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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 Train clearer and more systematic thinking Create memory aids for client and worker Improve Therapeutic Alliance BENEFITS OF MAPS Provide a method for getting “unstuck” Focus attention on the topic at hand Provide easy reference to earlier discussions 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 Training, CPD, supervision Appropriate care pathways, facilities and quality assurance systems Setting Psychologically minded workers Culture Facilitative organisation 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 Assessment skills Therapeutic Relationship Attitudes Structure Intervention 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