Integrating ITEP BETI across services

Luke Mitcheson, Clinical Team, National Treatment Agency“O ti i i T t t Eff ti ” KCA L d“Optimising Treatment Effectiveness”, KCA, London30th November 2009

StructureStructure

• What is ITEP / BTEI?• Why might we want to adopt and implement these approaches?• Implementation challenges • The role(s) of key-working• What do we know about adopting new practices?• Where are we now with ITEP and next steps

OriginsOrigins

• Ideas developed by Dwayne Simpson at TCU• Brought to UK by the NTA as central to the ‘treatment g y

effectiveness strategy’ and branded as ITEP• Piloted in 3 regions and evaluated in NW and West Midlands• In West Midlands branded as BTEI (Birmingham Treatment

Effectiveness Initiative)

• ITEP and BTEI manuals on NTA website• ITEP and BTEI manuals on NTA website

3 Key components3 Key components

1 M i d l1. Mapping and manualsVisual “maps” to enable focused topic specific conversations with clients.

2.Organisational assessmentsThe Organisational Readiness to Change questionnaire (ORC). E bl i t l t th l b fEnables services to evaluate themselves on a number of parameters related to organisational health and functioning.

3. Service User Feedback MeasuresThe Client Evaluation of Self in Treatment (CEST) evaluative tool. Provides feedback on clients’ experience of treatment and provides a basis for targeted intervention as well as feedback onprovides a basis for targeted intervention as well as feedback on service changes.

IBRIBR HOME PAGE

IBRA National Research Center A National Research Center

for addiction treatment studiesfor addiction treatment studiesEVIDENCE

for addiction treatment studiesfor addiction treatment studiesin community and correctional settingsin community and correctional settings(over 600 free resource files available)(over 600 free resource files available)

SUMMARY

TCU Mapping-Enhanced

Counseling•• Overviews ofOverviews of TCU TreatmentTCU Treatment

MANUALSFORMSEVIDENCE

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TreatmentProcess

CounselingManuals

•• Overviews of Overviews of TCU TreatmentTCU TreatmentSystemSystem & & Conceptual ModelsConceptual Models

•• GuideGuide for Selecting from 20for Selecting from 20Intervention ManualsIntervention Manuals

ABOUT IBR-TCUSTAFFPUBLICATIONSPRESENTATIONS

Corrections-Based

Treatment

NationalE l ti

Intervention ManualsIntervention Manuals

•• GuideGuide for Selecting from 80for Selecting from 80Assessment FormsAssessment Forms

PRESENTATIONS PROJECTSNEWSLETTERS

OTHER LINKS

EvidenceEvidence--Based Treatment ModelBased Treatment Model

Evaluations

OrganizationalReadiness

AssessmentFact Sheets

•• Project Updates & SummariesProject Updates & Summaries

•• New New Publications (Abstracts),Publications (Abstracts),P t ti N l ttP t ti N l tt

WHAT’S NEW

SITE GUIDES:

ProgramProgramProgramStaffStaffStaff

ResourcesResourcesResources

ClimateClimateClimate

PatientPatientPatient

SeveritySeveritySeverity

ReadinessReadinessReadiness

SufficientRetentionSufficientSufficientRetentionRetention

Early Early EngagementEngagement

Early Early RecoveryRecovery

PosttreatmentPosttreatment

DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations

SocialSocialRelationsRelations

ProgramParticipation

ProgramProgramParticipationParticipation

TherapeuticRelationshipTherapeuticTherapeuticRelationshipRelationship

BehavioralChange

BehavioralBehavioralChangeChange

Psycho-SocialChange

PsychoPsycho--SocialSocialChangeChange

CognitiveCognitiveStrategiesStrategies

BehavioralBehavioralStrategiesStrategies

Social SkillsSocial SkillsTrainingTraining

Family &Family &FriendsFriends

SupportiveNetw orks

SupportiveSupportiveNetworksNetw orks

Personal Health ServicesPersonal Health Services

Social Support ServicesSocial Support Services

Simpson, 2001 (Addiction)

ProgramProgramInterventionsInterventions

ReadinessReadinessTrainingTraining Fact Sheets

(with norms)

ib dib d

Presentations, NewslettersPresentations, Newsletters

““VisitorsVisitors””SelectedPresentationsDATOSDATOSDATOSDATOS www.ibr.tcu.eduwww.ibr.tcu.edu 600/day600/day

30 30 minsmins

© 2009

“Adaptive” Treatment“Adaptive” Treatmentpp

Assessments of Client Needs/ProgressAssessments of Client Needs/Progress

Client Recovery Stages in Treatment Other Other TreatmentsTreatments

Other Other TreatmentsTreatments

Assessments of Client Needs/ProgressAssessments of Client Needs/Progress

y gEarly Early

EngagementEngagement•• ParticipationParticipation

Th tiTh ti

Treatments Treatments or or

Support Support NetworksNetworks

Treatments Treatments or or

Support Support NetworksNetworks

TreatmentTreatmentTreatmentTreatmentReadiness:Readiness:•• NeedsNeeds--RiskRiskS itS it

RetentionRetention & & Continuing Continuing

ChangeChangeFollowFollow--upupOutcomesOutcomes•• Drug useDrug use•• CrimeCrime

•• Therapeutic Therapeutic RelationshipRelationship••

•• SeveritySeverity•• MotivationMotivation Early Early

RecoveryRecoveryChanges in Changes in ----

ChangeChange

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•• CrimeCrime•• Social Social

FunctionsFunctions•• ThinkingThinking•• ActingActing

ferr

als

eds/

Ris

ks

InterventionsInterventions (Behavioral & Cognitive)(Behavioral & Cognitive)

Ref

(Nee

Interventions Interventions (Behavioral & Cognitive)(Behavioral & Cognitive)

Simpson, 1995, 2001, 2004, 2006© 2009

“TCU Mapping” Interventions for “TCU Mapping” Interventions for Adaptive Treatment ProcessAdaptive Treatment Process

Stages of TreatmentStages of Treatment

pp

RetentionRetentionEarly Early

RecoveryRecoveryEarlyEarly

EngagementEngagementTreatmentTreatmentReadiness:Readiness: RetentionRetention

& Change& ChangeChanges in Changes in •• ThinkingThinking•• ActingActing

•• ParticipationParticipation•• Therapeutic Therapeutic

RelationshipRelationship

•• NeedsNeeds--RisksRisks•• SeveritySeverity•• MotivationMotivation

OrientationOrientation ReRe--EntryEntryTreatment ATreatment A Treatment BTreatment B

PreparingPreparingfor Changefor Change

GettingGettingMotivatedMotivated

BuildingBuildingNetworksNetworks

BetterBetterCommComm

HIV RiskHIV RiskReductionReduction

UnlockingUnlockingThinkingThinking

ReducingReducingAngerAngerIT

EPIT

EPB

TEI

BTE

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MappingMappingJourneyJourney

WorkshopWorkshopfor Menfor Men

TransitionTransition

Using ClientUsing ClientAssessmentsAssessments

MappingMappingCare PlansCare Plans

DownwardDownward M iM i

ParentingParentingSkillsSkills

WorkshopWorkshopfor Womenfor Women

CM/RewardCM/RewardStrategiesStrategies

TransitionTransitionto Reto Re--entryentry

DownwardDownwardSpiralSpiral

Mapping Mapping ’12 Steps’’12 Steps’

© 2009

“TCU Mapping-Enhanced Counseling”

What is mapping?What is mapping?

• Presents visual and spatial relationships between ideas and tasksU i l iti i i l d bl l i• Uses simple cognitive principles and problem solving techniques

• Not a new theoretical technique but a way of recording and• 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

Mapping: A Visual Representation Strategy

© 2007

Health and Physical

Social Relationships Problem Solving

What are your strengths?

Emotions/Temperament Values and Beliefs

strengths?

Work or Avocation

How will these strengths help you succeed in your treatment journey?

Provide a workspace for

exploring

Improve Therapeutic

Alli

Focus attention on the topic at handexploring

problems Alliance p

BENEFITS Train clearer and more systematic

Provide easy reference to earlier

OF MAPSy

thinking discussions

Create memory Provide a method Useful structure yaids for client and

workerfor getting “unstuck”

for clinical supervision

UK programme evaluationUK programme evaluation

• Positive outcomes in terms of acceptability and usage• “Services where more mapping was implemented had clients who

reported significantly higher levels of rapport with key-workers, better p g y g pp y ,levels of participation in treatment, and better peer support.”

• 3 months post-training - Mapping maintained, ‘Changing your thinking patterns’ falling awaypatterns falling away

Campbell A, Finch E, Brotchie J, and Davis P (2007) “The international p , , , ( )treatment effectiveness project: Implementing psychosocial interventions for adult drug misusers.” NTA. www.nta.nhs.uk

Lessons from ITEP / BTEI implementation – a virtuous circle?

Clients betterClients better engaged, more satisfied with

treatment

Workers less stressed, more

motivated

Management more effective, clearer mission

Why? The broader contextWhy? The broader context

D t t R i l i l i d i t ti• Drug strategy: Recovery, social inclusion and reintegration• Be more “ambitious” for service users• Centrality of psychosocial interventions• Workforce development

Why? The role of psychosocial interventionsWhy? The role of psychosocial interventions

“Pharmacological treatments for cannabis and stimulant misuse are not well developed, and therefore psychosocial interventions are the

i t f ff ti t t t ” (NICE 2007)mainstay of effective treatment.” (NICE 2007)“Treatment for drug misuse should always involve a psychosocial

component ” (DoH 2007)component. (DoH 2007)“Psychological treatment has a role as important as substitute

prescribing in treating opiate-dependent clients….” (NTA 2005)p g g p p ( )“Both pharmacological interventions and psychosocial treatment are

more effective when they work together in an integrated and h i d ” (D H 2006)harmonised manner.” (DoH 2006)

Why? Lessons from the Treatment Effectiveness ProgrammeWhy? Lessons from the Treatment Effectiveness Programme

• Mapping is a useful service user engagement tool• Can become a mainstream treatment approach and be adopted as a

core skill setcore skill set • Focuses on key-working and on psychosocial component of

treatment • Potential to support a recovery orientation to treatment delivery and

personalisation – self directed support• Platform for other evidence based approaches (NICE)• Platform for other evidence-based approaches (NICE)• CEST can help with client engagement and help measure progress• ORC can provide an analysis of the strengths and needs ofORC can provide an analysis of the strengths and needs of

treatment services

General challenges to implement psychosocial interventions

• Key-worky• Rapid expansion of workforce• Very variable: also more often not Orange; “80% chat”• Variable clinical supervisionp

• Formal psychosocial programmes• Many types uncommon in addiction• Training rarely delivered to achieve competenceTraining rarely delivered to achieve competence• Lack of leaders, protocols and `how to’ guides• Geographical variations in access to formal psychological treatment• Not enough intervention specific supervisorsg p p• Need drug services to have `learning and problem solving cultures` to be able to

implement new techniques • Commissioning

• Careful systems do not have ‘standard’ treatment for all• Understanding of psychosocial approaches

Tasks of key workingTasks of key-working

Engagement Strategies Assessment skills

Therapeutic Relationshipp pAttitudesStructure

Intervention skills Care-planning and reviews, TOP

Implementing changeImplementing change

Implementation is the least researched component of translating evidence based approaches into practice (Gotham 2004)evidence-based approaches into practice (Gotham, 2004)

Some ingredients for successful process improvement: • Understand and involve the “customer” (e g client families• Understand and involve the customer (e.g. client, families,

community)• Fix the key problems (e.g. TOP completion?)Fix the key problems (e.g. TOP completion?)• Pick a powerful change leader• Get ideas from outside the organisationGet ideas from outside the organisation• Use rapid-cycle testing to establish effective changes (implement

one small change and see how it works)

Implementing changeImplementing change

• 5-steps: • Pre-planningPre planning• Planning• Implementationp• Evaluation• Sustainabilityy

Implementing change in substance abuse treatment programmes (TAP31) 2009

3 groups of products

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

g p p

1. Psychosocial interventions in drug misuse: a framework and toolkit for y gimplementing NICE-recommended interventions:

http://www.nta.nhs.uk/areas/workforce/docs/psychosocia_%20interventions_implementation_framework_190309.pdf

2. Psychosocial Interventions Resource Library (PIRL): http://www.nta.nhs.uk/areas/clinical_guidance/psychosocial_interventions_resource_library_(PIRL)/default.aspx

3. ITEP and BTEIITEP introduction: http://www.nta.nhs.uk/areas/workforce/docs/itep_routes_to_recovery_part1_120309.pdfITEP manual: http://www nta nhs uk/areas/workforce/docs/itep routes to recovery part2 180209 pdfITEP manual: http://www.nta.nhs.uk/areas/workforce/docs/itep_routes_to_recovery_part2_180209.pdfBTEI introduction: http://www.nta.nhs.uk/areas/workforce/docs/itep_routes_to_recovery_part3_120309.pdf

Psychosocial interventions in drug misuse:a framework and toolkit for implementing p gNICE-recommended treatment interventionsStructure and interventions

High IntensityFormal therapies delivered by a specialist psychological therapistBehavioural Couples TherapyCBT for specific co-existing psychological problems (anxiety / depression)depression)

Low IntensityDelivered by key-workers may have an aspect of self-helpDelivered by key workers, may have an aspect of self helpMotivational interviewing and contingency managementGuided self-help and behavioural activation for anxiety and low ymood

Elements of toolkitElements of toolkit

Competencies of staff to undertake specific interventions; generic, basic, specific techniques and meta-competenciesspecific techniques and meta-competenciesTraining curriculaSupervision competenciesSupervision competenciesExample protocolsAdherence measuresAudit tools for implementation

PIRL Resource LocatorPIRL Resource Locator

Drug misused: Alcohol

Intervention:12 step facilitationAlcohol

CannabisStimulants

12 step facilitationCBT Community reinforcement

Client group:AdolescentsAdults

Contingency management Family interventions ITEP/BTEIAdults

Families Parents

ITEP/BTEIMotivational interviewing Relapse prevention

Skills ConsortiumSkills Consortium

• PURPOSEPURPOSE• To support the drug treatment sector to identify the knowledge attitudes and skills

required to promote and sustain beneficial treatment outcomes for service users and their communitiesS l i h i i i d i h h i i kill• Support employers to equip their practitioners and managers with the requisite skills

• Core group taking forward the development of a constitution and work-plan priorities

Skill f k• Skills framework• Define effective and evidence based practice, support organisational

development initiatives and ‘early adopters’ for psychosocial interventions• Skill d l t• Skills development

• Define a framework and mechanisms to connect training to this framework

• Intelligence / influence• Intelligence / influence• Advice to sector, policy development and responding to new initiatives

Issues to address in implementing ITEP / BTEIIssues to address in implementing ITEP / BTEI

• Is it a clinical tool, the clinical tool or a quality improvement system? • Branding (more than ITEP / BTEI)• Different versions of maps and manuals in circulation• Data management resources• Potential for research not yet realised• More work on translating into clinical practice

Next stepsNext steps

• Further pilots (IDTS)• Branding. “Recovery, engagement and life-skills”. Product differentiation• Skills consortium to define and endorse a programme that ensures leadership, of p g p

work and sharing of knowledge across the treatment sector• Mapping

• Integrate with assessment, care-planning and the TOP.• Further training and investigation of training impact• Develop a recovery manual

• Client feedback and organisational assessment tools• Fi d t ff ti t ll t d t d t• Find cost effective ways to collate and report data• Make it more useful for clinical practice

• NTA website developments• Library of materials• Library of materials• Share implementation information

Conclusions: Bridging the gap between guidelines and practiceg g g p g p

Clinical Guidelines

Facilitative organisationClinical leadership

Workforce competenciesClinical leadership

Manuals, protocols, care-pathways, training, supervision,liquality assurance systems

IMPLEMENTATION OF EVIDENCE-BASED PRACTICE

Conclusions: fPrinciples of implementing organisational change

• No single model for or approach to implementing organisational changechange

• Needs to be individualised to accommodate specific needs, goals, culture and readiness to changeculture and readiness to change

• Change is not a linear process• Change is ongoingChange is ongoing• The ultimate goal is to create changes that can be sustained over

time

All resources can be accessed at:All resources can be accessed at:

www nta nhs ukwww.nta.nhs.uk

Thank you for your attention