Transcript Slide 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
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 evidencebased 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 NICErecommended 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
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 reliving 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 plan
Review, inc. TOP
KEYWORKING
 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
KEYWORKING
In-pat stabilisation
out-patient methadone maintenance
CBT for
depression
Related NTA work streams
 Strategic
 Improving quality not just quantity of treatment
 Focus on outcomes
 Improving workforce competencies
 Guidelines / products
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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