Introduction

This chapter will review the care pathways available to mentally disordered offenders who have a dual diagnosis (hereafter referred to as dually diagnosed clients [DDCs]). There is no prescribed legal definition for dual diagnosis (also known as co-morbidity), which serves to complicate an already complex debate around the provisioning of appropriate services for this client group. There is a great deal of debate concerning the nature of dual diagnosis (for a review of the main models, see Mueser et al, 1998) and a subsequent lack of definitional clarity. For the purposes of this chapter, the broad spectrum guidance offered by the Department of Health (DH, 2002a) will be utilised, according to which a dual diagnosis can be one of the following:

• • a primary psychiatric illness precipitating or leading to substance misuse;

• • substance misuse worsening or altering the course of a psychiatric illness;

• • intoxication and/or substance dependence leading to psychological symptoms; and

• • substance misuse and/or withdrawal leading to psychiatric symptoms or illnesses.

This chapter will introduce three care pathways available to DDCs under Part III of the Mental Health Act 1983 and its 2007 amendments (hereafter, MHA). A clarification of these established statutory care pathways will be outlined through the use of case studies drawn from the author's practice experience. These will demonstrate the ways in which DDCs experience significantly different treatment interventions and life outcomes from ‘mainstream’ mentally disordered offenders. The case studies will also demonstrate the arbitrary and haphazard nature of inter-agency risk assessment when considering DDCs from a sentencing perspective, which is exacerbated by the MHA ‘exclusion criteria’ for alcohol and drugs. In particular, it will be argued that the presence, influence and agendas of the ‘managing agencies’ for DDCs result in care pathways that do not equate to the effective treatment of the actual presenting risks.

Contextual background to Part III of the Mental Health Act

In practice, statutory criminal justice disposals for DDCs have been in existence since the Mental Health Act 1983 in conjunction with the evolution of community-based orders starting with the Community Service Order (1972), the Combination Order (1991), the Drug Treatment and Testing Order (2001) and, finally, the Community Order (2005), which was introduced by the Criminal Justice Act 2003.