Mapping the routes to recovery

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Mapping the Routes to Recovery:

NTA resources to support implementation of psychosocial interventions

Luke Mitcheson, Clinical Team, NTA

Drugs and Alcohol Today Exhibition, London

29th April 2009

Structure of talk

Psychosocial interventions; what and why?

NTA products

Toolkit

Psychosocial Interventions Resource Library

ITEP / BTEI

Implementation

What is a psychosocial intervention?

“Interactions between clinicians and service users to elicit changes in substance use behaviour (cognition & emotion), grounded in psychological theory”

The therapeutic relationship and process of key-working:

Includes skills to do assessments, care-plans, the TOP, structuring sessions, using ITEP / BTEI Maps

Formalised interventions and programmes:

Contingency management, motivational interviewing, relapse prevention, motivational and cognitive elements of BTEI

Why psychological treatment / interventions?

• Treatment is relational – how we talk, and are with clients influences outcomes

NICE 51 / ORANGE: Core to all treatment and for some substances the only treatment

• Can be integrated with other approaches such as pharmacological stabilisation and detoxification

• Adaptable to abstinence and harm reduction goals

Relevant to specific issues at different points in recovery journeys

• Congruent with both acute and chronic care models of care

Instilling hope and repairing damaged lives

Building social capital – the “ecology of addiction recovery”

Why do we need these products?

• Workforce has rapidly expanded

• Workforce skills are variable

• Practice and skills of supervisors variable

• Training often delivered at a dose which is unlikely to be effective and not resourced to develop specific skills

• Key-working ill-defined

• Pressures on time

• Geographical variation in access to suitably qualified therapists able to deliver treatment for co-occurring psychological problems

Toolkit

Psychosocial interventions in drug misuse: a framework and toolkit for implementing NICErecommended treatment interventions

Structure and Interventions covered by the Toolkit

High Intensity

 Formal therapies delivered by a specialist psychological therapist

 Behavioural Couples Therapy

 CBT for specific co-existing psychological problems (anxiety / depression)

Low Intensity

 Delivered by key-workers, may have an aspect of self-help

 Motivational interviewing and contingency management

 Guided self-help and behavioural activation for anxiety and low mood

Elements of toolkit

 Competencies of staff to undertake specific interventions; generic, basic, specific techniques and meta-competencies

 Training curricula

 Supervision competencies

 Example protocols

 Adherence measures

 Audit tools for implementation

Why use the low / high intensity IAPT structure?

• Establishes a common language with Improving Access to

Psychological Therapies (IAPT) services

• Incorporates the same interventions for common mental health problems

• Introduces and brings stepped care back home

• Provides a structure for thinking about care-pathways through treatment

• Helps to target and manage resources

• Same goals of social inclusion and employment

Why a competencies framework?

• Compatible Skills for Health / DANOS and with the NHS Knowledge and Skills Framework (KSF)

• Variation in therapist competence is a significant contributor to variance in outcomes

• Competences not always stated in treatment manuals

• Identifies and incorporates the essential foundations of psychosocial interventions

• Enables flexibility and adaptation at the level of work with individual service users

• Provides a framework around which other products can be clearly developed to support implementation (supervision and training)

Toolkit Intervention competencies model

(adapted from Roth and Pilling, 2007a)

Generic competences in psychological therapy

The competences needed to relate to people and to carry out any form of psychological intervention

Basic competences

Basic intervention-specific competences that are used in most sessions

Specific technical competences

Specific intervention competences that are employed in most sessions

Meta-competences

Competences that are used by therapists to work across all these levels and to adapt the intervention to the needs of each individual service user

Competencies 1

• Generic competences

Employed in any psychological or psychosocial intervention

• Often referred to as ‘common factors’ in psychological therapy

• e.g. establishing a positive relationship with the service user, establishing good relationships with relevant professionals or gathering background information

• Basic competences

Establish the structure for the effective delivery of both high and low-intensity interventions

• e.g. establishing the MI approach, plan and review homework assignments, knowledge of family approaches to drug misuse and mental health problems

Competencies 2

• Specific techniques / competences

Core technical interventions employed in the application of a specific intervention (e.g. specific MI techniques or information-giving specific to behavioural activation)

Represent common techniques within each therapeutic modality (especially

CBT e.g. Eliciting cognitions)

May vary according to the nature of the presenting problem (e.g. the use of re-living experiences in the treatment of PTSD)

• Metacompetences

Used to guide practice and operate across all levels of the model

Awareness of why and when to do something (and when not to do it)

Make links between theory and practice in order to plan and adapt an intervention to the needs of individual service users

• Difficult to observe directly but can be inferred from therapists’ actions

Psychosocial Interventions Resource Library

(PIRL)

• An evolving web-based resource of manuals and treatment protocols

• Consistent with Orange Guidelines (2007) and NICE clinical guideline 51 (NICE, 2007)

• Resources identified through the resource locator which lists them by drug misused, client group and intervention

• Resources are also categorised according to whether they are:

Evidence-based (group 1)

Expert consensus-derived (group 2) - includes some commissioned by the NTA

PIRL Resource Locator

Drug misused :

 Alcohol

 Cannabis

 Stimulants

Client group:

 Adolescents

 Adults

 Families

 Parents

Intervention:

 12 step facilitation

 CBT

 Community reinforcement

 Contingency management

 Family interventions

 ITEP/BTEI

 Motivational interviewing

 Relapse prevention

ITEP and BTEI manuals

• ITEP (the International Treatment Effectiveness Project)

• BTEI (the Birmingham Treatment Effectiveness Initiative)

• Culmination of three year programme of activities and research

Survey of organisational functioning using the ORC and CEST questionnaires

Training in mapping interventions

Evaluation of the training

Implementation of interventions in treatment services

Follow-up of impact of training and organisational changes

What is node link mapping?

• Presents visual and spatial relationships between ideas and tasks

• Uses simple cognitive principles and problem solving techniques

• Not a new theoretical technique but a way of recording and communicating ones that already exist e.g. motivational interviewing and relapse prevention principles

• Not prescriptive, offers substantial key worker and client freedom

• A way to structure and review sessions

Mapping: A Visual Representation Strategy

© 2007

Provide a workspace for exploring problems

Improve

Therapeutic

Alliance

Focus attention on the topic at hand

Train clearer and more systematic thinking

BENEFITS

OF MAPS

Provide easy reference to earlier discussions

Create memory aids for client and worker

Provide a method for getting

“unstuck”

Useful structure for clinical supervision

Implementation

• Lessons learnt

• Conditions for quality service provision

• Stepped-care and care pathways

• Tasks of key-working

• New developments from the NTA

Lessons from ITEP / BTEI implementation

– a virtuous circle?

Clients better engaged, more satisfied with treatment

Management more effective, clearer mission

Workers less stressed, more motivated

Conditions for improving provision of psychological therapies

QUALITY OF

PROVISION

Effective assessments and treatment

Skills Setting

Training, CPD, supervision

Psychologically minded workers

Culture

Facilitative organisation

Appropriate care pathways, facilities and quality assurance systems

Clinical leadership, communication

Definition of Psychological Mindedness

(Conte et al 1996)

• Ready access to feelings

• Willingness to understand oneself and others

• An interest in the meaning and motivation of thoughts, feelings and behaviour

• Valuing discussion of problems and motivation to change

Stepped Care

(adapted from Wanigaratne 2002)

Aftercare

Maintenance

Stabilisation

High intensity CBT for Common Mental Health

Problems

Engagement

Low intensity CBT for Common Mental Health Problems

Behavioural Couples Therapy

Motivational Interviewing

Contingency Management

Basic and enhanced treatment pathways

Discrete psychosocial for drug misuse

KEYWORKING

In-pat stabilisation out-patient methadone maintenance

CBT for depression

Tasks of key-working

Engagement Strategies

Intervention skills

Therapeutic Relationship

Attitudes

Structure

Assessment skills

Care-planning and reviews, TOP

Related NTA work streams

Strategic

 Improving quality not just quantity of treatment

 Focus on long term recovery outcomes

 Improving workforce competencies

 Guidelines / products

 New commissioning guidelines

 New keywork guidance

 CM implementation trial findings

Summary

• There is always a psychological element to the treatment of drug problems

Psychosocial interventions are integral to acute care and recovery orientated treatment systems

• Services need to be commissioned to provide these psychological treatments for drug addicted people including those for co-occurring common mental health problems

Service managers need to set up governance structures to support the practice of delivering psychological treatments

• Workers may benefit from adopting a competency based approach to developing their practice and using the resources presented today

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