Substance misuse services: delivery of psychological interventions

Executive summary

Introduction

This guide sets out a strategy for the delivery of psychological interventions for substance misuse services in Scotland. Fundamentally, its purpose is to increase access to evidence-based psychological interventions for people working to recover from problematic alcohol and drug use.

Who is the guide for?

The guide was written primarily for managers and commissioners to support the development of psychological intervention provision in substance misuse services. It is also intended as a guide for training providers to assist them in prioritising, designing and implementing training programmes, and for practitioners to benchmark their own practice and guide their professional development.

Which interventions should be delivered, and by whom?

A matched-care model of delivery is presented. This model offers ‘tiers’ of care, so that each step up leads to more intensive interventions for service users with more complex needs, requiring additional competencies, training and supervision structures for providers.

The model proposes that the foundation for all service delivery within a substance misuse service should be psychologically informed care (Tier 1). Psychologically informed care uses principles of Motivational Interviewing, therapeutic engagement and node-link mapping to support service users on their recovery journey. Clinical staff working across all services (including integrated non-statutory or social care partners) will have a role in delivering Tier 1 interventions

Low intensity interventions (Tier 2) are aimed at mild-to-moderate addiction difficulties, and mild-to-moderate co-morbid mental health problems. They are delivered by a range of multidisciplinary practitioners trained in specific structured interventions.

High intensity interventions (Tier 3) are aimed at moderate/severe addiction difficulties and co-morbid mental health problems. These are standardised psychological therapies delivered to protocol by applied psychologists and Cognitive Behavioural Therapy therapists trained to certificate and diploma level. Tier 3 interventions require specific competencies, accreditation in the particular intervention, and supervision by an appropriately trained supervisor.

Highly specialist interventions (Tier 4) for complex and enduring problems are individually tailored interventions based on case formulations drawn from a range of psychological models. They are most frequently delivered by clinical and counselling psychologists where there is a need to modify standardised approaches or devise a novel approach for a specific presentation.

Considerations around particular groups

Trauma

Most people attending substance misuse services are thought to have a history of trauma (as well as being particularly vulnerable to experiencing further trauma). The concept of complex trauma has been proposed to capture the often-overwhelming range of symptoms with which people with such histories present.

Integrated interventions that address both difficulties in a parallel intervention are recommended when working with co-morbid trauma and substance use.

In cases of complex trauma and substance use, phased or staged approaches are recommended by expert consensus.

A matched-care model for the delivery of trauma-informed care within a substance misuse service is presented. The model mirrors the one outlined earlier in the guide, but relates specifically to different levels of interventions for co-morbid substance misuse and post-traumatic stress disorder ( PTSD)/complex PTSD.

Cognitive impairment

Due to the impact of chronic alcohol and drug use on the brain, many service users presenting to substance misuse services will experience impairment of cognitive abilities. When this goes unrecognized, it can impact on an individual’s ability to engage with, and make progress in, treatment. It is therefore important to screen for cognitive impairment early in treatment, when clinically indicated.

Recommended screening tools include the Addenbrooke’s Cognitive Examination, 3 ^rd edition, and the Montreal Cognitive Assessment. Where cognitive screening suggests that further investigation is indicated, a referral for comprehensive neuropsychological assessment should be made to a clinical psychologist or clinical neuropsychologist.

Once again, a matched-care model of interventions for people with cognitive impairment is presented.

Training and governance of psychological interventions

This section outlines the minimum training requirements for the competent delivery of psychological interventions at each tier of the matched-care models.

When should different interventions be provided?

To engage in a psychological therapy, some stability in substance use is recommended, but an individual does not need to be completely drug- or alcohol-free. In general, dependent or chaotic substance use needs to be addressed prior to engaging in more formal psychological interventions (tiers 2–4). However, psychologically informed care will support engagement and motivation in all service users.