Better Care for People with Co-occurring Mental Health and Alcohol/Drug Use Issues

This e-learning resource has been co-created with specialist clinicians, academics, and people with lived experience in partnership with Revolving Doors, Clinks, Public Health England, Coventry University E-Learning and University of Huddersfield, to support the implementation of the "Better Care for people with mental health and co-occurring Alcohol and/or Drug conditions".

There are links throughout the e-learning to further information. You can use the bookmark at any point to enable you to come back to where you left off. At the end there is a brief quiz. You will then be able to print a confirmation of completion for your records.

Part 1 - About the resource

This guide was developed by an expert panel in order to provide an up to date guide for commissioners and service providers.

This e-learning resource was developed to support the implementation of ‘Better Care for people with co-occurring mental health and alcohol/drug use conditions’ (PHE, 2017). We refer to it as the ‘Better Care guidance’.

This e-learning resource is designed to support workers with some general information about how best they can help. In it we refer to Co-Occurring Mental Mealth and Alcohol / Drug issues as “COMHAD”. Some general information about how best they can help. It also signposts readers to a number of online resources to support their work. It is not intended to be an exhaustive resource, rather it is intended as an awareness raising tool, and readers are advised to seek further learning opportunities in their local area. As this e-learning is designed for a wide readership some aspects may be more or less familiar to you, or less relevant to your role.

An important aspect of the e-learning resource is that it includes the lived experience voice throughout. People who present with COMHAD also face severe social exclusion and marginalisation, therefore it is vital they have an opportunity to be able to express how they see treatment, and for workers to hear and understand what is important to them. This resource has been co-produced with people with lived experience via the Revolving Doors forum.

1 - About the resource

The Better Care guidance is based on two key principles:

  1. Everyone’s job. Commissioners and providers of mental health, alcohol and drug use, and other social and criminal justice services have a joint responsibility to meet the needs of individuals with co-occurring conditions by working together to reach shared solutions.
  2. No wrong door. Providers in alcohol and drug, mental health and other services have an open door policy for individuals with co-occurring conditions, and make every contact count. Treatment for, and prevention of, any of the co-occurring conditions is available through every contact point.

We will be returning to these two key principles throughout the e-learning.

2 - Objectives of the e-learning

By the end of the e-learning, participants will:

Using the resource

Please read through each section and explore the accounts of people with the lived experience. We have provided links to further relevant resources as well. At the end of the e-learning there is a short multiple choice quiz. Successful completion of this will take you to a page which confirms completion and you can print this page as evidence for your continued professional development. We also invite you to complete a very brief questionnaire which will help us evaluate the resource.

3 - Background to Co-occurring Mental Health and alcohol/drug conditions

3.1 - What are Co-occurring Mental Health and Substance Alcohol/Drug use conditions(COMHAD)

Click on the boxes in the quadrant to see examples.

The Quadrant Model of Co-Occurring Disorders

A HIGH alcohol/drug use condition/s, LOW mental health
B HIGH alcohol/drug use condition/s, HIGH mental health
C LOW alcohol/drug use condition/s, LOW mental health
D HIGH mental health, LOW alcohol/drug use condition/s
alcohol/drug use condition/s
Mental Health

A HIGH alcohol/drug use condition/s, LOW mental health

e.g. a person who is opiate dependent, who also experiences mild anxiety


B HIGH alcohol/drug use condition/s, HIGH mental health

e.g. a person with bipolar disorder who is also alcohol dependent


C LOW alcohol/drug use condition/s, LOW mental health

e.g. A person with mild depression who drinks alcohol at the weekends


D HIGH mental health, LOW alcohol/drug use condition/s

e.g. a person with schizophrenia who smokes cannabis occasionally

The Quadrant model (figure above) is a useful way of categorizing people depending on the severity of need in relation to mental health and alcohol/drug use condition/s.


3.2 How common is it?

In the Better Care guidance, the first of the two key principles is that co-occurring mental health and alcohol/drug use conditions are everyone’s job. The second key principle is “no wrong door”. The reason for this is that it is a very common phenomenon across a range of health and social care services. Co-occurring mental health and alcohol/drug conditions are the norm, not the exception and therefore it is the responsibility of all health and social care, and criminal justice services to meet the needs of people with co-occurring conditions wherever they attend. All services should take responsibility to help as much as they can, and assist proactively, to offer support and assistance in accessing relevant services.

Did you know:

3.3 Consequences of COMHAD

When people have multiple needs, it often complicates and impacts negatively on all aspects of their life. We know from research and listening to people’s stories that having COMHAD can lead to the following:

In addition, people with COMHAD have often struggled to find and maintain employment, and have experienced housing problems and homelessness. Many women with COMHAD have experienced intimate partner violence, sexual abuse and exploitation, and may have had children taken into care. These multiple needs greatly impact on the ability to recover, and in many ways, compound and entrench poor mental health and alcohol/drug issues. Faced with such complexity, it is often hard to foster hope for the future. However, recovery is possible and we have included positive examples of what has helped people in their recovery throughout the resource.

There are a number of ideas (theories) as to why its so common that alcohol/drug use condition/s and mental health co-exist:


3.4 Impact of co-occurring mental health and alcohol/drug use

Mental health conditions and alcohol/drug issues interact in complex ways and are sometimes hard to predict. It is also very difficult to be certain in terms of what is causing what. For instance, someone who experiences psychosis may also be smoking cannabis. The cannabis use could have triggered the psychotic episode, but also they could be smoking more cannabis because they are trying to manage and cope with increasingly unpleasant mental health symptoms.

The important thing is to ask people about what they are experiencing and what is important to tackle from their point of view. Certain issues will always need to take priority in appropriately managing risk and keeping people safe. For instance, it is important that anyone who presents with a current pattern of heavy use of alcohol or drugs should be assessed for dependency and receive appropriate medical treatment for this. Another example of an urgent situation would be if someone is intoxicated but is also expressing feelings of self-harm or suicide. Whilst it is harder to undertake a psychiatric assessment when someone is intoxicated, it is also important to keep someone safe until they can be assessed once the effects of the substance have worn off.

Here are some narratives about people’s experiences of COMHAD:

“Ten years ago I started taking heroin and crack cocaine. 22 years ago, I was diagnosed with a mental health problem. Living [with a combination of drug and mental health problem] has been very very hard… at times I’ve been suicidal, my husband died two years ago of an overdose. Although we weren’t together, he was still the father of my children, so. I’ve had a few breakdowns over the last ten years”

“Taking the drugs you get really low on them, at first its high, the first time you take them. The heroin especially it gives you a warm glowing feeling, like you’re wrapped up in cotton wool and it’s like, you don’t feel any pain, you forget about your past issues. Until it actually gets a grip of you and then once it’s got a grip of you it’s like, every day you wake up needing it. Every day you wake up needing it. The illness of the effects of it are horrendous, to actually try to and do and detox yourself is bad”

“Urm, I’m also on crack cocaine. The first time you take that people [say that it] sends things off in your brain, your feel good factor … After a while you need it, it’s not a physical addiction, it’s a mental addiction because it’s taken the feel good factor away from your brain, so the crack cocaine once you’re addicted to it, that puts the feel good factor back in it.” ”

Click here for a useful resource “Out of Your Head” which is about the interaction of commonly used drugs and alcohol and mental health co-produced by people with lived experience.

4 - Best practice guide for working with COMHAD

The next section of the e-learning will focus on how you as a worker can best help people with COMHAD.

“Services don’t listen and ask people what they want – a lot of them say they do it, but they don’t on the ground.”

We have brought together the themes from the Better Care Guidance with the experience of people who have both mental health and alcohol/drug use condition/s in order to provide some real advice about what is important and also what helps. These themes are:

  • 4.1 therapeutic alliance
  • 4.2 collaborative delivery of care
  • 4.3 care that clearly reflects the views, motivations and needs of the person
  • 4.4 care that clearly supports and involves carers and family members
  • 4.5 therapeutic optimism about recovery
  • 4.6 considering physical health needs
  • 4.7 strategies to promote health and health behaviour change
  • 4.8 right care, right time

4 - Best practice guide for working with COMHAD

4.1 Therapeutic alliance

The values and attitudes of staff and their ability to create a therapeutic relationship is highly valued by people with lived experience of COMHAD. We know that when a strong supporting relationship is established, people are more likely to complete treatment, actively explore problems, experience less distress, abstain from alcohol and drugs during treatment, and achieve better long-term alcohol/drug use condition/s outcomes

“I have trust issues, I am going there from the street, I don’t have anyone to rely on. If they are not compassionate, I am going back on the street”

“She treated me like a human… it was from her heart, it was sincere” “She was real, like she had some lived experience”

Skills include:

“What stuck out… I came into the room and she offered me a tea. I couldn’t look at her, she was trying to look me in the eyes and I couldn’t look at her. I expected her to look at me like everyone else. That’s what made the difference”

“People having sympathy for me and those giving genuine compassion was a huge difference”

4 - Best practice guide for working with COMHAD

4.2 Collaborative delivery of care

People who have multiple needs must have access to care that can comprehensively meet those needs and build on an individual’s strengths/assets. In addition, people value consistency and stability in their treatment and support. This aligns with the NICE guideline on severe mental illness and alcohol/drug use condition/s.

“If they were more on the same page… the different agencies, if they were talking together, in a room like this…”

Care may be provided by the same person or by relevant practitioners/services working in close collaboration.

“but he [psychiatrist] actually asked me things like, what I thought, and what I wanted. He asked me if he can take notes, he didn’t just go ahead and do it. At the end of every appointment, he said when do you think it would be a good time to come back, or when would you like to see me next, kind of involving me in the process, and I never felt forced to do anything”

This requires accountability and clarity of role, information sharing agreements, and shared care planning with the individual at the centre of the process. There should be a named person who can coordinate care and act as a central point of contact for the person and their carers (including young carers) and the other service providers. For people with severe mental illness this would be led by and managed within the care programme approach (CPA) process by a mental health team.

“... We sat down and talked about what things worked in the past, and why they did not, and we tried something different. Until that point, everything was prescriptive. . . [T]hey sat down to listen to me. It wasn’t their version of recovery or even my version of recovery – we created a common solution. That is important: Common solutions together”

When assessing co-occurring conditions, practitioners should think about the interrelationship and mutual influence of both conditions, rather than assessing both parts separately. The key question should be ‘how do you see your alcohol/drug use helping or hindering your mental health and vice versa?’

“The advocate was able to eliminate some of the risks I put myself under. They were able to coordinate the appointments, and help me focus on my wellbeing, prevented a lot of stress. And they were more able to talk to me as the key person – they were able to support the multiagency approach. In all the years I have been in services, that was probably what made the most difference”

4 - Best practice guide for working with COMHAD

4.3 Care that clearly reflects the views, motivations, strengths and needs of the person

“It is very rare for services to ask ‘what can we do for you?”

This should include:

4 - Best practice guide for working with COMHAD

4.4 Care that supports and involves carers and family members

Carers (including young carers) have needs in their own right. Practitioners should identify carers and family members who may have unmet needs, making appropriate referrals for carers’ assessments and/or to family support services. This approach ensures compassionate and effective care to people with co-occurring conditions, and is in line with the Care Act 2014.

When assessing carers, it will be particularly important to consider:

“It isn’t anywhere near the help families need to get… there isn’t enough money to help them”

“They should definitely look at families – my family has gone through alcohol and drug addiction, and they had the attitude like, they know best, but then, services had different level of engagement with them”

“Back then there was no family support – but looking back, if they had family support groups like Family Anon, services like that back then, maybe my mom, bless her soul, could have benefited from a bit of support, she would have blamed herself less”

Some useful resources to consider are:

4 - Best practice guide for working with COMHAD

4.5 Therapeutic optimism about recovery

“Hope, not heart-sink”

“When people leave treatment, they are brought [back] to the same housing, same environment, that got them in [trouble in] the first place. They need to know that, most people need to stay out, environment has got a lot to do with recovery”

“She got me a safe accommodation it got me to a place where I can kind of level with the medication and get some psychotherapy and deal with the other issues. It gave me an opportunity to engage with the support and take control of my life”

Practitioners should demonstrate a genuine belief in the possibility of recovery. All interaction and engagement with people using services should be undertaken in a spirit of optimism, with a clear commitment to helping them to achieve this. In practical terms, services should adopt a ‘whole person’ approach, supporting people to enjoy the rights and responsibilities of active participation in their community.

This may involve:

All this can help foster a sense of self-efficacy and self-esteem.

Remember: It’s preferable to work with smaller goals over the long term than rush people towards big changes which they may not be equipped to achieve right now.

Here are a range of e-Learning resources which provide the underpinning knowledge to support the delivery of very brief or brief interventions.

4 - Best practice guide for working with COMHAD

4.6 Considering the physical health needs

There are a number of preventable health conditions which are exacerbated or even caused by lifestyle choices such as: diet, exercise, and alcohol consumption. When faced with someone who has multiple needs sometimes standard health advice is overlooked. People with COMHAD conditions experience significant physical health issues and we know that people with serious mental illness, as well as people with long term alcohol or drug use issues, are much more likely to die younger than their peers. Therefore it is important that we use every opportunity to help people understand the link between smoking, diet, exercise and their physical health. Addressing physical health conditions should span health promotion and preventive strategies (primary prevention), treatment, managing long term conditions, through to providing acute and critical care. Everyone has a role in considering health issues and knowing what services can help and support people with various aspects of health.

A key part of the “no wrong door” principle is that providers should make every contact count – taking every opportunity to reduce health harms by offering advice and support to:

Consider the list above. Would you know how to advise someone on these aspects of health and lifestyle? For instance do you know how to help someone calculate their “Body Mass Index”? What are the recommended safe levels of alcohol consumption per week? What do you and your service offer in terms of health promotion. What opportunities are there to undertake more health promotion in your service?

4 - Best practice guide for working with COMHAD

4.7 Strategies for promoting health and health behaviour change

“The only person who can assess my health is my GP”

Change is hard for everyone, many of us struggle to make changes to our diet, lifestyle and exercise etc. Even when we do make changes we often relapse. Maintaining a change requires a variety of strategies to help us to cope with cravings, set realistic goals, and self-monitor. For people with multiple needs which include mental health and alcohol/drug use conditions, these changes can be even harder and we need to be very mindful of just how challenging these multiple issues are. Services often put huge expectations on people to change (and change quickly). Challenges can exist where people don't have good support systems, for example they may not have a supportive family or friends. Sometimes they're very isolated and struggle on their own. Often this is because the symptoms of mental health problems are so distracting and difficult that they get in the way of thinking through what they want to do. Using drugs and alcohol, being intoxicated, or experiencing withdrawal symptoms can complicate how people want to move forward.

Challenges for change:

It is important to recognise these additional challenges and help people develop strategies to tackle them:

4 - Best practice guide for working with COMHAD

4.7 Strategies for promoting health and health behaviour change

There are some simple tips and key principles to support health behaviour change which can be applied within a routine clinical contact and can make all the difference to peoples’ lives.

“Some professionals would look at me and I feel like I am being told off”

The good news is that if people feel physically more healthy they are more likely to feel better emotionally and have more “recovery capital” to use to help move forwards in their lives. A useful resource for nurses working in mental health is here

How to

Please listen to this clip as an example of how to do it

How not to

Please listen to this clip as an example of how not to do it

4 - Best practice guide for working with COMHAD

4.8 - Right care at the right time

People with COMHAD can experience significant negative outcomes, including risk of self-harm and suicide, it is therefore vital that they get access to the right care at the right time especially in times of crisis. This includes keeping people safe and providing a crisis plan with contacts for when things become overwhelming or unmanageable.

This also includes appropriate help when intoxicated. People can be at risk of harm to self and/or others when experiencing a mental health crisis and the risks are heightened if they are intoxicated. Services including the police, ambulance personnel, mental health crisis teams, and accident and emergency staff need to ensure that they are equipped to respond. This means being able to identify the signs of intoxication and responding appropriately to the associated risks, in particular not being able to maintain one’s own safety, physical risks (toxicity, overdose) and disinhibition (possibly enhancing feelings of distress or anger). Once the crisis has been managed and urgent mental and physical health needs have been met it is important to use the opportunity to engage the person in subsequent treatment. This is where psychiatric liaison teams can help in providing assessment and engagement with the person and linking to the appropriate after-care. All staff in the crisis pathway should have an understanding of co-occurring mental health and alcohol/drug use condition/s, how to effectively engage with this group, and knowledge of the local care pathways available.

The Mental Health Crisis Concordat provides further information and guidance on:

“There were five appointments at any time and it was difficult for me to keep up with them and get my point across because of the severity of the position I was in, because I was homeless, I was evicted, I had mental health crash”

Part 5 - Quiz

Completion page

Further resources to support your learning and development

You’ve now completed the Co-Occurring Mental Health and Alcohol and Drug (COMHAD) Issues e-learning.

To support this e-learning, we’ve also developed a Capabilities Framework for working effectively with people who have co-occurring mental health and alcohol/drug use conditions. It is recommended that you use this capabilities framework alongside this e-learning to review and develop your current values and knowledge and skill levels.

The aim of the framework is to describe the values, knowledge and skills required to work with people who have co-occurring mental health and alcohol/drug use conditions. It is designed to be relevant to workers in mental and physical health settings, alcohol/drug misuse services, social services, and the criminal justice system. This framework is underpinned informed by, and based on, the lived experience of people with COMHAD conditions, some of whom are the most marginalised and excluded people in our society.

Useful links to support your learning and development