The Skills Consortium The proposed skills framework West Midlands workforce consultation event 1 st November 2010

Overview The context of workforce development-established and emerging The Skills Consortium & the evolution of the skills framework The framework Resources & next steps

Context: Suite of evidence-based clinical guidance 2007 NICE: National Clinical Practice Guideline No. 51. Drug Misuse: Psychosocial Interventions Orange: NICE and expert consensus

Contexts: Psychosocial Interventions Pharmacological treatments for cannabis and stimulant misuse are not well developed, and therefore psychosocial interventions are the mainstay of effective treatment. (NICE 2007) Treatment for drug misuse should always involve a psychosocial component. (DoH 2007) Psychological treatment has a role as important as substitute prescribing in treating opiate-dependent clients…. (NTA 2005) Both pharmacological interventions and psychosocial treatment are more effective when they work together in an integrated and harmonised manner. (DoH 2006)

NICE 51 Key priorities for implementation Brief interventions (structured feedback advice / motivational enhancement) Facilitated self-help Contingency Management (CM) - targeting drug use - targeting physical health compliance Behavioural couples therapy CBT for common mental illness (anxiety disorders and depression)

Orange went further- based on expert consensus Motivational interviewing Contingency Management (attendance, behavioural change and BBV) Low intensity interventions for common mental illness: Computer-based CBT Guided Self-Help Relaxation techniques Relapse prevention Mapping Techniques Community Reinforcement Approach Behavioural Couples Therapy Social Behaviour and Network Therapy CBT for depression and anxiety Psychodynamic Therapy

Does adding psychosocial therapy to OST improve outcomes? Ball and Rosss study of methadone programs (1990) McLellan et al (1993) conducted a 24-week clinical trial involving 3 treatment groups: – methadone with minimal counselling – methadone plus moderate (i.e. more intensive) counselling – methadone plus enhanced counselling (including on-site medical/psychiatric, employment, and family therapy) NTORS – patients in MMT who received drug problem counselling sessions had significantly better heroin and cocaine outcomes than those receiving no counselling + NICE

The evidence generally indicates 3 key factors: Workers who have clear techniques achieve better outcomes Supervision and governance is key Outcomes are determined by the quality of the working alliance

Implementation Whatever the skills / potential of individual practitioners, the evidence suggests that the quality of the organisation has a more substantial impact on effective outcomes than either the intervention chosen or worker involved

Manualised therapy STICKING TO THE THERAPY MANUAL: A HAPPY MEDIUM WORKS BEST US study on dynamics of cocaine treatment found: counsellors who either strictly followed a counselling manual or largely ignored it had the worst outcomes departing from the therapeutic script without abandoning the overall structure seems a positive attribute. Barber J.P. et al., 2006

For the NTA- the three must dos 1.Organisational competence 2.Care coordination / case management competence 3.Deliver evidence based psycho-social interventions

The Skills Consortium and the evolution of the skills framework

A brief history of the consortium Convened to develop a sector led consensus on good practice and lead workforce development For the sector, by the sector Two large sector-wide stakeholder workshops in 2009 These tasked a smaller working group to develop the ideas and the constitution Build it and they will come Large stakeholder group endorsed the framework in July Executive now formed November website launch

Recovery orientated systems One of the key principles of a recovery-orientated model is it's integrated. That is, all of the constituent parts, all the various elements of a local system are co-coordinated, speak the same language, communicate with each other and have a congruous set of values and principles that orbit around the affirmative and empowering possibilities of recovery…. Every part of the system is involved in a collaborative effort to increase positive outcomes …….. allow greater flexibility and non-linear movement between system elements. NSPs in a recovery-orientated system, Stephen Bamber

From this…….to this……..

HR, MI, ITEP, CM….. recovery communities………

The roots of the framework Based on: Previous guidance (Care Planning Practice Guide in particular) NICE drug misuse guidance 2007 Clinical Guidelines Informed by emerging thinking on recovery and personalisation. It is also informed by ITEP, BTEI and Recovery, Engagement and Life Skills model developed by TCU. As interventions, approaches and technologies emerge it is anticipated that they can be absorbed by the framework.

Phases of treatment: Care Planning Guide

Stages of Treatment Retention & Change Early Recovery Changes in ThinkingThinking Acting Acting Early Recovery Changes in ThinkingThinking Acting Acting EarlyEngagement Participation Participation Therapeutic Relationship Therapeutic RelationshipEarlyEngagement Participation Participation Therapeutic Relationship Therapeutic Relationship TreatmentReadiness: Needs- RisksNeeds- Risks SeveritySeverity MotivationMotivationTreatmentReadiness: Needs- RisksNeeds- Risks SeveritySeverity MotivationMotivation TCU Mapping Interventions for Adaptive Treatment Process Orientation Re-Entry MappingJourney Workshop for Men Transition to Re-entry Using Client Assessments Mapping Care Plans Care Plans DownwardSpiral Mapping 12 Steps Mapping 12 Steps Parenting Skills Workshop for Women Treatment A Treatment B Preparing for Change GettingMotivated CM/RewardStrategies BuildingNetworks BetterComm HIV Risk Reduction UnlockingThinking ReducingAnger © 2009 TCU Mapping-Enhanced Counseling ITEPBTEI

The Framework

Engagement Preparation Change Completion Reintegration DeliveryDelivery PreparationPreparationChangeChange CompletionCompletion EngagementEngagement Re/integrationRe/integration Keyworking – process Keyworking – low intensity psychosocial interventions Interventions focussed on: building the therapeutic relationship; engagement with the care-planning process; building motivation for change and setting initial treatment goals. Session topics could include: personal strengths and resources cost-benefit of drug use ambivalence risk awareness and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: refining treatment goals and preparing for change. Session topics could include: commitment to change recovery goals & change plans triggers for using & management strategies personal & community resources and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: initiating and maintaining changes in substance use, behaviour and cognition, and building recovery capital. Session topics could include: cravings relapse prevention and lapse management leisure/vocational/educational plans personal and community resources skill development (social, personal, vocational) and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: Graduation from treatment: reviewing achievements, planning for reintegration, developing recovery capital and exiting formal treatment. Session topics could include: recovery check lists reviewing changes achieved Relapse prevention and lapse management Undertaking leisure/ vocational/ educational plans personal and community resources skill development (social, personal, vocational) and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: strengthening community integration, developing recovery capital and exiting formal treatment. Session topics could include: future plans and support structuring time skill development (social, personal, vocational) Undertaking leisure/ vocational/ educational plans personal and community resources skill development (social, personal, vocational) and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Keyworking+ – interventions requiring additional competencies Motivational Interviewing Family support Motivational enhancement therapy Contingency management (attendance) Low intensity interventions for common mental illness: Computer-based CBT Guided Self-Help Behavioural Activation Relaxation techniques Contingency management (BBV) Family support Contingency management (behavioral change) Community Reinforcement Approach Social Behaviour and Network Therapy Family support Community Reinforcement Approach Social Behaviour and Network Therapy Family support Community Reinforcement Approach Social Behaviour and Network Therapy Family support High intensity or specialist interventions / Specialist/external services BBV testing and vaccination Counselling (registered/accredited) Specific physical health interventions Mutual aid Medically assisted recovery Inpatient assessment & stabilisation OST IOT Counselling (registered/accredited) Specific physical health interventions Mutual aid Medically assisted recovery Inpatient assessment & stabilisation OST IOT CBT for depression and anxiety (IAPT) Behavioural Couples Therapy Family Therapy Psychodynamic therapy Counselling (registered/accredited) Specific physical health interventions Mutual aid Community detox Inpatient detox Residential and community rehabilitation CBT for depression and anxiety (IAPT) Family Therapy Psychodynamic therapy Counselling (registered/accredited) Specific physical health interventions Recovery communities Mutual aid Residential and community rehabilitation CBT for depression and anxiety (IAPT) Psychodynamic therapy Counselling (registered/accredited) Specific physical health interventions Recovery communities Mutual aid Residential and community rehabilitation Comprehensive assessment inc Child protection Risk Assessment/reassessment of recovery capital Cataloguing strengths Recovery/care planning Care coordination (if applicable) Risk management Crisis management Health monitoring Advocacy Coaching Pro-active engagement/re- engagement Building social networks Harm reduction Multi-agency work, including Child protection Mental health Appropriate supported/facilitated referrals to: Medical monitoring and healthcare Mutual aid Financial and legal advice Housing, employment, education and training The care plan should specify the detail of the case management interventions, as agreed with the service user. Case management and key working interventions may utilise mapping techniques and manuals to support their delivery. Keyworking RECOVERY Review / Plan / Optimise. (CP Review, TOP, other inc CEST) Care planned

Engagement Preparation Change Completion Reintegration Keyworking – process Keyworking – low intensity psychosocial interventions Interventions focussed on: building the therapeutic relationship; engagement with the care-planning process; building motivation for change and setting initial treatment goals. Session topics could include: personal strengths and resources cost-benefit of drug use ambivalence risk awareness and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: refining treatment goals and preparing for change. Session topics could include: commitment to change recovery goals & change plans triggers for using & management strategies personal & community resources and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: initiating and maintaining changes in substance use, behaviour and cognition, and building recovery capital. Session topics could include: cravings relapse prevention and lapse management leisure/vocational/educational plans personal and community resources skill development (social, personal, vocational) and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: Graduation from treatment: reviewing achievements, planning for reintegration, developing recovery capital and exiting formal treatment. Session topics could include: recovery check lists reviewing changes achieved Relapse prevention and lapse management Undertaking leisure/vocational/ educational plans personal and community resources skill development (social, personal, vocational) and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Interventions focussed on: strengthening community integration, developing recovery capital and exiting formal treatment. Session topics could include: future plans and support structuring time Undertaking leisure/ vocational/ educational plans personal and community resources skill development (social, personal, vocational) and may be supported by protocols and mapping tools, and delivered in 1:1 or group settings Keyworking+ – interventions requiring additional competencies Motivational Interviewing Family support Motivational enhancement therapy Contingency management (attendance) Low intensity interventions for common mental illness: Computer-based CBT Guided Self-Help Behavioural Activation Relaxation techniques Contingency management (BBV) Family support Contingency management (behavioral change) Community Reinforcement Approach Social Behaviour and Network Therapy Family support Community Reinforcement Approach Social Behaviour and Network Therapy Family support Community Reinforcement Approach Social Behaviour and Network Therapy Family support High intensity or specialist interventions / Specialist/external services BBV testing and vaccination Counselling (registered/accredited) Specific physical health interventions Mutual aid Medically assisted recovery Inpatient assessment & stabilisation OST IOT Counselling (registered/accredited) Specific physical health interventions Mutual aid Medically assisted recovery Inpatient assessment & stabilisation OST IOT CBT for depression and anxiety (IAPT) Behavioural Couples Therapy Family Therapy Psychodynamic therapy Counselling (registered/accredited) Specific physical health interventions Mutual aid Community detox Inpatient detox Residential and community rehabilitation CBT for depression and anxiety (IAPT) Family Therapy Psychodynamic therapy Counselling (registered/accredited) Specific physical health interventions Recovery communities Mutual aid Residential and community rehabilitation CBT for depression and anxiety (IAPT) Psychodynamic therapy Counselling (registered/accredited) Specific physical health interventions Recovery communities Mutual aid Residential and community rehabilitation Comprehensive assessment inc Child protection Risk Assessment/reassessment of recovery capital Cataloguing strengths Recovery/care planning Care coordination (if applicable) Risk management Crisis management Health monitoring Advocacy Pro-active engagement/re- engagement Building social networks Harm reduction Multi-agency work, including Child protection Mental health Appropriate supported/facilitated referrals to: Medical monitoring and healthcare Mutual aid Financial and legal advice Housing, employment, education and training The care plan should specify the detail of the case management interventions, as agreed with the service user. Case management and key working interventions may utilise mapping techniques and manuals to support their delivery. Keyworking

Resources

Design Guidance and evidence Manuals Competencies Training Implementation Shared Learning

In the mean time………

and the Psychosocial Interventions Resource Library

Skills Consortium Work Plan Three strands: Populating the framework/ implementation/ early adopters Qualifications Evidence and research