The Birmingham Treatment Effectiveness Initiative (BTEI)
An Introductory Guide
Dr Ed Day, July 2009
NOTE: Key documents can be accessed by clicking on the hyperlinks
The Birmingham Treatment Effectiveness Initiative started in late 2006 with 3 aims
1. To improve the assessment of service users problems by making the assessment and
care planning process more comprehensive and client-centred
2. To use the information gained from improved assessment to tailor better
interventions to client problems
3. To understand the organisational barriers to implementing client-focussed
assessments and interventions into clinical practice.
The process started with an evidence-based model of a drug treatment system, which is
presented below. The grey box represents the treatment service, and the client’s progress
can be followed through a number of stages.
This model is not surprising, original or unique – many experienced workers feel it is intuitive
and uses methods that they already know. The treatment process from initial contact
through to (re)habilitation and recovery is best understood in a series of stages. Although
the process is not necessarily linear (‘two steps forward and 1 step back’), and need not
follow all the stages, it provides a useful template for thinking about the delivery of
Key points are that:
o Higher pre-treatment levels of client motivation and readiness for treatment (including
problem severity) are related to better treatment results
o More time in treatment is related to better outcomes (therapeutic benefits tend to
begin showing up behaviourally only after about three months of treatment)
o Indicators of early engagement in treatment predict better long-term outcomes. Clients
entering treatment must participate (i.e. turn up regularly for scheduled sessions) and
begin forming positive therapeutic relationships with the worker
o Indicators of early recovery (defined by behavioural and cognitive assessments of client
thinking and actions) by month 3 are directly related to the level of treatment
If you have measurable stages of treatment, interventions can be strategically planned and
evaluated as to their efficacy for addressing specific needs and progress of clients
Aim 1 - The assessment process
At the start of the project, all agencies in Birmingham were using a 17 page (‘Pan-
Birmingham’) comprehensive assessment document. Although this was usually done very
well, it was very focused on problems and difficulties and was very ‘service-led’. It was rare
that, once completed, the assessment document would be referred to again during the
course of treatment. How could we broaden this assessment process to make it more client-
led, whilst at the same time collect consistent and useful information that would guide
To address this we decided to split the process into 3 parts: i. Initial Assessment; ii. Maps;
iii. Client Evaluation of Self at Intake (CESI); these are summarised in the map below:
The assessment process
It is essential –no data, no
It is useful –it lets us know
who comes to our services
Form a rapport Collect info
Get the client to come back again
initial assessment maps CESI graph
Looks like a traditional drug service
assessment –heavy on facts &
numbers. It creates a story of a
persons’ life, but in the order that the
commissioners want it.
Looks a bit different -
the client can fill it in
Gives more of an opportunity for the
client to set the agenda.
Something very different: a self-
complete questionnaire. The
resulting graph can tell a client about
how they compare to others
attending the service
The client’s opportunity to
Prepares them for using
maps later in treatment
A tool for planning treatment
and for monitoring progress
Develop the best possible treatment plan
i) Initial Assessment: The traditional assessment document was still required to collect basic
information for national data collection systems (e.g. NDTMS). However, it was shortened
(10 pages instead of 17) and simplified (and later incorporated the Treatment Outcome
ii) Maps: In order to increase a client-led component to the assessment, we trained all staff
in the simple concept of ‘Node-Link Mapping’ (NLM) (for detailed summary click here).
Node-Link Mapping, which uses boxes (nodes) and lines (links) to illustrate thoughts,
feelings, and actions, and how they relate to each other, forms the foundation of a more
client-centred approach to drug working. Research shows that there are strong
communication and thinking advantages for visual representations like NLM compared to
traditional language. As computer graphics and printing have improved, so graphic or
pictorial representations have become a predominant form of communication in advertising
media, business, and educational organisations. Why not bring this graphic advantage to
drug treatment services?
The choice of NLM as the graphic tool for the manuals was supported by research reports
describing its positive impact on distinctive stages of drug treatment process and client
recovery (see Dansereau, 2005, & Simpson, 2004, for reviews). In general, the results
establish that NLM improves communication, attentional focus, problem solving and
decision making in comparison to purely language-based approaches, and that it is
particularly beneficial for individuals with deficits in these domains.
Therefore, two template or ‘guide’ maps (‘Me Today’ and ‘My History’) were introduced as
part of the routine assessment process, allowing the client to talk about positive aspects of
their life and demonstrate their strengths.
iii) CESI: Finally, we introduced a third different method of collecting assessment data. The
Client Evaluation of Self at Intake (CESI) (CESI Form) is a self-rating form completed by the
client at the start of an episode of treatment. It is made up of 87 statements, and each offers
the client 5 choices (‘agree strongly’, ‘agree’, ‘uncertain’, ‘disagree’, and ‘disagree strongly’).
Each answer is scored between 1 and 5 depending on the response, providing client scores
for 3 different areas (scales):
a. treatment motivation (problem recognition, desire for help, treatment readiness)
b. psychological functioning (self-esteem, depression, anxiety, and decision-making)
c. social functioning (hostility, risk-taking, and social consciousness).
These scales provide a baseline for monitoring client performance and psychosocial changes
during treatment, both at the client and the overall program levels. A simple Excel file was
created to score the CESI and produce a graph showing the client’s scores compared to an
‘average’ client attending the service. This enabled the worker to instantly feedback the
results, using it as a tool to enhance and refine the assessment process.
Another advantage of use of the CESI instrument is the possibility of re-administering it to
the service user at different stages of their treatment journey in order to monitor and
feedback progress. The Client Evaluation of Self and Treatment (CEST) (CEST Form) is a
slightly longer version of the CESI, containing an additional set of scales exploring client
engagement with treatment (including treatment participation, treatment satisfaction,
counselling rapport, and peer support) (see “CESI and CEST graph explained” document].
Aim 2 - Better Treatment Interventions
Having made all staff familiar with the concept of the stages of the treatment process, and
trained them in the principles and practice of Node-Link Mapping, it was possible to start to
develop a library of simple treatment strategies that staff could use to plan and deliver
A whole range of manuals based on NLM had already been produced by the team at the
Institute of Behavioral Research in Texas [TCU Mapping-Enhanced Counselling] and so we
set about adapting these for use in BSMHFT services. A sensible place to start was Care
Planning, as this was a compulsory element of practice as outlined by the National
Treatment Agency for Substance Misuse in its document Models of Care [Good Practice in
A study of hundreds of Care Plans produced in drug treatment agencies across the city had
led to 2 conclusions:
Firstly, the problems highlighted in Care Plans were often limited to drug misuse only,
and the solutions usually centred on prescription of medication. Care Plans rarely
included goals in other client problem areas such as psychological health, finances,
relationships, physical health or exercise.
Secondly, when goals were set in Care Plans they were often vague and unrealistic, and
therefore never re-visited by the client or worker. For example, a common goal was ‘to
stop using heroin’, without any indication of how the client would go about doing this.
Therefore a Care Planning intervention [Care Planning Manual] has been developed that is
built around the use of 3 simple Node-Link maps, and that aims to tackle these two issues in
a collaborative manner with the client.
By adapting the ‘Happiness Scale’ from the Community Reinforcement Approach, the
intervention invites the client to consider all potential problem areas in their life and
helps them to prioritize the top three.
The concept of setting Specific, Measurable, Agreed-upon, Realistic, and Time-limited
(SMART) goals is then used to help break down problems into small, achievable
elements that can then be monitored and followed up.
Thus, the previously ‘administrative’ task of writing a Care Plan can be turned into an
effective problem solving technique that can form the basis of all Drug Working sessions
with a client.
The new assessment and intervention tools described above have not appeared overnight,
and have evolved through an ongoing process of revision in consultation with clinical staff.
Use of the new assessment tools and the Care Planning intervention have led to the
development of detailed descriptions of clients’ needs, as well as a better summary of their
existing strengths to tackle these problems. Alongside this process has come the
development of a series of NLM guide maps to address individual client problems [The Map
Book], as well as a growing collection of simple treatment manuals [TCU Manuals]
The next stage in the process was to begin to disseminate these new materials to all clinical
staff along with training to help them to make the best use of them. Starting from
September 2009 the Addictions Training Academy within BSMHFT began the process of
providing 4 days of core ‘drug working’ training to all clinical staff
Day 1 – Turning assessment into an effective Care Plan [Routes to Recovery Part 4]
Day 2 – Assessing and managing risk, and monitoring client progress in treatment [“CESI and
CEST graph explained”].
Day 3 - Building motivation to change with individuals [Routes to Recovery Part 6]
and groups [Routes to Recovery Part 7]
Day 4 - Delivering effective ‘Relapse Prevention’ [Routes to Recovery Part 5] and ‘Harm
Reduction’ messages using Node Link Mapping [see “Promoting Harm Reduction Maps”
The ‘map of maps’ below summarises the NLM maps (blue text) and manuals (black text)
available to address problems identified through the assessment and Care Planning process.
The initial training for staff in the BTEI process was delivered in a ‘train the trainers’ format,
whereby a member of each clinical team was trained in Node-Link Mapping and the Care
Planning process, and was asked to train all other members of their clinical team. This
process was variable in its implementation, and so the role of ‘BTEI Coach’ was created in
The Coach was given protected time each week to support their colleagues in implementing
BTEI processes, and met on a monthly basis with the BTEI development team to keep up to
date with the latest information about assessment and treatment. This process was
coordinated by the BTEI Coordinator, Nick Shough.