TREATMENT
TREATMENT PRE-CONFERENCE SESSIONS
Arturo Ongay Pérez
Moderator
National Council on Addictions
(CONADIC)
Ministry of Health
Mexico
COMPREHENSIVE TREATMENT
PLANS
Comprehensive Treatment Approaches for Women
Robin Hoskins
Women’s Treatment Network
Phoenix, Arizona
United States
THERAPEUTIC COMMUNITIES
Standards for Prison-Based Therapeutic Communities
George DeLeon
Center for Therapeutic Research, National Development and Research Institute, Inc.
United States
Treatment Program for Heroin Use
María Elena Ramos
Programa Compañeros, A.C.
Mexico
RECOVERY PROGRAMS: FAITH-BASED MODELS
Christianity Interventions
Roberto Bital Pineda
Alcance Victoria
Mexico
RECOVERY PROGRAMS: SOCIAL MODELS
EVAC and PREHAB of Arizona: Successful Multi-Systemic Approaches Within a Community Context
Tom Hutchinson
Prehab of Arizona
United States
HIV Prevention, Addictions and Social
Reintegration of Street Kids
Martín Pérez
El Caracol
Mexico
COMPREHENSIVE TREATMENT PLANS
Comprehensive Treatment Approaches for Women
Robin Hoskins
Women’s Treatment Network
I want to welcome those of you who are here
today. We were expecting about 70 people
today, so we’re happy that you all are here. My
name is Robin Hoskins and I work here in
Phoenix, Arizona for the Adult Probation
Department. I am a Director, and I oversee a
program that supervises female substance
abusers in the criminal justice system. I was
asked to talk about our comprehensive
treatment approach for female offenders. So
what I’m going to do is spend a little bit of time
telling you what we do here locally, and my
hope is that some of the things that I tell you
today are things that you can apply to where
you’re from.
I want to make sure that I have something to
share that’s of value. And so, what you’ll find in
my presentation today is that it’s very simple.
When we do our comprehensive treatment
planning for our women in our program, we use
a very, very simple basic concept. What we do
at the “Women’s Treatment Network,” which is
the name of the program I oversee in adult
probation, is we treat each individual client as
an individual client. And that’s really important.
What’s traditionally done in criminal justice is
that our clients are not seen as offenders or
defendants. A lot of times our clients are defined
as either just being a substance abuser or
maybe a violent offender. But what we try to do
is to take a look at that client as an individual.
In doing that we take a holistic approach in our
treatment planning. But what’s most important
to tell you in our approach to treatment planning
is that it all starts with a comprehensive
assessment. And I don’t really know where you
all are from or what your backgrounds are, so if
this seems very basic and simple, I apologize.
I’m not trying to make it too basic or boring for
you. I found in my job in working in our
department is that it’s hard for people to keep it
basic. It’s hard for people to continue to look at
our clients as whole people rather than just
criminals.
When we develop our comprehensive treatment
plan for our clients, we focus on seven life
areas. And those life areas are mental health,
family, employment, education, social, medical
and legal. When we develop our treatment plan
we assess the need of the client in each of those
7 life areas. That’s critical to the success of our
program. Also important in what we do, is that
we put the time and energy at the front end of
our assessment, development of our treatment
plan which is the assessment. What I mean by
that is that we employ Master’s level, certified
counselors to do our assessments. Other
programs will have assessments done by maybe
Bachelor’s level folks or people that are not
certified in counseling. And we have chosen to
spend the time and energy and resources up
front so that we can get a comprehensive
assessment and that will pave the way for a
better treatment plan.
What we also know is not every woman that we
see has needs in every life area. But what we do
consistently is we approach each life area to
make sure that the woman is being addressed
as a whole, like I said, as a whole person. I
keep saying this, but I would imagine that most
of you know what I mean when I talk about the
traditional criminal justice system identifying the
clients as just defendants rather than people.
One of the exciting things about what we’re
doing in the Women’s Network is, we’re one of
seven programs across the nation that is
supported by Washington, DC in our efforts. And
our plan is to take our approach with women—this comprehensive approach—and apply it to
other populations. For example, we’re in the
process now of developing the same type of
approach for our juvenile offenders.
What makes our approach unique, and I think
one of the reasons why I was asked to be here
today as a resource for you all, is that we have
the same kind of approach, systems delivery
and supervision for our clients whether they
come from jail and they’re pre-sentenced or pretrial
or if they’re coming out of prison on parole.
So the whole continuum is covered and we have
a consistent approach with these clients. One of
the main things that we teach our staff when
they deal with our clients is called a strengths-based
approach. This means that we focus on
solutions rather than problems. Our clients, the
women that we see, are very used to being
unsuccessful and not completing things. And
what we do is we focus on their strengths. We
involve the client in her treatment planning. We
believe that the client has the energy within
herself to propel her towards success. It’s not
really our energy, it’s hers. We really focus on
the client and her strengths. We try to mobilize
the client’s attributes so that she can move
forward. And this really gives us the greatest
potential to produce positive outcomes we
believe.
One of the other things that’s important to do
when you’re trying to develop a comprehensive
treatment plan is that it’s important that
everybody’s on the same page. So what we’ve
done here at The Women’s Network, is that we
have a treatment team that includes the client,
the probation officer, a case manager, and a
clinical director. Any agency in the community
that’s providing services to that client is
welcome to be a part of the treatment team.
And these folks meet every month to discuss the
progress of the client.
By approaching the client in a holistic manner,
using a treatment team and sharing the
comprehensive assessment and treatment plan,
we’re able to better address the needs of the
client. We save money, we save resources, we
save time. And that’s a key element. I’ve been
in the criminal justice system for a very long
time and my experience has been that it’s a very
fragmented system. Probation usually doesn’t
communicate well with parole. City governments
don’t usually communicate with local or state
governments and it’s very fragmented. And the
people that are suffering the most from that are
the clients, ultimately.
One of the things I will share with you as some
of our outcomes because everyone’s interested
in tangible outcomes. The clients that we see
are probably not very different from the clients
that you see in your communities. The majority
of the women that we serve choose
methamphetamine as their drug of choice. And
the second drug of choice is cocaine. And for us
the third drug is alcohol. The majority of our
clients, about 75%, are in their late 30s. And the
majority of our clients, again about 75%, have
children. Also the majority of our clients are
unemployed and under-educated. As a result of
our comprehensive approach to taking a look at
the whole person addressing those 7 life areas,
I’ll give you some statistics of the women that
we have in our program.
Eighty percent of our clients are in stable
housing which is key for our clients. When I say
stable housing, I mean they’re in a home on
their own. They’re not relying on family or a
husband or a boyfriend. It’s a stable home that
they have control of. And that’s a key issue for a
lot of our clients. Seventy percent of our clients
are employed either part-time or full-time. And
62% of our clients are enrolled in education or
vocational programs. When we talk about
demand reduction, reducing the demand for
illegal drugs, what we know we have to do is
reduce the barriers that prevent our clients from
succeeding in their recovery. And some of those
barriers are housing, childcare, employment,
education, health, legal issues—those life areas
that I talked about–and mental health
problems. So as the Women’s Treatment
Network, what we do is try to break down those
barriers. I talked about making a commitment at
the assessment level where we hire a qualified,
certified counselor to do the assessment.
Another thing that we do as part of our
comprehensive treatment plan is we have funds
set aside that we can spend on housing and
childcare and parenting classes. We pay for rent
for the first couple of months on some of these
homes for these women until they can get on
their feet. By doing that, we break down the
barriers, ultimately resulting in demand
reduction. These women are able to take care of
business and they’re not relying on drugs.
You know, you’re going to leave here today and
you probably in a year and one-half or a week,
or maybe even six months from now, you won’t
remember me. And that’s ok. I don’t take that
personally. But I do hope that you remember a
statement that I want to read from a client, a
graduate. She wrote a statement that I’d just
like to read to you all. Again, this is a tangible
result. “I’m a Black, 46 year old woman who’s
had a problem with drug addiction and self-esteem.
As a child, I aspired for great things:
being an Olympic track star, being the fastest
jump-roper in the world, or a lawyer. But I
never imagined I would be a drug addict. I have
a Bachelor’s degree in business and three
beautiful daughters who depend on me for
everything. I’ve overcome many obstacles, but
drug addiction is done on a day-to-day basis.
What turned my life around was going to jail
and losing custody of my baby. There are so
many things that I’ve been blessed with—where do I begin? I went from living in a shelter
after being released from jail to living in a
mansion.” She actually owned her first home
which was a two-bedroom home, but it felt like
a mansion after jail. “I found a new career with
St. Mary’s Community Kitchen as a chef trainer,
and make money, up to $30,000 a year. I can’t
believe it. I’m planning on purchasing my own
home in a year, a larger home, and a decent car
for the first time. I’m on the Board of Advisors
for the Probation Department. I’m a motivational
speaker for The Women’s Network, and I’ve
been asked to meet the Drug Czar from
Washington, DC. Some days I question myself.
Am I worthy? Do I deserve this? You’re DAMN
right I do. I’ve worked hard to achieve this
dream, and I don’t see myself going to a life of
drugs and crime again with God’s love and
grace. Today I’m successful because I choose to
be.”
It’s these kinds of things that keep me going as
far as developing new programs and changing
policies and procedures, not only locally but
nationally. I hope that your experience here this
week provides you with some information, some
guidance and resources where you can do some
things in your own communities that will make a
difference to your clients. My number is in the
workbook that was given to you all. And please
feel free to call me if you have any questions.
THERAPEUTIC COMMUNITIES
Standards for Prison-Based Therapeutic Communities
George DeLeon
Center for Therapeutic Research, National Development and Research Institute, Inc.
United States
Good afternoon. I was asked to speak on
therapeutic communities, in particular, recent
developments for therapeutic communities. We
now have standards in the United States for
delivering therapeutic community programs,
both in the general community and particularly
in correctional settings. I don’t know how much
this audience knows about the therapeutic
community approach. That term therapeutic
community is used very generally, but the
approach is actually a very specific one. And so,
before I talk with you about the standards
themselves, let me take a few moments and
review with you the basic theoretical approach
of the therapeutic community.
As some of you may know, this particular
treatment approach is very well researched.
There are some 30 years of research on
therapeutic communities documenting the
effectiveness of this treatment. This treatment
has been demonstrated to actually serve the
most serious of substance abusers: usually anti-social,
with many other psychological problems
in addition to their substance abuse. So
therapeutic communities have been serving the
most serious of the addicts over the years. And
the research has shown, of course, that the
treatment is effective. The basic findings of that
research, for those of you that may not be
aware of it, is that the longer clients stay in
residential treatment, the greater the likelihood
of their long-term success. The treatment
approach has been modified and adapted for
numbers of populations including adolescents,
mentally ill, chemical abusers, those in homeless
shelters, those in mental hospitals, and of
course, those in prisons.
The approach that the therapeutic community
has that governs everything that it does, is
straightforward. This perspective views the
disorder one of the whole person, so substance
abuse essentially is only one component of what
has to change in the treatment.
Secondly, the persons themselves can be
understood in terms of a variety of
characteristics. Many of them may be seen as
character disorder features, along with other
psychological dysfunction like depression,
anxiety and low self-esteem.
Recovery of the individual requires a multi-dimensional
and a multi-interventional approach
to change the individual. The goals of the
therapeutic community are to transform
lifestyles and identities. So, the goal is much
beyond the issue of using drugs.
And finally, the fourth view that constitutes the
perspective is that this approach teaches right
living. The assumption here is that individuals
cannot sustain their recovery, cannot change
their lifestyles unless they actually have learned
certain values to govern them. And so, much of
what goes on in the therapeutic community
involves teaching those values and teaching
individuals how to live.
That’s the perspective, admittedly very briefly
said to you, that governs and guides everything
that is done in a therapeutic community. These
treatment programs are generally long-term
residential settings, self-contained, primarily
managed by recovering people themselves. It’s
a self-help approach, a mutual self-help
approach, with relatively few staff compared to
the number of residents. And that of course
ultimately has been shown to be very cost-effective.
But, if you actually want to understand
the treatment, the active treatment ingredient in
the therapeutic community, it is the use of the
community, which is peers and staff, and all of
the activities that go on in that community as
the method. So, unlike traditional treatment
approaches, there is less emphasis on traditional
counseling, traditional psychotherapy, traditional
psychiatric approaches, and relatively few
programs with medication. In the therapeutic
community, the primary treatment change agent
is the community itself. And that’s why, over the
years, I have used the term “community as
method” to indicate what is the primary active
treatment ingredient.
When we actually spell out community as
method, it can be summarized in four points:
the context, which means all of the influences in
a contained environment; the people; the
relationships; and the daily regimen of activities
which is groups, meetings, seminars, recreation,
dining, eating together, personal time. All of
those activities are defined as the context, and it
is assumed in the theory that every one of those
activities is potentially an intervention for
changing the individual.
So, it is not only whether the individuals go to
groups, or whether they attend meetings, but
it’s everything that they do. Work, meetings,
groups, recreation, informal time together,
dining together. Every element of the social life
in the therapeutic community is an intervention
to produce change. Every element is used to
teach the individual or to train the individual.
And the theory says, in order to bring about
multi-dimensional change, you have to have a
multi-interventional environment. That’s context.
But there is more to community as method. It
says that the community is not only the context
for learning and changing, but it also sets the
expectations for individuals’ participation in that
community. This is a very critical feature to
understand this method. The community itself
establishes explicit requirements in terms of how
the individual should participate and how much
they should participate. So, there is a basic
demand characteristic in the community. Not
only is this the place where you can change, but
there is expectation about how you should use
this place to change.
The third assumption in community as method is
that the community is also continually assessing,
observing, whether you are in fact participating.
So, it is a requirement of the community to
continually confront, support, provide feedback
to the individual as to whether they are
participating in the community. And the fourth
element is that the community, peers and staff
provide responses, both positive and negative,
concerning whether the individual is
participating. So again, to understand
community as method, the community—all of
its people, its relationships and its daily activities—provide the social learning setting for producing change in the individual. The
community sets the expectations for how you
should participate. The community will assess,
continually observe through challenging you,
testing you and exposing you as to whether you
are participating and using the community to
change yourself.
And finally, the community will provide the
responses, the affirmations, the supportive
responses as well as the negative ones and the
corrective responses. Now, while this may seem
obvious to you, what needs to be emphasized is
that all of this method essentially describes
individuals living together and carrying out the
process of recovery. So it’s very unlike
traditional treatment.
And now, just a word about how the community
produces change. What I’ve just described in
the previous slide is what we mean by
community as method. And this slide tries to
communicate briefly to you how community
produces change. Again, everything that is done
in the therapeutic community is addressing a
behavior, attitude, value or emotional
management issue in the individual: how they
work, how they relate to people in the dining
room, how they participate in the meeting, how
they participate in groups. All of those activities
essentially surface individual behavioral,
attitudinal, emotional characteristics which can
then be changed. And that’s what we mean by
everything can be an intervention.
In order for change to occur, the individual has
to have some relationship to the community.
That’s why I’ve used the words “affiliation,
participation and change.” What that means is
that in order for individuals to use the
community to change themselves, they have to
have some affiliation with the community, some
connection with the community. So much that
goes on in the therapeutic community is
designed to strengthen affiliation. If I am
affiliated with the community, I listen. If I listen,
I change.
The process of change is a gradual, gradual
gradient path of learning that leads to
internalized change. There are really four levels
of internalization, people changing. First, they
can change initially through compliance. I do
what the community says I have to do because I
don’t want to be thrown out and go to jail or go
to the street, or go back home. So one reason I
do what I’m supposed to do is “I’m complying,”
with very little internalization. Initially, in the
therapeutic community, the first changes that
we see in most clients are compliance.
The second stage is conformity. They gradually
now begin to do the behaviors and attitudes
that the community is expecting them to do,
based upon their increasing affiliation with
others. They do not want to lose the
relationships in the community. It’s still a form
of compliance, but it has shifted now to
relationships with the community. They don’t
want to lose those.
The third stage of learning is one in which the
individuals now are making a commitment, and
the commitment stage of internalization. They
will make the commitment that they want to
finish the program. These are the first changes,
learning and changing in recovery, that are
actually related to the experience of the
individual. I keep my room clean, because now I
feel better about myself and clearer in my head.
When I first came into the program I kept my
room clean because I didn’t want them to throw
me out. As I stayed on, I kept my room clean
because I didn’t want my peers to in some way
to discourage me. The third stage is, I keep my
room clean because when I keep my room
clean, my head is clean. That’s based on my
experience. You’re now entering internalization.
And the last stage of internalization is a
commitment to the change process. The
individuals now learn that for them to continue
to change, they have to literally “remain in the
change process even though I may leave
treatment.”
And the fourth point that you see in terms of
how the process occurs has to do with emphasis
on motivation and readiness. Most of the change
that comes about in an individual requires a
continuous sustaining of motivation—I want to
change—and readiness—I take action to
change. That must be, those two characteristics
must be sustained throughout, and much of
what goes on in the community is designed to
sustain motivation and readiness. And we say, in
the therapeutic community that individuals of
course bring about their own recovery but they
do that by using the community to change
themselves. To continually use the community,
they have to remain motivated and ready.
Again, the reason why they wanted me to speak
about program standards of therapeutic
communities is that it is a recent development.
And it was a very big step forward in the
evolution of this treatment approach. As I
mentioned earlier, the treatment approach is
well documented in the research literature. But
until recently we did many, many treatment
activities that would actually call themselves
therapeutic communities because that phrase is
a general phrase, therapeutic community. What
you have been hearing from me is that it is
actually a very, very specific methodology that
has a very sound theory to it and a set of
prescribed practices and a research base. So the
need for standards has been to address the
issue of quality assurance, making certain that
programs that call themselves therapeutic
communities were in fact treatment programs
that were adhering to the basic theory, method
and model of the therapeutic community. This
is a great step forward.
Therapeutic communities have been here for
about 40 years. We now have a significant body
of research, a theoretical framework that is well
described in the literature, and now we have a
set of standards which will help to prescribe best
practices. We’re not going to go through those
standards here, but what I want to make sure
that you learn today about these is that the
standards themselves apply to community based
therapeutic communities as well as special
adapted therapeutic communities such as those
in prison. These were developed for prisons and
they’re very detailed, therefore very educational
for those of you who want to learn more about
the therapeutic community and how actually to
implement properly implement therapeutic
community programs.
But the other very important feature about
these standards is that they are grounded in
both the theory and the research. So I will give
you some examples of that, just quickly. The
entire theoretical framework of the therapeutic
community and what I’ve called the theory—the program model and various methods which
we call community as method—can be
organized into 11 domains. There are some 121
item standards across all those domains.
If there’s a therapeutic community in the prison—and there are many of them now in the
United States—the field reviewer has a review
document and can spend two or three days in
the prison therapeutic community, and review
exactly how all of these domains are actually
functioning and whether the program is actually
delivering the treatment in accordance with
these standards. Let’s look at one or two
examples of these domains.
For example, there are standards which strictly
reflect the theoretical basis of the therapeutic
community. It says in the standards manual that
it’s essential that they have a program grounded
in the theory. And then it simply resummarizes
some of the key theoretical points. And then it
present some sample items of exactly how I
would walk into your program and check
whether you are meeting this particular
standard. There are more items than these
three, but this is an example. So that was the
theoretical domain.
Similarly a very critical domain in the standards
is the general clinical principles. I’ll just give
you one example. It is essential that program
participants identify with the therapeutic
community and feel a sense of belonging in
order to change their patterns of criminality and
substance use. Remember I mentioned the
issues of affiliation. There must be a continuous
24 hour atmosphere of constructive
confrontation and feedback—24 hours a day—to the individuals in the community as a whole, in order to raise personal awareness of the
individual behaviors and attitudes. Now that’s
the principle that governs the standards which
are very explicit items. And then there’s the
rationale for this principle and then some
examples.
It’s much better that you actually look at the
standards, but what I want to get across to you
is the relationship between the basic theory of
the therapeutic community, the elements that
therefore essentially should flow from that
theory and then the basic assessment method
through the standards themselves.
Let’s try one more area. Even on the
administrative level a standard is necessary.
Here’s the general principle. It is necessary that
key administrative and management staff
interface with a particular agency. This happens
to be a prison therapeutic community. So that in
a prison, the therapeutic community is in the
prison and may be provided by an outside
agency for the prison. And this standard says
that the individual agency, the prison itself and
the treatment provider have to be in a very
close interface. They have to be closely related
to the success of the program. And then there
are some standards to essentially assess
whether that relationship between the prison
and the treatment provider exists. I’ll take one
more and then we’ll stop.
It is essential that the entire staff function in a
manner consistent with the philosophy and the
practice of the therapeutic community. Let me
make a point about this because in my general
introductory comments I didn’t have the time to
detail the roll of staff in a therapeutic
community model which is largely a peer, self-help,
mutual self-help model. Staff have very,
very critical roles in therapeutic communities.
Their key role is as a community member. That
is, they have to role model what the program
itself is teaching. But they have other roles. Staff
are rational authorities making assessments
about individuals in the therapeutic community.
But they are not conventional therapists and
they are not conventional counselors although
counseling and therapy actually go on all day at
all times in the therapeutic community. I call
that informal. There’s much informal counseling
and therapy. It may be for two minutes at a
time, three minutes at a time. So that the
traditional view of counseling and therapy where
the client comes in to a counselor’s office for 50
minutes or one hour is relatively infrequent in a
therapeutic community. Because the primary
treatment agent is the community itself, not the
individual therapist. So that the role of staff,
when they are in a counseling situation, or in a
therapeutic situation, are always directing the
client to in fact go back to the community to
deal with what they have to deal with. So the
role of staff is really as facilitator and guide, not
really as traditional therapists. Even though
therapeutic moments go on all the time.
So this notion of the standards is very difficult to
get across because traditional professionals,
psychologists, social workers, psychiatrists, have
their own tendencies and want to essentially
carry out that role as they have learned it. The
traditional approaches in the therapeutic
community are not effective. There has to be a
change in the whole staff mindset when they
work in therapeutic communities. That’s been a
lot of my work over the years to try and teach
staff this model and method—how to move
from a primary provider to a primary facilitator.
Of course the therapeutic community is not a
provider-consumer model. It is a self-help
model. And the role of staff is to facilitate self-help.
So the standard becomes very important,
particularly as you move into prisons and you
move into mental hospitals. As you use more
and more of the traditional staff, this standard
becomes a very important standard and there is
an entire training initiative that essentially
follows this standard. How to get staff well
trained in this very powerful self-help model.
There are seven or eight other domains. I’m
going to not talk about those. You’ll look at
those in the monograph if you’re interested. But
let me stop and take some questions.
The question was, “How difficult was it to move
from the general statements, the general level
of the theoretical statements of the therapeutic
community to the very specific?” In reality, it
was for many years impossible to do that. But
once we were able to write a clear theoretical
basis for the therapeutic community, once we
were able to make that theoretical writing very
clear about what we do and why we do it in the
therapeutic community, then it was much less
difficult to move from the general statements to
the specific standard items. We needed an
explicit theory to do that. That was the difficult
part—the years of making that theory explicit
and clear. That was the difficult part. This part,
beginning to write the specific items for the
standards, this was much easier once we had
the theory.
Can we consider a little clinic? The answer is
yes, we can consider any clinic or any particular
environment as a therapeutic community if it
adheres to the perspective and the method.
That’s the important part of your question. And
I’ll answer it, if you allow me, in another way. I
have developed programs in many settings now,
prison settings, shelters for the homeless, in day
treatment settings for methadone clients. The
idea is that once we had a theory and a model
and a method, then you can use it to guide the
transformation of the environment into a
therapeutic community. Even if it’s day
treatment, or if you like, outpatient—even if
they don’t live there—you can, in fact,
incorporate the essential elements of the
therapeutic community. But you have to have
those essential elements and you have to
understand the theory behind those essential
elements. So the answer is yes, you can have
small clinics, schools, shelters, hospital wards,
and whole sections of prisons, which we have in
the United States now serving almost 12
thousand inmates in therapeutic communities in
prisons. So the answer is yes, but it takes
training and you need to know the elements and
you need to know the theory.
EVAC and PREHAB of Arizona:
Successful Multi-Systemic Approaches
Within a Community Context
Tom Hutchinson
Prehab of Arizona
United States
Thank you. I appreciate the opportunity to be
here this afternoon. My name is Tom
Hutchinson, and I’m Director of Community
Services for Prehab of Arizona. A colleague of
mine, Dr. Frank Scarpatti, is sitting to my left
and he works for the organization, East Valley
Addiction Council. These are two separate
organizations. Today, we are going to talk about
those two organizations. We are featuring one
program that deals mainly with adults and one
program that deals mainly with teens.
We’re going to talk about general concepts used
in the social model as well as characteristics of
two successful programs, the one being East
Valley Addiction Council, the other being Prehab
of Arizona. We want to talk a little bit about
client experiences within those programs, and
then we have time for questions and answers.
When Dr. Scarpatti and I were speaking the
other day, it was interesting because we found
things in common that our programs had. And
the word “caring” came up—that we have
caring, dedicated and committed staff who work
with our clients. Often these people are
forgotten, the people who work directly with our
clients. They show much love to the clients with
whom they are dealing. We also favored small
program size, feeling that clients feel cared for.
There’s a certain level of intimacy that develops
and also it helps with retaining staff members
over time.
Flexibility to meet client needs. We both are
from Arizona. We’re from the East Valley of
Maricopa County, and there is a variety of
people who reside there. So, our programs are
both flexible, in terms of language, in terms of
transportation, in terms of different services that
clients need at various levels. In both of our
programs there’s integrated treatment that
happens. EVAC features a medical detoxification
and yet there are other elements of treatment
that are involved – in particular, across a
continuum of care. Our youth programs which
we will talk more of in a few minutes, are very
comprehensive. Both organizations work with a
continuum. And we have a cooperative,
collaborative mindset which we practice in our
community, among organizations. One key
aspect was to protect the length of stay for the
client. Both of our programs are publicly funded
and therefore there is pressure around dollars
and moving people quickly and we felt that it is
very important to protect the length of stay of
the client in order for the client to be successful.
Our idea of the social model had to do with the
idea that substance abuse and addictions
operate in a context. They are simply not
something that can be described from a
biological or medical point of view or solely from
an environmental point of view. They grow out
of a person’s environment and also, they have
very serious repercussions across society.
Therefore, it’s important that for a person in
treatment, a person in recovery, that the
professionals work with all the client’s social
systems. We speak mainly of families, but also
of peer groups, neighborhoods. I would also say
that we need to deal with the various systems
that the clients find themselves in, whether it be
the public health system in our state, whether it
be the corrections system, whatever kind of
system that person is in. Our programs seek to
help that person understand how to best utilize
the resources available to them. Families are
crucial to success and failure. Peer groups and
neighborhoods and communities make a
tremendous difference in the recovery of
individuals.
The East Valley Addiction Council is located in
Mesa, Arizona. It’s located in the south central
part of the city and it is a gem. It is a very well-kept
physical plant. It’s essentially a small
hospital in the neighborhood. Dr. Scarpetti is to
be complimented for the great work he’s done
with building that facility in the last five years. It
has a budget of about 1.5 million dollars from
various sources. Most of that comes from the
state of Arizona, but the East Valley cities
support the program as well as does The United
Way. There is a continuum of care. It is licensed
by the Department of Health Services. It is
accredited by the Council on the Accreditation of
Rehabilitation Facilities, and 80% of the patients
that were seen in 1999—and there were 4000
patients that went through the program—are
homeless. A good percentage of the remaining
20% are low income individuals. So, these are
people in tremendous need of assistance. EVAC
provides some prevention services mainly
through the schools, provides training for staff,
presentations to youth, and various other
activities in the community. They are very
involved with presenting literally hundreds of
different presentations to different
organizations, to educate those people about
substance abuse.
The core service, SORT, stands for Stabilization,
Observation, Referral and Treatment. And when
an individual is referred to the detoxification
center, the first day or so is spent in that part of
the process. Some individuals leave after a day
of treatment. If they are severely affected and
toxified they will go into the medical detox. The
slogan is “detox with dignity,” and the program
prides itself on its staff. The medical director is a
toxicologist. All the staff members are either
registered nurses or trained as emergency
medical technicians. After the detox period the
program refers them to halfway homes and
residential treatment centers with emphasis on
relapse prevention for these individuals.
When we think of detoxification centers there’s
sometimes a problem with the idea that they’re
revolving doors in the sense that we see the
same people, time and time again. The vision of
EVAC is to stop that revolving door. They’ve
been working at it for about 5 years.
In the old model, there would be a crisis and
there would be a crisis team response, including
transportation and then the individual would end
up in the detoxification center and spend
anywhere from 0 to 5 days getting various levels
of care. Then they would often be released back
to their same circumstances. What EVAC has
done is included the SORT time, which is an
intensive assessment time, as well as a
stabilization period for the individual, and then
he or she moves into the detoxification phase.
The counselors who are on the staff are known
as transition counselors and they’re more
interested in transition management than they
are in actual process of giving clients therapy.
So, they work with our local healthcare
enrollment, social services assessment, family
reconnection, medication management and case
management referral. As the person moves
through the system, they’re given services
around relapse prevention. There is an aftercare
Naltrexone treatment program that saw about
400 people last year. And some individuals are
going into residential treatment environments.
However, in the state of Arizona, there are not
many residential beds, so most of the people are
referred to some kind of therapeutic community.
In the city of Mesa, there were some 80 or so
halfway houses. EVAC studied those and came
up with a list of 12 facilities they felt were
adequate to deal with the individuals that were
placed there. They audited each site for the
proper environment of care for cleanliness, for
training of staff, for staffing patterns. When it
came right down to it, there were 12 facilities
that met their standards, and many of the
individuals who go into the detox part, go into
the halfway homes. Of those, 75% have not
returned in need of detoxification. So that effort
at stopping the revolving door, seems to be
working with a significant number of individuals
in our community.
By the way, the most frequently occurring
circumstances that bring people to EVAC are
difficulties with heroin, alcohol, and methamphetamine,
and various combinations of
those drugs. The fact that most of the people
are homeless also leaves them in very physically
incapacitated, and often, there are 9-1-1 calls,
just to assist those people through their detox
phase. These people are suffering a great deal
and are given the kinds of comfort at EVAC that
they need. The model is based on the American
addiction medicine treatment model. And all
those standards are applied and monitored by
their accrediting body.
I appreciate the opportunity to provide two
presentations today.
I am an employee of Prehab of Arizona. We are
also located in Mesa. And we have a budget of
about $11 million from a wide variety of
sources. We have monies from the court,
monies from the Department of Health, from our
local Department of Economic Securities, as well
as various grants and foundations. In order to
survive, we have 2.5 individuals who simply
write grants and obtain various monies in order
to keep our programs going. We have 13
programs. We are private, non-profit, licensed
by the state, and we are accredited by the Joint
Commission on the Accreditation of Health Care
Organizations. We serve children, youth, adults
and families. We have an out-patient counseling
service, with about 1500 open files. We have
domestic violence and family homeless shelters.
We have training employment for hard to serve
individuals. We have alternative crisis centers for
youth. Then we have long-term residential
treatment with the school.
When people come to us, all medical services
are provided including psychiatric care and
psychological services. We have two doctors
that we use for psychiatric care as well as a
psychologist. The children receive mental health
counseling—group, individual, and family. We
have 20 kids, and there are about 20 staff.
There are 4 or 5 clinical staff and then other
support people. Our philosophy is to support
and promote abstinence, and we do that and
monitor individuals on a daily basis. We also
have support groups using the 12-step model
generally speaking with youth: Narcotics
Anonymous. And we also have our own school.
So we try and have an integrated program that
involves the mental health and t social aspects
of treatment as well as the recovery program.
We feel very fortunate that we have been able
to keep the length of stay at a level where we
feel it needs to be.
We also support aftercare. Family involvement
starts early. In fact, in the interview process the
family is involved. And if the family is unwilling
to support the teen who’s in treatment, we will
not accept that teen. There needs to be a level
of support for the treatment process or we will
not accept that individual. We start within 2-4
weeks family counseling on an individual family
level. We do work with extended families. We do
work with Spanish speaking people in particular
and have staff that can provide that service.
Also on a weekly basis we have multi-family
groups, most weeks of the year. We have onsite
visitation on a weekly basis on Sundays. And we
have home and neighborhood visits as the youth
start to become ready to return to their
environment. If the family is unsupportive and
there are active addictions going on within the
family setting, we will seek alternative
placements, whether that be the extended
family, other people within that environment, or
through any other means that we find
necessary.
In terms of the accreditation, we are considered
a Level One facility. We are not a locked facility.
The elopement rate is quite low because the
screening is pretty rigorous. We screen people
to make sure that they are willing to do work
and to stay in treatment. The elopement rate is
not high. Our environments are more homelike
than they are institutional. We believe in
creating a healthy milieu for the youth and
really focus on doing that in a thoughtful way.
And of course the idea of having individuals and
having leaders and having followers who are
committed to the long-term. Who are willing to
stay on a task such as their careers, we feel is
very, very important organizationally and
programmatically. And it’s important to express
to the community around us that we care about
and respond to their needs. And in doing so, we
gain community support. And that is not only on
a formal level through the United Way or
through the city councils, but also on an
informal level. For example, in Frank’s
neighborhood, there is a community garden.
And individuals from the neighborhood itself
come onsite, tend that garden, reap the fruits of
that effort and feel connected to their
institution. So, those kinds of activities we feel
are very important to create success, not only
for the organization, but for the clients involved.
In our youth centers we have celebrations. We
have graduations from school, graduation from
programs. We have holiday events, birthday
events. We bring in service groups to support
the environment in which they live and try and
keep that environment really appropriate for
their stays.
We also believe that people need to always
learn. That is the staff. We continue to
professionalize staff. I can speak for our
organization—it being mainly publically funded,
but we make every effort to train staff through
events like this, or through supporting their
education, because much of the work is done by
direct care people who maybe are not degreed
in some functions. We really promote that and
promote lots of training and education.
Also the need to collaborate and network with
other organizations creates strength. It’s not so
long ago that people competed with each other
organizationally, and they competed for the
dollars. That atmosphere is changing on the
program level to a great extent, and that allows
for more healthy environments overall. In terms
of client support, there were times when the
doors were closed to different people who were
interested. I can speak for our organizations
that all supportive people who were involved
with the client are invited to become involved
with those individuals in the treatment process.
We consider it very important within our settings
to do that with immediate families, even families
who are struggling with their own issues and
their own addictions, and also extended families
in particular.
I appreciate your time and your attention.
