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1 Contents Foreword Acknowledgements How to use the manual Chapter 1: Introduction : Overview and aims : Key concepts Chapter 2: Recovery principles : Defining recovery : The evidence base for recovery : What does a recovery orientated service look like? Chapter 3: Treatment Process Model (TPM) and using maps : The Treatment Process Model : Introduction to mapping : How do maps work? : Using the maps Chapter 4: Recovery capital : Introduction : Measuring recovery capital Chapter 5: TPM Phase 1 Treatment engagement and motivation : Introduction : Enhancing client motivation : Engaging client in treatment Chapter 6: TPM Phase 2 Building psychological resources and skills : Introduction : Self-esteem : Self-efficacy : Building a positive identity

2 Chapter 7: TPM Phase 3 Recovery and reintegration : Introduction : Exploring a recovery identity : Being active in recovery : Building a recovery future : Sustaining recovery journeys : Family and the recovery journey : Communication skills : Recovery and the future : Community recovery capital : Recovery plan reviews Chapter 8: Conclusion References Appendices 1: Book of Maps : Client Evaluation of Self and Treatment (CEST) and supplementary information.155 3: Assessment of Recovery Capital (ARC) and supplementary information : Recovery Group Participation Scale (RGPS) : Linking the Treatment Process Model to Evidence Based Psychosocial Interventions

3 Foreword Scotland has a serious drug and alcohol problem and in recent years, the Scottish Government has signalled a change in the way we deal with substance misuse. The 2008 drugs strategy (Road to Recovery) and the 2009 alcohol framework (Changing Scotland s Relationship with Alcohol: A Framework for Action) both call for an approach which places not only the individual but also their community, at the centre of all care. In achieving change in any behaviour, it is vital that the individual accept responsibility for such change. Similarly, it is essential that communities change how they support and facilitate recovery from substance misuse. With an emphasis on recovery, a Treatment Process Model (TPM) has been developed which brings together evidence-based psychosocial interventions and enhanced client engagement in the treatment process. The TPM, based around a manualised treatment programme, helps emphasise the importance of enhancing client s motivation for change, instilling hope in a more positive future, and developing a range of strategies that increase feelings of self-worth and confidence. The TPM recognises that, over time, the needs of clients will change. To be effective, therefore, treatment approaches must adapt as they move towards a planned treatment exit. Through the use of tools such as the Assessment of Recovery Capital (ARC) the TPM targets specific areas where support is required, resulting in a highly tailored intervention programme. The move toward a recovery orientated system of care is challenging. However, through the use of the TPM, in combination with ARC and other tools, it is hoped that both service users and staff will appreciate significant benefits. Dr Gary Tanner Clinical Director Addiction Services NHS Lanarkshire { }...enhancing client s motivation for change, instilling hope in a more positive future... 3

4 Copyright statement Copyright University of the West of Scotland 2010 Unless explicitly stated otherwise, all rights including those in copyright in the content of this manual are owned by or controlled for these purposes by the University of the West of Scotland. The right of David Best to be identified as the author of this work has been asserted by them under the Copyright, Designs and Patents Act All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise, without permission in writing from the copyright holder. Except as otherwise expressly permitted under copyright law or the University of the West of Scotland's Terms of Use, the content of this manual may not be copied, reproduced, republished, downloaded, posted, broadcast or transmitted in any way without first obtaining the University of the West of Scotland's written permission or that of the copyright owner. Where documents are the responsibility of individual authors, the views contained within said documents do not necessarily represent the views of the University of the West of Scotland. Copyright permissions from Texas IBR/TCU for adapting and reproducing maps/materials have been obtained. 4

5 Acknowledgements This manual owes a considerable debt to two of the most significant figures in addiction research Dwayne Simpson, Director Emeritus of the Texas Institute of Behavioural Research at Texan Christian University (TCU), Forth Worth and William White, author and historian, and Senior Research Consultant at Chestnut Healthcare Systems. This manual is in effect an extension and development of the work done within the Treatment Effectiveness Initiative developed by the National Treatment Agency in England. Special thanks therefore to Ed Day, Consultant Psychiatrist at the University of Birmingham, who along with the author was responsible for the Birmingham Treatment Effectiveness Initiative (BTEI). Node-link mapping is the central cognitive tool being used in this manual for promoting thinking skills and decision-making strategies. It was developed by Professor Donald Dansereau (2005) for special applications in education and counselling, and it has an extensive base of evidence for its effectiveness. It is embedded in a rich history of pictorial and visual communication traditions (Dansereau and Simpson, 2009). Special thanks also to the Lanarkshire Treatment Process Model Steering Group and Cara McDowell for their help in editing this version of the manual. Dr David Best, West of Scotland University, April

6 How to use the manual This manual aims to support dynamic change in the treatment and care workforce within Lanarkshire and should form the basis for delivering psycho-social evidence based interventions. The manual is supplemented by a book of maps which you will find in Appendix 1 and these maps will provide the basic tools for the delivery of each phase of the Treatment Process Model. The objectives of the manual and the training programme are: To provide materials and tools to allow workers to develop stronger therapeutic relationships with their clients To use these therapeutic relationships to deliver psycho-social evidence based interventions in the form of node-link maps To enable workers to support clients in their recovery journeys and to develop the support system and recovery communities that are needed to support recovery-orientated treatment interventions. This manual is designed to be used as a reference guide. However, please note that the maps contained within the manual are a means of supplementing and complementing the recovery support skills and therapeutic input of the key worker, not a replacement for these. We hope these will provide the foundations for creative and dynamic work by staff which will support the recovery ethos in Lanarkshire. { }...aims to support dynamic change in the treatment and care workforce within Lanarkshire... 6

7 Chapter 1 Introduction 1.1 Overview and aims The growth of the Recovery Movement in the UK, building on strong foundations in mutual aid and local recovery communities over many years, has provided the addictions field with a renewed sense of hope and increased beliefs and aspirations for our clients. This new wave of optimism is captured in the Scottish alcohol and drug strategies - in which recovery is made central to the philosophy and aims of all treatment and care systems. Much of what is presented within a recovery model is not new but is an attempt to build on the successes we know from our own field and to learn from other areas including the recovery movement in mental health and the significant work done in North America. In 2010 the Alcohol & Drug Partnership (ADP) set out their vision to develop a recovery oriented system of care in Lanarkshire within their Recovery Strategy ( ). The central pillars of this system of care include: providing all drug and alcohol users with hope of recovery and the skills and support to help them plan for this journey creating a sense of dynamism that does not accept that clients get stuck or that some clients are too chaotic to move forward generating communities of recovery where peers are active participants in recovery journeys and who can act as icons of recovery for those starting recovery journeys, while the role of the professional diminishes over time ensuring that all clients in recovery maintained or abstinent have clear goals of participation in their local communities and families and through doing so challenge stereotypes and stigma acknowledging that recovery is seen as a complex and multi-faceted process requiring partnerships that are flexible and fluid and that include not only those in recovery but also their families providing a variety of routes to recovery to enable clients to own their journeys and have real choices about whether treatment is needed and if so what that treatment means. As outlined within the strategy there is no assumption that having more people in treatment or having people in treatment for longer are positive outcomes. Ultimately the question will be how many of those who seek help receive meaningful choices in a timely way. The purpose of this manual is to assist staff to help clients achieve their goals around the psychological aspects of recovery (wellbeing, quality of life, coping, self-esteem and self-efficacy) and social functioning (including relationships, family engagement, training, employment and domestic arrangements). 7

8 1.2 Key concepts Treatment Process Model This manual is essentially designed to enable key workers to support clients through three sequential phases of the recovery process in treatment, as defined by the Treatment Process Model (TPM). The TPM model is based on three distinctive phases of treatment: Phase 1 - Treatment engagement and motivation This model suggests that there are stages in recovery where treatment is part of the recovery process. The creation of a strong therapeutic relationship and a client motivated to change are the two key elements of treatment that can offer a difference. Phase 2 - Building psychological resources and skills This enables a process of psychological growth involving the emergence of a positive identity, increased self-esteem and self-efficacy, and that these manifest themselves in improved selfregulation (resilience skills and preventing relapse) and self-management (which includes basic life skills and coping with the demands of sober living). Phase 3 - Recovery and reintegration The growth of personal resources enables and is in turn supported by the development of longterm recovery capital primarily based on social supports and the active engagement with the local community. The therapeutic relationship between key worker and client remains the primary building block of what treatment has to offer. It should provide the spark of hope and the belief that not only is recovery possible but that treatment will provide that goal and direction. Recovery capital Throughout this manual, there are references to building recovery capital. This is a key outcome of the Treatment Process Model that will be implemented in Lanarkshire alcohol and drug services. Recovery capital is the quantity and quality of internal and external resources that can be mobilised to initiate and sustain the resolution of severe alcohol and other drug problems (Granfield and Cloud, 1999). Within the wider definition of recovery capital, there are three main concepts that contribute to the building of overall recovery capital : Personal recovery capital - key strengths and resources that clients have Social and family recovery capital - helpful people they are engaged with that can support them Community recovery capital community resources and supports including treatment services, housing etc. Thus, recovery capital will change over time and is amenable to measurement as a mechanism for assessing appropriate interventions at different phases in the Treatment Process Model. This will be discussed in more detail in Chapter 4. 8

9 The Assessment of Recovery Capital Star (ARCS) - Measuring recovery Treatment engagement Recovery group capital Phase 3 Social recovery capital Phase 1 Treatment motivation Personal recovery capital Phase 2 The ARCS is an essential tool for key workers in Lanarkshire s alcohol and drug services. This tool is used to Indicate where the client is in their recovery journey Map out the strengths they have and what domains those strengths are in Direct the key worker to which areas may be the most appropriate for focusing their efforts Linking to the maps in this manual to suggest specific areas for mapping and discussion Indicating whether the focus should be on psychological interventions or on linkage to recovery groups and activities in the community. The ARCS is a visual depiction of assessment scores, created by key workers and clients undertaking a series of assessments throughout the three phases of the Treatment Process Model. Further information about these assessment tools and how they create the ARCS is provided in Chapter 4. Maps Key workers will be supported to implement this new Treatment Process Model by a series of tools called maps (Appendix 1). These can be used by workers to improve communication and support the growth of the therapeutic relationship with their clients and psychosocial change. The maps provided are modelled on a set of techniques call Node-Link Maps. Research across a range of disciplines has shown that visual displays have a number of significant advantages over standard language and they can enhance communications between key workers and clients. In turn, this improves the therapeutic relationship and in a more empowering way, actively engages the client in the treatment process. It does this by helping make ideas clear and simple, ensuring both parties are talking about the same thing and providing a record of the discussion that worker and client can return to at the next meeting. More information about maps can be found in Chapter 3 of this manual. 9

10 Recovery champions The Lanarkshire ADP s Recovery Strategy ( ) outlines our commitment to establishing a network of community, therapeutic and strategic champions who are visible across the whole treatment system, within all organisations and in each locality in Lanarkshire. Recovery champions are the community component of enabling effective recovery journeys. Using the Asset-Based Community Development model, the assumption is not that champions have to be created but that they have to be identified and supported through clear guidance and leadership. Strategic recovery champions: are professionals who have the role of commissioners or strategic managers within key services in a locality who will be required to have the energy and vision to challenge cultural, funding and pragmatic barriers to implementing recovery practices. The strategic champions are represented within the Lanarkshire Alcohol and Drug Partnership, the Addictions Partnership Board in North Lanarkshire and the Joint Services Management Group in South Lanarkshire. Therapeutic recovery champions: are the frontline key workers who see the merit in the recovery movement, perceive themselves to have a key role to play in it and who will drive forward the change to a recovery model in the services they work in. Community recovery champions: will consist of a range of people in recovery, but will not be restricted to them. They are the human resources in the local community and so will also include the families of those in recovery and active addiction, the forceful drivers of local community development and all of those local community stakeholders who can be engaged in recovery transformations of local communities. However, the people in recovery themselves have a crucial role to play as the social learning role models of recovery the living proof that recovery does happen and that it has happened to the peers of people in active addiction. But this group needs to be supplemented by a wider network of community supports and systems that will maximise the opportunities for individual recovery. These individuals will be key to the successful integration of service users, community based support structures (e.g. mutual aid groups), existing health and social care providers and third sector organisations. In essence, they will be the nucleus of a network of interconnected cells, developing multiple connections across and within each locality in Lanarkshire. 10

11 The role of therapeutic recovery champions Therapeutic recovery champions are aiming to help people discover their own solutions, and to offer what support they can to allow people in recovery to learn and grow for themselves, rather than to provide solutions for addiction problems. The key role for the key worker or therapeutic agent in promoting a recovery model is to offer: Empowerment Choice Hope Respect Guidance The therapeutic recovery champion will recognise that the treatment service is not the locale in which recovery will take place and that partnerships with the wider community are essential within a recovery focussed service. The therapeutic recovery champion will therefore: act as a bridge to key resources in the community- not only mutual aid groups but key associations and institutions in the community (fishing groups, neighbourhood watch schemes, churches, libraries) and that they will also be prepared to get involved in assertive linkage with these groups (Dennis et al, 2009). enable and support change among their colleagues and in the service by challenging professional attitudes and barriers and acting as the visible and forthright champion of strengths-based working and recovery thinking as the means of delivering support to clients. deliver a strengths-based approach to the face-to-face work done with clients by utilising strengths based assessment and recovery planning processes, focusing on building recovery capital and acting as a guide and a bridge to enabling client recovery. Note: We have used the word drug throughout this manual. This means any drug which has caused problems in the past, including alcohol. { }...a renewed sense of hope and increased beliefs and aspirations for our clients... 11

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13 Chapter 2 Recovery principles 2.1Defining recovery The UK Drug Policy Commission convened a meeting of senior UK practitioners and academics, people in recovery and family members to develop a UK vision of recovery. Recovery was characterised as a process of: voluntarily sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society (UK Drug Policy Commission, 2008, p.6). The report emphasises the range of routes to recovery and also suggests that this includes medically maintained abstinence (UKDPC, 2008, p.6). In The Road to Recovery (Scottish Government, 2008), recovery is defined as: a process through which an individual is enabled to move from their problem drug use, towards a drug-free lifestyle as an active and contributing member of society. The Report went on to declare that recovery is most effective when service users needs and aspirations are placed at the centre of their care and treatment.an aspirational and person-centred process (Scottish Government, 2008, p.23). In the United States, the Betty Ford Institute Consensus Panel (2007, p.222) defined recovery as a voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship. The Consensus Panel further detailed the meaning of sobriety by explicitly stating that formerly opioid-dependent individuals who take naltrexone, buprenorphine, or methadone as prescribed and are abstinent from alcohol and all other non-prescribed drugs would meet this definition of sobriety (p.224). The Panel further differentiated the stages of recovery as early sobriety (the first year), sustained sobriety (between 1 and 5 years), and stable sobriety (more than five years). Through this collective definitional work to date, recovery from a substance use disorder has been characterised by three core dimensions of change (White, 2007): 1. remission of the substance use disorder 2. enhancement in global health (physical, emotional, relational, occupational and spiritual) 3. positive community inclusion { } Recovery is most effective when service users needs and aspirations are placed at the centre of their care and treatment. 13

14 2.2 The evidence for recovery There is a history of research that shows that alcohol and drug treatment is effective in supporting change and promoting recovery from substance use problems. These date back to the DARP study in the US (Simpson and Sells, 1990) which investigated four different treatment modalities and involved follow-up windows of up to 12 years, showing that among those patients who had been daily users of opioids before treatment, more than half (53%) reported no daily opioid use at one year. Opioid use continued to decline over time until year 6, when it stabilised at 40% for 'any' use and 25% for 'daily' use. At some point during the 12 years following treatment, three quarters of the sample had relapsed to daily opioid use, but at the year 12 interview, nearly two thirds (63%) had not used opioids on a daily basis for a period of at least 3 years. Subsequent large-scale US followup studies (TOPS, Hubbard et al, 1989; DATOS, Flynn et al, 1997) continued to show positive gains across treatment modalities, that were subsequently replicated in an English (NTORS, Gossop et al, 2005) and Scottish (DORIS, McKeganey et al, 2003) treatment settings. According to William White, recovery is the rule rather than the exception: most (50% or more) people with significant alcohol or other drug problems (meeting diagnostic criteria for a substance use disorder) will eventually resolve those problems (See White, 2008a for a review). In the review of recovery evidence by the Centre for Substance Abuse Treatment (2009), the overall estimate of the proportion of those with a lifetime substance dependence who will eventually achieve recovery is 58%. The prognosis for long-term recovery varies markedly by degree of problem severity and by personal, family and community recovery capital (White, 2009b; Granfield & Cloud, 1999, 2001). There is a growing body of scientific literature positing stage theories of addiction recovery (DeLeon, 1996, 2007; Frykholm, 1985; Klingemann, 1991; Prochaska, DiClimente & Norcross, 1992; Shaffer & Jones, 1989; Waldorf, 1983; Waldorf, Reinarman & Murphy, 1991). When research on recovery stages is viewed as a whole, four broad stages of recovery are evident: 1) Pre-recovery problem identification and internal/external resource mobilization (destabilisation of addiction and recovery priming) 2) Recovery initiation and stabilization 3) Recovery maintenance 4) Enhancements in quality of personal/family life in long-term recovery and across the personal/family life cycle. The point of recovery stability/durability (point at which the risk for future lifetime relapse drops below 15%) is typically 4-5 years of sustained recovery for alcohol dependence, but potentially longer for other drug dependencies. White & Kurtz (2006) have estimated that the typical time from last use of heroin to stable recovery is around 5-7 years. 14

15 Recovery careers their initiation and durability are influenced by the interaction of problem severity/complexity and personal recovery capital. Much of the assessment and measurement work of Chapter 4 will use recovery capital as a way of assessing what is appropriate for the client in treatment. Internal assets can be thought of as personal recovery capital and external assets can be thought of in terms of family and community recovery capital (White & Cloud 2008). Thus, recovery capital will change over time and is amenable to measurement as a mechanism for assessing appropriate interventions. Evidence within the UK The primary source of this work, at least from a drugs perspective, comes from 70 semi-structured interviews conducted by McIntosh and McKeganey and published in papers in 2000 and Among the key desistance factors identified were developing new activities and relationships and developing a commitment towards new and changed lifestyles, at least in part by developing an identity as a non-addict. The authors identified two main mechanisms by which former users avoided relapse (1) the avoidance of their former drug-using network and friends and (2) the development of a set of non-drug-related activities and relationships (McIntosh and McKeganey, 2000). { }...developing new activities and relationships and developing a commitment towards new and changed lifestyles... In 2008, Best and colleagues published the findings of a survey of 107 former problematic heroin users who have achieved long-term abstinence about their experiences of achieving and sustaining abstinence. The cohort was recruited opportunistically from three sources, drawing heavily on former clients working in the addictions field. On average, the group had heroin careers lasting for just under 10 years, punctuated by an average of 2.6 treatment episodes and 3.1 periods of abstinence - the most commonly expressed reason for finally achieving abstinence was tired of the lifestyle followed by reasons relating to psychological health. In contrast, when asked to explain how abstinence was sustained, clients quoted both social network factors (moving away from drug using friends and support from non-using friends) and practical factors (accommodation and employment) as well as religious or spiritual factors. More recent work on the Glasgow Recovery Study (Best et al, submitted), has reviewed recovery experiences of 205 former drinkers and drug users and found that two factors strongly predicted the quality of life of those in recovery: 1. The amount of time spent with other non-users also in recovery 2. The amount of time the person spent engaged in meaningful activities (childcare, volunteering including engaging in recovery group activity, education and training, and part-time and full-time working) 15

16 While the evidence base around addiction recovery in the UK is limited, there is a much more vibrant evidence base around the mental health recovery movement. For the Scottish Recovery Network, Brown and Kandirikirira (2007) used a recovery narratives model as part of a methodology that acknowledges the uniqueness of the lived experience of people in recovery, and identified a range of both internal and external elements involved in recovery process. The internal elements included self-belief, belief that recovery is possible, meaningful activities in life, positive relationships, an understanding of the illness and active engagement in recovery strategies. The external factors included supportive friends and family, being told recovery is possible, being valued, having responsive formal support, living and being valued in the community and having life choices accepted. Defining a clear sense of self was seen as being as important as managing or overcoming symptoms. Also in the Scottish context, Shinkel and Dorrer (2007) have identified some key areas of recovery oriented culture change that have potential application in the addictions field, relating to key workers attitudes and beliefs about the recovery prospects of their clients: Belief in and understanding of recovery Respectful relationships Focus on strength and possibilities Care and support directed by the service user Participation in recovery of significant others Challenging stigma, discrimination and social stigma Provision of holistic services and supports Community involvement 2.3 What does a recovery orientated service look like? The purpose of a recovery focus is to help individuals achieve improvements in their quality of life and wellbeing with an assumption built in that this will not only be a personal process of development, but it has implications for services and for treatment systems. The Centre for Substance Abuse Treatment (CSAT, 2009) has outlined 17 recovery-oriented principles for a recovery system that are outlined below: Person-centred Inclusive of family and other ally involvement Individualised and comprehensive services across the lifespan Services anchored in the community Continuity of care Partnership-consultant relationships Strengths-based Culturally responsive Responsiveness to personal belief systems 16

17 Commitment to peer recovery support services Inclusion of the voices and the experiences of recovering individuals and their families Integrated services System-wide education and training Ongoing monitoring and outreach Outcomes driven Research based Adequately and flexibly financed The switch to a recovery model has been largely driven by the growth of a grass roots addiction recovery advocacy movement in the US and UK. Among the key objectives of this model is an approach that is 1) calling for a reconnection of addiction treatment to the more enduring process of addiction recovery, 2) advocating a renewal of the relationship between addiction treatment institutions and grassroots recovery communities, and 3) extolling the power of community in the long-term recovery process (Elise, 1999; Morgan, 1995; White, 2002, 2009b). Recovery models and links to acute treatment A fundamental part of initiating a recovery model is the switch from a pathology model to a strengths model, and is about identifying what key resources the client has to build on and where the gaps are that need to be addressed. The theoretical part of this process is the assumption that it is very difficult for clients to make significant progress in their recovery journeys unless two basic conditions are met: 1. The person has a place to live that is free from threat and provides basic warmth and safety 2. That they are sufficiently free of physical and psychological health symptoms that they can start to plan for the future {...help individuals achieve } improvements in their quality of life and wellbeing... 17

18 While at one level, the aim is to work towards eliminating threats and maximising strengths, there is not an assumption that recovery requires all of the threats to be eliminated. The underlying rationale is based on the idea that recovery is about the development of strengths that allow intractable problems mental health, addiction, etc to be managed and not to interfere with quality of life. The start of the recovery journey is likely to be predicated on fundamental changes that allow initiation of recovery. White (1990) has also argued that there is a physical zone in recovery that includes: ensuring recovery-enhancing physical shelter establishing daily rituals of self-care, cleanliness and dental hygiene reducing or removing the threat of physical violence resolving life-threatening or sobriety-threatening medical problems reversing drug-induced retardation achieving a normalised sleep pattern identifying and treating concurrent mental health problems overcoming drug-related anhedonia managing other toxic habits around caffeine, sugar and tobacco initiating drug-free sexual functioning Many of these elements of the physical zone of recovery will be essential prerequisites for initiating the key psychological, spiritual, social and lifestyle changes that are required. The model presented here is essentially about working with clients who have achieved that basic level of functioning. What does this mean in practice for services and service staff? A common purpose: Recovery in future mental health services, a Joint Position Paper, by the Care Services Improvement Partnership (CSIP), the Royal College of Psychiatrists and the Social Care Institute for Excellence (SCIE) suggested that in order to support personal recovery, services need to move beyond the current preoccupations with risk avoidance and a narrow interpretation of evidence-based approaches towards working with constructive and creative risk-taking and what is personally meaningful to the individual and their family (Joint Position Paper, 2008, p6). The recovery movement is about some key principles: 1. Empowerment of the service user 2. Involvement of their family, and developing community and peer supports 3. Dynamism that helps clients move forwards with their lives and that the focus is not all about the substance This means that services have to be open and adaptable to what is available in the communities they are based in. Repper and Perkins (2003) have advocated for mental health:...teams should develop central, indexed stores of information concerning community resources, housing, benefits, work projects and advocacy. All staff should have basic knowledge of what these stores contain (Repper and Perkins, 2003, p190). 18

19 The key worker therefore has to be clear about the individual needs and dignity of the client and to see their professional role as supportive and empowering. This is consistent with the findings of Kirkpatrick et al (2001) that professionals who project messages of hope are a greater help to their clients, and that clients confer extra value on professionals who are seen to go the extra mile and to act in the role of a critical friend (Berg and Kristiansen, 2004). This finding supplements the key finding by Norcross et al (2002) that the relationship between client and therapist accounts for the largest amount of variance that is not accounted for by pre-admission client characteristics. In Pathways from the culture of addiction to the culture of recovery (White, 1990), William White lays out six key tasks for the addiction professional in supporting recovery: 1. Create consciousness of excessive behaviour in the treatment environment 2. Teach that excess is a developmental stage in recovery 3. Encourage daily rituals for self-assessment and focusing 4. Teach sobriety-based coping skills 5. Facilitate the establishment of a sobriety-based social network 6. Periodic assessment of the client in aftercare for risk of relapse For the service, the key is to be linked into the community it serves that means effective links to: 12-step groups SMART recovery groups Other mutual aid groups Local community services and supports Aftercare groups Housing services Employment and training agencies Family support services The effectiveness of recovery journeys will happen in the community and will be based in part on the successful reintegration of clients into their local communities. Services have to act as part of those local communities with their doors open to the above groups and their staff aware of and engaged in local activities in the community (see Chapter 1.2 Key Concepts, Recovery Champions). 19

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21 Chapter 3 The Treatment Process Model & using maps 3.1 The Treatment Process Model (TPM) At the core of the notion of a treatment journey is the Treatment Process Model (TPM) developed by Dwayne Simpson who generated much of the research foundations for much of this manual. This research is based on three different types of studies about what works within the addictions field:- 1. The treatment outcome and evaluation studies conducted between 1969 and 1989 showing that treatment generally leads to improvements in client outcomes 2. Studies on conceptual model and treatment process between 1989 and 2009 focusing on the relationships between client attributes, the treatment context and treatment processes in predicting outcomes and 3. Current work on the strategic implementation of what works under the rubric of technology transfer. The culmination of this evidence base provides a model for treatment delivery. In essence this suggests three distinct phases of treatment:- Treatment engagement and motivation Building psychological resources and skills Recovery and Reintegration This manual is essentially designed to enable workers to support clients through these sequential phases of the recovery process in treatment. Figure 1 overleaf shows the basic formulation of that process in which workers map the interventions they deliver against the stage the client has reached in their treatment journey. Thus, much of the work in the early engagement phase has the objective of retaining and motivating the client and is predicated on the development of a therapeutic relationship between the key worker and client. Techniques that can be appropriate here include motivational enhancement work which is geared around improving the client s motivation to change and their motivation to engage actively in the treatment process. 21

22 Figure 1: The Treatment Process Model Motivation Early engagement Early recovery Change in treatment Post treatment Risk & severity Treatment readiness Program participation Therapeutic relationship Change: Behavioural Change: Psychosocial Increased personal capital Wellbeing Families Communities Adapted from Simpson (2004) and Simpson and Joe (2004). Phase 1: Treatment engagement & motivation This model suggest that there are stages in recovery where treatment is part of the recovery process and that where treatment can offer a difference it does so on the basis of a strong therapeutic relationship and a client who is motivated to change. Phase 2: Building psychological resources & skills This enables a process of psychological growth involving the emergence of a positive identity, increased self-esteem and self-efficacy, and that these manifest themselves in improved selfregulation (resilience skills and preventing relapse) and self-management (which includes basic life skills and coping with the demands of sober living). Phase 3: Recovery & reintegration The growth of personal resources enables and is in turn supported by the development of long-term recovery capital primarily based on social supports and the active engagement with the local community. In the first UK implementation of this work, the primary focus was on the early engagement phase with two of the manuals developed specifically targeting the engagement of clients by providing supports and techniques for workers to improve motivation and to encourage more participative care planning (these will be discussed in more detail within Chapter 5). However the primary focus of this manual will be on the last two phases where clients are looking to move forward in their recovery journey and so the focus is in part about building their recovery capital and in part about linking them to the support groups that will enable and facilitate their engagement in community and family life (discussed in more detail within Chapters 6 and 7). The therapeutic relationship remains the primary building block of what treatment has to offer in other words, it is the relationship with the service and particularly with the keyworker that should provide the spark of hope and the belief that not only is recovery possible but that treatment will provide that goal and direction. For this reason, the first phase of the model and the core principle underlying effective recovery treatment is therapeutic capital the recovery strength that flows from the treatment process and the resulting motivation to change and to strive for positive personal recovery outcomes. 22

23 3.2 Introduction to mapping The basic mechanism that the model is built on is designed to improve communication and to support the growth of the therapeutic relationship. Underlying this approach is a set of techniques that are called node link maps and they are the building blocks of this manual for the work that key workers will do with their clients. As Dansereau and Simpson (2009) have argued, research across a range of disciplines shows that visual displays have a number of significant advantages over standard language, and that they can enhance communications between counsellors and clients. A summary of some of the main advantages for the use of visualisation techniques is given in Figure 2 below: Figure 2: The benefits of maps Provides a workspace for exploring problems Improves the therapeutic alliance Focuses attention on the topic at hand Trains clearer and more systematic thinking The benefits of maps Provides an easy reference to earlier discussions Creates a memory aid for clients and workers Provides a method for getting unstuck A useful structure for clinical supervision Dansereau and Simpson have summarised research evidence that shows an advantage for pictorial representation over traditional language in the communication of complexity and emotion and what is depicted in Figure 2 are the main benefits that have been demonstrated from the research base about visualisation techniques. In essence, the node-link mapping approach is a way of distilling that into a model for supporting workers to share communications more effectively, to allow for exploration of new concepts and for clarity of purpose and goals. However, what the evidence base clearly articulates is that this is a mechanism for improving the therapeutic relationship by communicating more effectively and in a more empowering way that actively engages the client in the treatment process. 23

24 The basic principle of this model is about attempting to make ideas clear and simple, ensuring that both parties are talking about the same thing and that both client and key worker have a record of the discussion that they can come back to when they next meet. Maps will vary by the task being addressed in the mapping process but the basic principles of mapping remain the same and are highlighted in Figure 3 below: Figure 3: Node-link maps A NODE, which is just an idea captured in a box, circle, or other shape For example: Blockbuster movie LINKS (named or not) which show the relationship between nodes For Example: Blockbuster movie An Example of a Blockbuster movie is Titanic Titanic Nodes and links are the basic building blocks used in the maps in this manual. There are a number of benefits to using maps: consistency and effectiveness of communication create an audit trail for clients, key workers and managers, showing progress highlights areas for future exploration with clients flexibility - maps can be used in many ways However, the bottom line is that they work. The many studies done by Simpson and colleagues in the States and more recently in the UK and Italy have shown that the use of mapping: leads to greater client motivation for drug treatment improves the worker-client therapeutic relationship, and clients perceptions of the quality of therapeutic sessions enhances client self-perceptions reduces the number of missed client appointments reduces the number of positive urine tests Furthermore, in the UK, work completed jointly with the National Treatment Agency (NTA) in the English Midlands and North-West (Simpson et al, 2009; Best et al, 2009) illustrated that there were also indications that staff generally valued the approach and found that it led to better client engagement in services as well as to greater key worker engagement and satisfaction. 24

25 3.3 How do maps work? As highlighted below in Figure 4, there are basically three different types of maps that are used as the building blocks for the manuals and these are: Knowledge maps Guide maps Free maps Figure 4: Types of node link maps Node-link mapping C Over 50 publications have shown its effectiveness T T T Knowledge maps Free mapping Guide maps C C C C C C Worker produced Jointly produced Framework provided by worker Structured Spontaneous Structured/Free C C C Convey information Represent & explore personal issues Represent & explore personal issues Legend: T Type C Characteristic 25

26 Essentially, the maps offer different levels of structure. At the most basic level, an information map is not interactive but provides information to clients about particular topics. These would be handed out to clients to explain a particular issue. Thus, Figure 5 provides a basic map about HIV that is meant to be given to clients to improve their understanding of the basic concept. These can be useful for explaining complex topics but are primarily instructive and lack the interactive and shared quality that make maps useful as a therapeutic tool. Figure 5: An information map H I V R R R Human Immuno- Deficiency Virus C C C People Only Can not be spread by animals, plants, or insects A major problem with the Immune System that fights disease Smallest living microbe (germ) Survives by invading cells and destroying them HIV is a human virus that invades and destroys the cells of the immune system. A I D S R R R R Acquired Immune Deficiency Syndrome C C C C Can be acquired. In other words, it can be spread Refers to the immune system. White blood cells that fight disease Not working. Deficient. Unable to fight germs A group of illnesses or symptoms related to a specific cause (HIV) AIDS is the late stage of HIV infection, resulting in illnesses and cancers the body can no longer fight off. 26

27 The second kind of map is the guide map (also known as structured maps) basically this is a fill in the blanks graphic tool that can be used to facilitate self-exploration, planning, decision-making and problem solving. In the Birmingham Treatment Effectiveness Initiative (BTEI), these were widely used in the care planning process and in reviews but were also used as part of the initial assessment to help key workers get to know clients. Thus, Figure 6 below is basically a structured form that the client and key worker fill in jointly so that the client can describe themselves and the key worker can start to get a sense of them as a person. This kind of basic map can then be used at review points to explore change and to examine what is different about the client. Figure 6: A guide map Social relationships Health and physical Problem solving /Coping Emotions / temperament What are your strengths? Work and skills Values and beliefs It is important that the guide maps are completed as a shared process therefore the seating arrangement should allow the client not only to see what is being done but also to take the pen and to own the process. 27

28 The guide map is the basic tool of the mapping process and provides a record that each party should be given a copy of at the end of the session. The reason for this is to give the client a sense of ownership of the session, as a reminder of what has been done and of what needs to be done. Individual maps can be reviewed as part of the process of mapping the recovery journey or repeated, but the key thing is that they are living documents to be viewed as milestones in the therapeutic relationship and in the recovery journey. Guide maps can be used flexibly in other words, the structure and contents can be changed to suit the particulars of the working context and the needs of that client. This flexibility is most obvious when free maps are used. The third kind of map is the free map as shown in Figure 7 below. These are produced from scratch by clients and key workers and can be used as a note-taking technique or as a vehicle for expressing and organising personal knowledge. This may be a good way of getting to know someone and beginning the process of understanding how the client sees themselves and how they organise their thinking. Figure 7: A free map In our experience of delivering training around mapping, it is free mapping that key workers generally find the most useful and enjoyable but they will first need to reach a point where they are comfortable with using the technique and working with clients. 28

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