4. Considerations around particular groups presenting to substance misuse treatment services
There is growing recognition that some groups attending alcohol and drug treatment services may have specific vulnerabilities that can impact on their ability to engage with treatment. This section will consider two groups in particular: people presenting with difficulties relating to complex trauma; and those with cognitive impairment that may or may not be recognised.
Psychological interventions in trauma-informed substance misuse services
In early life, the quality of the attachment an infant develops with the primary caregiver influences the infant’s social and emotional development and ability effectively to recognise and regulate emotional experience. If the primary attachment relationship is inconsistent, neglectful or unpredictable, infants are unable to escape this, and so learn to manage themselves as best they can within the confines of the relationship. They may then grow into adults who are likely to have more difficulties in regulating their emotions and relationships.
Developing an insecure attachment style in early life increases the risk of developing poor mental health or addictive behaviours in later life, because it makes it harder to cope with adverse experiences. The ability to cope with adverse experiences may be mediated by an individual’s confidence in coping and being able to access support – in other words, his or her attachment security.
The Scottish Government Quality Principles state that all substance misuse services must be trauma-informed. Most people attending substance misuse services are thought to have a history of trauma, and some will meet criteria for post-traumatic stress disorder ( PTSD). People who have suffered prolonged, repeated trauma often experience additional symptoms, however, and the concept of complex trauma has been proposed to capture these symptoms.
Additional symptoms associated with complex trauma may include difficulties in regulating emotions and relationships, self-perception, memory and consciousness. Substance use may become a way of managing overwhelming difficulties in the short term, but it becomes a problem in its own right, leading to further difficulties with emotional regulation, the risk of further victimisation, and the substance use becoming increasingly entrenched.
Individuals may present with multiple mental health and physical co-morbidities alongside substance dependence, and a number of clinical decisions are required to ensure they receive comprehensive treatment:
- integrated interventions that address both difficulties in a parallel intervention are recommended when working with co-morbid trauma and substance use
- phased or staged approaches are recommended by expert consensus in cases of complex trauma and substance use; phase 1 of treatment should aim to establish safety and stability, including in substance use, and should enable the individual to develop skills in regulating emotions, reducing risk, and asserting and meeting their needs appropriately
- treatment of PTSD and complex trauma should also include an exposure component (phase 2); for this stage, it will be important for clients to have attained some measure of stability through, for example, feeling able to tolerate emotional distress without using substances, and with established supports and resources available within the community.
The development of trauma-informed substance misuse services means that services need to hold core values, including safety (physical and emotional safety), trust (clear expectations and boundaries), choice, collaborative treatment and empowerment. Staff in a trauma-informed service are required to understand the impact of trauma to recognise the multiple ways it may present, but are not all required to deliver trauma-specific interventions that seek to address the consequences of traumatic experiences.
Figure 2 suggests a matched-care model for the delivery of trauma-informed care within a substance misuse service. Trauma-informed keyworking competencies are described at Tier 1. Tiers 2 and above illustrate interventions recommended for PTSD and complex trauma. Practitioners at each tier should receive clinical supervision.
Figure 2: Matched-care model of trauma-informed psychological interventions
Trauma-informed keyworking competencies map onto those described as psychologically informed care in Figure 1. As a minimum, clinical staff should have some awareness of the emotional, physical and cognitive consequences of trauma and be aware of the range of behaviours that may manifest. Staff should have access to training in managing disclosure and recognise pathways of care outlined in the NHS Education for Scotland( NES)/Scottish Government Transforming psychological trauma knowledge and skills framework for the Scottish workforce. 
Low intensity interventions appropriate for PTSD and complex PTSD include CBT-based guided self-help materials to educate individuals about symptoms. Aspects of other interventions, such as Dialectical Behaviour Therapy, may be helpful for those with more complex presentations who are likely to require a period of developing stability and learning to regulate emotional difficulties in the here and now.
High intensity interventions appropriate for PTSD are designed to support individuals to process the impact of the traumatic event, and involve trauma-processing interventions such as trauma-focussed CBT, prolonged exposure, and eye movement desensitisation and reprocessing ( EMDR). Where individuals present with complex PTSD, particularly in cases where resilience and personal coping strategies are low, or where there is a high risk of relapse to substance use, a period of high intensity work around developing safety and stability is indicated. Individual and group interventions, including Seeking Safety, Survive and Thrive, and Safety & Stabilisation, have been designed to meet this need.
Formulation-driven approaches may be indicated where individuals are presenting with complex difficulties and multiple morbidity. The psychological intervention here is likely to be one component in a multidisciplinary care package.
Psychological interventions for cognitive impairment in substance misuse services
Cognitive functioning is often compromised in service users presenting with drug and alcohol problems. This may be due to the impact of chronic alcohol and drug use on the brain, or the impact of pre-existing difficulties such as learning disability, acquired brain injury or other neurological conditions. Those who have had a disrupted educational history may also experience literacy and numeracy difficulties.
As a result, service users presenting to substance misuse services may experience both transient and longer-term impairment of cognitive abilities. When this goes unrecognised, it can impact on an individual’s ability to engage with, and make progress in, treatment: he or she may, for example, forget appointments or not remember the content of sessions. A lack of engagement may be misattributed to lack of motivation rather than an impairment that may be managed with adaptations to treatment.
All substances are associated with some alterations in memory, emotional processing and some ‘higher-order’ processes, including decision-making. This means that the neuropsychological impact of these substances can directly influence an individual’s ability to control and change behaviour.
It is therefore important to screen for cognitive impairment at an appropriate stage of treatment, noting that current substance use will influence scores on screening measures. NICE recommended assessment of cognitive functioning as part of a comprehensive assessment for those presenting for treatment of alcohol use disorders,  but cognitive screening will also be useful for people presenting for treatment of other substance use disorders and for those on long-term maintenance prescriptions of opiates and benzodiazepines. Recommended screening tools include the Addenbrooke’s Cognitive Examination, 3 rd edition  ( ACE-III), and the Montreal Cognitive Assessment. 
The Mini Mental State Examination is not recommended for screening those with cognitive impairment relating to drug or alcohol problems, as it does not assess impairments of executive functioning (complex cognitive functions including planning, problem-solving and cognitive flexibility), which are frequently impaired as a result of drug or alcohol use.
Where cognitive screening suggests that further investigation is indicated, a referral for comprehensive neuropsychological assessment should be made to a clinical psychologist or clinical neuropsychologist. This will allow a more in-depth assessment of cognitive strengths and weaknesses, offer recommendations for individualised rehabilitation, and can support differential diagnosis where there may be multiple causes of impairment.
Adaptations to interventions can be made to support engagement and progress in treatment. These are made from adaptations to psychological therapies for those with brain injuries and are recommended where memory or executive functioning impairment may be likely. They include:
- providing prompts for attending appointments (text prompts, for example)
- providing visual or written summaries of sessions
- using a range of modes to aid learning and processing of therapeutic information (such as visual, movement-based and music) rather than relying on verbal strategies alone
- providing handouts or worksheets
- structuring sessions so they have a consistent format
- offering shorter sessions for service users with attention/concentration problems
- delivering interventions jointly with keyworkers
- integrating interventions with peer-support activities
- involving supportive family or network members in interventions.
The node-link mapping approach designed by the National Treatment Agency for Substance Misuse ( NTA) offers a structured and visual set of tools that is likely to support people with and without cognitive impairment to engage more fully with treatment. Figure 3 recommends competencies/interventions required for managing cognitive impairment at each tier.
Figure 3: Matched-care model to manage the impact of cognitive impairment on interventions
Tier 1 competencies for working with cognition include being aware of the impact of different substances on cognition, and the effect this may have on engagement and progress in treatment, particularly where individuals are prescribed high doses of opiates or benzodiazepines or have a chronic history of alcohol excess.
Tiers 2 and 3 include additional competencies in cognitive screening and awareness of how to adapt interventions to compensate for cognitive impairment.
Tier 4 includes neuropsychological assessment, where available. Clinical psychologists and neuropsychologists have specialist competence in delivering neuropsychological assessment and can provide liaison and consultation to support adaptations to existing interventions at tiers 1, 2 and 3.
Case example: Jim
Jim is attending keyworking appointments but does not seem to remember the details discussed, and his attendance is poor. His keyworker carries out an ACE-III assessment and discusses the results with the team clinical psychologist/neuropsychologist, who suggests that Jim may have executive functioning impairments impacting on his ability to retrieve information from his memory.
The keyworker begins to use phone prompts to support Jim’s attendance and mapping tools to provide Jim with visual memory aids of keyworking appointments. Jim agrees to recruit his partner to support his treatment, and discusses progress with her. She is invited to attend some appointments. Jim’s attendance improves, and he begins to make faster progress towards his recovery.
Alcohol and Drug Delivery team: Alcohol_and_Drug_partnerships@gov.scot