James A Pitts, M.A. Chief Executive Officer

1. “The Deterioration of Client Profiles at Odyssey House –Possible Contributing Factors”New South Wales Government Organisations Mental Health ConferenceSydney Masonic CentreMarch 1 – 2, 2007“Count Me In”Innovative Community Based Approaches To Better Mental Health” James A Pitts, M.A.Chief Executive Officer

2. ABSTRACT A number of factors have contributed to the deterioration of client profiles at Odyssey House. These factors have included the increase in pharmacotherapies; lowering in the age of first intoxification; change in drug use patterns; decline in educational attainment; decline in intellectual functioning; decline is psychiatric / psychological health; high rates of criminal activity. In order to meet the legitimate needs of our deteriorating population Odyssey House has had to make adjustments to its programming, particularly for MISA residents. These adjustments have included a reduction in the length of time in program; specific interventions for MISA residents which include group therapy and an earlier onset of 1:1 counselling. Staff training on diagnostic criteria has taken place. Liaison with the local mental health unit and accident and emergency at Campbelltown Hospital has assisted us greatly in the management of this client group.

3. ALTERNATIVE PHARMACOTHERAPIES • A number of factors have contributed to the deterioration of client profiles at Odyssey House. • The National Campaign Against Drug Abuse (NCADA), which began in 1985, had as it major policy the concept of “Harm Minimisation” • There has been a steady rise in the number of persons on methadone, and more recently other alternative pharmacotherapies (buprenorphine) since 1985.

4. ALTERNATIVE PHARMACOTHERAPIES • Steady rise in the number of persons on methadone / other alternative pharmacotherapies (buprenorphine) since 1985. Prior to the establishment of NCADA in 1985 there were 2203 people on methadone nationwide, by 2003-04 there were 36,300 people enrolled in alternative pharmacotherapy programs of which 8641 were on buprenorphine. • These figures are significant when it was estimated the total number of heroin dependent persons in Australia was estimated at between 62-74,000 (Hall et al, 2001).

5. Age on Onset of Intoxification • 1985 – 1996 the age of onset of intoxification was between 15-16 years of age. • Since the year 2000 the age of onset of intoxification has fallen to age 12-13. • Australia Treatment Outcome Study (ATOS) data on Odyssey House participants indicated the age of onset of intoxification to be 13 years of age . • Despite this chronological age averaging 27 years they operated at a level equivalent to being an adolescent (Lovinger et al, 1990).

6. Educational Attainment • Education - positive benefit upon self concept and participation in an educational role had been shown to enhance self esteem (Biase, 1981). • Lowered educational attainment places individuals at risk of lowered self esteem and negative and deviant self concepts which are often the precursors for continued drug misuse and other anti-social activities (Pitts, 1996). • ATOS data on the Odyssey House sample indicated the mean length of school education in 2003 was 10 years.

7. Educational Attainment • Odyssey House records indicate residents in years 1985 and 1986 had the highest rates of tertiary participation. From 1986 each subsequent sample had a greater proportion of residents whose educational attainment had a greater proportion equivalent to Year 10 or Year 9 or less. • The proportions of the resident sample in this category ranged from 64% in 1989 to 89% in 1998.

8. Drug Usage • Average age of Odyssey House residents had decreased since 1986. • Trend towards a younger population of users. • Change in drug usage patterns which have occurred since 1989. At that point there was an increase in other drug classes including alcohol and marijuana.

9. Drug Usage • Our most recent half yearly statistics, July 1, 2006 to December 31, 2006 indicate admissions to our residential program nominated the following as their drugs of concern: • Alcohol 31% • Heroin 17% • ATS 21% • Cannabis 14% • Methadone 9% • Benzodiazepines 2% • Cocaine 1% • Other 5%

10. Drug Usage • The ATOS study indicated participants in residential rehabilitation exhibited greater levels of polydrug use than methadone and detoxification groups. • The Odyssey House sample had used 9.4 drug classes. • Increase in the number of residents who use alcohol, amphetamine type substances (ATS) and marijuana impacts possibly on the psychiatric and psychological health of the Odyssey resident population.

11. Psychiatric / Psychological Health • The ATOS highlighted the high degree of psychiatric co-morbidity within the Odyssey House sample. • at baseline • 26% had a current Major Depression • 40% had a lifetime diagnosis of Post Traumatic Stress Disorder • 79% qualified for a diagnosis of Anti-Social Personality Disorder • 61% acquired a diagnosis of Borderline Personality Disorder. • The study indicated the Residential Rehabilitation (RR) group showed greater impairment than other modalities. • pre-admission psychiatric diagnosis of persons entering our residential program indicate in 2004-05, 22% did; and the 6 months of 2006-07 21% had.

12. Program Adjustments • The increase in the number of co-morbid presentations had necessitated adjustments to our programming to meet the legitimate needs of the client group. We have retained the basic methodology of the therapeutic community. However, there has been a greater focus on their intra-psychic conflicts particularly mood disorders (depression, dysthymia), thought disorders and general anxiety disorders as Axis I diagnosis. To incorporate our co-morbid residents in the program as fully as possible we have made several adjustments.

13. Program Adjustments • Participation in groups and meetings is of shorter duration. • Information is presented gradually, broken up, repeated and feedback given. • Greater emphasis on residents understanding their psychiatric condition. • “Double Trouble”, “Dual Diagnosis Intensive Group” (DDIG) enhances participation and avoid triggers for relapse. • Flatter hierarchy. • More 1:1 counselling • Psychotropic medication

14. Program Adjustments • Progression in program individualised according to developmental level, diagnostic differences. • Behavioural consequences are framed by “staff” before they become “community knowledge”. • Expected to manage the facility, participate in job assignments, uphold policies and procedures where appropriate and assist staff. The modified TC is less intense, more flexible and more individualised. • We are grateful for the assistance of the local mental health unit and the staff at the accident and emergency department at Campbelltown Hospital. They have both assisted us greatly in the management of this challenging group of residents.

15. Conclusion • The Therapeutic Community at Odyssey House has seen deterioration in the profile of its resident population over a number of years. The causal factors which have contributed to this decline are many. Increases in the presentation of people with co-morbid disorders have necessitated an adjustment and modification to our programming. This has placed a strain on resources, in doing so we have been able to provide the best services we are able to for this population.