14 th EFTC Conference, Prague, September 2013

1. 14th EFTC Conference, Prague, September 2013 INTEGRATED TREATMENT OF CLIENTS WITH DUAL DIAGNOSES IN THERAPEUTIC COMMUNITIES IN THE CZECH REPUBLIC Assoc. Prof. Dr. Kamil Kalina Dr. Petr Vácha Clinic/Dept. for Addictology, 1st Medical School, Charles University, Prague SANANIM Drug Services NGO – Therapeutic Community Karlov

2. PREVALENCE OF DD Before 2004: more close to the lower limit CR 2003: 37% EMCDDA 2004: 30-50 % After 2004: more close to the upper limit CR 2013: 47%

3. ARE DD INCREASING ? --- --- or do we pay more attention to them? Yates & Wilson (2001): individuals with dual diagnoses are a newly recognized rather than emerging group of clients. Kalina & Vácha (2013) for the CR: psychopathological profile of clients has worsened dramatically in the last decade; clients with dual diagnoses represent a new population of clients, different from that of the 1990s, when the majority of Czech drug services began to operate.

4. IT WILL NOT BE BETTER --- --- we have to cope with it. How to cope with it? • Successive treatment • Parallel treatment • Integrated treatment

5. SUCCESSIVE TREATMENT„ADDICTION FIRST“ Advantages: • Many psychopathological complications disappear in abstinence • Active users have very poor compliance to psychiatric/psychotherapeutic treatment Disadvantages: • Limits of the client´s involvement to substance abuse treatment due to psychopathological complications • Lower capacity to benefit from the treatment • Higher drop-out risk

6. PARALLEL TREATMENT„WE MAKE CAKES, BUY YOUR BREAD ELSEWHERE“ Advantages: • ??? • ?????!!! Disadvantages: • Problem with inter-disciplinary and inter-sectorial gaps and barriers • Lack of common conceptual framework • Difficulties to establish therapeutic relationship • The client takes the burden of integration on him/herself = Without linking cakebakers and bread bakers the parallel treatment is risky for the client

7. INTEGRATED TREATMENT 1 „WE ARE ABLE NOT TO DIVIDE THE CLIENT TO TWO PORTIONS“ Advantages: • Higher retention in treatment • Higher benefit for clients • Higher clients´satisfaction • Most cost/effectiveness It can also overcome the division of the client into two parts which may lead to disregarding the close relationships (pathogenetic, psychodynamic, [neuro]pharmacological) between substance use and other psychological problems which interact and combine to form an individual’s comprehensive clinical picture and unique individual’s experience.

8. INTEGRATED TREATMENT 2 „IT IS DIFFICULT FOR US AND IT MAKES TROUBLES TO OTHER CLIENTS“ Disadvantages: DD in general - • reduce patients’/clients’ abilities to engage and persist with the treatment and benefit from it; • represent a frequent source of motivation crises, interpersonal conflicts, and risky situations which may lead to relapse or the early termination of treatment; • place an extra burden on the individual, as well as causing • complications and risk to other patients/clients • place an extra burden and responsibility on the staff, who must be able to work with all the types of disorders

9. REQUIREMENTS FOR INTEGRATED TREATMENT What matters is the therapeutic team’s capacity: • their training in the issue of dual diagnoses, • psychotherapeutic approach and expertise, • empathic understanding, • reasonable level of individualization. The last also requires a certain redefinition of the role ofa key worker: • to guide their clients on the uneasy paththrough the inner and outer pitfalls of their treatment • to help them to share it within the group

10. WHAT MATTERS IS THE THERAPEUTIC TEAM’S CAPACITY In order to cope with the demands of integrated treatment,the therapeutic team should possess the following capacities: • establishing a safe therapeutic alliance with the client • supporting their motivation • promoting insight into their problems, their mutual linkage, and the interpersonal consequences • shifting the emphasis from behaviour modification to interpersonal learning and helping the client develop their abilities to deal and cope • with multiple problems, • encouraging the client to develop their skills to maintain the benefits of their treatment • to expand the concept of “relapse” and “relapse prevention” to include various failures in the client’s life, whether in relation to drug use or other psychological and interpersonal problems and difficulties.

11. THERAPEUTIC COMMUNITY / INTEGRATED TREATMENT OF CLIENTS WITH DD TC in itself has a large potential for integrated treatment: • As an original method and system, TC is an effective treatment modality for many mental health disorders other than addictions • TC for drug addicts has a much wider spectrum of therapeuticfactors than those specificic to addictive disorders • Addiction is not an object of treatment, it is the person who is the subject of treatment

12. THERAPEUTIC COMMUNITY OFFER FOR CLIENTS WITH DD • structure, order, clear rules • emotional and interpersonal safety • support for the structures and boundaries of the Self (Ego-syntonic approach) • understanding oneself and to the others • sharing and support in the therapeutic group • interpersonal learning • understanding the problem-solving strategies • training in social and communication skills

13. INTEGRATED RECOVERY STRATEGY • Psychological complications among drug addicts in TC are largely manageable by theprocess in itself, enhanced by the well-trained and experienced team. • Nevertheless, the integrated treatment of dual diagnoses in therapeutic communities also requires the availability of a psychiatric service, early diagnosis and its accurate interpretation for the other staff members, consultation of approaches, and the prescription of psychiatric medication, although this is not necessary in all cases. • It is the involvement of a psychiatrist that creates a sensitive moment within the integrated recovery strategy, as the psychiatric/medical and psychosocial paradigms of the model may not always align with each other.

14. ARE THE PSYCHIATRIZATION WORRIES JUSTIFIED? Prerequisites for specific services and interventions in TCs for addicts (De Leon, 2000): • they are integrated into the programme of the TC as complementing the basic treatment model, • they must extend and enhance the effectiveness of the TC approach rather than modifying or replacing its foundations, • they must be compatible with the TC philosophy and approach, • they must be reasonably incorporated into daily routines, • the staff who provide the services and interventions must have adopted and support the TC principles.

15. PSYCHIATRIC MEDICATION = SENSITIVE ISSUE • Does it extend and enhance the effectiveness of the TC treatment? • Is it in line with the treatment philosophy • Or, on the contrary, does it violate the TC essential principles? The basic requirement for psychotropic medication in combinedtreatment is to open, and not to close, the doors to psychotherapy • Medication that alters the emotional, physical,and mental state can aggravate the disorder and delayor prevent the process of recovery • The reasonableadministration of psychiatric medication can reducethe burden imposed on the client and improve their engagementin the programme

16. REQUIREMENTS FOR PSYCHIATRIC SERVICE IN TC • Integrated treatment of dual diagnoses can be taken seriously only if a psychiatric consultant was integrated into the team of the therapeutic community and operated within the same conceptual framework. • This is what the team of the therapeutic community expects and needs.

17. AND WHAT ABOUT THE STAFF? Consequences of the integrated treatment of dual diagnoses for the TC team: • greater uncertainty and tension in dealing with complex situations that arise; • a tendency to avoid clients with “complicated” histories and look for “normal” ones; • efforts to extent the scope of collective decision in cases of “complicated” clients; • the need for a well-defined approach and cooperation and feedback from the psychiatrist “on the team”; • the need for training in the issue of dual diagnoses; • the ability to change a rigid perspective on which client’streatment is successful and whose is not.

18. RECOMMEDATION FROM THE TC KARLOV • to soft TC rules is not the way; • a higher level of involvement with the individual by the • key worker is necessary and justified; • with great patience and sensitivity, a client should be encouraged to share individually communicated topics within the group process; • it is advisable to respect the client’s limits ensuing from their co-occurring psychological disorder; • the creation of special conditions put these clients in a tricky, burdensome, and even dangerous position and situation within the group • cooperation and consultations with a psychiatrist are an essential part of the determination of the further therapeutic processes and the planning of the future goals

19. LIMITS, TOO • The expression of a psychological disorder secondary to the diagnosis of dependency must not exceed the therapeutic resources of the therapeutic community and its team • The expression of a psychological disorder secondary to the diagnosis of dependency must not jeopardize other members of the therapeutic community.

20. THERAPEUTIC COMMUNITIES OF SANANIM NGO TC Karlov (est. 1997) Capacity: 25 beds for two target groups: • youngsters and young adults of both gender (16 - 25) – 15 beds • mothers with small children (10 rooms) TC Němčice (est. 1991 – first in Czechia) Capacity: 20 beds for two target groups of both gender: • adults over 25 • chronic users with social problems and criminal history

21. CONTACTS WITH THE PSYCHIATRIST2011-2012

22. PSYCHIATRIC CARE

23. PSYCHIATRIC CARE

24. PSYCHOPATHOLOGY

25. POSTPONED ABSTINENCE PSYCHOPATHOLOGY (PAP) Working term since 2011 Characteristics: • Occurence after 3-4 months of abstinence, before it a period without significant problems • Symptoms: anxious, depressive, also symoptoms of eating disorders or depersonalization/derealization • Previous disorder or serious traumatization cannot be detected • Clients reported similar troubles in periods of abstinence in the past as a frequent trigger of their return to drugs Theory: • Underlying personality disorder, hypothesis of self-medication

26. PHARMACOTHERAPY

27. UNTIMELY ENDS OF STAY, DROP-OUTS

28. LIMITS, TOO • The expression of a psychological disorder secondary to the diagnosis of dependency must not exceed the therapeutic resources of the therapeutic community and its team • The expession of a psychological disorder secondary to the diagnosis of dependency must not jeopardise other members of the therapeutic community.

29. NEEDS FOR FURTHER RESEARCH • What is the rate and the psychopathological profile of dual diagnoses in our TCs for drug addicts? • What is the treatment of clients with dual diagnoses, and what are its complications and outcomes? • What is the way in which psychiatric interventions are carried out and what is the role of the psychiatrist in relation to the team of the TC? • What is the impact of psychiatric interventions on the process and outcomes of treatment in the TC? • What are the good practices for enhancing the capacities of “standard” (= non-specialized) TCs, as regards the integrated treatment of dual diagnoses? • Are specialized TCs necessary?

30. THANK YOU FOR YOUR ATTENTION!kalina@adiktologie.czvacha@sananim.czE