Substance misuse services: delivery of psychological interventions
Strategy aimed at increasing access to support for people working to recover from problematic alcohol and drug use.
5. Training and governance of psychological interventions in substance misuse services
The matched-care model assumes a staff skill mix in substance misuse services, with staff working at different tiers having a set of competencies appropriate to the level of therapeutic intervention provided. As the model outlines, while all frontline staff should have some level of psychological knowledge, smaller numbers of staff will require more specialist training. Competency frameworks are outlined in the NTA/ BPS document Routes to recovery: psychosocial interventions for drug misuse. [21]
All staff delivering psychological interventions should receive regular clinical supervision and be able to access more specialist psychological advice when required. Supervision is essential in ensuring that the delivery of the intervention adheres to protocols and maximises effectiveness for the service user. Supervision makes a fundamental contribution to quality assurance and evaluation of competence, as well as supporting the therapist’s educational development and practice. Psychological therapies that are inappropriately or inadequately delivered can cause harm and supervision is key to ensuring safe practice. [22]
The Psychological Therapies Matrix provides guidance on the recommended psychological interventions to consider in the quality assurance and clinical governance plans of Scottish alcohol and substance misuse services. Guidelines for supervision and training are included to ensure that training, supervision and delivery of low and high intensity interventions meet the standards necessary for evidence-based implementation.
Training in psychological interventions can be co-ordinated by the local substance misuse psychology service, psychological interventions team (or equivalent), or psychological therapies training co-ordinator of each NHS board. Training may include a blend of courses from different providers, including NES, the Scottish Drugs Forum ( SDF), in-house training delivered by organisations, and bespoke modules from individual trainers.
The way in which training is delivered may be blended to enhance accessibility and effectiveness, and may include e-learning modules, short workshops, multiple-day courses and workplace-based coaching to apply learning. Table 2 outlines the minimum training requirements for the competent delivery of psychological interventions at each tier, based on the Psychological Therapies Matrix.
Table 2: Minimum training requirements for the competent delivery of psychological interventions at each tier, based on the Psychological Therapies Matrix
| Tier of psychological intervention |
Training |
|
|---|---|---|
| Tier 2 |
Low intensity psychological intervention for alcohol/substance use disorders |
- Pre-employment professional training plus additional training in psychological interventions, usually comprising a series of short courses/workshops (e.g., core cognitive and behavioural skills in relapse prevention and recovery management ( NES); MI ( SDF)) - The minimum training required is typically 5–10 days plus regular ongoing supervision |
| Tier 2 |
Low intensity psychological intervention for mild–moderate common mental health conditions delivered within protected therapy time |
- SPIRIT training - Certificate-level CBT training - Individual clinicians who have been trained to a recognised high level in a specific therapeutic approach - The minimum training required is typically 5–10 days plus regular ongoing clinical supervision |
| Tier 3 |
High intensity psychological therapies for moderate–severe presentations with significant complexity and impact on functioning; standardised psychological therapies delivered to protocol, within protected therapy time |
- Individual clinicians with a highly developed special interest, who have been trained to a recognised high level in a specific therapeutic approach - Diploma/master’s-level CBT training - Doctoral-level clinical psychology training (or equivalent) - The minimum training required is 24 days formal teaching of CBT plus 24 days of workplace CBT practice plus intensive supervision over at least one year - Ongoing clinical supervision is required |
| Tier 3 |
High intensity specialist psychological therapies for moderate–severe presentations with significant complexity and effect on functioning; standardised psychotherapies developed and modified for specific patient groups |
- Individual clinicians with a highly developed special interest, normally including involvement in research and identified by colleagues as having the requisite knowledge and skills - Diploma/master’s-level CBT training plus further training in the application of CBT to specialist area, acquired through formal training or specialist supervision - Doctoral-level clinical psychology training (or equivalent) - Ongoing clinical supervision is required |
| Tier 4 |
Highly specialist psychological therapies for highly complex clinical presentations, including enduring mental health problems with a high likelihood of co-morbidity that are beyond the scope of standardised treatment |
- Individual clinicians with a highly developed special interest, normally including involvement in research and identified by colleagues as having the requisite knowledge and skills - Doctoral-level clinical psychology training (or equivalent) - Ongoing clinical supervision is required |
Competent delivery of psychological interventions requires that interventions are delivered to protocol, practitioners have the necessary training and knowledge, practice is observed to ensure fidelity, and interventions are delivered under supervision. National initiatives on practice development and coaching groups for low intensity psychological therapies are intended to complement supervision provision, rather than replace it.
The intensity of supervision provided will vary in accordance with the intensity of therapy and, consequently, the severity and complexity of clinical presentation. A high intensity CBT therapist may receive individual supervision on a fortnightly basis, whereas a low intensity practitioner may receive supervision together with one or two colleagues every three to four weeks.
Training and supervision alone cannot ensure that training is implemented in practice. When staff attend training, it does not always translate into changes in practice without work-based implementation support. This wastes resources and potentially deprives service users of receiving interventions based on the best and most up-to-date evidence available. Without opportunities to consolidate training into practice and receive feedback, staff can feel de-skilled and unmotivated. Implementation science highlights this problem: Figure 4 illustrates factors that support implementing training into practice. There is a need for strategic planning and leadership so that training is provided in a targeted way and in line with service requirements.
Figure 4: Factors that help support training into practice [23]
There is a need to develop a strategic approach regarding CBT training for addiction service staff. It is important that the substantial investment in training CBT therapists yields a return for the service. Therapeutic skills need to be utilised for the provision of CBT following completion of training, and trained staff need protected time in which to practice and attend supervision to maximise the significant investment. Trained CBT staff can also be a valuable resource in supporting practitioners at tiers 1 and 2.
There is also a need to consider the numbers of CBT therapists that need to be trained to provide sufficient capacity to meet future demand, and to identify locations in which there may be gaps in provision. In a similar vein, the level of provision of psychologists needs to be considered as part of a strategic plan, rather than on an arbitrary basis. In addressing these issues, it is necessary to consider the competency and skill mix required to deliver the stepped/matched-care model of psychological therapies delivery.
It is important to consider the role of applied psychologists in supporting delivery of psychological interventions in substance misuse services. All services should have access to consultant-level psychologists to lead on the development and delivery of interventions and support supervision structures.
An example of an audit proforma to support the development of robust training and supervision structures for psychological therapies in substance misuse services is provided in Appendix 1.
Outcome measurement of interventions is an essential component of delivery that allows services to measure effectiveness, continually improve delivery, ensure that the integrity of interventions is maintained and add to the evolving evidence base. Appendix 2 provides an overview of validated outcome measures recommended for different aspects of psychological therapies delivery. This should not be read as an exhaustive list, but provides examples of the types of measure that may be useful for clinicians and commissioners alike. Outcome measures chosen may reflect mandatory service requirements, balanced with the need to accurately measure target symptoms for change.
Case example. Ensuring access to MI
A local area decides to implement a programme to ensure that all service users have access to high-quality MI delivered effectively by practitioners in the substance misuse team.
The local Alcohol and Drug Partnership ( ADP) and managers work together to identify the finances and administrative support needed and identify strategies to ensure staff-release time for training, coaching and supervision. A competency framework is agreed upon (such as MIA- STEP) that provides a structure for quality assurance and clinical governance, as well as a strengths-based format for enhancing MI practice.
Practitioners in the service who are highly experienced in MI are identified as potential trainers and/or coaches as the plan rolls out. The trainers, who have workplace experience in delivering and coaching MI, are commissioned to roll out a programme of training in MI which consists of an initial e-learning module providing the foundation of knowledge, principles and attitudes, followed by a three-day training that emphasises the practice of skills and direct feedback. A follow-up training is provided two months later, allowing practitioners to apply learning in the workplace and bring their challenges back to the trainers.
Practitioners who have already had training in MI participate in the training as a refresher course and are encouraged to engage with skills-based practice exercises at their more experienced level, with the goal of encouraging the most experienced practitioners to become trained and develop their skills as coaches. A programme of coaching is rolled out, with practitioners attending monthly coaching sessions. Refresher training with the latest developments is offered yearly and a rolling programme of training is developed to meet the needs of new staff, with local practitioners offered the opportunity to be trained as trainers.
Contact
Alcohol and Drug Delivery team: Alcohol_and_Drug_partnerships@gov.scot
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