TCIE Therapeutic model of TC “Phoenix” for drug dependent individuals

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ii) Therapeutic model of TC "Phoenix" for drug dependent individuals

Therapeutic approach

1. Community as method. The therapeutic approach consists of: The group and its rules, culture and expectations Educational process – built up system stimulating the positive behavior and giving negative response to the unacceptable behavior of the residents. It provides goal and meaning for moving up in the hierarchy in the programme. Each move toward upper position brings more responsibilities and opportunities for learning.

2. Application of Cognitive-behavioral therapy. Residents present cognitive formulation of the connection between personality and drugs as a part of their treatment

3. Application of psychoanalytic therapy. Residents develop their personal growth and skills for coping with unconscious fears in the group

The messages for change are inherent to every element from the social and the psychological organization of the community. The rules, the clear norms, and the hierarchical organization increase the culture of change in the programme. The different social roles and interpersonal relationships facilitate the therapeutic process. To achieve the final goal, defined as behavioural modification and personal growth, the residents must fully immerse themselves in the community life. Taking part in all of the activities from the daily regimen develops the learned skills and integrates the changes in experiences and image of self and world within a new lifestyle. The whole change unfolds as a process of development, reflected in the programme stages. The skills acquired at each stage enable the learning at the next one, and thus the change reflects the move towards the aim of rehabilitation.

Programme stages 1. Orientation (1 month) A period of adaptation to the programme and building motivation for personal change. The focus is primarily on the behaviours, self-control and the development of skills for managing everyday task in community life.

2. Primary treatment (6 months) Developing responsibility through participating in all activities and roles in the programme Gaining understanding and awareness of the dysfunctional mechanism and challenging one\'s own personal limits Developing skills for relapse prevention

3. Re-entry (1-4months) This stage of the residential programme is oriented towards testing skills learned in the therapeutic community in the real life. Residents are actively involved in sessions for relapse prevention to increase their understanding of the relapse process and learn strategies for dealing with high-risk situations.

4. Re-socialization (6 months) Its iam is to prepare dependent individuals for life of full value and professional realization. The first step is detail evaluation of family and personal resources, the professional skills and experience and results achieved in the programme. The next step is formulating an individual plan including professional develop. This plan integrates needs, skills and abilities of the individual and specifies the aims of every phase of the re-socialization programme. The following activities are included: social reintegration through training professional skills, mediation for finding jobs and practices, building social net of supporting elements, training groups for parents and family therapy, individual and group counseling, club activities.

iii) External context: area specific legislation, regulation and policy


1. Law for control of narcotic drugs and precursors This law provides the legal grounds for existance of therapeutic communities alongside with other tratment centres.

2. Regulation N 4 from 16/03/99 issued by the Ministry of Work and Social Policy Provides guidelines for delivering social services

"...Institutions providing social services can be public, municipal, private or mixed..."

"...Types of institutions for social services delivery:

  • social services provided within the usual home setting: day care houses, bureaus for social services, centres for social rehabilitation and integration of people in unequal social position
  • social services provided out of the usual home setting: houses for children or adults with mental disorders, children\'s villages, old peoples houses, shelters..."

"...The National Agency for Social Support approves minimal norms as to how institutions providing social services should operate..."

3. Regulations No 30 from 20 December 2000 issued by the Ministry of Health Provides rules for rehabilitation of drug dependent individuals

"...Art.7. (1) In order to satrt rehabilitation programme one needs to present at the Ministry of Health: licence for services delivery as a health centre, description of the programme, staff members and procedures, routes for supervision (2) rehabilitaiton programmes can be realised in houses for medico-social care, health inpatient centres for psychiatric care and centres for social rehabilitation and integration..."

"...Art.9. (1) Individuals who have been dependent on drugs participate in the delivery of rehabilitation programmes at the following conditions fulfilled:

  • they have not abused drugs during the last 2 years\'
  • they have successfully completed rehabilitation programme
  • they have successfully completed one-year training programme, delivered in accordance to a plan developed by the National centre on drug addiction and approved by the Minister of Health..."

4. National anti-drug strategy of Republic of Bulgaria (2003-08) together with an Action Plan.

"...Section 5: DEMAND REDUCTION STRATEGIC TASKS Based on the assessment of drug distribution within the country we recognise the threat of a wider variety of patterns of drug abuse particularly among young Bulgarians, along with the need to enhance our response. Following the endorsement of this strategy by the Government, work will immediately commence on the development of an action plan that will establish the tasks and activities required to deliver the strategic demand reduction objectives. We have highlighted (Section 2) the need to ensure that the national strategy is comprehensive and we have also identified the need for the strategic objectives to build upon and link with a number of other strategies in the field of health and social policy, including: the National AIDS Programme; National Health Reform; National Insurance System (which will contribute to funding of treatment); integration of the National Programme for Treatment and Prevention; compliance with EMCDDA/Focal Point indicators. Cross-ministry working groups will further develop the strategic approach to demand reduction set out here; they will be assisted by partners operating under a number of assistance programmes (Twinning, EMCDDA, World Bank).

Task 1. PREVENT THE INCREASE OF THE NUMBER OF NEW DRUG ADDICTS Task 2. REDUCE ABUSE OF ILLEGAL DRUGS Task 3. REDUCE ABUSE OF NARCOTIC SUBSTANCES USED FOR MEDICAL AND VETERINARY PURPOSES Task 4. OVERCOME SOCIAL ISOLATION AND SOCIAL DEPRIVATION OF HIGH-RISK GROUPS Task 5. LIMIT THE SPREAD AMONG DRUG ABUSERS OF DISEASES WHICH HAVE AN IMPACT ON SOCIETY: BLOOD-TRANSMITTED INFECTIONS (HIV/AIDS, HEPATITIS B, C), TUBERCULOSIS, SEXUALLY TRANSMITTED DISEASES, ETC. Task 6. ENCOURAGE EMPLOYMENT OF DRUG ABUSERS WITH THE MEDIATION OF EMPLOYMENT BUREAUS Task 7. DEVELOP A SYSTEM OF EFFICIENT AND VARIED TREATMENT PROGRAMMES Task 8. PROVIDE EASIER ACCESS TO EFFICIENT TREATMENT PROGRAMMES Task 9. DEVELOP AND INTRODUCE BEST PRACTICES FOR PREVENTION, TREATMENT, REHABILITATION AND REDUCTION OF HEALTH HAZARDS Task 10. DEVELOP AND IMPLEMENT PROGRAMMES FOR SOCIAL REHABILITATION AND REINTEGRATION Task 11. ENHANCE INTERNATIONAL CO-OPERATION, SCIENTIFIC AND RESEARCH ACTIVITIES TO THE BENEFIT OF THE NATIONAL ANTI-DRUGS STRATEGY Task 12. MONITORING AND ASSESSMENT OF RESULTS IN THE AREA OF DEMAND REDUCTION

5. National programme "Independent again" issued by the Ministry of Work and Social Policy

iv) Service context

  1. Types of client

Quotation from the National anti-drug strategy; refers to the profile of drug addicted people in the country, not only those in TC: "...Heroin presents the most serious threat to public health; over the past 5-6 years it accounted for over 90% of the cases when drug abusers sought treatment by the specialised units in Sofia. In most of the cases (over 75% of abusers during the same period) heroin is taken intravenously. The average age of those who sought treatment due to abuse of heroin in the period 1995-2001 has dropped from 24.7 down to 22.5

There is a very dangerous tendency of reduction of the age of first-time consumption. The average age of first-time heroin consumers is going down from 21.4 to 18.8 over the past 7 years.

Being confronted with drugs at an age when one\'s personality is still unstable results in quick and grave dependency and early social alienation as well as in risk syringe and sexual behaviour. Therefore about 1/3 of the treated heroin addicts in the past few years are without secondary education and in 2001 about 90% of them have not had a permanent job over the past year. It is very worrying that in 2001 the percentage of the Hepatitis C infected people among the treated intravenous heroin addicts went beyond 70%. The increased percentage of Hepatitis C carriers is an indication of the real public and health risk of an outbreak of AIDS epidemic; it is also an indication of the progressive somatic damage and the necessity of complex health care for those people..."

This profile is representative for the profile of clients seeking help and coming for treatment in TC Phoenix.

  1. Typical routes of admission

A significant part of the clients are being referred by hospitals, psychiatric departments, detoxification units, municipality information centers on the problems of addictions operating in all major cities in Bulgaria, psychiatrists and psychologists private practices. Some of the clients are self-referred. Phoenix has two Admission centres – first is in Sofia in the premises of a hospital and the second is in the city of Bourgas – the centre is not in hospital setting. In these centres information is being provided to clients and Motivational Enhancement Therapy is being done.

  1. Service agencies and the place of TC within them

Drug dependence treatment is provided in one specialised state hospital, which ahs 20 beds for drug addicts adn 20 places for alchohol problems. Detoxification is done in two toxicology units of state hospitals in the country, single cases go for detoxification in psychiatric units (11 state psychiatric hospitals and 4 psychiatric cliniques to University hospitals).

Psychosocial rehabilitation TC (residential)

  • licensed programme - therapeutic community Phoenix (function since 2001); 30 residential places
  • anotehr community was licensed 2003 in teh city of Veliko Tarnovo with 14 residetial places, funded by Open society partly and partly self-funded; currently closed due to lack of residents
  • Spanish church (evangelist) had started three programmes – TC religion oriented, non-professional, not-licensed according bulgarian law; average 20 places in each programme.

Outpatient day care programmes - there are three state day programmes – 2 in Sofia and 1 in city of Varna.

Substitution One state programme – methadone substitution (Sofia) offering 300 places Two private programmes – methadone substitution Two municipality programmes – methadone substitution (in city of Varna and Plovdiv)

Total: 770 places in methadone substitution.

  1. sources of funding:

Self-funding, funding through projects, support from the Ministry of Work and Social Policy. For example in 2004 the Ministry financed the renovation of the building of the TC Phoenix for 10 000 euro. The biggest problem is that routes for financing TC in Bulgaria is totally unresolved. The government does not finance rehabilitation in TC in Bulgaria.

v) programmes in practice: TC Phoenix: 1. Staff background and qualifications Program Director is Peter Vassilev, MD. He is a psychiatrist with over 10-year experience as a director of the Addictions Department at Military Medical Academy. He s a cognitive-behavioral psychotherapist and is a chairman of the Bulgarian Association or Cognitive-Behavioral Psychotherapy and a member of Member of Editorial Advisory Board of International journal for the helping professions "Behavioural and Cognitive Psychotherapy" with editor Prof. Paul Salkovskis. He is a psychoanalytic therapist as well and a supervisor in psychoanalytic therapy at West Deutche Academie. Completed a four year UNDCP project "International Drug Abuse treatment Training for Eastern Europe", certified by University of San Diego. (the training included modules on TC). He has over 34 publications in the field of drug and alcohol addictions.

The remaining of the staff consists of one psychiatrist working at the Admission center, 7 psychologists (BSc and MSc in Clinical Psychology), two social workers, a psychiatrist nurse, and 4 ex-residents working as volunteers. Of them one psychologist, a social worker and an ex-resident are working in the Resocialisation programme. The remaining of the staff members are working in the TC. Two of the staff members are licensed cognitive-behavioural psychotherapists. All of the staff has undergone specialized training in therapeutic community model.

2. Typical day at TC Phoenix

 7^30^ – Getting up, personal hygiene
 8^00^ – Breakfast
 8^30^ – Morning meeting
 9^20^ – 10^00^ – Labour  

10^00^ – 10^15^ – Coffee break and team meetings 10^15^ – 11^45^ – Labour 11^45^ – 12^00^ – Team meetings 12^00^ – 12^30^ – Meeting of high level of hierarchy 12^30^ – 13^00^ – Lunch 13^00^– ^^13^30^– Cleaning 13^30^ – 14^00^ – Personal time 14^00^ – 15^30^ – Group 15^30^ – 16^00^ – Coffee break 16^00^ – 17^30^ – Group 17^30^ – 17^45^ – Personals time 17^45^ – 19^00^ – Sports 19^00^ – 19^30^ – Dinner 19^30^ – 20^00^ – Personal time 20^00^ – 20^30^ – TV-News broadcast 20^30^ – 22^00^ – Games "Something interesting" 22^00^ – 22^30^ – Evening community meeting 22^30^ – 23^00^ – Personal time for hygiene 23^00^ – Goodnight


3. Interventions The Therapeutic process in TC Phoenix integrates the following therapeutic elements:

1. Therapeutic-educational

Individual treatment plans Each resident meets his own referent right after entering the programme. The referent is a staff member who is completely engaged with the individual therapeutic project of the resident. This project includes basic problem areas in the resident\'s life and describes ways of their solving within the framework of the programme. The resident and his referent work together on identifying the main problems which are results of the addiction, achieving therapeutic aims, writing a cognitive formulation as well as coping with difficulties in the therapeutic process.

Encounter group The aim of this group is to increase the individual awareness of specific dysfunctional behaviors and attitudes. What is important are honesty and responsible care, which ensure the effect of the group process as well as the rehabilitation at whole.

Static group The aim of this group is working on currents problems which have practical significance for each resident as well as for the group as a whole. Most of the themes discussed in these groups concerns mistrust, personal responsibility, affiliations, shame, guilt, confusion, pain, anger, assault and unsolved feelings. Residents face their problems in order to process them mentally and emotionally using the group resources.

Group for personal growth The aim is identification the dysfunctional mechanisms that underlay drug using behaviours, decreasing use of defense mechanisms, develop alternative interpretation of emotional traumas, develop skills for emotional expression and understanding.

Relapse prevention group The aim of this group is gaining understanding of the relapse process and developing general and specific skills for managing high-risk situations. A key element is preparation of individualized emergency card for each resident.


Goal group The goal group is a key tool for realization of the individual treatment plans. Within these groups, led by referents, residents are guided to set concrete weekly aims. Attainment of these aims incrementally leads to achieving the goals outlined in the treatment plan.

Group by similarity Residents from each hierarchical level work separately on themes and iant for their particular status and responsibilities in the programme.

Seminar The aims of the seminar are training communication skills and intellectual development.

Vocational training The vocational skills training are realized by professionals from a leading center licensed by the National agency for vocational education and training.

2. Elements that strengthen the structure and affiliation to the therapeutic community

Morning meeting It serves for planning the daily activities. The morning meeting goes in a way, which creates positive attitude and expectation for a successful day and motivates residents to participate actively in the activities.

Evening meeting It goes every evening and it is a structured way for reporting tasks and summarizing the important things of the day.

System of privileges The system reflects levels of personal autonomy and status of the resident. They are gained through successful moving from one programme satge to the next. They confirm the autonomy and capability for self-regulation and at the same time they presenet new challenges.

System of behavioral sanctions Sanctions are used in hierarchical order depending on frequency and heaviness of the misbehavior.





vi) Current issues (strengths & weaknesses of TC)

Main areas of achievement

Renovation of the former school where the community is functioning. The large rooms were divided so that staff and residents have small rooms and personal space.

Some of the furniture was donated by United Dutch Organizations (grant), which made the conditions in the community more comfortable.

Development of strong affiliations in Bulgaria\*

Development of affiliations abroad\*

Good level of training of staff (Ley Community, Phoenix Haga, Norway)

Training of staff and residents at the Ley Community, UK (6 staff members and 3 residents) and at Phoenix Haga, Norway (one satff member and one resident). All of the satff members have taken part in trining provided by Prof. Igor Koutzenok, University of California, San Diego and Ruud Bruggeman, TC Trempoline.

Development of programmes in Admission centres, residential and non-residential Resocialisation centre.

Development of clear procedures in the TC, including individual treatment plans and the institution of the referent.

The integration of CBT elements within the milieu.

Membership in ACT and EFTC

Recent translation and utilization of TCU/CESI Pretreatment Survey of Clients for clients evaluation at intake and TCU/CEST Survey of Programme Clients for client evaluation of self and treatment

Regular sharing of experience and first results at national and international conferences and Bulgarian scientific journals


Areas for improvement

The living conditions still need to be improved; furniture: old, insufficient; no office equipment.

Stability of the project-financial stability and resources in terms of trained people.

Further development of systematic long-term training.

Development of the supervision.

Evaluation of the effectiveness of the programme.

\* Affiliations in Bulgaria

In June 2004 Phoenix programme director Peter Vassilev was the first who answered the appeal of Ministry of labour and social policy for join work in treating addictions in Bulgaria. Ministry of labour and social policy supported Phoenix programme among 5 other proposals for partnering. In October 2004 the state engaged in supporting therapeutic community for drug addictions in a meeting between minister of labour and social policy Hristina Hristova and young people in Phoenix programme, Brakjiovtzi village.

Ministry of labour and social policy and non-government organization Institute for ecology of cognition established a partnership and signed a contract for common activities in the area of rehabilitation and social integration of addicted individuals.

Institute for ecology of cognition and Phoenix programme have built partnerships with Ministry of health and respectively with National center for addictions in the area of training process in therapeutic community model.

\* International affiliations

In April 2002 Phoenix became a member of the Association of Therapeutic Communities (ATC). In May 2003 Phoenix covered the European criteria for professional practice and became a full member of the European Federation of Therapeutic Communities (EFTC).

A mark of high evaluation is Phoenix participation in European expert group in the area of therapeutic communities called Community of Communities – A Quality Network of Therapeutic communities, Royal College of Psychiatrists, London.

In December 2002 Phoenix programme and Ley Community, Oxford, UK established a partnership, which founds expression in exchange residents and staff practices.

In 2002 and 2003 doctor Peter Vassilev had three working visits in KETHEA therapeutic communities, Greece and in Ley therapeutic community, Oxford.

In September 2003 the president of EFTC and director of Phoenix therapeutic community, Norway visited Phoenix programme.

In September 2003 the British expert of ATC d-r Paul Goodman was on a work visit in Phoenix programme.

In December 2003 Phoenix and National center for addictions organized together training in therapeutic community model that was conducted by experts from KETHEA.

In December 2003 staff members Teodora Groshkova and Diana Radulova had a 1-month practice in Phoenix programme, Norway.

In May 2004 d-r Peter Vassilev had a work visit in Trampoline therapeutic community, Belgium. In 2004 and 2005 the Trampoline pedagogical director Ruud Bruggeman conducted 3 training sessions for the staff of Phoenix programme.

In May 2004 the vice-director of Ley Therapeutic community, Oxford, Jane Brogan had a 1-week visit in Phoenix programme.

In 2004 Phoenix programme, Bulgaria and World federation of therapeutic communities /WFTC/ established collaboration through meeting between d-r Peter Vassilev and Msgr. William B. O\'Brien, president of WFTC.

Contacts

Addictions:

Therapeutic Community Phoenix, Bulgaria Contact Names: Peter Vassilev, MD Programme Director Addresses: 1407 Sofia, Lozenetz 5 Rilski ezera str., ap 1 BULGARIA Phone: +359 898 209 175; +359 2 962 35 84 Fax: + 359 2 8687568 Email: [peter.vassilev@contact.bg-mailto:peter.vassilev@contact.bg] Website: [1]


Contributors to the Chapter

Addictions:

Name: Peter Vassilev Position: Programme Director Brief Professional Bio: please find attached Contact Details: Addresses: 1407 Sofia, Lozenetz, 5 Rilski ezera str., ap 1, BULGARIA Phone: +359 898 209 175; +359 2 962 35 84; Fax: + 359 2 8687568 Email: [peter.vassilev@contact.bg-mailto:peter.vassilev@contact.bg]

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