We all recognise that moment when we find out we need to provide a bank of new data to those on high, although drug and alcohol workers might ask ourselves why we can’t just be left to get on with the ‘real job’ – helping service users to improve the quality of their lives.
So what drives the latest version of the data we are being asked to submit – data set J of the National Drug Treatment Monitoring System (NDTMS)? What does it have to do with real and enduring recovery? Why are modalities being relabelled as interventions, and what is the point of having sub-interventions? And what was wrong with the old system anyway?
Anyone using or working in UK drug and alcohol services will be aware of the impact of the recovery agenda on expectations of what drug treatment is really about, with the focus now not only on achieving reduction of drug use or abstinence from it, but on recovery in a much wider sense.
Few would argue with the idea of drug and alcohol services aspiring towards offering the best opportunities possible for service users to achieve their goals by using the most effective treatment interventions, in the most appropriate ways, to stimulate and maintain behaviour change. Opioid substitution treatment (OST) has a very well-established evidence base in helping to reduce harms caused by opiate use and engage people in drug treatment. Increasingly, however, there is recognition that provision of effective OST can be the place where treatment starts, rather than the only meaningful intervention we can offer.
The way in which we have recorded what we do with service users in treatment reflects the past emphasis on OST as the mainstay and focus of treatment. In NDTMS data sets to date, we record ‘specialist prescribing’ as an intervention which necessarily incorporates key working, with key working defined as having qualities such as being based on a therapeutic relationship and having regular contact with service users, including assessment, goal setting and review.
However, although the intensity, quality and frequency of this contact varies widely between, and even within, services, little attention has been paid to recording what we as workers actually do with service users and what treatment models we use or what treatment philosophy we come from.
If we do use a specific evidence-based treatment intervention we have only been able to record this as ‘other formal psychosocial intervention’. This lack of specificity makes it difficult to represent the differences between, for example, a targeted motivational intervention and working with a service user on their anxiety using CBT.
Perhaps the emphasis on recording the prescribing element of what services do and the merging of psychosocial interventions into an ‘other’ category has not encouraged us to consider which psychosocial interventions we are using and how effective they are. Using previous NDTMS data sets may have yielded information on very important aspects of harm reduction – such as offer and acceptance of BBV vaccinations or prevalence of injecting – but what has been missing is the ability to record the psychosocial interventions we know are often essential to recovery in the wider sense, such as improvements in psychological health, resilience and overall quality of life.
We are all aware that patterns of drug use are changing, and the nature of the work we do will continue to develop. So how might the new data set J make a difference? When we talk about translating ideas about recovery into everyday practice, we are often talking about focus on psychosocial and recovery-specific interventions. Data set J is much more specific about using the evidence base to actually make a difference to our practice. Rather than using modalities such as ‘other structured intervention’ we are now encouraged to think about what we are offering to our service users in a well-defined way.
For example, the type of intervention is entitled ‘psychosocial’ but the sub- interventions refer to evidence-based treatments we should be offering, such as ‘motivational interventions’, which includes manualised motivational enhancement therapy. Data set J pays specific attention to the role of the service user’s social support by having a category for ‘family and social network interventions’. It also recognises the need for treatment of co-existing mild to moderate mental health problems within drug and alcohol treatment services by referring to low and high intensity CBT-based interventions for problems such as anxiety and depression.
If we are only ever recording one type of psychosocial intervention as being offered in addition to OST, then we need to question why we are not offering other types, where the knowledge and supervision gaps might be, and how the service can address these. Being asked to record what we do in a different way can actually encourage us as workers, managers and commissioners to assess the quality of what we are offering to service users and how to improve it.
Within data set J, additional sub-interventions relate to recovery support with specific reference to peer support involvement, mutual aid and working with service users’ social networks. The evidence base for working with people in their social contexts is well established yet too often within treatment services we may have relied on an individualised treatment programme and not been encouraged or prompted to make active efforts to invite specific support from social networks or actively facilitate mutual aid attendance. Again, attention to recording these sub-interventions invites us to consider how much we are doing to promote and facilitate real recovery options and make the wider recovery community visible to all.
The demands placed on treatment services by attention to psychosocial and recovery interventions are challenging yet exciting. We are now expected to know about, and use, a range of psychosocial interventions in a structured way. There are demands not only on training staff to offer interventions at measurable competence levels but also to maintain these competence levels with good quality frequent clinical supervision.
The definitions within data set J are clear that specific competences over and above those required for key working with supervision are necessary to legitimately record the intervention as being delivered. We would argue that clinical psychologists have a unique role to play within drug treatment services through their experience in psychological principles and their commitment to behaviour change, service evaluation, research and contribution to multi-agency working. Sub-interventions specified in data set J are clearly based on those suggested by the 2007 NICE guidelines and incorporate fundamental principles from the recovery agenda.
Clinical psychologists have been at the forefront of developing and researching effective psychosocial interventions and using knowledge of treatment contexts and human motivation to embrace community psychology in addition to more traditional individualised treatment approaches. Recent advances in the use of positive psychology and focus on strengths-based working lead us to consider how theories and research-based evidence can be applied in the real world, and clinical psychologists are ideally placed to bridge the gap between theory and practice.
More detailed attention paid to the types of psychosocial interventions we offer and how we can measure continued competence and outcomes of these approaches encourages us to consider how the profession of clinical psychology can help services to develop in a climate which, although challenging, is full of opportunities to make real and lasting improvements in the quality of options offered to our service users. DDN
Jan Hernen is a clinical psychologist at Turning Point Somerset, and Dr Christopher Whiteley is consultant clinical psychologist at East London Foundation Trust.