Ed Day
Publish date: Mar 2015
The challenge of delivering psychosocial interventions
A wide variety of psychosocial treatment interventions have been described in the addictions field. A search of SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) elicits more than 75 different treatment packages aimed at improving outcomes for drug or alcohol users. The comprehensive NICE Clinical Guideline 115 identified more than 20 psychosocial approaches with some evidence for effectiveness in managing alcohol. Many of these approaches share common theoretical and practical elements, and some authors have distilled common components of effective treatment [1]. Furthermore, treatment methods are not simply technical interventions and cannot be divorced from the relationship between client and therapist .
In reality delivering complex psychosocial interventions in practice has proved difficult, as time, large caseloads, lack of training, and limited access to supervision have all hampered efforts to deliver gold-standard interventions in practice [2 3]. However, the salaries of professional staff delivering ‘counselling’ or ‘key working’ interventions make up a large proportion of the expenditure on addictions treatment in the UK, and so we should expect them to deliver evidence-based interventions. How can the effective elements of treatment be broken down into manageable pieces that can be trained and supervised?
A visual representation strategy
Addiction is a complex biopsychosocial problem, requiring a range of strategies and approaches. A key element of the work of counsellors in addiction services has been problem solving, and the counselling process has been conceptualised as a co-operative problem solving activity. However, barriers exist between clients and even the best therapists. Don Dansereau and colleagues at the Institute of Behavioral Research (IBR) in Texas noted that the commonest way of representing information passing between counsellor and client was natural language, primarily in the form of linear notes made by the counsellor. However, note taking didn’t seem to enhance client perceptions of the counsellor, and the linear nature of natural language appeared to limit its value as a representational tool. In contrast, a research evidence base was building to show that visual displays of information had advantages over the use of technical language in many circumstances. The use of diagrams – flowcharts, organisational charts, pictures and graphs – was seen as more efficient than natural language for most complex problems. Whereas natural language tended to string related components out in a linear sequence, diagrams could cluster them together, making them better at capturing parallel lines of thought, feedback loops, and circular thinking.
The IBR team developed a visual representation system for clarifying problems, issues, and potential solutions associated with drug abuse counselling called Node-Link Mapping (NLM). The primary components of this system were maps or diagrams that represented the interrelationships between the thoughts, actions and feelings that led to personal problems or their potential solutions. The nodes contained thoughts, actions, or feelings, and named links were used to express their interrelationships. These general purpose tools were able to capitalise on the advantages of graphical representations while maintaining the flexibility and power of natural language.
NLM in practice
Counsellors and clients tend to either collaborate on building a map from scratch on a blank piece of paper (a ‘free map’), or else fill in a pre-formed map (‘guide map’). The maps provide clear summaries of the key issues, and their simple ‘grammar’ appears to reduce barriers that can potentially distract and distort communication. Crucially, two of the main findings of the research on NLM techniques are greater client readiness and motivation for treatment [4-7], and an improvement in the counsellor-client therapeutic relationship and the perception of the quality of counselling sessions [8]. Other benefits are best shown as an information map: 
A further advantage of NLM techniques is their ready adaptation for use as a clinical training tool and in supervision [9]. Client maps can be shared by the counsellor with supervisors and peers to gain extra perspectives on treatment options.
The NLM framework has been used to deliver a range of interventions. Initially the TCU group developed a range of manuals for both individual and group work. Later these were adapted for UK contexts in the Birmingham Treatment Effectiveness Initiative (BTEI), ultimately resulting in theRoutes to Recovery series of manuals. The latest version of the Routes to Recovery Community Treatment Manual [10 11] helps clinicians to distill key elements of a range of evidence-based psychosocial interventions into a practical and usable NLM format. This represents a pragmatic response to the challenge of delivering of evidence-based strategies in a UK context, underpinned by the effective NLM strategy. These materials help busy clinicians to plan treatment strategies and deliver structured interventions, whilst providing materials to enhance client understanding and participation, and clinical supervision.
Summary
Node-Link Mapping is a visual representation counselling strategy for improving communication and decision making that can enhance any therapeutic or psycho-educational exercise, either in group or individual settings. Evidence shows it significantly improves treatment engagement and client progress indicators, and helps compensate for a variety of cognitive and social deficits common among drug users in treatment. It has been adapted for use in the UK and used as a framework on which to hang a range of theoretically-driven strategies for behaviour change.
If you only read one thing…
Dansereau DF & Simpson DD (2009) A Picture Is Worth a Thousand Words: The Case for Graphic Representations. Professional Psychology: Research and Practice. Vol. 40, No. 1, 104–110
References:
1. Moos RH. Theory-based active ingredients of effective treatments for substance use disorders. Drug and Alcohol Dependence 2007;88(2-3):109-21
2. Carroll KM, Rounsaville BJ. A vision of the next generation of behavioral therapies research in the addictions. Addiction 2007;102:850-62
3. Day E. Maximising the treatment outcomes of opioid substitution treatment. Evidence Based Mental Health 2010;13(1):5-7
4. Czuchry M, Dansereau DF, Dees SM, Simpson DD. The use of node-link mapping in drug abuse counseling: The role of attentional factors. Journal of Psychoactive Drugs 1995;27(2):161-66
5. Dansereau DF, Dees SM, Greener JM, Simpson DD. Node-link mapping and the evaluation of drug abuse counseling sessions. Psychology of Addictive Behaviors 1995;9:195-203
6. Dansereau DF, Joe GW, Dees SM, Simpson DD. Ethnicity and the effects of mapping-enhanced drug abuse counseling. Addictive Behaviors 1996;21(3):363-76
7. Joe GW, Dansereau DF, Simpson DD. Node-link mapping for counseling cocaine users in methadone treatment. Journal of Substance Abuse 1994;6:393-406
8. Czuchry M, Dansereau DF. A model of the effects of node-link mapping on drug abuse counseling. Addictive Behaviors 2003;28:537-49
9. Dansereau DF, Dees SM. Mapping training: the transfer of a cognitive technology for improving counseling. Journal of Substance Abuse Treatment 2002;22:219-30
10. Day E. Routes to Recovery via Criminal Justice: Mapping Using Manual. London: National Treatment Agency for Substance Misuse, 2010.
11. Day E. Routes to Recovery via the Community. London: Public Health England, 2013.
The opinions expressed in this commentary reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the Society for the Study of Addiction.
