1. 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

2. Structure of talk Psychosocial interventions; what and why?
NTA products
Toolkit
Psychosocial Interventions Resource Library
ITEP / BTEI
Implementation

3. 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

4. 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” 4

6. 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 6

7. Toolkit
Psychosocial interventions in drug misuse: a framework and toolkit for implementing NICE-recommended treatment interventions 7

8. 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

9. 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 9

10. 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 10

11. 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) 11

12. 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
MI E.g.
Generic
Knowledge of drug misuse and mental health problems
Establishing a positive relationship with the service user
Basic
An ability to adopt an evocative tone throughout the intervention which draws out the service user’s ideas, feeling and
Specific
A knowledge of the levels of reflection including: repeating; re-phrasing; paraphrasing; and reflecting feeling
Meta
An ability to integrate motivational interviewing into routine assessment systems
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 12

13. Competencies 1 Generic competences Basic 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 13

14. 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 14

15. 15

16. 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 16

17. PIRL Resource Locator Intervention: 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 17

18. 18

19. 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 19

20. 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

21. Mapping: A Visual Representation Strategy
© 2007

22. BENEFITS OF MAPS Provide a workspace for exploring problems
Improve Therapeutic Alliance
Focus attention on the topic at hand
BENEFITS OF MAPS
Train clearer and more systematic thinking
Provide easy reference to earlier discussions
Create memory aids for client and worker
Provide a method for getting “unstuck”
Useful structure for clinical supervision

23. Implementation Lessons learnt Conditions for quality service provision
Stepped-care and care pathways
Tasks of key-working
New developments from the NTA

24. Lessons from ITEP / BTEI implementation – a virtuous circle?
Clients better engaged, more satisfied with treatment
Workers less stressed, more motivated
Management more effective, clearer mission

25. Conditions for improving provision of psychological therapies
Effective assessments and treatment
Facilitative organisation
Psychologically minded workers
QUALITY OF PROVISION
Appropriate care pathways, facilities and quality assurance systems
Skills
Setting
Training, CPD, supervision
Culture
Clinical leadership, communication

26. 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

27. 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 27

28. Basic and enhanced treatment pathways
Discrete
psychosocial
for drug
misuse
CBT for
depression

29. Tasks of key-working Engagement Strategies Assessment skills
Therapeutic Relationship
Structure
Attitudes
Engagement Strategies
Assessment skills
Intervention skills
Care-planning and reviews, TOP

30. 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

31. 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