TCIE Therapeutic Communities for Drug-Dependent Individuals in Bulgaria

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The period 1990 – 2000 saw epidemic spread of drug misuse in Bulgaria. According to expert estimations made by the Ministry of Health the number of people misusing heroine in 2000 was between 20 000 and 30 000 ones. The figures for cocaine and cannabis were 5 000-10 000 and 80 000-110 000 respectively. Regular amphetamine users were said to be between 10 000 and 15 000 ones. The misuse of heroin in Bulgaria became a real and significant public health issue. The rate of intravenous users infected with hepatitis C has dramatically increased reaching 70% in 2001. The epidemic spread of drug misuse has led to increased demands on the national health system. The number of drug misusing clients in residential/inpatient treatment has increased more than six times for the period 1990-1999. In this context a major priority for the national drug policy was development of a national programme for prevention, treatment and rehabilitation of drug dependence (2001 – 2005) and a national strategy for combating drugs (2003 – 2008). A concrete action plan was also required/developed. With regard to rehabilitation a set of Regulations were issued by the Ministry of Health in 2000 setting rules for establishment and conduct of rehabilitation programmes.

BACKGROUND After 1995 there were explicit needs of treatment in therapeutic communities. Every year more than 200 Bulgarian youth with drug misuse problems go to therapeutic communities established by the church in Italy and Spain. Inevitably the need of establishment of therapeutic communities in Bulgaria was becoming more and more obvious to both the professional community and the society of mothers of drug dependent individuals, the latter being united in non-governmental parents\' organizations.

During 1994-1999 a training project for Eastern Europe was realized. It provided a strong theoretical base as well as practical training in the TC model (International European Drug Abuse Treatment Training Project). Professor David Deitch, University of California, San Diego and his team led the training. Associazione "Casa Familglia Rosetta", Italy, organized it. More than 30 professionals took part in the training project – psychologists, social workers and psychiatrists – among them Peter Vassilev, Igor Koutsenok, Rumen Sedefov, Tzveta Raicheva, George Vassilev, Alexander Angelov. Later on these people will play key role for the development of future projects. Philip Lazarov, PhD who was at that time the director of the National Centre of Drug Addiction, made the participation of Bulgaria in this project possible. In this way a transfer of knowledge and skills for work in TC was realized.

In 1998 Philip Lazarov, PhD opened a six-month rehabilitation programme for drug dependent people in a psychiatric hospital. Five clients participated in the programme. It had some of the basic programme elements of the TC. For example, behavioural instruments were implemented; morning meetings and groups for self-exploration were held. Unfortunately this programme did not develop, the reason being lack of independent building and the constant contact with new drug users referred to the hospital. Later the same year because of structural changes at the National Centre of Drug Addiction the further existence of the programme was no longer possible and it was finally closed.

In 2000 a self-help residential group occurred. Parents of drug dependent individuals organized it. However, the group lacked therapeutic process, it was unattended by any staff or personnel. Regrettably, a case of physical abuse occurred there and a young man has died. In fact the group exists outside the professional/ethical standards and legal regulations in the country. This accident has added to shaping negative public attitudes towards this type of treatment. In 2000 in the country there were about 40 non-governmental organizations aimed at opening TC programmes. However, the lack of adequately trained professionals, lack of financial support, and the presently ongoing mental-health reform in the country has made this objective extremely difficult at that time. Although there were explicit needs and some prerequisites have already been established, the development of TC movement in Bulgaria was still impossible to happen.


In June 2001 Peter Vassilev, MD established TC Phoenix. He is a psychiatrist, psychoanalytical therapist; until this moment he has 10-year experience as a chief of drug dependence treatment ward at Military Medical Academy. Two years before starting the TC he has formed a team and trained it into programme elements of TC. During the period of preparation a grant has been won from United Dutch Foundations, which provided financial resources for renovating the former school in village of Brakjovtzi near Sofia. Two work visits were realized: in TC Aebi Hus, Bern, Switzerland and Sato Picardie, France; collaboration has been set up with Soroptimist, the municipality and Ministry of Health. The non-governmental organization, which realizes TC Phoenix, is "Institute for Ecology of Cognition".

In June 2001 TC Phoenix has its first four residents; in September there were eight residents; since March 2002 the TC has been working with its full capacity – a caseload of 30 residents. Step by step it was thus possible to develop the hierarchy, expectations, values and culture of the TC.

In 2002 TC Phoenix became a member of the Association of Therapeutic Communities (ATC) and was involved in the Royal College of Psychiatrists\' research project Community of Communities, A Quality Network of Therapeutic Communities. In 2003 Phoenix became a full member of the European Federation of Therapeutic Communities (EFTC). In May 2003 close collaboration was set up with Ley Community, Oxford in terms of training, exchange of residents and trainingships of clinical staff. Until the current moment 8 people from TC Phoenix, Bulgaria (6 staff members and 3 residents) have undergone practical training at the Ley Community. In September 2003 Mr. Anthony Slater, President of EFTC made a work visit to TC Phoenix. The same year a contact was established with TC Phoenix Haga, Norway, KETHEA, Greece and Trempoline, Belgium. This provided opportunities for improved continuous staff training and integration of European experience/the experience of European colleagues. A significant role in this sense had the one-month training that two people from Phoenix, Bulgaria (one staff member and one resident) went through at Phoenix, Haga.

In the beginning of 2003 Phoenix started its programme for resocialisation, its first director being Teodora Groshkova, clinical psychologist, at that time involved in the MSc distance learning programme Drugs and Alcohol: Policy and Intervention at University of London. For 2003/2004 Department financially supported the programme for resocialisation for International Development (DFID), Embassy of UK. The programme of TC Phoenix is highly structured: with rigid rules, hierarchy, and daily regimen balancing between work, therapy and activities; intensive: each day two therapeutic groups are being conducted plus a morning and a community/evening meeting. The length of the programme is 14 months, divided into four stages: Orientation, Primary treatment, Re-entry and Resocialisation. The primary, distinct, yet overlapping categories of activity at Phoenix are as follows: behaviour shaping, emotional growth, intellectual development, vocational skills training and medical management. The main therapeutic groups are: encounter, static groups, groups for personal development, goal groups, phase groups, and commonality groups.

Developing an individual treatment plan together with each community member is a key element in retaining individuality, whilst sharing the common purpose of the large group. The plan includes resident\'s main problem areas, treatment goals and an outline as to how problems will be resolved within the therapeutic milieu. At programme entry each resident is allocated a referent. The referent is a staff member who is completely engaged with the individual treatment plan of the resident. The resident and his referent work together on developing the treatment plan, following it whilst the resident remains in the treatment programme as well as preparing him or her for entering the programme for continuing care - the resocialisation. The referent also serves as a main source of support for the resident when it comes for developing the cognitive formulation as well as coping with difficulties in the therapeutic process. The process of change unfolds when the negative behaviours is blocked through a process of self-exploration. Self-awareness is built through developing of case conceptualization, which links personality with drug use. A final element in the process of change is overcoming of behavioural deficit, determined by suppressed fears from childhood. Expanding of behavioural repertoire is reached through rehearsal of new roles and behavioural tasks in the structure. Until 2005 more than 150 residents have been admitted in the programme/completed the programme. Six of our ex-residents are now acting as staff members in the TC. The results from the two-year follow-up show 67 % positive treatment outcomes. The experience of our work so far has been presented in number of scientific publications ^(,2, 3).^ A good sign for the future development of TC movement in Bulgaria is the financial support that TC Phoenix received from the Ministry of Work and Social Policy in October 2004.

LOOK FORWARD The fourth module of Autumn University of Drug Addiction, led by Igor Koutsenok, PhD, University of California, San Diego, is of great value for the continuous education of professionals in Bulgaria. Highly appreciated and useful are also the training modules and clinical supervision provided to Phoenix by Ley Community, UK and Trempoline, Belgium. A number of training events have been provided in Bulgaria from KETHEA, Greece with the help of National Center on Drug Addiction taking care of the organization of the events. A very good sigh for the further development of TC movement in Bulgaria is the start-up of the second TC in Veliko Tarnovo under the leadership of Nadj Yalamova. A discussion was initiated within the Bulgarian Psychiatric Association. The discussion process is aimed at developing a set of standards for good practice in the field of TC in Bulgaria. References:

^1.^ Annual report of the National Council of Narcotic Substances and Drug Addictions in Bulgaria, 2001 ^2.^ National anti-drug strategy of the Republic of Bulgaria (2003-2008) ^3.^ Vassilev, P., 2003. Experience and first results from TC Phoenix, Bulgaria. Scientific paper presented at the IX E.F.T.C European Conference on Rehabilitation and Drug Policy. ^4.^ Vassilev, P and Groshkova, T., 2004. Application of cognitive-behavioural psychotherapy in the model of therapeutic community, Bulgarian Psychiatric Practice: 2 18-21. ^5.^ Vassilev, P., 2004. Application of cognitive-behavioural psychotherapy in a TC for drug dependent individuals. Practice and results. Scientific paper presented at the XIII Annual conference of the Bulgarian Psychiatric Association

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