting in a psychiatric inpatient unit, they are talking about people who are psychotic who are using heroin and drinking themselves to death. They don't think beyond that. Mainly they don't see people with lesser problems. Talk to people in the AOD sector and either they are talking about that group, because they are so unable to assist them in a safe and expert way and they can't do anything with them (they think "this is not our responsibility" but can't get them in anywhere else) [or] that great big group that we know about with anxiety, depression and so on (KI 41 (1), manager).

This informant points to a narrowness of focus in acute psychiatric wards, in contrast to the AOD sector's experience of seeing people experiencing problems at almost any point on the spectrum of symptom severity. Another informant agrees that mental health services focus on psychosis rather than other mental health problems:

They are not really psychiatric services, they are psychotic services. You even have some people in psychiatric services who don't think of nonpsychotic disorders as being psychiatric disorders--they've become that narrow (KI 5, clinician).

In figurative terms:

I think it's the fact that we're both talking about different ends of the elephant: even though we both love the elephant, we're talking about different ends, that makes our life very difficult (KI 16, policy executive).

The classic metaphor of the blind men touching different parts of an elephant and each creating a different image of the whole entity works to emphasize that multiple perspectives exist and should be communicated as such. Further, there are differing views about patient/client rights:

We are caught a bit between our ideas of patient autonomy (so if I choose to wreck my brain or wreck my body it's my right to do so) and a paternalism that says we should be assertively looking after people's physical health as well as their drug and alcohol health as well as their mental health. If you want to be helped, that looks good. If you don't want to be helped, or if you are on the margins of society or you are one of the vulnerable, then that means you really get dropped by the wayside. What I'd say is we now need to be clearer in a policy sense about what we mean by "assertive" and what we mean by "access to services." It's not just their availability, it's also what happens to you when you access them, whether you are engaged with them--and it clearly crosses with primary care (KI 16, policy executive).

This informant names polarities in dual diagnosis discourse: individual rights (to use drugs or not, to seek help or not) and the professional's duty of care (to allow risk taking or to assert control) and invokes the moral concept of the deserving or undeserving sufferer. Such issues--rights, social justice and social inclusion--go far beyond the duality of mental health and AOD systems and diagnoses.

Three narratives

Turning to the three dominant narratives identified in analysis of informants' responses, there follows a synthesis of views on the ways in which a focus on dual diagnosis has (a) transformed the sector, which we have labeled the progressive narrative, (b) aided it to some limited extent, a remedial narrative or (c) missed the point and distracted attention from bigger-picture issues, the radical narrative. After each narrative, we summarize informants' counterarguments.

The progressive narrative

The progressive view is that the move in AOD agencies towards willing and able screening, assessment, and treatment for mental health problems has gained real momentum across the state and has transformed it.

It's lifted the sector. They were lifted kicking and screaming, but that's been good--it's helped them to be more professional (KI 19, clinician).

The narrative began in the 1990s with dual diagnosis "champions," clinicians acting as role models, leading special projects and attracting funding for ongoing development, with the help of supportive individuals in government departments. In this view, the sector is still at a stage of partial improvement but there is little reason to doubt that, as a whole, it is approaching a uniformly better condition than 20 years ago.

Indeed, in this narrative, raising the capacity to deal with dual diagnosis will have benefited all clients, not only those with co-occurring mental health problems: the standard of screening, assessment and treatment has been raised and staff are better able to apply the techniques of secondary consultation, case coordination, and case management. Further, the processes of capacity building and facilitation of change have been and will be transferable to service delivery improvements for other neglected population groups, such as young people, families of service users, or people with acquired brain injury. This is generally the view held by people who have been closely involved with dual diagnosis projects and initiatives. One informant, for example, sees dual diagnosis as a step towards creating a system where multiple needs are addressed:

I think we are moving to a focus on complex needs rather than just mental health and substance use ... looking at people's plethora of needs [with] no-wrong-door service systems, much more effective models of early recognition and intervention with youth (KI 2, clinician).

The progressive narrative thus begins with pioneers and ends with the enlightenment of the AOD sector and beyond. Dual diagnosis discourse is recognized as having led the way.

Rebuttals to this view invoke the perceived "tokenism" in the implementation of dual diagnosis activities in the AOD sector, referring to inadequate investment in improving the response to people with mental health problems and general underfunding across all AOD sector functions. They also question the expertise of dual diagnosis specialists (KI 6, KI 15, clinicians). Others refer to the opportunity costs: dual diagnosis-specific work is seen as marginal to the AOD sector's needs, and can mean that other issues (such as physical health comorbidities, social exclusion, finance, housing) receive less attention (KI 4, KI 7, service managers). This counternarrative also rejects the idea that the learning is systematically diffused across the AOD sector. The reality, some informants emphasize, is more haphazard:

It does go well in some places for a while and that depends on the luck of having the right people in the right place and the right resources. The system doesn't seem to be able to identify that and encourage and reproduce it ... it's not so much about dual diagnosis itself it's about the whole health bureaucracy (KI 5, clinician).

This informant had earlier talked about the way the temporary presence (owing to a project grant) of a psychologist and a psychiatrist in an AOD service had led to identification of "a lot of people who had undiagnosed psychoses, who did much better when we treated them [for their substance use problems]" (KI 5, clinician). Similarly the 2011 Victorian Auditor General's report on the running of the AOD system (Victorian Auditor-General, 2011, p. 24) heard from service users that once they gained access to the service system there was a tendency for service providers to rely on personal contacts when making referrals. This meant that if the client saw a less experienced (and therefore less well connected) worker they were not assured of getting appropriate referrals to other services and supports. This supports the view that treatment in this AOD sector depends more on chance than good systems and challenges the story of dual diagnosis capability suffusing the sector.

The remedial narrative

Another perspective revealed in analysis of the interviews emphasizes the intrinsic limitations of the AOD sector and points to dual diagnosis discourse as one agent in helping to improve its quality. This narrative begins with the observation that the workforce is not professionalized (especially in comparison with clinical mental health services) and that it overvalues employment of workers with personal experience of AOD problems. Following from this there is, in the sector, a perceived overemphasis on the AOD service user's self-motivation and readiness for treatment, and inadequate attention paid to effective engagement and treatment methods. This view, from informants in both the MH and AOD sectors, holds that tackling these limitations through dual diagnosis capacity building has begun to make the AOD sector a more equal partner with MH services. An informant with extensive experience of managing an AOD service saw dual diagnosis work as: an opportunity for this sector (AOD) to actually become expert. Because mental health won't tolerate workers who are not properly qualified .... Let's try and insist that we do have expert treatment available instead of half-baked, good-communicating, we-like-you-and-we-care-about-you mush. Good communicating and care is absolutely essential to these people, but that's not expert drug treatment (KI 1, manager).

Such criticisms of the AOD sector are qualified or countered in part by querying whether views on its poor quality are informed by recent experience. Some informants refer to recent improvements (such as the increasing proportion of qualified staff) but more strongly to enduring prejudice:

Highly qualified drug and alcohol workers [were] coming into mental health and being treated like students ... Because they were coming from drug and alcohol they were sort of seen as inferior (KI 11, clinician).

A counterstory is that dual diagnosis training can erode rather than build the AOD sector's confidence in their ability to welcome people who are seeking help:

In some ways that's the downside of dual diagnosis--that people think it's a more complex diagnosis and they don't feel they have the skills to respond. That means that people don't get the services (KI 7, clinician/manager).

We've still got a way to go with treatment. There's still an issue of clinicians being unrealistically pessimistic about how efficacious they can be with treatment (KI 2, clinician).

The remedial narrative, in summary, begins with the AOD sector at a low base, with good intentions but fragile confidence, challenged by the low status of its workforce in comparison with the mental health workforce. A focus on dual diagnosis may offer a step up the ladder and greater respect for its expertise in alcohol and other drug treatment. The end of this story may be an expert professional drug treatment sector that more closely resembles the mental health sector.

The radical narrative

A third narrative is one of frustration with the last 20 or more years of health service system adaptations and restructures. In picaresque style, there have been a series of episodes leading to a mixture of gains and losses, and no great improvement or resolution. This aspect of the interview data suggests that, while improving education, training, supervision and other supportive resources for the workforce is clearly beneficial, real progress for effective AOD services cannot be made without bold structural investment focused on the needs of the service users. Dual diagnosis discourse serves to distract attention from the need for major change:

I think there's such ingrained structural problems with getting good quality treatment that I don't know whether an initiative like this would mean great change for any group. As a consequence, because there's a perception that things might be different and people are now being better responded to, [everyone might be losing]. If you hear about it enough, and you hear government saying "We've got this no-wrong-door policy and everybody that goes into this system will be assessed and blah-di-blah"--it's almost like "tick, tick, tick, everybody's happy" (KI 4, clinician/manager).

Further reform and new funding models are envisioned which overcome the unhelpful self-interest of existing organizations, as in:

Until everyone rethinks the model and standards and all those sorts of things, [mental health and drugs] are going to be worlds apart ... There's an allegiance to the organization rather than an allegiance to the patient. Most clinicians and workers are engaged in--and have to be--engaged in the needs of the organization, stopping people coming through the door and all those sorts of things ... I think as managers we are obsessed with bigger budgets and getting bigger and more influence and all of that, and at the end of the day my concern is how we influence the system and how we change it, because it's inadequate (KI 18, clinician/manager).

This informant acknowledges that clinicians and workers are inevitably protective of their organizations and will tend to perpetuate fragmented service structures. Another informant notes that this need for protection arises from the funding levers in operation: funding AOD services by episode of care led to stricter gatekeeping, "a much more differentiated and separated set of clients" (KI 1, manager) and hence more risk of gaps between services.

In the radical narrative, the final chapter would describe a well-resourced and interlinked service system able and prepared to recognize and respond to need, with specialist MH and AOD services a part of the broader and enlightened system of general health and social care, aided by legislative reform such as decriminalization of drug use. Unlike the progressive and remedial narratives, the radical narrative does not see the dual diagnosis lens as particularly relevant or helpful.

Discussion and conclusion

Three narratives drawn from informants' reflections shed light on concerns about the implications, for the AOD sector, of the turn towards a dual diagnosis focus. They invite the listener to believe different truths: that dual diagnosis discourse has helped services to be more responsive to complex needs in general (progressive), that it has simply helped to improve expertise in AOD treatment (remedial), or that it has been a distraction from the need for major system reform (radical). Quietly underlying all three narratives is conceptual confusion and uncertainty about diagnoses per se, as well as awareness that the term dual diagnosis bears the weight of many combinations of perceived problems. Finally, the much wider discourse of social justice and marginalization surrounds the narratives, which all carry the assumption that we are a long way from a satisfactory closing chapter. While this study has focused on the State of Victoria, Australia as a case study of dual diagnosis discourse, the different narratives identified resonate with other jurisdictions where a focus on dual diagnosis has been introduced into policy and practice.

Our informants believe, and dual diagnosis program evaluations have found (Australian Healthcare Associates, 2011; Australian State and Territory Peak Alcohol and Other Drugs (AOD) Non-Government Organisations, 2011), that dual diagnosis discourse has had a positive influence on the general quality of screening, assessment and treatment by AOD services. At the same time the informants all recognize notable barriers to quality improvement: inadequate service models in which the survival needs of organizations are misaligned with the needs of potential service users; high expectations that the sector will provide, from a low funding base, specialist, professional expertise as well as the more generic support needed by people who, as one informant put it, have been "dropped by the wayside" because of the failings of the broader system; feelings of frustration, inadequacy and pessimism associated with not only the nature of mental health and AOD problems but the systemic barriers. A recent international research review on integrating MH and AOD services (Torrey, Tepper, & Greenwold, 2011) suggests that the Victorian experience is far from unique.

What is the elephant?

The metaphor of the blind men describing separate parts of an elephant is worth exploring as one means of drawing together the implications of these narratives. First, there are the varying guiding images of dual diagnosis as a set of problems of the brain, the mind, the will, or the environment. Second is the polarization between the mental health system's idea of dual diagnosis as referring to people with severe mental illness and the AOD sector's inclusion of those with more common, mild, or moderate mental health problems. The metaphor is a reminder to be clear about who and what are the subjects of conversations about dual diagnosis and to attempt to describe the whole creature. Further, informants' narratives suggest that a focus on dual diagnosis as the elephant leads only to incremental improvements, while significant sociocultural and systemic barriers (the elephants in the room?) call for more radical change.

The work of the narratives

Each narrative can be seen as having particular functions (or "doing work") in the AOD discursive field. We have drawn attention to three parallel narratives (and there are potentially more) to bring to light tensions in the field which are seldom seriously addressed in clinical research, implementation studies or evaluations.

We speculate that the work of the progressive narrative is to inspire, through its vision of a system-changing endeavor that promises transcendence from dual diagnosis to a higher vision of more humane and inclusive care for all across the health and social service systems. With its champions marshaling limited resources and small bands of followers, its "no wrong door" catch cry and its evident successful skirmishes with hegemonic beliefs and practices, it is a classic tale that can rally support. As is the way with visionary narratives, it has its disbelievers who are dismissive of its claims. In a field, however, where the fostering of hope is critical to the service user's recovery and therefore to the therapeutic outlook of the sector, this narrative clearly contributes an exemplar. The remedial narrative covers work in the middle ground, with its pragmatic moral that any thoughtful new investment of time and money is worthwhile in the context of a chronically underfunded sector. It can thus be seen as a mediating narrative, although it risks offending those who are sensitive to misunderstanding of the nuances of the AOD sector's expertise, are wary of a takeover by psychiatry, and would bristle at criticisms such as that good communication and care is not expert treatment. The radical narrative arguably works to inspire and empower big-picture thinkers but could also, if seen as a too-hard narrative, be disempowering. All three narratives acknowledge that the problems of dual diagnosis are as much about social structures and inequities as they are about clinical classifications and treatments. Traditional professional turf and status play a part (Roberts, 2012).

As well as having distinct functions, the narratives share some plot components, such as the ideal of a welcoming therapeutic approach and of a "no wrong door" service system. They could all close with a common celebration of a health and welfare system that is resourced and able to provide well-tailored, timely treatment and care. Government policy makers, looking for a metanarrative or grand overarching theory, clearly embrace the progressive narrative, and this is the most prevalent narrative in policy discussion (Department of Human

Services, 2008, 2009). Accommodating other legitimate, although at times conflicting and even subversive, narratives is, however, an important consideration in gaining widespread cooperation and due investment in better services and systems. Otherwise there is a risk of differing perspectives being rejected as resistance to change, with a consequent potential loss of the knowledge and wisdom of those who differ, and a continuation of weary pessimism about solutions.

Acknowledging, even embracing, narratives that are not only empowering but are also critical enables a metanarrative of policy and practice that is more nuanced and better reflects divergent experiences of different players. It also creates a narrative that not only highlights the strength of the dual diagnosis journey but also acknowledges further need for reform. If dual diagnosis discourse (with the initiatives it has generated) continues on a separate and specialist path, it risks fading from fashion and itself falling into the system's gaps, however attractive its claims to be creating welcoming and appropriate treatment for all. "Dual diagnosis" is but one way of concentrating hearts and minds on the imperative of improving services. The diversity of informants' views in our case study supports an argument for a metanarrative which, combining the strengths of the three narratives, continues to be pioneering, brings additional knowledge and skills to AOD services, and is explicitly conceptualized as part of a story of structural reform.

Such a metanarrative, while desirable, may be optimistic in the current global economic climate. At the time of writing AOD service providers in Victoria are expecting imminent and major reorganization of state government funding, which will mean mergers and closures. At a time when cost-neutral change management is politically attractive, the progressive dual diagnosis narrative may continue to have continued currency and the energy of dual diagnosis champions will be needed, but the alternative stories will continue to provide a critical viewpoint, further highlighting deficiencies in an already stretched sector. We conclude that the next chapter in our meta narrative must be concerted action to secure adequate resources and raise the political priority of just and equitable service provision.

AUTHOR'S NOTE: For additional information about this article contact Bridget Roberts, Monash University Eastern Clinical School. E-mail: bmrob3@student.monash.edu.

Note

* Key informants are identified by the code KI # and their primary role(s)

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Author:Roberts, Bridget; Jones, Rebecca
Publication:Contemporary Drug Problems
Date:Dec 22, 2012
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