Substance misuse services: delivery of psychological interventions

6. When should different interventions be provided?

If individuals wish to address their substance misuse, services should support and build motivation to change, enable the development of belief in the person’s ability to make changes, emphasise the value and importance of the changes, and offer access to a range of interventions at different stages of the recovery journey.

Specific competencies that will support people to engage in treatment, prepare for change, make changes, consolidate the changes and reintegrate into a new lifestyle are outlined in Table 1. When integrating these with other psychological therapies, a number of questions arise. How stable does someone need to be before engaging in a psychological therapy? Do we need to consider dosage of opiate substitution therapy and other medications? How best to integrate psychological and medical interventions? These questions will be considered in this section.

How stable does someone need to be to engage in psychological therapy?

It is recommended that interventions for substance use and co-occurring mental health difficulties are integrated, so that any exacerbation of problematic emotional difficulties caused by stabilisation of substance use can be managed within the same package of care. This means that timing of interventions can be important. 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 psychological therapy. Regular and frequent use will also interfere with psychological therapy by adding to emotional and physical dysregulation, but psychologically informed care will support engagement and motivation. If use has reduced to the point where the individual is able to stay free of illicit drugs or alcohol for most of the time, beginning some higher-tier intervention is appropriate and may enable the individual to consolidate stability to engage with further interventions as appropriate.

Do we need to consider medication dosage?

The research literature is clear that psychological therapy enhances opiate replacement therapy ( ORT) outcomes: how ORT and other medications impact on psychological therapy is less clear, however.

There is some research indicating that methadone and buprenorphine maintenance treatments impair cognition, particularly attention, learning and memory. Benzodiazepines such as diazepam are also known to impair cognition, especially memory functioning. Expert consensus suggests that methadone doses over 70 mg and diazepam doses over 15 mg tend to interfere with the therapeutic process. Flexibility is required around this, however: in the context of psychological interventions, the impact of medication on engagement and progress may come down to clinical judgement on whether an individual’s dose interferes with his or her ability to experience, tolerate and process emotions and thoughts, along with the individual’s motivation to reduce medication. Where people feel that their medication is a ‘crutch’, building confidence in using psychosocial strategies to manage emotions may support decisions around dose reductions.

Integrated interventions

Psychological interventions should be integrated as part of a recovery care plan and delivered closely with medical, pharmacological, non-medical and social care interventions. Self-directed support may provide a framework in which to enable individuals to choose a range of psychological and social interventions. For this to happen, waiting times for interventions should be reduced as far as possible, in line with national standards.