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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!