Clients with dual diagnosis

in the TC

TC Magdaléna(Czech republic)

Den Haag 2009 Petr Nevšímal MD

Situation in Czech republic About 30 000 heavy drug users, most of

them in Prague, also in former industry regions with high unemployment

Main drugs are amphetamines, decline of heroin abuse, i.v. application and hepatitis C, low occurrence of HIV

13 TC‘s, capacity 200 beds, first in 1991 Short term programmes in medical fac. More drug free orient. then substitution

(tradition of Jaroslav Skála)

TC‘s charakteristic Financed by state (municipal) grants Location in countryside Lenght of programme 6-18 month Cooperation – federation A.N.O.

(sharing of experiences, lobbying) Community culture is influenced by

American, Europe and Skala tradition

CBT, integrative psychotherapy, psychodynamic accent

TC Magdaléna Founded in 1998 nearby Prague in

former military area (missile base) Capacity 25 clients (M : W – 2 : 1) Lenght of the stay 9-15 months

(including re-entry house) 9 staff members (therap. team)

included 2 exusers in the TC Occupational therapy – farm, gardening,

carpentery

Programme of TC 4 phases: induction, introspection,

responsibility, re-entry 20 hours of group therapy weekly 25 hours of work weekly Individual counselling (treatment

planning) Family counselling

Basic clients charakteristic

Average age 25 years Drug use 5,5 years Opioid users (heroin) 50 % Amphetamines 50 % I.v. aplication 85 % Sentence 30 % Hepatitis B/C 35 %

Dual diagnosis Personality disorders (borderline, narcistic) Neurosis (OCD, panic dis., gen. anx. dis.) Schizofrenia Mood disorders (depression) Eating disorders ADHD

(not acute psychosis related to drug abuse)

Portion of clients with DD

0

5

10

15

20

25

1999 2001 2003 2005 2007

2 DGneurosis

2 DGpsychosis

2 DGpersonal.

1 DG

Treatment models I. Serial treatment model

consecutive treatment with little communication between substance misuse and psychiatric services

clients tend to be shunted between services that are inadequate to meet their needs (in our condition is sometimes used to achieve stability and possibility of cooperation)

Treatment models II. Parallel treatment model

substance misuse and psychiatric services services establish liaison to provide the two services concurrently

in our settings e.g. cooperation with a day centre for patients with psychosis (our clients attend there individual and group therapy once a week, what helps them in orientation and understanding themselves, building real self-esteem, etc.)

Treatment models III. Integration treatment model

substance misuse and psychiatric services are integrated in one settings by one therapeutic team

in our community work psychiatrist, psychologist, experienced nurse (they work like other therapists and have training in group psychotherapy too)

Obstacles for the community Lots of energy (attention,

understanding) Different evaluation scales, individual

approach Less space for other clients and for

psychotherapy Shortage of „positive role models“ Risk of solidarity lack Risk of resignation from everybodies

influence on community process Lower effectivity of the treatment

Obstacles for an individual

Inadequate burden and claims Risk of state worsen, or it’s

chronification To be too exceptional can lead to

exclusion from the group Risk of relapse

Obstacles for the staff Individual therapy Diversity of attitude towards clients Shortage of clear guide lines

(exceptions) Doubts about their competence High demand for energy Exhausting work, burn out syndrom

(claims x reality)

Adequate therap. goals

Usual goals Adapted goals

I. Phase

Regime, coping with emotions and affects, adaptation, introspection, learning

Regime, stabilization, adaptation, accept leading

II.Phase

Initiative, self-reflexion, planning, responsibility, role model, leading

Stability, self-reflexion, learning, coping with difference and affects

III.Phase

Independence, tenacious, self-actualization, full resocialization

Stability, slow steps to independence and planning

Pharmacotherapy AD treatment

SSRI (citalopram, fluoxetin, paroxetin, sertralin)

Other (venlafaxin, tianeptin) Antipsychotic drugs (olanzapin,

quetiapin, zotepin, risperidon) Mood stabilizators and nootropics

Individual care Detailed guide / counselling Strong support 1 hour/week Family therapy Accessibility of psychiatrist and

psychologist with good knowledge of the TC

1 year after treatment

58%

13%

14%

15%

No use of illegal drug (work or study)

Another treatment State unknown Drug use

160 clients

(1999 – 2008)

Conclusions Amount of clients with DD is rising up Shortened total time of treatment Alternative to long term invalidity

(repeated stay in psychiatric hospital) Better chance for resocialization due to

community treatment Chance for independence in future life Integration of theese clients into the TC

lower the effectivity and have another claims on our staff (many thanks for their patience)

Magdaléna, o.p.s.Drug free treatment programs

The dining room

252 10 Mníšek pod Brdy, P.O.Box 3

Czech republic

tel. + 420 318 599 124-5GSM +420 603 867 384-5www.magdalena-ops.cz

Magdaléna o.p.s.

Thanks for your attention!