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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
g
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
s s)
•• 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
I
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