The use of Open Dialogue in Trauma Informed Care services for mental health consumers and their family networks: A scoping review.

WHAT IS KNOWN ON THE SUBJECT?: Open Dialogue was developed in Finland in the 1980s by clinical psychologist, Jaakko Seikkula. It is a development of family therapy, recognises previous trauma and has proven to be very effective in situations of acute mental illness, and in particular psychosis. Trauma Informed Care is a practice based on the understanding of and responsiveness to the impact of trauma. When people have experienced trauma, they may have difficulties in their everyday life and experience negative physical health outcomes as well as the risk of developing mental ill health. Open Dialogue is aligned to mental health care which aims to be trauma-informed, person-centred and rights-based. Examples exist of the use of both approaches for service delivery with limited evaluation. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no formal evaluation has been made of the use of open dialogue as a Trauma Informed therapy approach to support individuals and their family networks. Although both approaches recognise the impact of trauma on individuals, no study has explored the effectiveness of this treatment combination for use by mental health nurses. This review is timely as it provides insights into contemporary services that are trauma informed and have used Open Dialogue to extend therapy work with individuals and their family/networks. This scoping review was able to determine whether recommendations for clinical practice and training in Open Dialogue with Trauma Informed Care approaches could be identified. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review provided a broad overview on the current types of trauma-informed care services incorporating Open Dialogue approaches into their practice. The literature, though sparce, identifies that Trauma Informed Care recognises multiple origins for mental ill health. Open dialogue has an affinity with the common values of mental health nurses. As combined therapies, they are demonstrating usefulness in engaging families and people in their journey towards recovery. Rigid adherence to Open Dialogue focus and delivery as well as training practices could be revised to make them more open to what people and their families wish to discuss. The person with mental ill health and previous trauma should be able to direct the narrative. Trauma Informed Practice principles could be adapted to improve consumer satisfaction with Open Dialogue approaches. ABSTRACT: INTRODUCTION: A large proportion of people who access mental health services have a lived experienced of trauma and are more likely to have a history of complex trauma. Open Dialogue and Trauma Informed Care practices identify previous trauma as a factor related to later psychosis. This scoping review has identified similarities and contrasts in how an Open Dialogue and Trauma Informed Care approach have been combined to complement one another for clinical work with people presenting with psychosis and previous trauma. AIM: We aimed to answer the following research question in this scoping review: What is known of the combined use of Open Dialogue and Trauma Informed Care practice when working with consumers and their family networks? As such, the purpose of this paper was to explore the application to practice and identify if any training existed and been evaluated. METHOD: This scoping review was based on the Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases. Grey literature was also searched through Psyche Info and Google Scholar for books, Dissertation and Theses, alongside hand searching of the reference of the studies. Articles searched was from January 2013 to January 2023. RESULTS: Five distinct themes were identified from the literature: (1) Linking open dialogue with trauma, (2) Response to treatment, (3) Empowerment and information sharing, (4) Interpretation by clinical services, (5) Staff training outcomes. DISCUSSION: Some tentative recommendations for practice recognised the individuals' unique story and perspective, suggested that trauma is an important concept to assess. Services practising as Trauma Informed Services that have incorporated an Open Dialogue approach have mixed experiences. The use of Open Dialogue may have some benefits for family work and exploring consumer narratives while building a network of support. However, consumers identified similar frustrations with service delivery as with the family therapy literature. For example, it was difficult to bring family members together and difficult to discuss previous traumatic events in front of family. People experiencing training in Open Dialogue reported it taking a slow pace and not what they were familiar with. IMPLICATIONS FOR PRACTICE: Open Dialogue can facilitate engagement of consumers and their family networks and greater recognition of the peer workforce to promote collaboration in therapy is needed. Future research should also focus on evaluating the effectiveness of such services and comparing their outcomes across regions.

Locked external doors on inpatient mental health units: A scoping review.

The principles of least restrictive care and recovery-focused practice are promoted as contemporary practice in the care of individuals with mental ill health, underpinning legislation concerning mental health and illness in many jurisdictions worldwide. Inpatient mental health units with locked doors are incompatible with this style of care and throwback to a time where care for mental illness was primarily custodial. The aim of this scoping review is to determine whether evidence exists for locking mental health unit doors, whether this practice is compatible with recovery-focused care and to determine whether door locking has changed since a review conducted by Van Der Merwe et al. (Journal of Psychiatric and Mental Health Nursing, 16, 2009, 293) found that door locking was not the preferred practice in the management of acute mental health units. We used Arksey and O'Malley's (International Journal of Social Research Methodology: Theory and Practice, 8, 2005, 19) framework for scoping reviews, with our initial search locating 1377 studies, with screening narrowing final papers for inclusion to 20. Methodologies for papers included 12 using quantitative methodology, 5 qualitative and 3 that used mixed methods designs. Poor evidence was found for door locking to mitigate risks such as absconding, aggression or illicit substance importation. Furthermore, locked doors had a detrimental impact on the therapeutic relationship, nurse job satisfaction and intention to leave the profession. This scoping review indicates that research is urgently needed to address a mental healthcare culture where door locking is an entrenched practice. Studies of alternative approaches to risk management are required to ensure inpatient mental health units are truly least-restrictive, therapeutic environments.

An exploration of loneliness experienced by people living with mental illness and the impact on their recovery journey: An integrative review.

WHAT IS KNOWN ON THE SUBJECT?: There is evidence that social isolation and loneliness is more prevalent in people living with mental illness than in the general population. People living with mental illness frequently experience stigma, discrimination, rejection, repeated psychiatric admissions, low self-esteem, low self-efficacy, and increased symptoms of paranoia, depression, and anxiety. There is evidence of common interventions that can be used to improve loneliness and social isolation such as psychosocial skills training and cognitive group therapy. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper offers a comprehensive assessment of the evidence between mental illness, loneliness, and recovery. The results suggest that people living with mental illness experience elevated levels of social isolation and loneliness leading to poor recovery and quality of life. Social deprivation, social integration and romantic loneliness are related to loneliness, poor recovery, and reduced quality of life. A sense of belonging, ability to trust and hope are important aspects of improved loneliness, quality of life and recovery. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The existing culture in mental health nursing practice needs to be examined to address loneliness in people living with mental illness and its impact on recovery. Existing tools to research loneliness do not consider dimensions in loneliness experience as reflected in the literature. Practice needs to demonstrate an integrated approach to recovery, optimal service delivery and augmentation of evidence-based clinical practice to improve individual's loneliness, social circumstances, and relationships. Practice needs to demonstrate nursing knowledge in caring for people living with mental illness experiencing loneliness. Further longitudinal research is required to clearly understand the relationship between loneliness, mental illness, and recovery. ABSTRACT: INTRODUCTION: To our knowledge, there are no previous reviews on the impact of loneliness experienced by people aged 18-65, who are living with mental illness and their recovery experience. AIM/QUESTION: To explore the experience and impact of loneliness in people living with mental illness during recovery. METHOD: An integrative review. RESULTS: A total of 17 papers met the inclusion criteria. The search was conducted using four electronic databases: MEDLINE, CINAHL, Scopus and PsycINFO. Across these 17 papers, participants were most commonly, diagnosed with schizophrenia or psychotic disorders and recruited from community mental health services. DISCUSSION: The review revealed loneliness to be substantial in people living with mental illness and that loneliness affected their recovery, and their quality of life. The review identified many factors that contribute to loneliness including unemployment, financial strain, social deprivation, group housing, internalized stigma and mental illness symptoms. Individual factors such as social/community integration and social network size as well as an inability to trust, a sense of not belonging, hopelessness and lack of romance were also evident. Interventions targeting social functioning skills and social connectedness were found to improve social isolation and loneliness. IMPLICATIONS FOR PRACTICE: It is vital for mental health nursing practice to employ an approach integrating physical health as well as social recovery needs, optimal service delivery and augmentation of evidence-based clinical practice to improve loneliness, recovery, and quality of life.

Promoting and hindering factors in the use of advance statements by Australian mental health clinicians.

WHAT IS KNOWN ON THE SUBJECT?: Australia is a commonwealth of federated states and territories with each having unique mental health legislation. Victoria implemented advance statements based on legislation from overseas jurisdictions such as Scotland. The aim of this Victorian legislation was to underpin an individual's autonomy and decision-making in relation to treatment, particularly compulsory treatment. Advance statements allow individuals within the healthcare setting to document preferences for care and treatment during times of decompensated mental health, including informing nominated persons and preferences for recovery-oriented care; however, advance statements continue to attract barriers in their implementation and use. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: This paper focuses on legislation within one jurisdiction, Victoria, highlighting that several barriers to uptake exist, including uncertainty around the legal status of advance statements, the ideal setting to implement advance statements and concern around perceived consumer capacity to contribute to developing advance statements. There are substantial differences of opinion regarding adherence to treatment and recovery preferences contained within the advance statement, especially when decisions are made in the context of decompensated mental health. The Theoretical Domains Framework (TDF) model has been used to formulate recommendations in several other health studies, but to date has not been used to provide recommendations for greater implementation of advance statements. Implementation science is a contemporary research translation movement that seeks to identify factors and strategies that influence the adoption and integration of interventions like advance statements in real world settings. For this study it has been useful to identify barriers, consider implementation strategies and link this with policy frameworks to support practice change. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our study revealed that real challenges exist for mental health clinicians in adopting advance statements despite them having a strong held intention to empower service users to play a greater role in their own treatment and care decisions. The facilitators identified in this study highlight the notion that advance statements, and the concept of supported decision-making are needed in contemporary mental health care. Implementation science can assist in identifying barriers and suggesting facilitators including enhanced training, incentivization of advance statement creation, and greater awareness of the overarching purpose and principle of advance statement creation. Continued support and training in implementing and maintaining advance statements is required if mental health clinicians are to drive the uptake of this important reform to mental health legislation. Training needs to be provided that will address attitudes, and strongly held beliefs that pose barriers to the use of advance statements. ABSTRACT: INTRODUCTION: Advance statements, also known as advance directives or psychiatric wills, provide individuals the opportunity to document care and recovery preferences during a period of mental ill health. Although the use of advance statements has gained momentum, little research has explored the factors that promote or hinder further uptake. AIM: To determine the factors that promote or hinder the uptake of advance statements. METHOD: Cross-sectional online survey of healthcare workers (n = 190). RESULTS: Promoting factors include high perceived value of advance statements, particularly their role in recovery focussed care, while hindering factors include disagreement or responsibility for advance statement creation and legal status. DISCUSSION: This study indicates that several hindering factors or barriers to advance statement uptake remain, and until these factors are addressed future implementation is arguably hindered. In this paper, we have used the Theoretical Domains Framework (TDF) model to outline suggestions to address hindering factors to implementation and guide future implementation strategies for advance statement uptake and practice change. IMPLICATIONS FOR PRACTICE: The ongoing uptake of advance statements requires tailored implementation strategies address hindering factors. Strong promoting factors, such as the shared belief in the advance statement model and its role in recovery focused care, should be considered a strong foundation for implementation strategies.

Exploring the contribution of clinical placement to student learning: A sequential mixed methods study.

BACKGROUND: Increasing demand and limited supply of clinical placements in nursing underscore the need to better understand the role of clinical placements in students' learning. Identifying pedagogically rich activities that support work place learning alongside factors that influence educational outcomes has the potential to optimise professional placement experiences. OBJECTIVE: To explore student nurses perceptions of the value of nursing clinical placements to their learning. DESIGN AND METHODS: A descriptive research design was employed using a sequential mixed method approach. A cross-sectional student survey captured students' perceptions of work integrated learning based on the perceived contribution of a pre-determined list of activities undertaken on clinical placement. SETTING AND PARTICIPANTS: Four Australian universities took part. Participants included students undertaking entry to practice programs. RESULTS: Four hundred and sixty-nine students completed the survey. Thirty-eight students participated in 12 focus groups. Participants rated PRA including interacting and time with patients and performing assessments as the most useful activities. Less useful, were activities that took them away from the patient. CONCLUSIONS: To maximise workplace learning, consideration must be given to ensuring students are presented with goal directed activities that support learning and are focused on an expanding scope of practice with opportunities to discuss and engage with staff.

Reviewing the Consequences of Electronic Gaming Machine Misuse in Australian Older Adults: Implications for Addiction Nurses.

ABSTRACT: This review explores contemporary literature exploring electronic gaming machine (EGM) use in the Australian context. EGMs, colloquially known in Australia as pokies (poker machines), lead statistics on gambling losses in Australia and are a substantially different form of gambling when compared with other means, such as sports or casino wagering. This article focuses on Australian literature on EGMs, with comparisons made with international trends. Searches of the Scopus, CINAHL, and Medline electronic journal databases were performed to find literature examining problem gambling through EGM use in older adults. The results of the search found that little literature exists regarding problematic EGM use in older adults; however of the studies that do exist, problem EGM use in the older adult cohort is frequently related to mental ill health as well as alcohol, tobacco, and other substance use. Addiction nurses are in a unique position to assess and detect problematic EGM gambling in older adults; however, few screening tools are used in clinical practice. Given the ease of access and increasing sophistication of EGMs, it is foreseeable that problematic EGM use will be an issue addiction nurses encounter in their future practice and one they should be aware of.

Service integration: The perspective of Australian alcohol and other drug (AOD) nurses.

The recently released Victorian Mental Health Royal Commission report has recommended a shift to integrated treatment, defined as treatment for alcohol and substance use disorders and mental ill health occurring in parallel, rather than distinct systems catering to each need. However, little work has sought to determine the perceptions of nurses working in alcohol and other drug (AOD) treatment towards integrating with mental health services. In this study, we explore the perspectives of specialist AOD nurses towards the integration of mental health and AOD treatment services. Secondary analysis of semi-structured interviews with Australian specialist AOD nurses (n = 46) conducted as part of a wider workforce study in 2019. Data were analysed using thematic analysis and reported using the COREQ guidelines. Of the interviews analysed, six were AOD nurses working in an Australian state that had recently undergone service integration; however, many participants expressed perceptions of service integration. Two key themes are reported in this paper: (i) perceptions of service integration, where AOD nurses participating in our study were concerned that integration would result in the model of care they worked under being replaced by a mental health-based model that was felt to be highly risk averse, and (ii) experiences of service integration. Concerns about the focus of care as well as the complexity of care differing between the two services demonstrated a contrast in both philosophical approaches to work with consumers and legislative difference in voluntary versus compulsory care provision.

Mental health clinician training and experiences with utilization of advance statements in Victoria, Australia.

Advance statements, advance directives, or psychiatric wills are a key component of a shift to mental healthcare that promotes autonomy and choice and aims to reduce restrictive and coercive care practices in mental health treatment settings. The use of advance statements has gained momentum to provide a means for individuals to detail clear preferences for mental health treatment. This paper uses a qualitative descriptive design to explore the experiences of clinicians (n = 15) implementing advance statements in the state of Victoria, Australia, a region that introduced advance statements as part of an overhaul of mental health legislation in 2014. The study, reported using the COREQ framework, found two key themes after analysis: experiences of advance statement training, with the availability and quality of training and training as a driver of change emerging as sub-themes, and experiences of advance statements in practice, with participants providing narratives of the barriers and facilitators to successful advance statement implementation. We recommend that clinician and service user experiences of advance statement implementation are further explored to identify existing and emerging barriers to implementation of these tools, which are crucial to achieve autonomy and choice for individuals receiving mental healthcare.

"Only intelligent attendants need apply": the history of Western Australia's first asylum at Fremantle (1865-1909).

OBJECTIVE: To examine the history of Fremantle, Western Australia's first purpose-built asylum. METHOD: A range of primary sources were consulted. RESULTS: Fremantle was opened in 1865 to house inmates away from the populace and for the most part under the care of Dr HC Barnett. Attendants as well as inmates were occupied with work roles that kept the asylum functioning cost effectively. CONCLUSION: Within 15 years, the structure was neglected and overcrowded. Changes to the Penal Servitude Act limiting convict transportation, petty crime and a need to manage its proliferation resulted in large numbers of people being incarcerated at Fremantle.

Identification of authentic assessment in nursing curricula: An integrative review.

This article aims to identify the application of authentic learning principles to the assessment of nursing students. An integrative review was undertaken using the Whittlemore and Knafl (2005) framework: identifying the problem/purpose, searching and evaluating the literature, data analysis and presentation or results. Primary searches were conducted using MeSH terms identified as key words across four search data bases (PubMed, Cinahl, Scopus and ProQuest). Literature was identified using inclusion/exclusion criteria and critiqued. Three major themes emerged from the literature review: Clinical Practice, Self-Assessment and Simulation. Models of authentic learning exist that could guide the development of authentic learning assessment for students, however no identifiable tool for locating and mapping authentic assessment in nursing was found. This review challenges the contemporary belief that authentic assessment is to be found in nursing curricula and evidenced by clinical practice.

What Are Nursing Attitudes to Youth Who Engage in Self-Harm? An Integrative Review.

This integrative review explored nursing assessment of youth who self-harm. Eleven papers published between 2000 to 2020 met inclusion criteria. Three themes emerged: "Doctors and nurses' perceptions of assessment of self-harm", "Attitudes and experiences of assessment of self-harm" and "Assessments and outcomes". The ways youth communicate is an important consideration when assessing and planning for care. The metaphor of Narcissus is used to understand youth beliefs, self-image and how they communicate these thoughts. This paper suggests an alternative reading of what young people, who presents with self-harm, are trying to communicate to others and how this is integrated into assessment.

Advance Statements within the Victorian Mental Health Setting: A Contextual and Legislative Global Comparison.

This article provides context to the establishment of advance statements within the Australian mental health setting, in the state of Victoria. A movement to legislate for a more humane and liberal approach to mental health consumer care resulted in changes to the Victorian Mental Health Act (2014a). This Act mirrored legislative changes across the western world and resulted in a socially progressive movement embracing recovery focussed care and consumer clinician partnerships. Thus, we purport that an identified need for a more liberal way to work with individuals who have a diagnosis of mental ill health was a major aim of this law reform. The advance statement model is seen as a tool in addressing a growing recognition of how mental health providers engage consumers of mental health services, and value their preferences to care received. This article arises from a larger study which has aimed to explore the role and scope of advance statements. This research has sought to demonstrate how advanced statements can be used within mental health services by providing recommendations for the mental health nursing workforce in relation to the implementation and deliverables for training.

Alcohol Use in an Older Adult Referred to a Consultation-Liaison Psychiatry Service: A Case Report.

Alcohol use disorder in older adults is associated with a number of substantial medical complications, including cognitive decline. Due to limited success and application of screening approaches in this cohort, older adults are more likely to present to general hospital settings with undiagnosed problematic alcohol use. Consultation-liaison psychiatry services operating in general hospital settings are likely to be referred older adults with alcohol use disorders for assessment and management. A 77-year-old female presented to a metropolitan hospital with symptoms including frequent falls, slurred speech, difficulty judging distance, hypersomnia, poor reasoning, and odd behaviours. She also presented with severe anxiety and bruxism. Several diagnostic tests were inconclusive, and a consultation-liaison psychiatry assessment revealed a prominent heavy drinking pattern and concurrent abuse of oxycodone and benzodiazepines. This report adds further support to the case for uniform screening of all older adults for alcohol and other drug (AOD) use. A number of weeks had passed before the patient's drinking pattern was established, with no withdrawal management in place. A multifaceted treatment approach, including antidepressant therapy, anticraving medication, benzodiazepine as well as opiate rationalisation, and AOD counselling support was commenced prior to discharge from the general hospital.

Survey of antipsychotic medication curriculum content in Australian university nursing programmes.

Antipsychotic medication has long been one of the first-line interventions for people with serious mental illness, with outcomes including reductions in symptoms and relapse rates. More recently, however, questions have been raised about the efficacy of antipsychotic medications, especially in light of their side-effect profile. Such questions have implications for the nurses administering antipsychotic medications, particularly in relation to their knowledge of the antipsychotic medication, its efficacy, and side-effect profile. Also important is the education of nursing students about antipsychotic medications, their use, and management. The present study reports findings of research that explored current curriculum content concerning psychopharmacological treatment in Australian undergraduate and postgraduate nursing programmes. Using a survey design, the research examined the content and modes of delivery of this content to gauge how well students are prepared for administering antipsychotic medication to people with serious mental illness. Findings of the research suggested the need for improvement in preparing nursing students to administer antipsychotic medication, including indications, contraindications, as well as recognition and management of side-effects.

A Journey of Discovery: Experiences of Carers of People with Mental Illness Seeking Diagnosis and Treatment for Their Relative.

This study explores the experiences of informal carers of people with mental illness in an Australian mental health service. A qualitative descriptive approach was used with data collected via focus group interviews with a purposive sample of 19 carers. Data analysis revealed two major themes: (a) "Something is not right" and (b) "Now we have a diagnosis." The carers noticed that there was something wrong with their relative before they received a diagnosis but were often hesitant to engage Mental Health services. Carers have trouble understanding if the problems they are witnessing are part of normal development, contemporary culture, or are symptoms of mental illness. Fear of stigma remains a barrier to accessing services and early diagnosis. Findings suggest a need to target support for informal carers in the period prior to and leading to the establishment of a mental health diagnosis.

Prevalence of co-occurring alcohol and other drug use in an Australian older adult mental health service.

Co-occurring mental illness and substance use disorder, known as dual diagnosis, is a significant challenge to mental health services. Few older adult specific alcohol and other drug treatment services exist, meaning older adult mental health services may become the default treatment option for many. Evidence suggests that dual diagnosis leads to substandard treatment outcomes, including higher rates of psychiatric relapse, higher costs of care and poorer treatment engagement. This paper explores the prevalence of co-occurring alcohol and other drug (AOD) use in an older adult community mental health service in inner Melbourne, Australia. This aim was accomplished by using a retrospective file audit of clinical intake assessments (n = 593) performed on consumers presenting to the service over a two-year period, June 2012-2014. Of consumers presenting to the service, 15.5% (n = 92) were assessed by clinicians as having co-occurring AOD use. Depression predominated in the dual diagnosis group as the primary mental health disorder. Dual diagnosis consumers in this sample were statistically more likely to be male and younger than their non-dual diagnosis counterparts. A limitation of this audit was the lack of implementation of screening tools, leaving assessment to clinical judgement or the interest of the clinician. This may also explain the discrepancy between the results of this study and previous work. Although appearing to be a relatively small percentage of assessments, the results accounted for 92 individuals with complex mental health, AOD and medical issues. Poor screening procedures in a population that is traditionally difficult to assess need to be rectified to meet the future challenges inherent in the ageing baby boomer generation, changing drug use trends and extended lifespans through harm reduction initiatives and medical advancements.

An Ageing Methadone Population: A Challenge to Aged Persons' Mental Health Services?

Oral administration of methadone has been used as a treatment strategy for opiate addiction for many years. The state of Victoria, Australia, has a long-running methadone program with a large number of participants. Accordingly, a growing number of adults have utilised methadone maintenance treatment for a number of years and are now moving into older age due to advances in medical treatment and harm reduction initiatives. The objective of this review is to examine the literature pertaining to co-occurring mental illness in older methadone treatment participants and to explore the future challenges this growing cohort of ageing adults pose to aged persons' psychiatry services. As part of a broader study into dual diagnosis in older adults, a search of the Scopus, ProQuest, and CINAHL journal databases was performed. Twenty abstracts from literature published within the previous 15 years (1999­2014) were identified that explored methadone maintenance programs and the older adults maintained on them. A number of researchers have identified the ageing methadone population to have a high degree of comorbid mental illness and psychological distress. Studies also indicate that individuals enrolled in methadone maintenance programs may engage in a degree of continual substance use, potentially leading to deleterious effects on their psychosocial function. An ageing methadone population experiencing a high degree of comorbid mental illness is likely to challenge aged persons' psychiatry services. These services are likely to be increasingly called on to manage these individuals, particularly within Victoria where few substance use services exist for those over the age of 65. It is essential that aged persons' psychiatry services prepare to provide care for these individuals in a responsive manner that is inclusive of both their mental health and substitution pharmacotherapy.

Maturing out, natural recovery, and dual diagnosis: What are the implications for older adult mental health services?

In 1962, Charles Winick proposed that addiction was a self-limiting process, whereby individuals stopped using substances once the stresses of life transitions ceased. The notion of maturing out, as labelled by Winick, often forms the basis of the natural recovery movement in alcohol and other drug (AOD) research, aiding the notion that older individuals either cease their substance use or fall victim to the higher mortality rates prevalent in substance-using populations. As more consumers present to adult mental health treatment settings with co-occurring substance use disorders, the idea that individuals will simply cease using AOD is outdated. Given the future challenges of an ageing population, it is prudent to explore those who fail to mature out of substance use, as well as challenge the notion that older adult mental health services rarely encounter substance-using individuals. The present study explores Winick's research in the context of an ageing population and older adult mental health services. It also ponders the proposition put forth in subsequent research that older individuals with lifelong substance use switch to substances that are easier to obtain and better tolerated by their ageing bodies.