Substance misuse services: delivery of psychological interventions

1. Introduction

This guide on delivery of psychological interventions ^[1] for substance misuse services in Scotland is designed primarily to support commissioners and providers in developing effective recovery-oriented systems of care, with psychological and psychosocial interventions at their heart.

Psychosocial interventions are key components of effective substance misuse treatment. In some cases, where no pharmacological interventions are available, they offer the only evidence-based treatment. ^[2]

Although the guide focuses primarily on delivering psychological interventions in specialist substance misuse services, many of its recommendations are equally relevant to delivery for people with substance misuse problems in other settings, such as primary care, mental health and prisons/forensic settings.

The guide relates to a number of national strategies and policy drivers in the fields of substance misuse and mental health. Box 1 highlights Scottish Government health policy and guidelines that the guide aims to complement.

The guide has evolved from strategic work carried out by the Lead Psychologists in Addiction Services Scotland ( LPASS) and has drawn on work from the British Psychological Society’s ( BPS) Faculty of Addiction. ^[3] It was written to correspond with recently published UK guidelines on clinical management of drug misuse and dependence ^[4] and links directly to several actions outlined in the Mental Health Strategy 2017–2027, ^[5] particularly:

• Action 24 – fund work to improve provision of psychological therapy services and help meet set treatment targets
• Action 27 – test and learn from better assessment and referral arrangements in a range of settings for dual diagnosis for people with problem substance use and mental health
• Action 28 – offer opportunities to pilot improved arrangements for dual diagnosis for people with problem substance use and mental health diagnosis.

It also relates to two local delivery plan ( LDP) standards:

• 90% of patients to commence psychological therapy-based treatment within 18 weeks of referral (previously HEAT A12)
• 90% of clients will wait no longer than three weeks from referral received to appropriate drug or alcohol treatment that supports their recovery (previously HEAT A11).

Box 1. Scottish Government health policy and guidelines

Drug treatment

• Essential care: a report on the approach required to maximise opportunity for recovery from problem substance use in Scotland (2008) ( http://www.gov.scot/Publications/2008/03/20144059/0)
• The road to recovery: a new approach to tackling Scotland's drug problem (2008) ( http://www.gov.scot/Publications/2008/05/22161610/0)
• Delivering recovery. Independent expert review of opioid replacement therapies in Scotland (2013) ( http://www.gov.scot/Publications/2013/08/9760)
• The Quality Principles: standard expectations of care and support in drug and alcohol services (2014) ( http://www.gov.scot/Publications/2014/08/1726)

Alcohol treatment

• Changing Scotland’s relationship with alcohol: a framework for action (2009) ( http://www.gov.scot/Publications/2009/03/04144703/14)
• Quality alcohol treatment and support ( QATS) (2011) ( http://www.gov.scot/Publications/2011/03/21111515/0)

Mental health and co-morbidity

• Mind the gaps: meeting the needs of people with co-occurring substance misuse and mental health problems (2003) ( http://www.gov.scot/Publications/2003/10/18358/28079)
• Mental health in Scotland: closing the gaps – making a difference: Commitment 13 (2007) ( http://www.gov.scot/Publications/2007/12/10141643/0)
• Mental health strategy: 2017–2027 (2017) ( http://www.gov.scot/Publications/2017/03/1750)

Workforce development

• Supporting the development of Scotland’s drug and alcohol workforce (2010) ( http://www.gov.scot/Publications/2010/12/AandD)

Psychosocial interventions and psychological therapies

• The Matrix: a guide to delivering evidence based psychological therapies in Scotland (2015) ( http://www.nes.scot.nhs.uk/media/3325612/matrix_part_1.pdf).

The guide is designed to support services to deliver timely access to effective psychological therapies. It is anticipated that it will therefore assist services to meet and maintain the 18-week psychological therapies LDP standard. The effective delivery of evidence-based psychological interventions (through improving outcomes for patients, reducing failure demand on services and improving patient throughput) can also support services in meeting and maintaining the three-week drug and alcohol treatment LDP standard.

It is important to acknowledge that the guide has been influenced by, and sits alongside, the recently launched knowledge and skills framework for the Scottish workforce on transforming psychological trauma. ^[6] Section 4 of the guide, on the delivery of psychological interventions for people with co-morbid complex trauma and substance misuse, is very much in line with the framework’s recommendations.

A robust evidence base outlines effective psychosocial and psychological interventions that support people to change their behaviour and maintain recovery, based on a psychological understanding of addictive behaviours. Section 3 provides an overview of the evidence-based psychological interventions recommended in substance misuse services. Section 5 outlines supervision and training requirements, highlighting the importance of workforce development and partnership-working across substance misuse services. In short, the guide seeks to illustrate which interventions will work for which people, when, and how they should be delivered.

The aim is to provide an aspirational model for delivery of psychological interventions in substance misuse services in Scotland. Delivery of the proposed model will require commitment from commissioners, managers and frontline staff, alongside creative thinking about prioritisation of service delivery within the context of available funding. The model is designed to be adapted for NHS boards of different size and scale, and recommendations support this where possible. Section 5 presents recommendations on access to training and support for areas in which the capacity and competency level of the workforce currently is not able to deliver the model as presented.

Fundamentally, the guide seeks to ensure that all people looking to recover from problematic substance misuse have access to the evidence-based psychological interventions they need. At all levels of the proposed delivery model is the acceptance that people will often still be using substances while accessing psychological interventions: indeed, many of the recommended psychological interventions aim specifically at a person’s substance misuse problems.

Historically, people struggling with mental health problems alongside their problematic drug and alcohol use (often termed co-morbidity or dual diagnosis) have experienced difficulties accessing psychological interventions. The model presented here accepts that for many people, stopping substance misuse before dealing with co-morbid psychological difficulties is simply not possible. Indeed, the function of substance misuse is often to help the person cope with underlying and unaddressed psychological difficulties. It is therefore vital that people have access to treatment for these difficulties alongside treatment for their substance misuse problems if they are to achieve lasting recovery.