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GOOD PRACTICE

❝ every therapist should have structured supervision with a trusted colleague ❞

Even the best therapists tend to drift from doing structured treatment. However experienced, it is good practice regularly to review therapy sessions.

Becoming an effective therapist

Help seekers bring with them their substance use history, their mental health and their social circumstances and so it is important to be realistic about what difference practitioners can make. That said, practitioners do make a difference - often the difference between recovery or continuing an addictive lifestyle. Practitioners come from a range of professional backgrounds and sometimes with the experience of personal recovery from addiction. People who are in recovery often choose to practise the treatment approach that they found helpful - twelve step or SMART programmes are perhaps the most common examples. In these examples training is akin to an apprenticeship although more formal training may also be part of individual development. 

For those coming from health or social care backgrounds it is probable that formal addiction training should be the starting point. The quality of training in addiction is variable and it is a good idea to take some career advice before committing to an educational programme. Practitioners who are involved in treatment delivery should have motivational interviewing skills and be competent in a treatment approach. Integrated Social Behaviour and Network Therapy is a flexible all round intervention. Practitioners who can use a manual in an imaginative way have been shown to be more effective.

Maintaining good practice

Every practitioner needs to monitor the quality of their work. Keeping up to date with best practice is part of the professional life of a team or an individual. Most people combine reading journal articles, attending case reviews and conferences, and discussions with colleagues to know what best practice currently  is.

Guidelines are a helpful benchmark of good practice. They are not a rule book, they get out of date quickly and need to be interpreted by senior practitioners for local use. Guidelines have two weaknesses. First, quite properly, the focus is on the available evidence especially from well conducted trials - this fails to acknowledge practice based evidence for which there may be scant research data. Second, expert groups are made up of people who often have particular agendas - this fails to acknowledge what is actual front line practice.

Audit is a valuable tool. Projects may be at a national or organisational level, for example monitoring deaths or untoward incidents, or at a local team or individual level when it is possible to look into an aspect of care where it appears that improvements can be made. 

Video recording of treatment sessions is the gold standard for evaluating individual practice. Much can be learned simply by watching yourself in session. Better to have objective views in a peer group or with a competent and trusted supervisor. Structured supervision with ratings such as the Working Alliance Inventory or the Brief Addiction Therapy Scale is most likely to lead to continuous improvement of practitioner skills - see My Practice (next page). 

Organisational constraints

A healthy organisational climate, the conditions under which practitioners work, is a prerequisite of being able to deliver best practice and achieve the best outcomes. The elements of a healthy addiction treatment service and their measurement have been researched in the United States.

How do you measure organisational health?
Key point :: how organisations operate affects practitioners
This study is part of a programme of research looking at how addiction services operate. The researchers have developed 18 subscales to assess organisations' readiness for change and have evaluated how organisational health impacts on practitioner performance. Healthy organisational characteristics were: practitioner autonomy, openess of communication, a shared vision of purpose, cohesion and a continuous improvement orientation.

The people who get to direct organisations in the UK tend to be light on clinical experience and have a fondness for centralising and creating management roles to control services. There is scope for improving the health of these organisations and achieving better outcomes from treatment services.