TCIE Therapeutic Communities in Greece

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Therapeutic Communities in Europe

The therapeutic communities in Greece

Charalampos Poulopoulos, PhD

Director of KETHEA

KETHEA, Sorvolou 24

Mets 116 36, Greece

Tel. 0030-210-9241 993-6

Fax. 0030-210-9241 986

The social and policy context

Greek therapeutic communities originate from the democratic therapeutic communities in England for people with mental health problems and from the hierarchical therapeutic communities in America for drug addicts. Therapeutic communities in Greece developed mainly for drug addicts and consequently the term implies the drug addiction treatment programmes rather than the mental health intervention programmes, although some efforts were also present in this area to develop therapeutic communities.

In Europe and in USA the development of therapeutic communities contributed to the explosion of social reforms that characterized the 1950\'s. The new radical ideas of reforming education and mental health institutions found many supporters especially amongst the novices in the field. On the other hand, traditional psychiatry and education were rather critical of the values of these new methods and approaches. The social change movement was expressed in the \'60\'s with the students\' movement in Paris, in the American riots against the Vietnam War and in the adoption of a new free life style.

In the context of this social climate the primary goals of new mental health professionals were to support human rights and to improve living conditions in psychiatric units, prisons, educational and social care agencies. These goals were interlinked with the antiwar, antiracism, feminism and ecological social movements.

In the field of drug addictions at that time, the therapeutic community was the new concept that was suggested against the status quo in America along the lines that the European therapeutic community for mental health professionals was developed.

The 1960\'s were also characterized by the expanded use of drugs mainly from young people who used them as a way of avoiding personal and social problems, for recreational purposes and for changing their mood. The use of cannabis, LSD, amphetamines and opiates was more also pervasive than in the past and by the early 1970\'s heroin also became part of the youth subculture.

At that time the rapid developments in the field of social psychiatry were connected with the efforts to democratize psychiatric units and emphasize social rehabilitation. In France and in Italy, the new philosophical trends were linked with the political movements for social and human rights and became the basis for the development of the anti-psychiatric and anti-institutionalization movement (Roth & Kroll, 1986).

The economic crisis which became apparent in the 1970\'s, the increase in the use of "hard drugs" and in mental health problems in the general population were followed by the first signs of ambivalence over the success of the therapeutic communities and the social psychiatric movement. According to Clark (1977) some came to believe that the efforts for «open doors» in psychiatric hospitals were a touching, romantic but not effective approach.

The interest in the therapeutic community model began to decrease by the time of the \'80\'s. At that time they were seen more as a method that run the risk of institutionalizing drug users rather than helping them to re-integrate and they were identified in this respect with the traditional psychiatric hospitals. The trend of the era was to establish smaller independent units in city centers. The therapeutic community methods were doubted and criticized for serving more a conforming mechanism rather than being critical to the status quo.

When some European countries started to question the significance of the therapeutic community, Greece made the first efforts to develop therapeutic communities. The anachronism and the maintenance of old institutional practices in the mental health field were directly related with the general backwardness in the development of social policy and social care in post-war Greece. This lateness in developing social services also characterized the phenomenon of drug abuse trends. Lack of policy in the social welfare state was the result of a dynamic interaction between historical, social, political, economic and cultural phenomena of the time.

The later developments on the psychosocial reforms in Greece should be attributed to social and political circumstances. These hindered the development of a socially sensitive policy on one hand and affected on the other the attitudes that mental health professionals had in relation to mental illness and drug addiction.

The four years of civil war following World War II and the seven years of dictatorship (1967-1974) contributed to the development of suspicion and mistrust against any effort that strived to change the existing status. For decades, human and political rights were suppressed and therefore the social movements and innovative ideas that developed at that time were harder to implement than in the rest of Europe.

In general, social care funds were minimal in relation to other European Countries. The Greek family had to care for the needs of its individual members. The traditional expanded family was still dominant and it was characterized by a strong degree of cohesiveness and solidarity amongst its members at all levels of economic, social and emotional life.

In Greece there were no special services for drug users and the general public used to see them as "rotten". The lack of social services left no alternative but marginalization, imprisonment or abandonment in a psychiatric unit. This phenomenon of abandonment was also present in the way that people with chronic mental health problems were treated. It is worth noting that this attitude contradicts the high degree of family support and mutual protection that characterized the times. Social and personal attitudes towards mental health and drug abuse contributed to this contradiction as much as the unique cultural features of Greek society at that time.

Drug addiction and mental health had negative moral connotations and they were perceived as contaminating diseases genetically inherited or family induced. Therefore, they stigmatized both the person and his/her family of origin. In particular, drug abuse was considered to be the result of family \'psychopathology\'. As such it was then proof of the family\'s \'failure\'. On one hand, the \'identity\' of the person was strongly affected and connected to the family of origin and on the other his or her characteristics influenced the way in which society perceived his or her family. The family of the drug user, as the first socializing agency, was \'forced\' to abandon its member in an effort to protect itself and survive socially. Drug abusers usually ended up in a prison or a psychiatric hospital isolated from the rest of society and thus \'saving\' the family from social stigma.

Another factor that contributed to the maintenance of institutionally provided care is the role and the attitude of mental health professionals. Greek psychiatry was strongly in favor of biology and neurology (Bleu, 1999). It is worth considering that academic schools of sociology and psychology developed in Greece after 1982. Thus the main practice and attitude did not favor psychotherapeutic methods and alternative forms of treatment and often disregarded the need for psychosocial rehabilitation. In this context the psychiatric unit was the basic method for coping with mental health problems. Besides that, until the end of the \'70\'s, use of illegal drugs in Greece seemed to be restricted to specific groups in large urban areas and mainly concerned artists, workers from Minor Asia (who smoked cannabis mainly within the east traditional culture) and night workers (Greek Reitox Focal Point, 1996).

The Greek State intervened only by making some occasional arrests and the public remained distant and aloof to the phenomenon as alien to Greek society. Drug use did not raise public concern at that time. As a result of this the only relevant Greek laws were developed due to external pressure and obligation that the Greek State had towards the international community.

However, by the end of the 1970\'s a steady increase in drug use started to appear and this is also confirmed by the data collected from the police and the courts\' records of the time (Greek Reitox Focal Point, 1996). The trends of expanding (and forms of) drug use brought the problem to the surface. Heroin began to be portrayed in the press as a \'hazardous\' drug with catastrophic consequences for society at large.

These changes were followed by an attitude shift of Greek society at large in relation to drug addiction. The press contributed to the development of these new attitudes when the first officially declared drug deaths appeared in the 1980\'s by raising significantly public concern and interest. However, exaggerations and panic in relation to the dimensions of the phenomenon were not avoided. These were due to the lack of statistical data to confirm the number of drug addicts in the general population and in treatment settings. This lack of information was equally true not only for incidents, prevalence and treatment admissions but also for prevention and de-criminalization efforts.

However, drug addiction was not considered a major political issue. Nevertheless political promises were made in the absence of proper government planning and led to the first official initiative on demand reduction on behalf of the socialist party government (Tsili, 1995). This initiative coincides with the beginnings of debates around the National Health System and the first efforts of psychiatric reform in Greece.

The therapeutic communities for people with mental health problems

The development and implementation of social psychiatric programmes appeared in the early \'80\'s together with the debate on psychiatric reform. The Open Psychotherapeutic Center founded in 1980, was the first effort for implementing the components of the therapeutic community for people with mental health problems and for training mental health professionals (Kennard, 1998). This center was established in the city center and out of psychiatric hospitals and it was influenced by the psychoanalytic therapeutic communities method developed in England. Other efforts to work in line with the therapeutic community components were also found in the psychiatric inpatient unit of the University General Hospital of Ioannina in 1983 and in the psychiatric hospital in Tripoli in the early 1990\'s (Kennard, 1999).

Another significant effort to implement the therapeutic community values for people with mental health problems was made in 1984 in the Psychiatric Hospital of Thessalonica, in North Greece. A unit was founded there for the social integration of people with mental health problems. This unit was influenced by Franco Basaglia\'s Democratic Psychiatric Movement in Italy and aimed to de-institutionalize people (who lived in psychiatric units for several years) and assist them get back in to society. The goal of this model was also to influence and democratize the whole functioning of the psychiatric hospital by being a model of intervention. The components of this model include but are not limited to the following. Staff and resident community meetings for problem solving and decision making; the development of social competencies through work on action, crisis reduction through staff client interactions, all aimed at reducing the dichotomy and distance between treatment team and members. However, by the end of the 1980\'s the executive board of the psychiatric hospital contributed to the crisis of this re-entry unit. This occurred even though the unit assisted enormously in the rehabilitation of people with mental health problems who were institutionalized in one of the worst psychiatric hospitals in Greece located on the island of Leros. Despite this crisis, staff working in other psychiatric units in Athens and in Petra Olympus followed its example (Bairaktaris, 1994).

Therapeutic community "Ithaca" for people with drug addiction problems

In 1983 when Greece was already for two years a member of the European Union, the first therapeutic community for people with drug addiction problems "Ithaca" was founded on the basis of the reforms that eventually started to appear in the structure of the Greek State and in social life as well. This model gave emphasis from the very beginning to the social integration of people with drug addiction problems. The decision to choose a psychosocial model of intervention rather than a medically oriented model was not independent of the social reforms of that era in general and of the political climate affecting Greek society at that time in particular. "Ithaca" was characterized by the principles of community living, collective work, social and personal change. "Ithaca" supported and promoted the right to public treatment and for the first time in Greece suggested that the whole of society should be involved in the fight against drug abuse and not just experts in the field. The therapeutic community encourages drug users and their families to expose in public their problem. This is regarded as a means for eliminating social prejudice and helping drug users to come out of the secrecy and life on the margin of society. Staff and community members shared the idea that the therapeutic community was an alternative way of living for staff as much as for the treatment community members. Drug use was regarded mainly as a social problem, strongly associated with the social structure and dysfunction in social and family life and in interpersonal relationships. They also agreed that addiction was not a \'disease\', in the way mainstream psychiatry and medicine defined the term, but rather a psychosocial problem.

In the beginning, the number of staff was small and this helped in the development of close friendly relationships among them, and in great enthusiasm in the creation of a family type of culture. In 1983-1986 a strong bond was formed between the Greek and the Dutch therapeutic communities for drug addicts. Even though these were affected by Maxwell Jones\' model they were eventually transformed to hierarchical semi-open system concept-based therapeutic communities due to the influences they received from the American model (Kooyman, 1992). The paradox of the time was that although ideology and beliefs of the era were aiming at social change and in promoting democracy, the model itself was hierarchical and structured. This is probably the most significant paradox of therapeutic communities for drug addicts. Kennard (1983) has described these differences and similarities in the therapeutic communities, analyzing the influences of each model.

Also, the therapeutic community for drug abusers "Ithaca" and the other therapeutic communities for people with mental health problems were interacting with each other. This helped professionals in both types of communities to share experiences and ideas and to develop an open dialogue of the different models\' pros and cons.

From a therapeutic community to an organization of TC\'s.

In 1987, the therapeutic community "Ithaca" together with other units (counseling centers, detoxification centers and re-entry houses) were evolved into a new organization; the Therapy Center for Dependent Individuals (KETHEA). From there onwards therapeutic communities in Greece developed to cover the increasing needs of the drug using population and the demands expressed by parents, siblings and the general public. Up to a certain time, KETHEA therapeutic programmes were dominant in the areas of treatment, prevention and training. Within KETHEA every therapeutic community developed its own unique features but in response to the needs of drug users. KETHEA developed new models of intervention while maintaining T.C. values and methods. For example "Ithaca" (1983) the first therapeutic community began to give emphasis on developing vocational training workshops (farming, printing, pottery and carpentry) and the same did the therapeutic community "Exodos" (1989) since both are rural residential communities. Also "Strofi" (1988) the first open care therapeutic community in Greece for adolescent drug users, focused more on education, and later established its own transitional school. Further, "Paremvasis" (1989) a residential therapeutic community in the suburbs of Athens influenced by the ecological movement introduced a new way of dealing with the drug abuse problem by combining personal recovery with social and ecological interventions in the local community. The emphasis was laid on community development through the co-operation between the therapeutic community and the local community aiming to give effective answers to local problems. This development trend continued. "Diavassi" (1990) an \'open-care\' community for adult drug addicts, located in an urban underprivileged area, emphasized the need for culturally oriented interventions. On the other hand, "Nostos" (1993) the youngest residential community, located on an island, put emphasis on the Greek nautical tradition, vocational guidance and rehabilitation.

Each therapeutic community is the core and the main phase of a complete multiphase programme that covers a geographical region and aims to fully reintegrate former drug addicts into society. Each programme consists of an induction center, a therapeutic community and a rehabilitation center and develops its own activities in research, training and prevention.

The therapeutic communities and the whole treatment programme also focuses on the role of the family. The involvement of the family starts from the first phase of the therapeutic programme, the Induction Center, continues through out the therapeutic community and it is completed at the Re-entry phase. Parents Associations were also formed to support the families of the drug addicts in the process of recovery and the therapeutic programmes.

During the period of 1987-1993 the development of KETHEA\'s therapeutic communities attracted the attention of the media and received the support of the Greek Government and other agents. Nevertheless, towards the end of this period and even though the organization was rather comprehensive in terms of number of services offered, the social and governmental pressure was to offer more diverse services at a lower cost. At the same time (early \'90\'s) the harm reduction approach increased in popularity in Greece. The therapeutic communities were no longer regarded as sufficient in number and approach to meet the growing needs of heroin users. The development of methadone maintenance programmes was rapid and these programmes were portrayed in the media as the \'solution\' to the drug using problem. National policies against drug addition are usually linked with the pressures exercised by various agents in the field and clients themselves. Mass Media also played an important role, and still does, in determining and implementing national policy.

The numerous pressures from both, external and internal environments led to changes in the therapeutic community activity. Over many years a great deal of knowledge was obtained by T.C\'s on how to implement effective change. There were two critical aspects for this change: the first was the new research data coming from outside that exposed the internal operations to relevant new practices. The second was to create a synthesis of the relevant external and internal elements and explore the necessary ways to sustain the synthesis.

In mid 90\'s the need for evaluating the effectiveness of treatment programmes became more obvious. As a result of this KETHEA started to place emphasis on the collection of data and the training of professionals. It also used elements from both therapeutic communities\' models in order to develop new programmes adapted to the emerging realities. The aim was to increase the number as well as the size of therapeutic interventions and to improve the services each programme offered. Each programme was given the opportunity to organize its own therapeutic intervention, relevant to geographic location, to the unique relationships with the local community, to the available human resources and most importantly to the special needs of the people to whom it was addressed.

In spite of financial and other shortages a critical dimension of continuous qualitative improvement studies as well as training and education in new methods were introduced. The organization also started to examine and analyze its services and the population to whom they were not attractive. As a result of these studies, KETHEA while yet implementing the values of therapeutic communities began to provide new services in order to attract drug using populations that had not approached its facilities previously.

The modified therapeutic communities

KETHEA created new innovative programmes and continued to promote the idea of drug-free treatment trying to be responsive to the different needs of different groups of drug addicts. However, during that time methadone programmes expanded rapidly and attracted greater financial and other public and government support. On the other hand, therapeutic communities were represented in the press as old-fashioned programmes with little effectiveness.

Nevertheless the organization continued to grow. Out of this, "Exelixis" an outreach programme for drug addicts who are not motivated to enter treatment in a traditional therapeutic community was developed. The programme applies the therapeutic community values in a new model which provides in a resource reach and safe environment drug addicts the chance to visit multiple facilities. The programme also runs a coffee shop for drug addicts, the "Off Club". "Off" implies staying away of drug use even for an hour and \'club\' means participation in an open setting. The idea of the \'club\' has its roots on the Northfield Hospital and in the work done by Harold Bridger and others (Harrison, 2000). This Multiple Intervention Center also developed street-work and motivational interviewing programmes for addicts in prison.

In addition, an Evening Therapeutic Community for working addicts was developed to cover the needs of the drug using population with a rather stable family, social and working life. Along similar lines, a Secondary Prevention Programme for adolescents named "Plefsi" was constructed to cover the needs of young people who still go to school but are somehow involved with using drugs. In addition, KETHEA paid a lot of attention to developing primary prevention programmes for interventions in primary, secondary and tertiary education. These programmes run in collaboration with the Ministry of Education and promote social skills and health education at schools applying the values of the therapeutic communities.

The Treatment Programme "Ariadni" was also developed on the island of Crete to include a non-residential therapeutic community, a family programme, a counseling center and a re-entry unit. The programme now expands its activities in prison and in developing an adolescent non-residential therapeutic community. During this same period KETHEA developed research and training activities.

All these changes became the starting point for organization improvement and evolution. The organization offered improved and broader services based on staff participation in decision making and continuous feedback from external and internal evaluation processes. These evaluation processes were the result of continuous qualitative improvement activities principally done with peer review with objective criteria, as well as the recruitment of international experts to independently review all program activities.

The further developments include a treatment programme for members from ethnic minority groups, called "Mosaic" and located in Athens and specialized programmes for addicted mothers where they can also bring their children, located in Thessaloniki. Services also include an emergency helpline for drug users and their families. Further for the first time in Greece, KETHEA developed a therapeutic community in a Women\'s Prison in Athens called "In Action". Women in that prison have the opportunity to follow the therapeutic community programme in a drug-free wing. After release they can go to one of two, support centers for discharged prisoners, located in Athens and in Thessaloniki.

Furthermore the organization tried to develop services in diverse geographic areas in Greece where drug addicts had no access to treatment or even counseling facilities. One of the most recent attempts was the development of a programme for Alcohol users and Gamblers, called "Alpha". This is the one of only three relevant programmes in Greece. There is one alcohol detox unit in the Psychiatric Hospital in Athens and a programme for alcoholics and gamblers in the psychiatric hospital in Thessaloniki.

The organization had to adapt to the new external conditions and the ever-changing needs of drug users through internal reorganization and establishment of new services. The social and the political climate also changed towards the organization as the substitution programmes found their place and role in Greek society. Treatment staff and all concerned parties came to realize that not all drug addicts are the same and that there is a need for adopting different intervention models for different population groups, even though drug-free treatment continued to be applied in the design and implementation of new services.


Bairaktaris, K. (1994). Mental Health and Social Intervention: experiences, systems, policies. Alternative Publications, Athens.

Blue, E. (1999) The creation of Greek Psychiatry, Exantas, Athens

Clark, D.H. (1977) The therapeutic community. British Journal Psychiatry, Vol. 131, pp. 553-564.

Greek Reitox Focal Point (1996). First Report of the Greek Reitox Focal Point in 1996, University Mental Health Research Institute, Athens

Harrison, T. (2000). Bion, Rickman, Foulkes and the Northfield Experiments: Advancing on a Different Front. Therapeutic Communities 5. Jessica Kingsley Publishers, London.

Kennard D. (1999) Therapeutic Communities in Europe: one modality with different models, In Campling, D. & Haigh, R., Therapeutic Communities: Past, Present and future, Jessica Kingsley Publishers, London

Kennard D. (1983). An Introduction to Therapeutic Communities, Routledge & Kegan Paul, London

Kooyman, M. (1992) The therapeutic community for addicts; intimacy, parent involvement and treatment outcome, Erasmus University, Rotterdam

Roth, Μ. & Kroll, J. (1986) The reality of mental illness, Cambridge Press, New York

Tsili, S.(1995) Drug addiction as an ideological construction: The case of Greece, National Centre for Social Sciences, Athens

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