Psychological interventions and drug treatment provision Luke Mitcheson, Clinical Team, NTA Its time to talk Drug treatment and psychological therapies,

Psychological interventions and drug treatment provision

Luke Mitcheson, Clinical Team, NTA

“It’s time to talk” Drug treatment and psychological therapies, London conference

20th March 2009

Structure of talk

Why psychological interventions?

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

Implementation and IAPT

How does it fit together?

The Long and Winding Road (Lennon/McCartney)

Many times I've been aloneAnd many times I've criedAnyway you'll never knowThe many ways I've tried

But still they lead me backTo the long winding road

You left me standing hereA long long time ago

Don't leave me waiting hereLead me to your door

Expectations and attitudes

“If you treat an individual... as if he were what he ought to be and could be,

he will become what he ought to be and could be”

Johann Wolfgang von Goethe (1749-1832)

Why psychological treatment?

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

Represents the core of treatment

Integrated with other approaches such as pharmacological stabilisation and detoxification

Moves the debate on from abstinence vs. harm reduction

Congruent with the recovery agenda

Building hope and repairing damaged lives

Building social capital

Adaptive to specific problems at different points in recovery journeys

Suite of evidence-based clinical guidance 2007

NICE: National Clinical Practice Guideline No. 51. Drug Misuse: Psychosocial Interventions

Included in Orange Guidelines as well as other evidence-based psychosocial interventions

Psychosocial interventions

Interactions between clinicians and service users

to elicit changes in substance use behaviour (cognition & emotion),

grounded in psychological theory

NICE: National Clinical Practice Guideline No. 51 Drug Misuse: Psychosocial Interventions

Co-existing psychological problems (anxiety disorders and depression)

Evidenced based psychological treatments should be provided for the treatment of co-existing disorders in line with existing NICE guidelines

CBT for common mental illness

No evidence that using substances makes usual psychological interventions ineffective

Implementation

Psychosocial interventions in drug misuse: framework and toolkit for implementing NICE-recommended treatment interventions

Why do we need this document?

Workforce has rapidly expanded

Workforce skills are variable

What happens in key-working can be fuzzy

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

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

Content

Uses the IAPT (Improving Access to Psychological Therapies) structure

High Intensity

Formal therapies delivered by a specialist psychological therapist

Behavioural Couple Therapy

CBT for specific psychological problems

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 disorders and depression

Why use the IAPT structure?

Establishes a common language with IAPT

Incorporates the same interventions for common mental health problems

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

Stepped Care(adapted from Wanigaratne 2002)

Engagement

Stabilisation

Maintenance

Aftercare

Motivational Interviewing

Contingency Management

Low intensity CBT for Common Mental Health Problems

Behavioural Couples Therapy

High intensity CBT for Common Mental Health Problems

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 a competencies framework?

•Compatible with the approach taken by Skills for Health in the development of 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 the essential foundations of psychosocial interventions •Enables flexibility and adaptation at the level of the individual service user•Provides a framework around which other products can be clearly developed to support implementation (supervision and training)

Generic competences in psychological therapyThe competences needed to relate to people and to carry

out any form of psychological intervention

Basic competencesBasic intervention-specific competences that are used in

most sessions

Specific technical competencesSpecific intervention competences that are employed in

most sessions

Meta-competencesCompetences that are used by therapists to work across all

these levels and to adapt the intervention to the needs of each individual service user

Toolkit Intervention competencies model (adapted from Roth and Pilling, 2007a)

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 or 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. Elicit 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 higher-order 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

Implementing the tool-kit

Services need to be commissioned that have the capabilities and capacity to build, implement and deliver psychosocial interventions

Psychosocial interventions need to be considered core to the treatment process and require governance structures to support this

Services need knowledgeable and skilled individuals who are competent to deliver:

• The training (or at least monitor its delivery by external agencies)

• The supervision

• The evaluation and quality assurance of the interventions

Drug treatment services and IAPT – silos or synergies?

What IAPT can offer drug treatment service users

A mainstream service and interface at the level of primary care

Improved access to psychological treatments for depression and anxiety disorders

Assistance in seeking employment

What drug treatment services can offer IAPT

Expertise in assessment and screening of drug misuse

Care-pathways through drug treatment, including detoxification and stabilisation

Expertise in psychological treatment of co-existing disorders

Keyworking as “THE GOLDEN THREAD”

Care planning including interventions such as ITEP mapping

Co-ordination of care and review

Drug related advice and information

Interventions to reduce harm, e.g.. reduce injecting &overdose risk

Motivational interventions & interventions to prevent relapse

Help to address social issues, e.g. housing

KEYWORKING

Review, inc. TOPCare plan

KEYWORKING

In-pat stabilisation out-patient methadone maintenance

Basic and enhanced treatment pathways

Discretepsychosocial for drugmisuse

CBT fordepression

Related NTA work streams

Strategic Improving quality not just quantity of treatment Focus on outcomes Improving workforce competencies

Guidelines / products New commissioning guidelines New Care-plan / keywork guidance ITEP / BTEI reports “Routes to Recovery” (Feb ‘09) BTEI manuals CM implementation trial findings Psychosocial library - web based resource (Late March ’09)

Summary

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

The NICE psychosocial guidelines set out the requirement to provide treatments for co-occuring common mental health problems

Services need to be commissioned to provide these psychological treatments for drug addicted people

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

http://www.nta.nhs.uk/areas/workforce/psychosocial_tools.aspx