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2!! E F T C 6 09 Ca Prison Retrospective


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2!! E F T C 6 09 Ca Prison Retrospective

  1. 1. Clients with d ual diagn osis in the TC TC Magdaléna (Czech republic) Den Haag 2009 Petr Nevšímal MD
  2. 2. Situation in Czech republic <ul><li>About 30 000 heavy drug users, most of them in Prague, also in former industry regions with high unem p loyment </li></ul><ul><li>Main drugs are amphetamines, decline of heroin abuse, i.v. application and hepatitis C, low occurrence of HIV </li></ul><ul><li>13 TC‘s, capacity 200 beds, first in 1991 </li></ul><ul><li>Short term programmes in medical fac. </li></ul><ul><li>More drug free orient. then substitution (tradition of Jaroslav Skála) </li></ul>
  3. 3. TC‘s charakteristic <ul><li>Financed by state (municipal) grants </li></ul><ul><li>Location in countryside </li></ul><ul><li>Lenght of programme 6-18 month </li></ul><ul><li>Cooperation – federation A.N.O. (sharing of experiences, lobbying) </li></ul><ul><li>Community culture is influenced by American, Europe and Skala tradition </li></ul><ul><li>CBT, integrative psychotherapy, psychodynamic accent </li></ul>
  4. 4. TC Magdaléna <ul><li>Founded in 1998 nearby Prague in former military area (missile base) </li></ul><ul><li>Capacity 25 clients (M : W – 2 : 1) </li></ul><ul><li>Lenght of the stay 9-15 months (including re-entry house) </li></ul><ul><li>9 staff members (therap. team) included 2 exusers in the TC </li></ul><ul><li>Occupational therapy – farm, gardening, carpentery </li></ul>
  5. 5. Programme of TC <ul><li>4 phases : induction, introspection, responsibility, re-entry </li></ul><ul><li>20 hours of group therapy weekly </li></ul><ul><li>25 hours of work weekly </li></ul><ul><li>Individual counselling (treatment planning) </li></ul><ul><li>Family counselling </li></ul>
  6. 6. Basic clients charakteristic <ul><li>Average age 25 years </li></ul><ul><li>Drug use 5,5 years </li></ul><ul><li>Opioid users (heroin) 50 % </li></ul><ul><li>Amphetamines 50 % </li></ul><ul><li>I.v. aplication 8 5 % </li></ul><ul><li>Sentence 3 0 % </li></ul><ul><li>Hepatitis B/C 3 5 % </li></ul>
  7. 7. Du al diagno sis <ul><li>Personality disorders ( borderline , narcistic) </li></ul><ul><li>Neuro sis (OCD, panic dis., gen. anx. dis.) </li></ul><ul><li>Schizofreni a </li></ul><ul><li>Mood disorders (depres sion ) </li></ul><ul><li>Eating disorders </li></ul><ul><li>ADHD </li></ul><ul><li>( not acute psychosis related to drug abuse ) </li></ul>
  8. 8. Portion of clients with DD
  9. 9. Treatment models I. <ul><li>Serial treatment model </li></ul><ul><ul><li>consecutive treatment with little communication between substance misuse and psychiatric services </li></ul></ul><ul><ul><li>clients tend to be shunted between services that are inadequate to meet their needs (in our condition is sometimes used to achieve stability and possibility of cooperation) </li></ul></ul>
  10. 10. Treatment models II. <ul><li>Parallel treatment model </li></ul><ul><ul><li>substance misuse and psychiatric services services establish liaison to provide the two services concurrently </li></ul></ul><ul><ul><li>in our settings e.g. cooperation with a day centre for patients with psychosis (our clients attend there individual and group therapy once a week, what helps them in orientation and understanding themselves, building real self-esteem , etc. ) </li></ul></ul>
  11. 11. Treatment models III. <ul><li>Integration treatment model </li></ul><ul><ul><li>substance misuse and psychiatric services are integrated in one settings by one therapeutic team </li></ul></ul><ul><ul><li>in our community work psychiatrist, psychologist, experienced nurse (they work like other therapists and have training in group psychotherapy too) </li></ul></ul>
  12. 12. Obstacles for the community <ul><li>Lots of energ y ( attention , understanding ) </li></ul><ul><li>Different evaluation scales , individu a l approach </li></ul><ul><li>Less space for other clients and for psychotherapy </li></ul><ul><li>Shortage of „po s itiv e rol e models “ </li></ul><ul><li>Risk of solidarity lack </li></ul><ul><li>Risk of r e s igna tion from everybodies influence on community process </li></ul><ul><li>Lower effectivity of the treatment </li></ul>
  13. 13. Obstacles for an individual <ul><li>Inadequate burden and claims </li></ul><ul><li>Ri sk of state worsen , or it’s chronification </li></ul><ul><li>To be too exceptional can lead to exclusion from the group </li></ul><ul><li>Ri sk of relaps e </li></ul>
  14. 14. Obstacles for the staff <ul><li>Individual therapy </li></ul><ul><li>Diversi ty of attitude towards clients </li></ul><ul><li>Shortage of clear guide lines ( exceptions ) </li></ul><ul><li>Doubts about their competence </li></ul><ul><li>High demand for energ y </li></ul><ul><li>Exhausting work, burn out syndrom (claims x realit y ) </li></ul>
  15. 15. Ade quate t h erap. goals Usual goals Adapt ed goals I. Phase Re gime , coping with emo tions and affects , adapta tion , introspe ction , learning Re gime , stabili z a tion , adapta tion , accept leading I I . Phase Ini t iativ e , self- reflex ion , pl anning , responsibility , role model, leading Stabili ty , self- reflex ion , learning , coping with difference and af f e cts I II . Phase Independence , tenacious , se lf- a c tualiza tion , full resocialization Stabilit y , slow steps to independence a nd pl anning
  16. 16. Ph arma c ot h erap y <ul><li>AD treatment </li></ul><ul><ul><li>SSRI (citalopram, fluoxetin, paroxetin, sertralin) </li></ul></ul><ul><ul><li>O ther (venlafaxin, tianeptin) </li></ul></ul><ul><li>Antipsychoti c drugs (olanzapin, quetiapin, zotepin, risperidon) </li></ul><ul><li>Mood stabiliz ato r s a nd nootropi cs </li></ul>
  17. 17. Individu al care <ul><li>Detai led guide / counselling </li></ul><ul><li>S trong support </li></ul><ul><li>1 h our / week </li></ul><ul><li>Family therapy </li></ul><ul><li>Accessibility of psychiatr ist and psychologist with good knowledge of the TC </li></ul>
  18. 18. 1 year after treatment <ul><li>No use of illegal drug (work or study) </li></ul><ul><li>Another treatment </li></ul><ul><li>State unknown </li></ul><ul><li>Drug use </li></ul>160 clients (1999 – 2008)
  19. 19. Conclusions <ul><li>Amount of clients with DD is rising up </li></ul><ul><li>Shortened total time of treatment </li></ul><ul><li>A lternativ e to long term invalidi ty (repeated stay in psychiatric hospital) </li></ul><ul><li>Better chance for re socializa t i on due to community treatment </li></ul><ul><li>Chance for independence in future life </li></ul><ul><li>Integration of theese clients into the TC lower the effectivity and have another claims on our staff (many thanks for their patience) </li></ul>
  20. 20. Magdaléna, o.p.s. Drug free treatment programs
  21. 21. The dining room
  22. 22. 252 10 Mníšek pod Brdy, P.O.Box 3 Czech republic tel. + 420 318 599 124-5 GSM +420 603 867 384-5 Magdaléna o.p.s. Thanks for your attention!