Drug Treatment Matrix cell C2: Management/supervision; Generic and cross-cutting issues

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Effectiveness Bank Alcohol Treatment Matrix

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Effectiveness Bank Drug Treatment Matrix

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Management/supervision; Generic and cross-cutting issues

Key studies on the role of management and supervision across psychosocial and medical treatments of problem drug use. Highlights that “Manners Matter”, asks, “Is there anything more instructive than being the patient?”, explores the role of patient choice and preferences in treatment planning, and queries the ubiquitous stages of change model. See the rest of row 2 of the matrix for more on features common to psychosocial and medical treatments.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Qualifications do not a counsellor make (1984). Whether counselled by ex-addicts, paraprofessionals or degreed professionals, patients at methadone maintenance and drug-free outpatient services did just as well, findings in line with later work indicating that for these kinds of roles formal qualifications and experience are not indicative of quality. More on recruitment below and in cell C2 of the Alcohol Treatment Matrix.

K First get the staffing right (2004). US study suggests that recruiting the ‘right’ clinicians who have not been trained in appropriate ways to relate to patients would be better than choosing the ‘wrong’ ones who have been, and the former gain most from training. More on recruitment above and in cell C2 of the Alcohol Treatment Matrix.

K Motivating aftercare (2007). US residential centre systematically applied simple prompts and motivators to substantially improve aftercare attendance and sustain recovery. See also later report (2008) from same study. For discussion click here and scroll down to highlighted heading.

K Try walking in their shoes (2008). When senior staff role-played the process of becoming a new client (a ‘walk-through’) at their own US substance use service, the resulting enlightenment helped halve waiting times and extend retention. See also this extension (2012) to the programme and this account (2007; free source at time of writing) of the ‘walk-through’ procedure. Walk-throughs are a key element in the NIATx quality improvement model; see document and web site listed below. For discussion click and scroll down to highlighted heading.

K Systematically link assessments to services (2005). In Philadelphia automatically linking problems identified at treatment intake to relevant local services transformed assessments from clinically redundant paperwork into a practical route to the ‘wrap-around’ care advocated to deepen and extend recovery. For discussion click and scroll down to highlighted heading.

K Responsiveness to patients’ needs means better outcomes (2010). Analysis based on over 3000 US clients found they stayed longer and did better at services which showed responsiveness to need by offering help to get them to treatment and organising needed ‘wrap-around’ services.

K You cannot treat an empty chair (2013; free source at the time of writing). Title is from a report of how 67 US substance use outpatient clinics used the NIATx quality improvement model to reduce ‘no-shows’ through reminder calls (had to be sensitively handled), cutting waiting times, increasing capacity (eg, extra hours), and psychosocial approaches to bolster engagement such as motivational interviewing. More on the NIATx model below and on its application above.

R How to generate evidence-informed practice ([Australian] National Centre for Education and Training on Addiction, 2008). Though they found few studies on substance use treatment, reviewers extracted valuable lessons from health promotion and medical care services on how to implement research-based innovations to improve treatment practice.

R Cycle of change model poor guide to intervention (2001). Its simplicity is beguiling, but can services trust Prochaska and DiClemente’s ubiquitous model to guide them in matching interventions to a client’s ‘stage of change’? This thorough but easy-reading review found little evidence to support this popular strategy. Since it was written not much has changed. For discussion click and scroll down to highlighted heading.

R Care enough to be personal but also to be systematic and persistent (2004). In seemingly mundane tasks like reminding patients of appointments and checking how they are doing after they leave, individualised and welcoming communications characterise retention-enhancing services. Systematising these procedures is not the antithesis of being caring, but a sign that the service cares enough to make the most of every contact. For discussion click and scroll down to highlighted heading.

R Tentative support for matching treatment to patient preferences (2016). The first review to evaluate shared decision-making and matching substance use treatment to patient preferences found some evidence that greater patient involvement in decisions has no negative impacts and can improve outcomes. For discussion click and scroll down to highlighted heading.

R Involving former problem substance users in promoting recovery (2014). For such a widely implemented and widely supported adjunct to formal treatment, the revelation from this review is how little evidence there is for involving former substance users in promoting recovery from problems similar to those they had experienced – a lack which may simply reflect the paucity of adequate research. However, on balance the evidence we do have is positive. Related UK and US supervision guidelines below.

G UK staff development toolkit ([English] National Treatment Agency for Substance Misuse, 2006). Recruitment, training and staff development, appraisals and supervision, exit interviews and more.

G Criteria for quality in substance use treatment in Scotland (Convention of Scottish Local Authorities and Scottish Government, 2014). Developed to ensure anyone looking to address their problem drug and/or alcohol use receives high-quality treatment and support that assists long-term, sustained recovery and keeps them safe from harm. Can act as a quality-assurance checklist for service managers.

G English inspectorate’s criteria for quality in substance use services ([English] Care Quality Commission, accessed 2020). Official inspector of health and social care services in England asks five key questions of specialist substance use services in the NHS and independent sectors, including “Is it well-led?”, assessed by questions such as “Is the culture centred on the needs and experience of people who use services?” More on what ‘well-led’ means in appendices to prior consultation.

G Assessing whether the workforce has the required knowledge, skills and ability (NHS Health Scotland, 2009). Desired competencies and assessing the training needs of Scotland’s substance use workforce at all levels, from specialists to generic workers who may deal with substance use only peripherally.

G Managing peer supporters ([UK] Substance Misuse Skills Consortium, 2015). Guidance from (now no longer operational) government-supported skills body for the substance use sector on how to manage current and former problem substance users who support and mentor other users through and out of treatment. Related review above and US guidelines below.

G Supervising peer supporters (2017). US checklist and training curriculum for evaluating and developing competence to supervise (ex-)substance using peers to promote recovery among a service’s patients. Related review and UK guidelines above.

G Managing non-residential programmes ([US] Substance Abuse and Mental Health Services Administration, 2006). US expert consensus on running outpatient, counselling and day-care substance use programmes, including strategies to meet “the challenges facing executives and the opportunities for employing available resources and skills to meet program goals”.

G Clinical supervision and professional development of counsellors ([US] Substance Abuse and Mental Health Services Administration, 2009). US expert consensus on supervision methods and models, including how these can address cultural, ethical and legal issues, and monitoring performance. Includes an implementation guide for administrators.

G Workforce development aid for managers ([Australian] National Centre for Education and Training on Addiction, 2005). Evidence-based strategies to address priority workforce development issues such as supervision, team building and performance appraisal, plus resources to help managers implement the strategies. Endorsed by the Australian government.

G Improving efficiency and capacity means more patients can be helped ([US] NIATx, accessed 2020). Web-based service based at University of Wisconsin and supported by US government. Offers practical strategies to improve the management of substance use treatment services. Objectives include reducing waiting times and the number of ‘no-shows’ and increasing admissions and retention; examples above (1 2).

G Implementing change ([US] Substance Abuse and Mental Health Services Administration, 2009). Guide for managers on how to assess an organisation’s capacity to identify priorities, implement changes, evaluate progress, and sustain effective programmes, and how to implement these programmes. Substantially draws on a broader review.

G US guide to matching type of treatment to the patient (American Society of Addiction Medicine, 2013). What the US professional body for addiction medicine society says are the world’s “most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions”. Helps decide what intensity and setting of care to offer and when to stop or change.

more Search for all relevant analyses or for subtopics go to the subject search page or hot topics on why some treatment services more effective than others, matching interventions to the patient’s ‘stage of change’, and individualising treatment. See also a reading list from a leading US analyst intended to help treatment services develop recovery-oriented programmes, and a resource list from the UK Substance Misuse Skills Consortium to (among other topics) help managers recruit and supervise staff, manage organisational change, and foster effective team working.

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What is this cell about? The five-cell matrix row in which this cell is located focuses on generic processes common to treatment, whatever the setting or modality. Patients have to decide to get or accept help, find their way to treatment, decisions must be made about the objectives, form, intensity and duration of care, relationships forged, and attention paid to psychological problems and social circumstances which affect the chances of a sustained end to dependent substance use.

The current cell narrows in on how these processes are affected by the management functions of selecting, training and managing staff, and managing the intervention programme. In highly controlled studies, it may be possible to divorce the impact of interventions from the management of the service delivering them, but in everyday practice, whether interventions get adopted and adequately implemented, and whether practitioners can maintain recovery-generating attitudes and knowledge, depend on management and supervision. Compared to interventions, research on these issues is scarce, but also exciting and inspirational, because at this level whole organisations can be transformed from merely going through the motions into enthusiastic client-engagers.

Where should I start? With the truism that ‘Manners matter’ – the title of a series of reviews by Drug and Alcohol Findings not on what services do, but how they do it. Part one (listed above) dealt with seemingly mundane management tasks like managing waiting lists, setting up reminder systems for appointments, and checking on patients after they leave. In each case, research showed that individualised and welcoming communications characterise effective and retention-enhancing services. The overall conclusion was simple: “the human qualities which cement relationships outside treatment also do so within it”.

Managements and services which care enough about these qualities also care enough to be organised and persistent about embedding them in routine practice. They centre initial contacts on the patient’s priorities, provide (if need be, interim) help quickly, take the responsibility for reminding patients they want to see them and help them get to appointments, prepare the ground for keeping in touch after they leave, and then persistently and actively check how they are doing and if they need more help, at each stage showing that someone rather than some machine at the clinic is concerned about them and wants to see them. One of the best examples is our Highlighted study below.

Step by step improvements in aftercare attendance

Highlighted study It is unusual for a series of studies to coherently explore a single theme over many years, each study building on the other, and the results have been among the most valuable in addiction treatment research. A perfect example is a series of studies (listed above) at a US residential centre, which systematically applied one tactic on top of another to cumulatively improve aftercare attendance and sustain recovery.

We first introduced this work as a ‘Transformation story’ in the Manners Matter series (turn to the sixth page of this PDF file), where we tracked the improvements from a dispiritingly poor record to 100% initiation of aftercare and 80% of patients attending for at least three months chart. Those studies and later reports (1 2) showed the procedures also substantially improved long-term abstinence rates – and they cost little or nothing.

If your service is finding it hard to sustain treatment gains through aftercare, these studies prove that performance can be transformed by a welcoming attitude, personalised reminders, recognition of patients’ achievements, and, more generally, the systematic application of process analysis, sensitivity to patients, and evaluation of how things turn out.

Issues to consider and discuss

Is there anything more instructive than being the patient? The review discussed and listed above ended with, “Perhaps the main lesson of the research is that there is nothing special about … how substance misuse patients react. Reflection on how we might react if we were in their shoes can predict much of what researchers have painstakingly set out to prove.” From cell B2 and general psychotherapy research we know that the therapist’s ability to think themselves into the shoes of the client (‘empathy’) is fundamental. Perhaps this is also true of the managers of those therapists, and that for them it is better actually to try on the client’s shoes and feel them pinch rather than risking the self-serving illusion that all is well in a service for which you are responsible.

Trying on those shoes was exactly what staff did (see listing above) at 327 US services, ‘walking through’ their service’s admissions and induction procedures as if they were a client. The process was required in the application procedure for a quality improvement programme, and the results were fed back to programme managers. An analysis of the ‘walk-throughs’ – which started with the first phone or other contact and extended to the early stages of treatment – showed that the role-players experienced: poor staff engagement and impersonal interactions; shortcomings in equipment, administrative procedures and premises; poorly communicated information; burdensome and repetitive processes and paperwork, including lengthy intake interviews focused not on the client’s needs, but those of the agency; and failure to provide for clients with complex lives and problems. Extended to another twelve US areas, walk-throughs by senior staff became the key tactic for the strand of the quality improvement programme listed above intended to identify service delivery problems and improve clinical procedures.

All three original articles in the entry listed above are freely available, the first two via the ‘alternative source’ link in the Effectiveness Bank analyses, part of the article reference towards the top. Also freely available is practical guidance (1 2) on how to do a walk-through.

These reports offer abundant evidence that as part of a broader improvement programme, leaving the office and ‘becoming’ a patient opens eyes to shortcomings previously invisible to management and paves the way for improved procedures, streamlining admissions and retaining patients for longer – why the tactic features so strongly in the US quality improvement resource listed above. But can you think of any circumstances in which it might be counterproductive? And wouldn’t it be better to systematically gather feedback on how real patients experience treatment procedures? What about true ‘mystery shopping’ – engaging an outsider to act the part of a client and to feed back the results. After all, in walk-throughs staff know what is happening and usually also know the staff doing the role plays and that they are not really patients. Look at the US guidance (1 2) on how to do a walk-through. Is this how you would do it at your service?

Match interventions to the client’s ‘stage of change’? Prochaska and DiClemente’s ubiquitous ‘stage of change’ model seems to offer managers a scientific system staff can follow to decide how to work with patients, avoiding wasteful change attempts with those not yet ready to change, a rationale for instead nudging them to the next more receptive stage, and a way to recognise when someone is ready to commit to the changes needed to overcome their substance use problems. Cycle of change Implicitly or explicitly, in services across the UK this system is used to categorise patients and clarify how to efficiently promote progression to sustained recovery. Its simplicity is beguiling, but can it really be used to generate change by matching patients to interventions, or does it simply describe one type of change process? Should managers promote or discourage its use?

Analysed in an Effectiveness Bank review and hot topic listed above, the model portrays motivational transition as a fixed, segmented sequence leading from ‘No acknowledged problem’ through to ‘No problem now.’ In between are stages where change is pondered, prepared for, implemented and stabilised. Among its attractions is the feeling that one has gained insight into something important, technical and scientifically valid, yet which accords with common sense understandings. It seems self-evident that it is no use trying to close the deal on a change plan if the client has yet to see the need for change, and that overcoming dependent substance use is no quick fix, but sequentially requires awareness, thought, preparation, implementation and stabilisation, each stage of which must be completed to give the next stage a chance of success – and it just feels more scientific to talk of someone being in ‘precontemplation’ with its objective criteria, than to say, ‘S/he just doesn’t seem ready to stop’.

If it truly gets to the heart of the change process, then interventions built on the model ought to improve on those which are not. It is at this crunch point, when it actively engages with change through treatment, that research support is almost entirely lacking. That is true not just of drug and alcohol problems and of smoking, but of therapy for psychological problems in general. Read our review and you will understand why the American Psychological Association (APA) could only say matching interventions to stage of change was “probably effective” – and even “probably” seems optimistic. In contrast, the APA could be much more definite about matching to other patient characteristics: patient preferences (discussed below); the patient’s resistance to change or being directed; culture; and religion/spirituality. The stages of change model has, however, been very widely applied, and in other fields (promoting exercise seems an example) it may be better supported.

Another problem for the model is that it cannot account for precipitous, unplanned transitions to abstinence which defy the requirement to pass through the stages. Though of great importance in the overcoming of problem substance use, these are beyond the model’s remit, which is confined to intentional change. Unfold text Unfold supplementary text for more.

Despite its limitations, there may still be reasons why the cycle of change model remains valuable, though perhaps not in its intended role of helping match interventions to stage of change. Look at the last paragraph of the Effectiveness Bank review. The author, a cogent critic, nevertheless finds many ways in which the model might be a positive influence – a kind of benevolent fiction which gives hope to and motivates both worker and client. Is this enough? Or in the end, should we let science consign this popular prop to the ‘unproven’ shelf of history?

Is patient choice supreme? We return to an issue addressed in cell A2 – the role of patient choice and preferences in treatment planning. There it was in the context of advocates for certain treatment goals claiming the ethical ‘high ground’ of being on the side of the patients. Here instead the context is the steer service managers might give staff on eliciting and responding to patient preferences, drawing on a review listed above for evidence of whether acceding to those preferences might improve outcomes. There are no easy answers, partly because whether a treatment is safe and effective itself partly depends on the patient’s preferences; a nominally safe and effective treatment may no longer be either if the patient does not comply or engage with it.

First there is a fundamental question to be settled: does addiction limit the patient’s ability to make rational choices related to their drug use and its treatment to the degree that those choices must be made for them? In the end we go along with guidance offered the World Health Organization, that other than in extreme circumstances, this is an unwarranted diminution of the patient’s autonomy and human rights. However, this is not a trivial or easily settled issue because definitions of dependence entail impaired self-control and decision-making. For more on this fundamental issue, unfold the Unfold supplementary text supplementary text.

On the basis that the patient’s choices cannot be dismissed as merely manifestations of their addiction, we can turn to how those choices should be responded to. Guidance for substance use services from Public Health England says service users should be involved in their own treatment, and illustrates how this can be done. UK clinical guidelines on the treatment substance use problems seem to go further – and constitute an important yardstick for courts and tribunals in determining what constitutes lawful and acceptable medical practice.

In the guidelines ‘informed consent’ is the bedrock, but more active involvement is demanded: “the main role of clinicians is to assist patients in making their own, informed, choices about their treatment goals and priorities, and to agree the actions to try to best achieve them”. Treatment organisations should, say the guidelines, “ensure there is a visible positive service ethos … supporting patient choice and access to the variety of recovery paths and options”. Referring to trauma-informed care, one principle was said to be that it should “support patients to make choices and take control of treatment decisions”. The control these and other patients might exercise includes deciding to withdraw from opioid maintenance programmes, to opt for non-drug based treatment, determine their recovery pathway, and whether to participate in group therapy, but on other issues the patient’s preferences are simply to be taken into account. Among these are which medication to use to aid withdrawal, the duration of maintenance, and how to address mental health problems alongside dependence. More generally, “Prescribing is the responsibility of the person signing the prescription” – not one they can abdicate to the patient.

The clients’ influence is relegated to the elements that to them matter least

Nowhere is this more evident than in the decision on whether to prescribe heroin itself to heroin-dependent patients. Gone are the days when with a relevant drug use profile and dogged insistence, a heroin-dependent patient could in some clinics be fairly confident of being prescribed heroin. Now that preference will generally be denied, or if accepted, be trammelled with other conditions the patient would not prefer, such as having to attend several times a day to be dispensed and inject their prescribed heroin under clinical supervision. They and other patients who would prefer not to have to take medication under supervision will often find their preferences subjugated to clinical guidelines and safety-first principles. When in 1999 and 2001 a London clinic surveyed its patients’ satisfaction levels, the researcher admitted that:

“how far the clinic could/would move to satisfy clients’ desires was constrained by national guidelines and professional standards on issues such as supervised consumption, daily pick-up of prescriptions, and the prescribing of injectables. Agencies and doctors are not prepared to risk being pilloried for transgressing these ’guidelines’ if something goes wrong. Though they can express an opinion on whatever they like, the clients’ influence is effectively relegated to the elements of the service that for most probably matter least. For the rest, a central authority has already decided (perhaps rightly) what is best for them.”

Decisions such as those on supervising consumption, on dose levels, and on leaving treatment, are potentially life and death decisions which no responsible practitioner could leave up to the patient. Even when studies have allowed methadone patients to select their own dose, this has been done within rules set by the clinic to ensure safety. But clinicians also have to consider that a treatment which in theory is safe and effective cannot be either if unacceptable to the patient. A patient who rejects opioid substitute prescribing treatment because in the interests of safety it requires supervised consumption and witnessed urine testing will probably be less safe with no treatment than with treatment shorn of these elements.

Ethical considerations are bound up not just with offering safe, but also effective treatment. If acceding to patients’ wishes improves effectiveness, that in turn strengthens the ethical case to provide the treatment they want, since offering effective treatment is an ethical requirement. Across psychotherapy, evidence on effectiveness is strongly in favour of patients and therapists collaboratively agreeing goals and how they will go about reaching them, and underscores the centrality of incorporating patient preferences when making treatment decisions. In relation to substance use treatment in particular, a review listed above found the evidence on whether matching treatment to the patient’s preferences improves outcomes was equivocal, opting instead to recommend that patients be involved in treatment decisions via shared decision-making.

For more read our hot topic on patient involvement, our commentary on the review listed above, and the ethical arguments rehearsed for the World Health Organization’s opioid prescribing guidelines. You will then be well equipped to consider what weight your own and other services should give to patient choices and preferences, whether this weight changes in respect of different types of decisions, and whether if acceptably safe, feasible and likely to prove effective, the presumption should be in favour of providing treatment in line with the patient’s informed choice. Another stance – one many patients may endorse – is that they have come to a specialist service to take advantage of its concentrated expertise, and it is expected that the service will rule in some options and rule out others, and sometimes strongly argue for treatments in the face of the patient’s less well-informed, and perhaps more ambivalent, wishes.

Along the way you may also consider that by definition an addicted patient persists in doing something harmful which they wish to stop doing but can’t, and that this failure to do what is best for them may also extend to their preferences for treatment. An alternative argument advanced by some is that the very fact that someone has come forward for treatment means they have transcended their loss of control and started to get a grip on their own destiny which should be nurtured, not co-opted by the clinician. Moving up a level, are these kinds of issues susceptible to management policymaking, or should management step back and let the dialogue between practitioner and patient take its natural course?

What use is assessment … without some way to act on the results? With admirable simplicity, a US study listed above developed a computerised index of local resources and keyed these in to the broad range of needs revealed by a substance use service’s assessments of patients. It transformed the assessments from redundant but required paperwork in to a practical route to the services seen today as important to holistic and sustainable recovery – and twice as many patients completed treatment. If you work in treatment, do you have such a system, is it easy to use, is it hard for counsellors to ignore, and is it used? If you have no such system, would it work in your service?

This is a rare study of the neglected assessment process – an unfortunate neglect, because research has backed up the common view that assessment is not a just a preparation for treatment, but its start, and the start of building a therapeutic alliance.

Thanks for their comments on this entry in draft to George Christo of WDP drug and alcohol treatment and recovery services in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

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