Therapeutic Communities in Poland

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Therapeutic Communities in Poland

by Jolanta Koczurowska. The MONAR Association


Back in 1978, 27 years ago, when a group of drug dependent persons decided to stay together to join efforts in overcoming their dependency in the psychiatric hospital nearby Warsaw nobody could think that it was the beginning of the unique for Poland treatment method. Although the word "treatment" fitted neither the way of care for „patients" nor the applied methods and procedures to help drug dependent people, the spontaneous and grass-rooting model of a community of dependent people became a basis for the professional system of addiction care. In the 70s, the therapeutic communities functioned in a considerably modest forms only in psychiatric hospitals in Poland and practiced more or less regular staff and wards\' meetings, however it was not the time to speak about the apparent and strong promotion of the ideas of therapeutic communities in their classic form.

In October 1978 a group of people addicted from Polish heroin, so called "compote", settled in a ruined and abandoned estate in Głosków near Warsaw. They were those ones who lived in the margins with no means for life, no future, who together with Marek Kotański, the psychologist abandoned the psychiatric hospital. Kotański who became the spiritual leader of the first therapeutic community for drug dependent people, proposed them to join efforts in "fight" for own lives and the future. That extraordinary House of people trying to find their own humanity was called "MONAR".

Kotański\'s long experience in work with dependent youth made him base the Głosków\'s program on the principles of self-management and self-control of inhabitants. It was the important role of patients to create the Center\'s Code. The main principle of the Code was the strict abstinence from drugs and alcohol. Proposed by Kotański method of help to drug dependent people had been inspired by the philosophy and practice by Synanon, in spite of very limited access to American sources. Three years later, in 1981, the catholic community "Betania" was founded by an ex-addict to work though several years without awareness and permission from authorities. The Government was not interested to come up with any kind of help to drug dependent people at that time. Problem of drug dependency officially did not exist. Approval of authorities for establishing centers for drug dependent people was rather thinking that it was better to keep all the "junkies" under control in one place than to care for other people\'s lives.

2. In the early 80s, the scale of drug use in Poland evidently grew. Głosków\'s Center became a „ray of hope" for many people to overcome the dependency. In 1981, the youth appealed to authorities to tackle drug use. In a public letter to the Parliament, Superior State Council and the Central Party Committee, which was published in press, the youth demanded establishing care services for drug dependent people based on Głosków\'s model. Then, for the first time the word MONAR has been pronounced. Due to the pressure exerted by the youth, teachers and parents, MONAR – Youth Movement for Drug Prevention has been established, which in October 1981 became officially registered as a legal entity and non-profit association.

During the year of 1982, in different regions of Poland the next five MONAR centers were founded. The need for services for drug dependent people constantly grew. Apart from residential care offered in MONAR centers, drug dependent people could benefit from few services, mainly detoxification, in several hospitals. There were no state services, nor a system of help to dependent people.

Before 1990, the MONAR Association established over 20 centers. All of them are based on the created by Głosków dependency treatment model. The MONAR centers were often called Houses of Warmth and usually occupied old buildings which badly demanded repair. These were houses in the country side or in suburbs, they had land, gardens, forests or parks. All houses followed the principle of abstaining from alcohol, drugs, sexual relationships, and aggressive behavior. Those ones who stayed in these houses had to farewell the "junkie\'s past", subordinate to the group and to take an active part in the life of the "House". These centers did hardly employ personnel: all house duties were fulfilled by inhabitants. So called personnel was usually formed by ex-addicts. All inhabitants were members of the community and met regularly to discuss literally all issues related to the center\'s life and inhabitants. The community established norms and the code, executed punishment and bestowed privileges. The condition for stay in the center was the subordination to the community. The majority of time was occupied by physical work related to farming, gardening and repair. There was a conviction promoted that the hard physical work, honesty and involvement in center\'s life as well as faith in mutual help and close emotional ties between people were the main conditions needed to be met to overcome dependency. All centers admitted the "leader" model of community, wrote "conditions" to farewell dependency, hung the bell in a central place of the house as a symbol of right for mutual and immediate help for every inhabitant. When the bell rang, all the inhabitants were obliged to gather in the community meeting room and give others help and support. MONAR established centers for children and adolescents, specialized services for people living with HIV/AIDS. Several centers became specialized in work with mothers with children, ex-prisoners and other.

The MONAR therapeutic communities became to meet up every year during so called „Monarowisko" festivals which gathered patients from all over Poland. To celebrate the birthday of every center became a tradition and an occasion for graduates to hold an annual reunion. The mentioned activities became a form of promotion of therapeutic communities ideas as a method of addiction treatment.

In the late 80s and early 90s, many non-governmental organizations were founded to tackle problems of drug use. These organizations establish residential treatment services based on the MONAR experience. In 1987, the Catholic Anti-Drug Movement KARAN was founded, and it is now the largest non-governmental catholic organization. KARAN promptly opened a center for youth with drug problem. The Society for Drug Prevention established a center for adolescents under 18 years old in Wólka Przybojewska near Warsaw. In Gliwice Andrzej May-Majewski established the first in Poland center for double diagnosis patients based on the therapeutic community method "Familia". In the South of Poland, by an initiative of priest, professor of the Lublin Catholic University Czesław Cekiera, the Catholic Center for Upbringing and Resocialization for Youth was established. Near Warsaw, in Grzmiąca, the first state residential treatment facility was opened. The organizations listed above and many other which address the issue of drug use currently run residential centers for drug dependent people which are based on the therapeutic community method.

3. The Polish system of treatment and rehabilitation of drug dependent people, besides counseling units, out-patient prevention and treatment centers, detoxification centers and numerous day-centers, offers residential care services which is the most developed services and possesses the richest experience. Residential care is offered by rehabilitation or rehabilitation and readaptation centers (both titles are commonly used) being run by the public sector (public health service) and non-governmental organizations (MONAR, The Polish Society for Drug Prevention, The Society "U-Return", KARAN Association, "Familia" Association, Catholic Association "Betania", Catholic Association "Hope", The Society "Mrowisko" and many others). Prisons also attempt to implement treatment programs based on therapeutic community method for inmates with drug problem.

In spite of structural, formal or philosophical differences, almost all existing services accepted the therapeutic community formula as a main instrument of therapeutic activity towards drug dependent people and people with problematic drug use. The current state drug policy provides for treatment to be offered free of cost. Such an approach to assistance to people with drug problem is a result of the common conviction that the drug dependency is one of the most dramatic diseases of the modern world. This disease is of an extensive and complex character therefore it requires a specialized treatment. According to the research data, the majority of Polish people are convinced that drug-dependent persons should be treated. The specificity of the disease, difficulties in clear picture of "recover", necessity to apply different medical and therapeutic procedures impose the condition for rehabilitation to thoroughly choose the outer settings. Good results achieved by the therapeutic communities, "tangible" evidence collected during decades which prove that a drug addict can be returned to life, as well as lack of other services – all these arguments contributed to belief that the therapeutic community is one of the most effective drug dependency treatment method.

Costs of treatment are reimbursed by the National Health Insurance Fund which as an ordering party imposes conditions to be met by a residential treatment facility. These conditions are regulated by the law on public health institutions and the law on drug prevention. The above mentioned documents define the formal procedures and health services which should be observed by every facility which seeks refund for its services. For the last 15 years, all therapeutic communities which are entitled to refunds from the National Health Insurance Funds have the status of the public health institution. That means that in organizational, administrative, social aspects and in terms of health and rehabilitation services offered the facilities do meet legally defined criteria. The criteria concern first of all personnel employed, types of services, professional and ethic standards and other.

Once a year, the tender for implementing specialized services to drug dependent people is announced, the finances are distributed among facilities which meet the main criteria. Statistical data on implemented by the therapeutic communities services are being collected and processed by the Institute of Psychiatry and Neurology, whereas the overall monitoring is made by the National Bureau for Drug Prevention. Currently 90% of all services to drug dependent people have the status of the public health institution and therefore are funded by the National Health Insurance Fund. Every division can also take part in tenders for additional projects (therapeutic camps, recreation, sports, family assistance, social care) both from the central state budget (through National Bureau for Drug Prevention) and local budgets.

4. Currently in Poland, the system of care for drug dependent people includes 77 centers based on the therapeutic community model (27 for youth under 21 years old and 50 for adults over 21 years old and without upper age boundary). The majority is managed by non-governmental organizations: 48 (MONAR runs 30), catholic organizations – 11, public health service – 18 (Source: Address Book, The Ntional Bureau for Drug Prevention, 2004). All therapeutic communities are managed in residential settings and implement the following three types of the rehabilitation (therapeutic) programs:

- short-term (program duration 3 weeks to 6 months) 11 centers - medium-term (program duration 6 to 12 months) 15 centers - long-term (program duration 12 to 24 months) 51 centers (among them are 10 centers which implement also the medium-term therapy).

Different program duration is an object of specificity of the clients and program contents. Short-term and medium-term programs are mainly implemented towards youth, persons with drug problem (not dependent), without opportunist mental disorders. Long-term treatment programs are usually applied in treatment of adults with long history of drug-use.

Residential centers based on the therapeutic community method have all together 2,784 seats, among them non-governmental organizations – 1,831 (MONAR – 1166), catholic organizations – 278, public health services – 675 seats. Four centers based on therapeutic community method (about 100 seats) offer services for double diagnosis patients. In the rest of the centers, clients with mental disorders are admitted in regular TC program. Almost all the centers apply the complex and integrated model of work with persons with drug problem. Therapeutic communities admit also persons referred for treatment by courts as well as persons on parole (referred to treatment instead of prison sentence): in MONAR such group constitutes about 20 % of TC clients.

Usually TC clients are young people (below 25 years old), mainly male (female clients proportion is about 30 – 35 %) with problematic drug use who originated from different social groups, often having conflict with law, distorted social ties and difficulties in fulfilling everyday tasks. Over 70% of TC clients have emotional difficulties, symptoms of behavioral and mental disorders. The most typical clinical symptoms are personality disorder such as borderline, bulimia, anorexia, anxiety and distorted social behavior, adaptation difficulties etc.

Clients are referred to residential centers by the specialized counseling units, family doctors or courts. If needed, before becoming admitted by the TC, the client undergoes hospital detoxification. Residential center admission procedures include medical diagnosis (also psychiatric and psychological) and drug tests. Also, during admission the other special requirements (such as epilepsy, HCV and other) for client care are being identified. On the therapy stages the diverse health services are being rendered, among them are daily and periodical services adjusted to the state of patients\' health, his possibilities, possibilities of the center and its personnel. However, all the centers financed by the National Health Insurance Fund, apply the standard set of such services. Therefore, everyday services include individual therapy, group therapy (also TC meetings and therapeutic groups called Stage Groups), game therapy, crisis intervention, nursing, other forms of therapy such as motivational, supporting etc. Periodical services include medical examinations, psychological tests, assessment of the treatment achievements, rehabilitation camps. Such plan of implemented health services (all therapeutic services in Poland are called health called) in therapeutic communities imposes the certain program order.

5. The Polish therapeutic communities usually inhabit estates or farms distant from the urban environment. Normally, centers for children and youth however are situated in suburbs of cities for school reasons. The therapeutic community normally consists of 20 to 70 members. All communities are served by therapeutic teams consisting of professionals (psychologists, pedagogues, social workers), as well as workshop instructors and program graduates (ex-drug users who have completed drug treatment successfully).

The members of the therapeutic team are obliged for regular professional training and are required to held special certificates entitling them for work with drug dependent clients. Every center employs a psychiatrist and a therapist. Many centers, especially those run by public institutions, employ administrative and maintenance staff, however other centers\' maintenance staff is minimal, and all their tasks are taken over by TC members (MONAR applies the latter model). The centers with the long tradition apply the so called leader model of therapeutic community which defines the strong position of the leader for the therapeutic team and TC members.

In all centers based on therapeutic community model the essential form of activity of the TC members is labor (everyday house keeping duties, repair, gardening, farming etc. which provide for the order and prosperity of the house), education and recreation. Besides, every TC member has an obligation to take part in the therapy (individual and group), TC meetings and active forms of leisure time spending. Both everyday labor and therapeutic measures adjust the primary principles, inner regulations, daily schedule and ethic code which stands for all TC members. The majority of Polish TCs are guided by the following 6 basic principles such as: 1. strict abstinence from any psychoactive and pharmacological substances (except for medical prescription cases for somatic reasons), 2. ban for aggression, 3. submittion to the therapeutic group, 4. active participation in life of the house, 5. openness and limited trust, 6. sexual abstinence. Ususally, the principles are written down and put in a visible place in the house.

The therapeutic process (stay in the program) is divided into several stages, which enables TC members to control process and results of the own therapy. The majority of centers apply the classical division into 3 basic stages: a newcomer, a housekeeper and a resident (or inhabitant, or "monarer"). For example, in long-term therapeutic programs the newcomers\' stage lasts from 3 to 6 months, housekeepers\' stage from 7 to 9 months and finally residents\' stage – for about 9 months. There are special tasks, obligations and privileges which stand for every therapy stage. The decision about stages\' change is made by the community on the individual basis. In centers for adolescents and youth the medium-term therapeutic process (7-12 month) is divided into more stages. For instance, the TC for drug users of 14 to 19 years old applies 7 stages such as an observer, a newcomer, a housekeeper, an organizer, a warden, a master and a resident. The stages are shorter and precisely define and justify the results to be achieved, which makes the results more visible. Stages are more attractive and easier to go through. In the majority of the therapeutic communities all the duties are fulfilled by the TC members. Democratically elected council (or board) of the house manages the everyday TC life.

The characteristic feature of all therapeutic communities is care for personal growth of every TC member. That is why the centers implement diverse creative, artistic and sporting activity, these are: music, theatre, dance, martial arts, fine arts, design, as well as foreign languages, computer lessons, other educational activity, and sporting (aerobics, body-building, team games), extreme sporting (mountain climbing, parachuting). Some of these activities are obligatory for TC members. At least twice a year therapeutic communities organize the recreational and therapeutic camp such as biking, canoeing or walking trips.

The specificity of the Polish Therapeutic Communities is the care for inheriting tradition and build the feeling of social and cultural belonging. In order to implement this task, TC conduct diverse center ceremonies. Communities usually track the center\'s history and have the so called "family album" (pictures of everybody who were community member), there are special "rites" related to change of treatment stages, graduation or "TC anniversary". "TC anniversaries" are organized yearly and are gathering of all TC graduates. Besides, the TC celebrates Christmas, Easter, Day of all Saints – Halloween, birthdays and important life events (i.e. graduation from the school, admission to the next school, employment).

The community gathers in the morning and evening meetings called "ritual", the intervention meetings (called by the bell, in difficult crisis circumstances), therapeutic meetings (held regularly once or twice a week) as well as during the organizational meetings (concerning current issues of TC members and community in a whole), and formal meetings (birthdays, holidays etc.). During the meetings the community makes decisions on all the issues of the center, established principles of co-existing in a group, dictates the condition for stay in the program and assesses therapy achievements. Polish therapeutic communities promote, in a more or less direct way, the principle of the Christian philosophy – love, help and respect to others, restrain from judging on others, belief that a person can change, respect for diversity and personality, perceiving to do good, stimulate for creating attitude towards one\'s life in every sphere.

The typical day of the therapeutic community, apart from the gymnastics, morning hygiene and the breakfast, begins with the morning meeting which is scheduled as a classical TC meeting all over the world. The normal day schedule in one of the centers looks as follows:

8.30 – 12.00 – Labor (House tasks), school education 12.00 – 12.10 – Second breakfast 12.30 – 14 30 – Labor (House tasks), school education, or individual learning 12.30 – 13. 30 – Individual therapy (every TC member once a week) 15 .00 – 15.30 – Lunch 15.30 – 16.00 – Free time, leisure 16.00 – 18.00 – Creating and sporting activities groups 18 .00 – 19.00 – Leisure, individual learning. 19.00 – 19.30 – Dinner 19.30 – 21.00 – Therapeutic groups (housekeepers)- other TC members have free time or are involved in integrating activities, games, watching TV. 21.30 – 22.00 – Evening meeting 22.00 – 22.30 – Preparing for sleep 22.30 – Sleep.

6. The method of therapeutic community, in spite of its long history and role in treatment, raises as much admiration as doubts. The advantages of the methods are proved by the fact that it is the certain form of the social and psychological community treatment which is based on the dynamic context of the group of people living together. Structural and organizational frameworks, as well as philosophy and atmosphere in the TC are used for therapeutic purposes. The social group in which drug dependent people stay give them all equal opportunities to modify, normalize and change of the pathologic attitudes and behaviors, solving individual and group problems.

The fact of its reality and truthfulness stands for one more virtue of the method: it operates with concrete and real life situations, in which the person participates and lives through. These are situations which could provide for more meaningful experience and serve to social learning. Therapeutic community is a kind of social micro cosmos, "small society" which is characterized by the division of roles, tasks, positions and career tracks, there exist law, obligations and privileges, executive and policy making authorities, parliament and citizens. It gives an excellent occasion for learning on the social interactions, experience social emotions and social responsibility. Every member of the community has the right of free expression and exchange of authentic feelings, opinions and thoughts. Doubtless virtue of the therapeutic community method is the creation of the opportunities for social learning, which means bringing community members experience due to which they can obtain new behavioral skills useful in life. It is not only about gaining what has been lost before while taking drugs, but also about obtaining skills of building and maintaining ties with other people. Therapeutic community gives the skills of independent problem solving, analyzing the reasons for difficulties, becoming more independent and responsible for self and chances for mobilizing energy and initiative for further personal growth.

The next advantage of the therapeutic communities is the possibility of basing on the authentic experience and feeling in work with a client. Besides, we can also participate and witness at the same time. It is possible to state that all in the therapeutic communities is therapy: even the simplest every day duties are real mines of knowledge for TC members about themselves, and the number and quality of interpersonal contacts are the best school for social adjustment. The influence of the therapeutic community on the person is proved by the curing factors which TC possesses. According to the specificity of the addiction (multifaceted, negative social stigmatization, epidemiological character, risk of relapses) there is no better method for dependency therapy. Even simple factors such as isolation of clients from the pathological environment, opportunity to continue education, new acquaintances and other are extremely important.

Of course, this method is not free from disadvantages. It is believed that the main disadvantage is the long duration of treatment, in isolated environment, which can make troublesome the return to society. They often use the word "therapy under the cloche", meaning therapy which does not consider the real life circumstances and is based on the out-of-time values, such as honesty, courage, independence and other. The long time of stay in the program, often far from the place of the former residence, makes more difficult the systematic contact with the family and rebuilt of the family ties. One of the disadvantages is also high therapy cost. If we count the cost of a client stay per day we can really see that its expensiveness is not in favor for use of this method. Next arguments of opponents refer to the small proportion of individual treatment and limited possibilities to satisfy the individual need of every TC member, and to limited flexibility. The necessity of physical work, confrontation in therapy and limitation of the personal freedom are among next negative arguments.

Probably out of the personal attachment and sympathy for the therapeutic community I am not able to be objective. The beauty of this method lies in its simple character, universal values and existential truth.

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