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 alone And many times I've cried Anyway you'll never know The many ways I've tried But still they lead me back To the long winding road You left me standing here A long long time ago Don't leave me waiting here Lead 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 Clinical guidelines Last updated 1999 Reflects NICE UK-wide consensus document, primary and secondary care NICE TAs Methadone and bup Naltrexone CGs Psychosocial Detox PHI

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 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) 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

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)

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

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

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

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