ASSA - M

ANNOTATION

     The book "Therapeutic Communities - Service Standards for Addiction Therapeutic Communities" is a practical handbook for working with individuals with addictive behaviours. It is a timely response to the need in the addiction field in Bulgaria of developing an effective, practice-based structure of clinical guidelines and procedures.
     The presented approach is derived from a seven-year experience of Therapeutic Community (TC) Phoenix and from the results of effectiveness evaluation studies.
     The book provides a thorough theoretical framework of current treatment and rehabilitation of addictive behaviours. The value of the principles for addiction treatment is highlighted, contributing towards the quality of therapeutic interventions and programme effectiveness. Several principles and their importance to clinical practice are being outlined:
     1. the therapist is where the client is, implying that therapeutic interventions should be selected          so that they are appropriate to client's stage of motivation and readiness for change;
     2. establishing a therapeutic relationship is crucial to the therapeutic process. Trust and direct          feedback, amongst others, is key elements of therapeutic relationships;
     3. case conceptualisation is the key to case management and development and implementation          of individual therapeutic plans;
     4. it is crucial that development of a supportive social network is attempted as part of          addressing all significant factors within a client's context, including family of origin.
     A historical account on the evolution of TC model highlights the role of a collection of individuals who have contributed to the establishment and development of this treatment approach worldwide. Alongside, the contribution towards implementing up-to-date clinical practices in the addictions field of individuals in Bulgaria is detailed.
     In 1994 Philip Lazarov negotiated Bulgaria's participation in a five-year International Addiction Treatment Training project, where professionals from Eastern Europe had the opportunity to undergo training in TC and other addiction treatment approaches by Professor David Deitch. University of California, San Diego. The training took place in Italy and just over 50 psychiatrists, psychologists and social workers took part, including, amongst others, Tzveta Raicheva, Igor Koutsenok, and Peter Vassilev. Completion of this training enabled transfer of TC model know-how in Bulgaria - in 2001 Peter Vassilev established TC Phoenix House.
     Within the TC philosophy, addiction is viewed as a disorder of the whole person - substance use is a symptom of an underlying dysfunction (De Leon, 2000). Recovery, on the other hand, is perceived as an incremental process where development of a new lifestyle is brought about through behavioural modification and identity transformation. Hence, a TC programme aims beyond achieving abstinence - towards sustained recovery and maintenance of a drug free lifestyle.
     The recovery process includes:
     1. development of responsibility through self-help and mutual self-help;
     2. recognition of the need to change;
     3. development of skills for change in the areas of thinking, behaviour and emotions;
     4. change of social identity.
     TC is a model of long-term rehabilitation aimed towards full recovery and identity change. It differs from other therapeutic models in two fundamental ways - firstly, it is based on the notion of the community as a primary instrument for individual change and, secondly, it utilises a structured method.
     The view of TC as a method incorporates four interrelated components (De Leon, 2000):
     - context (the relationships between residents, specific roles, and the daily regimen of        activities);
     - community's expectations for participation;
     - community's assessments;
     - community's responses concerning the individual's participation and progress.
     Extensive research on TC and its effectiveness has been carried out over the last 20-25 years. There is a growing body of evidence that the TC is best suited to multiple drug users, those with a history of criminal offences and with poor psychosocial functioning. Generally, the TC is most successful where other treatment interventions have little to offer towards improvement of very complex and deep problems (De Leon, Sacks, Staines, & McKendrick, 2000).
     The model defines addiction as a disorder of the "whole person" (De Leon, 2000). Clinical observations on characteristics of drug dependent individuals in TCs can be summarised in the following areas: cognitive and behavioural characteristics, perceptual, emotional, social and interpersonal characteristics. They overlap with the results of research on the psychopathology and personality of drug dependent individuals (Hendriks, 1990; Ravndal, 1994; De Leon, 2000).
     The social organisation and interactions form the basis of TC as a model and treatment structure. The structure gives the residents an opportunity to learn to function in a hierarchical system, to identify, through full immersion and participation in community roles, the underlying problems, and to learn achieving their goals through a sequence of planned steps. According to De Leon (2000) the social organisation has four components:
     - rules and daily regimen;
     - organisational hierarchy;
     - procedures;
     - communication.
     The content of therapy encapsulates a number of therapeutic activities. These fall into three groups: activities reinforcing a sense of belonging to the community, activities for behavioural management, and therapeutic groups.
     The activities reinforcing a sense of belonging to the community serve to increase residents' community membership perceptions and experiences. These are daily activities which provide a forum for evaluation of group processes and the state of individual residents so that timely interventions can be planned and exerted towards reducing the risk of drop out of a resident, preventing suicidal behaviour, violence or other untoward behaviours against programme rules. Programme elements reinforcing a sense of community belonging are the morning meeting, the general meeting, and seminars in the community.
     The TC employs a coherent system of behavioural management where old behavioural patterns are modified and shaped through positive and negative reinforcing. This system conveys the clear community response regarding individuals' progress towards community expectations. The effectiveness of the systems is directly contingent upon all community members' engagement in its consistent application on a daily basis, the latter being an important indicator of the process in the community.
     In technical terms, behavioural management shares common principles with behavioural therapy.
     It is highlighted that staff should intentionally look out for positive behaviours rather than, as more often the case, be tuned and excessively focused on residents' negative behaviours. Moreover, in the process of personal growth and development, what matters has little to do with whether a certain task has been accomplished or not, but is closely associated with the attitude implied and the group support it had received.
     Based on our experience from TC Phoenix we have come to the conclusion that behavioural management can be clinically effective only where the following principles have been in place:
     1. positive and negative reinforcements are congruent with the current group dynamics in the          TC;
     2. the choice of interventions is based on the: nature and severity of programme rule violation          and the personal resources and learning potential of the resident who is responsible for the          violation;
     3. chosen interventions should not disturb the fine balance between individual and community          interests;
     4. the choice should be in favour of minimally harsh sanctions that have the potential to gain          maximal learning effect.
     The therapeutic groups in TC have their specificities due to the unique characteristics of the group process. These characteristics are related to the direct nature of feedback, respect towards residents with longer recovery experience, the need of clear rules and set boundaries. Since residents are sharing common characteristics, they tend to know each other much better than a therapist would know them. They are therefore sometimes more effective in confronting each others behaviours than the group leader.
     That is why application of conventional group therapy in the TC is very limited. At the same time, it is the group - with its specific context and clear elements of self-help and mutual self-help - which is much more effective than any form of individual intervention.
     I would like to highlight that there is a further reason why TC magnifies the effect of group work. This is the link between the therapeutic milieu with its social organisation and the variety of groups. Dysfunctional behaviours and negative emotions which occur in the everyday life of the community are targeted in the group setting and the skills that residents learn as a result of the group interventions is practiced within the roles back in the community life.
     De Leon (2000) divides groups in TC into clinical and educational. Clinical groups are aimed at change through understanding of one's behaviour, expression of emotions and shaping of behavioural alternatives.
     Clinical groups in TC Phoenix are theoretically rooted into:
     - schema-focused therapy;
     - cognitive-behavioural therapy;
     - motivational enhancement therapy;
     - relapse prevention.
     Schema-focused therapy (Young, 2003) is an integrative approach for personality modification.
     Cognitive-behavioural therapy (Beck, 1993) consists of development of individual case conceptualisation, based on the cognitive model with addiction and replacement of drug related beliefs with control beliefs.
     Motivational enhancement therapy (W. Miller, 2002) employs interventions that assist residents moving through stages of change (Prochaska & Di Clemente, 1992). The stages of change are precontemplation, contemplation, decision, action, and maintenance. Each of the stages is characterised by specific thoughts and beliefs that can be targeted with highly specific interventions.
     Therapy for relapse prevention views relapse as a process and is aimed at development of new skills for dealing with lapses, and alternative coping strategies.
     According to De Leon (2000) a number of groups fall into the category of clinical groups: confrontation/encounter groups, static groups, and probe groups.
     In addition, in TC Phoenix there is a seven-year history of leading, on a weekly basis, of an extended group aimed at personal development. This group is based on the theory of V. Bernaskoni for the "five movements" (planning, submission, aggression, seduction, and reality testing). The central idea in Bernaskoni's theory is that these movements have been blocked, as s result of individual childhood trauma. This limits one's resources for relating to others, resulting in unmet basic needs through life. The drug serves the role of a "metasatisfaction." In the programme, residents learn the "missing movement," which leads to an increased potential for communication and development of relationships, which, in its turn leaves out the need of the substitute-drug.
     Educational groups include a variety of seminars that introduce programme elements (e.g. mock encounters), informal groups, led by staff members, addressing recovery issues, vocational training groups (where the focus is equally on learning vocational skills as well as adopting work ethics, and right work attitudes), life skills training (e.g. personal budget management, CV writing, parenting).
     Along with clinical and educational groups, a relatively recent development in TCs is the application of goal groups, groups for members of one hierarchical level, groups for members with common problems (e.g. history of sexual abuse), groups for parents or significant others.
     A key factor for success of rehabilitation in TC is working with the family or the significant others, along with working with the resident. The simple principle is that parents are developing and changing themselves whilst their son or daughter is in the programme - through group work corresponding to the programme stage of the family member-resident in the TC and facilitated by a dedicated TC staff member. Where necessary, a referral is made to a specialist family therapist.
     Group work is effective when the variety of groups is viewed as an interrelated sequence of clinical interventions sharing the common goals of change and recovery. For example, a confrontation of one's behaviour in the encounter may trigger painful emotions related to traumatic memories. These can be brought to and addressed in a different group setting. Also, if skill deficits are being identified in a clinical group setting, these can be targeted and potentially developed in an educational group. The recovery process in TC is a symphony of interactions between the structure and the therapeutic instruments. The way forwards to personal change goes through individual case conceptualisation and the individual treatment plan.
     The treatment process is a dynamic interaction between the therapeutic context and the individual, where lifestyle changes are brought about through integration of new behaviours, cognitions, attitudes and values. A precondition to lifestyle changes is the full immersion into community roles, which provide the resident with the opportunities for experiencing increased self-efficacy and the related benefits. It is thus, through internalisation of change that the new personal identity takes place.
     TCs are effective because they provide residents the environment and the mechanisms for learning of new roles, attitudes, skills, and identity. The most important mechanism of change is the community itself - it confronts each member whenever old values or behaviours are exercised, it reinforces - positively and negatively - so that residents are guided towards new, desired behaviours, it serves as a role model of a successful change.
     Modern cognitive therapy is based on scientific evidence and tailored to a broad spectrum of psychiatric and somatic disorders (Salkovskis, 1996). The fundamental idea of cognitive theory is that people are disturbed not by the meaning they attach to an activating stimulus and by the stimulus itself. In a state of emotional distress the ability for processing information are disturbed, resulting in a thinking style that is rather focused on a single absolute, generalised view about oneself and the others. This is manifested in certain types of cognitive distortions: dichotomous (black and white) thinking, overgeneralisation, catastrophising, mind-reading, personalisation etc.
     In her defended PhD dissertation - "The role of motivation for retaining drug dependent individuals in TC," Teodora Groshkova (2008) provides evidence that the internal motivation is positively associated with participation in the therapeutic process, thus, indirectly contributing to increased length of time in treatment and number of opportunities for learning and change. In this piece of research, conducted in TC Phoenix, Groshkova reports that 65,1% of residents complete the treatment programme successfully. The author discusses the high retention and completion rates as potentially related to the motivational interventions and the interventions enhancing programme participation.
     The study "Application of TC method in Bulgaria - the experience of programme Phoenix," conducted by Peter Vassilev and presented at the 11th EFTC European Conference on Rehabilitation & Drug Policy, demonstrates the effectiveness of the programme, reporting that 67% of those who have successfully completed the TC Phoenix programme remain drug free at 18 months follow-up. This result can be explained with the integration of cognitive-behavioural therapy in the TC and the implementation of individual treatment plans related to the individual case conceptualisations.
     The standards for good practice have been developed through the international project "Community of Communities: A Quality Network for Therapeutic Communities," which started in the year of 2002. (Service Standards for Therapeutic Communities, 2002, Royal College of Psychiatrists, College Research Unit). Participants in the project are 42 TC programmes across Europe. "Phoenix" is the TC project member from Bulgaria.
     The project activities reflect the philosophy, values, and principles of TC, where all community members - staff and residents - are given the opportunity to take part in the process of programme evaluation and development.
     The Standards incorporate information, derived from key regulating documents in the area of current application of TC model. Amongst others, these are KLAC 2 (Kennard and Lees Audit Check List 2), the ATC's Criteria for Accreditation of Training Quality, the Charterhouse Group Value Added Standards, the Network for inpatient CAMHS (QNIC), the Clinical Governance Support Service (CGSS), the Health Advisory Service (HAS), Interventions to Reduce Substance Misuse (NIHCE, 2006), Commissioning Standards: Drug and Alcohol Treatment and Care (1999) и the Commission for Health Improvement (CHI).
     The Standards are organised in the following seven areas:
     1. core Standards;
     2. physical Environment;
     3. staff: number, selection, clinical supervision, team working, training, theory, practice,          personal experience, quality;
     4. joining and Leaving: information, joining, assessment, leaving;
     5. therapeutic Environment: sensitivity, responsibility, daily learning, quality;
     6. treatment Programme;
     7. external Relations: networking, institutional context, effectiveness and participation in          research projects.
     The first edition of the Addiction TC Standards was put together by an expert group, chaired by Rowdy Yates, vice-president of the European Federation of Therapeutic Communities and seniour researcher at University of Sterling, UK. The expert groups comprises of 22 professionals with clinical and research background in the area of addiction TCs. Two experts from Bulgaria contribute to the work of the expert group: Peter Vassilev and Teodora Groshkova. The Standards are adapted from the fifth edition of the "The Service Standards for Therapeutic Communities."

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