1. 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

2. 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?

3. 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

4. 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 ( )

5. 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

6. 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

7. Psychosocial interventions
Interactions between clinicians and service users
to elicit changes in substance use behaviour (cognition & emotion),
grounded in psychological theory

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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)

24. 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