Imprving access t psychlgical therapies psitive practice guide fr wrking with peple wh use drugs and alchl Intrductin 1. This guide seeks t assist IAPT teams and substance misuse services t wrk cnfidently and inclusively with thse wh have drink r drug prblems and cmmn mental health prblems. It explains hw simple assessment techniques and prtcls can identify ptential IAPT clients with drink r drug prblems. It utlines criteria fr deciding whether peple with different kinds f drug and alchl use are suitable fr IAPT services. And it summarises hw IAPT and substance misuse services can wrk tgether mre clsely t imprve utcmes fr clients. Backgrund 2. A new natinal drug (and alchl dependence) strategy was published in December 2010 (HMG, 2010), and a mental health strategy a few mnths later (HMG, 2011). Bth strategies acknwledge the assciatin between mental health prblems and drug and alchl prblems. Successful utcmes fr bth prblems need early interventin and effective jint wrking between drug and alchl treatment and mental health services in integrated, recvery- riented lcal systems. 3. Peple with a histry f drug and alchl prblems, and receiving treatment, d nt necessarily pse any special challenges fr IAPT services but there are ften substantial clinical gains t be made in wrking with them. Substance misuse clients with mental health prblems shuld have access t NICE- recmmended psychlgical interventins, including CBT fr depressin and anxiety and there is n evidence that substance misuse per se makes the usual psychlgical therapies ineffective (NICE, 2007). 4. Illicit drug use, misuse f and dependence n ver- the- cunter and prescribed medicines, and alchl use are cmmn in Great Britain. It is estimated that 1.6 millin peple have mild, mderate r severe alchl dependence (McManus et al 2009). Thirty six per cent f adults reprt lifetime use f illegal drugs, with eight per cent using in the last year and five per cent in the last mnth (Hare and Mn, 2010). A significant number f IAPT clients are therefre likely t be using illicit r prescriptin drugs and/r drinking at hazardus r harmful levels that may be cntributing t their mental health prblems. Versin 11 PPGIAPTLM11-LS.dc 1
5. Between 70 and 80 per cent f clients in drug and alchl services have cmmn mental health prblems, largely anxiety, depressin and trauma (Weaver, 2003). The same study als fund high levels f drug use and hazardus and harmful drinking in the ppulatins using mental health services. The study cncluded that substance misuse services shuld wrk mre cllabratively with lcal psychtherapy services and GPs t imprve management f c- mrbid patients wh d nt meet the criteria fr access t cmmunity mental health services. 6. IAPT services d nt prvide cmplex interventins t treat substance use prblems but drug and alchl use shuld nt be an autmatic exclusin criterin fr accessing psychlgical therapy. Mst drug and alchl users d nt need specialist r clinical interventins t change their substance use behaviur and, f thse that d, many will respnd t brief interventins delivered in primary care. Only a small prprtin f drug and alchl users will require specialist treatment services and, in sme circumstances, referral t drug and alchl services will be apprpriate. 7. The expertise available within drug and alchl treatment services t prvide evidence- based psychlgical interventins will ften be limited. IAPT services may prvide ne f the nly lcal resurces fr clients f drug and alchl services t access psychlgical therapy fr cmmn mental health prblems. It is imprtant, therefre, fr IAPT and drug and alchl treatment services t wrk tgether t address the needs f peple with c- ccurring prblems. Infrmatin- sharing and cmmunicatin between IAPT and drug and alchl services at the lcal level can be a significant first step. Understanding the needs f users f drugs and alchl 8. While peple with serius drug and alchl prblems cme frm all walks f life and different backgrunds, they are ften affected by multiple disadvantages, either as a cnsequence r as a cause f their dependent drug use (Carpentier, 2002). 9. Sci- ecnmic factrs related t drug use include lw educatinal levels, early schl leaving and drp- ut; unemplyment, lw salaries and difficult jbs; lw incme and debt; insecurity f accmmdatin and hmelessness; mrtality and drug- related diseases; pr access t care; and scial stigma. Relative differences in the scial cnditins f drug users are fund by substance used; the wrst cnditins being fund amng thse dependent n piates, particularly herin (EMCDDA, 2003). While these scial factrs may cmplicate aspects f psychlgical wrk, they als highlight the extensive need within the ppulatin and the imprtance f wrking inclusively with this grup. Versin 11 PPGIAPTLM11-LS.dc 2
Identificatin and engagement by IAPT f substance misusers 10. The NICE guideline fr alchl- use disrders recmmends that all NHS- funded services shuld be cmpetent t identify harmful drinking (NICE, 2011). Rutine assessment f current use f drugs and alchl is therefre recmmended fr all IAPT clients. 11. The Alchl Use Disrders Identificatin Test (AUDIT) is a useful screening tl fr alchl prblems. The NICE guideline fr alchl suggests that fr clients wh typically drink ver 15 units f alchl per day, and/r wh scre 20 r mre n the AUDIT, shuld be assessed fr cmmunity- based assisted withdrawal. This may be thrugh the General Practitiner r if there is safety cncerns may require assessment and management in a specialist alchl service. 12. In additin t alchl, questins shuld als capture the mst prevalent illicit drug use; cannabis, ccaine, ecstasy (MDMA) amphetamine, ketamine and herin as well as prescribed drug use: benzdiazepines and piid based pain relief. Lcal drug partnerships may have agreed simple screening tls that can be used by nn- drug specialist services, including IAPT. 13. It is imprtant t appreciate clients ptential sensitivities t direct questins abut their drug and alchl use. Their experience may have led them t believe they will be criticised abut their use r denied access t a service and they may have cncerns abut cnfidentiality. Many clients feel shame abut their drug use r drinking. It is imprtant t maintain a nn- judgmental and prprtinate attitude t infrmatin abut substance use, neither minimising the extent f a prblem nr ver- stating its significance. 14. Drug and alchl users may be cncerned abut discussing a drug r alchl prblem and accessing services because they fear that infrmatin abut illegal activity (in the case f use f cntrlled drugs) culd be passed t the plice r ther criminal justice agencies. In additin, peple with children in their care may be reluctant t admit a drug r alchl prblem. It is therefre imprtant t be clear and explicit abut cnfidentiality cnstraints, as per yur service s standard plicy. As fr all clients, a plicy fr addressing any child prtectin cncerns that may arise shuld be in place. While drug r alchl use may raise child prtectin cncerns in sme circumstances, it is imprtant t recgnise that peple with substance misuse prblems are ften caring and effective parents. Drug use r drinking alne is nt sufficient grunds fr child prtectin cncerns. 15. Questins abut use f drugs and alchl ver the previus mnth specifically, days used and amunt typically used per day give a gd indicatin f pattern f use and an idea as t whether specialist treatment is required as an adjunct r precursr t engaging in psychlgical therapy. The aim f these questins is t infrm a judgement Versin 11 PPGIAPTLM11-LS.dc 3
f the extent t which substance use is prblematic and needs direct targeted interventin. They are a platfrm t facilitate an understanding f the extent t which a client s life is rganised arund the acquisitin and use f substances, recvery frm the ill- effects f using, the extent f the client s recgnitin f their prblem and their desire fr change. Lcal drug and alchl treatment agencies shuld be able t ffer advice and guidance n individual cases. 16. Asking clients their view f the relatinship between their substance use and their psychlgical distress has the ptential t pen up a cnstructive dialgue and help t identify any functin the substance use serves. The use f drug and alchl diaries can als help t explre inter - relatinships and can be easily integrated with daily thught recrds in standard CBT practice. 17. Many clients whse use is nt significantly prblematic can respnd well t simple advice t cut dwn their drug and alchl use, particularly if the reasns t d s are articulated in a cherent psychlgical frmulatin. Hwever, if there are cncerns that the client may be dependent n alchl, GBL (gamma- butyrlactne) r benzdiazepines then the GP shuld review the situatin first, as attempting t stp their use abruptly and withut clinical supprt can be damaging. 18. If the level f use is cnsidered t have the ptential t interfere with psychlgical therapy, questins cncerning the extent t which the client has cnsidered making changes and hw cnfident they wuld be in initiating these changes will give an indicatr f mtivatin fr change. Again, an explanatin f why change is relevant, cuched in terms f a psychlgical frmulatin with reference t the client s anxiety r depressin, can be very influential. 19. As part f treatment cntracting, it is gd practice t specify that clients must cme sber t sessins, and that they shuld nt use if engaging in specific between- sessin behaviural experiments. This cnversatin can be integrated within a general scialisatin t cgnitive and behaviural therapy. 20. If a client cmes intxicated t a sessin, it is advised t reschedule it rather than make any attempt t have a sessin. If the client struggles t attend sber r fails t d s tw sessins in a rw, the cntract shuld be reviewed. It may be an indicatr that drug and alchl service interventin is necessary. Versin 11 PPGIAPTLM11-LS.dc 4
Assessment and engagement Gd Practice Tips Use screening questins that encurage discussin abut substance use, rather than seeking t screen ut any drug and alchl user frm services r phrasing questins in such a way that the client may react defensively r lie. Cnsider a client s current invlvement with a drug and alchl service an advantage t psychlgical therapy. Offer an assessment t any drug using r drinking client referred t yur service, even if substances feature heavily in the referral. A client may cme fr an appintment with a therapy service when they might be reluctant t attend a drug and alchl service, and this prvides an pprtunity t engage with and influence the persn s use, mtivatin and understanding f their difficulties. Many clients have repeated experiences f exclusin and refusal, and a psitive experience f cnsultatin can be a helpful cunterpint t this. Talk abut these issues in supervisin. Once a client is being assessed face t face, sme attentin t the attitudes f therapists is imprtant. These may lead t judgments and beliefs which can be verly negative r cndne the extent f the issue being assessed. Use cre skills t develp a therapeutic relatinship. Prfessinals in IAPT services may feel anxius abut a lack f knwledge abut illicit drugs. This need nt interfere with psychlgical wrk nr be a barrier t taking n drug using clients. Suspending judgement and embracing a spirit f curisity will enable the client t speak penly abut their experiences and fster a cllabrative relatinship. Deciding whether the IAPT prgramme is suitable r nt 21. When the assessment prcess identifies drug and alchl use as an issue, an infrmed decisin n hw best t rganise effective interventins fr the client can be made. 22. A prerequisite fr IAPT invlvement is that the client has a depressin r anxiety disrder that falls within IAPT s usual criteria. 23. NICE guidelines fr alchl recmmend first prviding effective treatment fr alchl prblems fllwed by treatment fr cmmn mental health prblems that may persist Versin 11 PPGIAPTLM11-LS.dc 5
after alchl treatment. Althugh cmmn mental health prblems may imprve fllwing a change in alchl use, this recmmendatin highlights the value f timely and c- rdinated respnses t enabling peple t access the services they require. IAPT shuld be cnsidered suitable if: 24. The client is able t attend sessins and has mtivatin t limit their drug r alchl use. This is demnstrated by cntrl f their drug r alchl use and / r when it is limited t clearly circumscribed cntexts. Sme examples include: A weekend user f ecstasy wh finds scial situatins anxiety prvking. A client wh is afraid f heights and manages flying by taking diazepam and alchl. 25. The client is stable, i.e. using medicatin as prescribed and nt using additinal nn- prescribed medicatin r illicit drugs. This wuld include clients n piid substitutin prgrammes (usually methadne r buprenrphine). N ne shuld be excluded frm IAPT services because they are being prescribed substitute medicatin Examples f clients suitable fr IAPT and stable n, r reducing, their prescribed medicatin wuld include: A client experiencing lw md, taking methadne but nt using herin r drinking alchl n tp f their prescriptin. A client with panic disrder reducing their prescribed benzdiazepine use. 26. The client has a histry f drug r alchl use but is nw abstinent, fr example: A client with scial anxiety wh has recently successfully cmpleted a cmmunity alchl detxificatin. IAPT wuld nt initially be suitable if: 27. The client is dependent n illicit drugs r alchl and nt in cntact with a treatment service. Examples include: A client reprting panic attacks and drinking alchl every mrning t stp the shakes. A client regularly bingeing n crack ccaine and becming very depressed in the recvery phase between these binges. 28. These clients wuld be likely t benefit frm referral t a drug and alchl treatment agency fr specialist assessment and a care plan frmulated and initiated targeting their substance use. Versin 11 PPGIAPTLM11-LS.dc 6
29. The client is in treatment with a drug r alchl treatment service but unable t make changes in their substance use as a cnsequence f mental health issues. Examples include: A client cntinuing t use herin in additin t their methadne because their lw md is perceived t be intlerable. A daily smker f cannabis whse smking has becme a cping strategy fr all daily life events. 30. In such cases, standard keywrking in the addictins service wuld cntinue t wrk n these issues until sme stability is achieved. If available, a specialist assessment and interventin by a psychlgical therapist within the addictin service may be required t develp and deliver a relevant frmulatin and treatment plan. In line with gd practice in care planning it wuld be helpful t specify a timeframe fr reassessment in an IAPT service pst detxificatin r when stabilisatin has been achieved. This may infrm a part f an agreed aftercare and recvery supprt plan. Training and develping the wrkfrce 31. The IAPT wrk frce wuld benefit frm basic drug and alchl awareness training t enable them t understand the effects f substances and related health issues including impact n mental health and psychlgical well- being. Training may be accessed thrugh the lcal drug (and alchl) partnership. Similarly, training and supervised practice in the assessment f drug and alchl use may be indicated fr peple wh are unfamiliar with r lack cnfidence in this area. 32. IAPT wrkers are in an ideal psitin t help peple wh may nt be suitable fr specialist addictin services t think abut their drug use r drinking. They will benefit frm training in brief interventins and shuld aim t gain familiarity with the ideas f mtivatinal interviewing, a cunselling style which lks t help clients reslve ambivalence abut change (Miller and Rllnick, 2002). Fr peple nt already familiar with these ideas, training will significantly advance their ability t wrk effectively with IAPT clients. 33. A framewrk and tlkit fr implementing NICE psychscial guidelines fr drug misuse has been prduced, adpting the same cmpetency mdel as that used in training IAPT practitiners. Of particular relevance t IAPT prfessinals, particularly lw- intensity wrkers, is the sectin n brief mtivatinal interventins (Pilling et al., 2009). Versin 11 PPGIAPTLM11-LS.dc 7
34. Many f the general cgnitive and behaviural techniques used by psychlgical therapy wrkers are transferable t wrking with drug r alchl use (Mitchesn et al., 2010). 35. IAPT wrkers shuld familiarise themselves with the lcal specialist addictins treatment services as well as lcal mutual aid grups (Alchlics Annymus, Narctics Annymus, SMART Recvery). Mutual aid grups can supprt individuals in achieving and maintaining abstinence. Many hld pen meetings and prfessinals are welcmed t experience them. SMART Recvery uses a mutual aid mdel similar t the lng- established 12- Step grups (AA and NA) but fcuses n cgnitive and behaviural cping strategies. 36. Jint case- discussin frums, supervisin grups and penness t mutual cnsultatin with addictin services are highly recmmended. References Carpentier, C. (2002). Drug Related Scial Exclusin, in the Cntext f Sci- demgraphic and Ecnmic Indicatrs. Wrking paper. Lisbn: Eurpean Mnitring Centre fr Drugs and Drug Addictin. EMCDDA (2003). Scial exclusin and reintegratin. In EMCDDA 2003 Annual reprt n the state f the drugs prblem in the Eurpean Unin and Nrway. Lisbn: Eurpean Mnitring Centre fr Drugs and Drug Addictin. HM Gvernment (2010). Drug Strategy 2010 Reducing Demand, Restricting Supply, Building Recvery: Supprting Peple t live a Drug Free life. HM Gvernment (2011). N health withut mental health: A crss- gvernment mental health utcmes strategy fr peple f all ages. Hare J and Mn D (2010), Drug Misuse Declared: Findings frm the 2009-10 British Crime Survey, Lndn: Hme Office. McManus, S., Meltzer, H., Brugha, T., Bebbingtn, P., and Jenkins, R.(2009) Adult Psychiatric Mrbidity in England, 2007. Results f a Husehld Survey, The NHS Infrmatin Centre fr health and scial care Miller, W.R. and Rllnick, S. (2002). Mtivatinal Interviewing: Preparing Peple t Change Addictive Behaviur, 2 nd Editin. New Yrk: Guilfrd Press. Versin 11 PPGIAPTLM11-LS.dc 8
Mitchesn, L., Maslin, J., Meynen, T., Mrrisn, T., Hill, R., Wanigaratne, S. (2010). Applied Cgnitive and Behaviural Appraches t the Treatment f Addictin: A Practical Treatment Guide. Chichester: Wiley- Blackwell. NHS Infrmatin Centre fr Health and Scial Care (2011), Statistics n Alchl: England 2011,The Health and Scial Care Infrmatin Centre. NICE (2007). NICE clinical guideline 51. Drug Misuse: Psychscial Interventins. Lndn: Natinal Institute fr Health and Clinical Excellence. NICE (2011). NICE clinical guideline 115. Alchl- use disrders. Diagnsis, assessment and management f harmful drinking and alchl dependence. Lndn: Natinal Institute fr Health and Clinical Excellence. Pilling, S., Hesketh, K. & Mitchesn, L. (2009). Psychscial Interventins in Drug Misuse: A Framewrk and Tlkit fr Implementing NICE- recmmended Treatment Interventins. Lndn: Natinal Treatment Agency & British Psychlgical Sciety Weaver, T., Madden, P., Charles, V., Stimsn, G., Rentn, A., Tyrer, P., Barnes, T., Bench, C., Middletn, H., Wright, N., Patersn, S., Shanahan, W., Seivewright, N., Frd, C. (2003) Cmrbidity f substance misuse and mental illness in cmmunity mental health and substance misuse services. British Jurnal f Psychiatry, 183, 304-313. Versin 11 PPGIAPTLM11-LS.dc 9