The Quality of Aftercare in the Czech Republic
Research on quality of life for individuals with special needs: SPP: 43413041 / 31. Institute of special education studies, Faculty of education, Palacky University, Olomouc, Czech Republic.
The following text aims to fulfil two purposes; the first purpose being to create a theoretical outline of aftercare. The second purpose comprises of presenting and comparing research regarding the explored subject. Most of the research presented in the paper was undertaken at the Institute of Special Education Studies at the Palacky University’s Faculty of Education. The results of three diploma theses supervised by the author of this text are also used.
Key words: aftercare, substance dependence, research, drugs, alcohol.
1. Introduction into the subject – a general outline of aftercare
1.1. A general outline of aftercare
Aftercare or aftercare programmes follow after the treatment of substance dependence in a psychiatric hospital, therapeutic community or specialised department in prison. Clients of these programmes are usually persons with impeded psychosocial development. Often they are graduates of institutional education, persons with criminal record, persons with aggression problems or persons with personality disorder in whom abstinence from the habit-forming drug uncovers therapeutic potential and the underlying cause of the initiation of dependent behaviour.
The purpose of aftercare is to retain the changes that occurred in the client throughout the treatment or, alternatively, spontaneously or after previous interventions.
In the last ten to fifteen years aftercare is the domain of aftercare centres that offer a wide range of services.
According to the conception of the Ministry of Labour and Social Affairs aftercare is one of the most essential factors for the overall efficacy of the process of treating substance dependence. The transition of the client from treatment to aftercare is in European countries considered to be the most important moment in the treatment process. This experience is in line with the practical experience of non-alcoholic drugs service providers operating in the Czech Republic. Therefore, ensuring adequate capacity in the aftercare programmes that would be commensurate to specific needs of the clients and logically complete the chain of existing services is absolutely crucial.
During the transition of the clients to the aftercare programmes the continuity of the treatment process should not be interrupted therefore it is desirable that aftercare centres communicate well with the programmes from which the clients are accepted. Ideally, contact between the client and the chosen aftercare programme should be arranged before completing the basic treatment. The team of the aftercare facility should be informed of basic principles of the treatment programme that the client has undertaken. An important element in the whole treatment process is a subsiding intensity of the support given to the client in aftercare. The client is given opportunity to take a full responsibility for his or her life. In practice the respective communities and psychiatric hospitals often collaborate long-term with aftercare centres and they inform their clients of the aftercare principles while they are still under treatment.
In aftercare programmes a multidisciplinary team is absolutely essential. The team of the program should be assembled based on the needs of the clients. Focus should be on the main purpose of aftercare which is to gradually disassemble the bonds between the client and his particular program. Each aftercare programme should aim to create a good quality network of specialists in response to the problematic areas of its clients.
The core team of the aftercare programme must comprise of a psychologist, a special pedagogue and a social worker. Special abilities include good quality training in counselling or psychotherapy and most importantly include relapse prevention. There is a vast field open in these programs for ex-users. Those work very well, under supervision and after having achieved specialised education, in the field of sociotherapy. (Kuda in Kalina, 2003).
What also appears to be helpful is contact between the given aftercare programme and external specialists such as a regional public health authority, dentists, general practitioners, free legal advisors etc.
Main elements of aftercare are:
- Psychotherapy – clients in aftercare programmes may manifest various traumatic experiences from the period of drug usage, personality disorders from time before the drug problem as well as other problems connected to the drug usage. Therefore it is essential to correctly diagnose what issues of the client are possible to deal with in real time. It is not possible to deal with all problems that arise during the period of addiction; rather, the work with client should focus on strengthening abstinence from the primary drug. For this reason support psychotherapy focused on stabilising client’s emotional state is being used. Current literature states that cognitive-behavioural therapy is a core therapeutic approach. According to the research among the staff of aftercare centres only few are educated in this therapeutic area. Currently, psychodynamic SUR training is prevalent.
- Relapse prevention – fear of failure is a basic motivational factor for entering an aftercare programme in newly-recovering people. For the majority of abstinent individuals it is very difficult to resist craving. The goal of relapse prevention is to equip the client with skills and knowledge and thus strengthen his self-control which lowers the risk of a relapse. Relapse prevention is therefore the theme of a substantial number of group sessions.
- Social work – a wide range of social and legal problems may be observed in clients in aftercare programmes, problems such as debts with the insurance companies and other debts, social benefits, prosecution, etc. The help offered by the social worker must be practical since most clients are not able to solve these problems on their own. A good social worker is a core member of an aftercare programme team.
- Work, sheltered employment and qualification – one of the basic elements of integration into a normal life is acquiring a job. This is one of the main tasks of an ex-user released from treatment. However, they often lack the necessary specialised qualification or the correct work manners. One possibility how these troubles may be overcome are sheltered workshops. Those enable the client to acquire basic work manners or to get a qualification. It is important to assess correctly whether the client really needs sheltered employment or is able to get a placement at the labour market. Therefore good cooperation between aftercare programmes and jobcentre offices, local firms, etc. is part of this area.
- Health care – drug-abuse is damaging to the human body. Among the most frequent problems of the clients are: hepatitis type B and C, gynaecologic and dental problems. Health care should not be forgotten in aftercare. The clients need both mental and physical stabilisation. Cooperation with doctors and help in ensuring adequate health care are elements of aftercare.
- Offer of leisure activities – to learn to “enjoy” without drugs is an essential goal of the treatment and aftercare. It is often observed that clients, in fear of relapse, fill their whole daily programme with tasks. It is not possible to continue this way indefinitely; energy is lost after some time. What had seemed protective before becomes the cause of stress leading to relapse. An offer of various types of leisure activities is what really prevents relapse.
During the transition of the clients to the aftercare programmes the continuity of the treatment process should not be interrupted therefore it is desirable that aftercare centres communicate well with the programmes from which the clients are accepted. Ideally, contact between the client and the chosen aftercare programme should be arranged before completing the basic treatment. The team of the aftercare facility should be informed of basic principles of the treatment programme that the client has undertaken. An important element in the whole treatment process is a subsiding intensity of the support given to the client in aftercare. The client is given opportunity to take a full responsibility for his or her life. (Kuda in Kalina, 2003)
1.2. Structure of aftercare programmes
In a narrow sense aftercare concerns post-treatment abstinence support and maintenance. In a broader sense the aim of aftercare is social integration of the client into normal life. Among the interventions necessary for the treatment of substance abuse are relapse prevention, support group therapy, individual therapy and counselling, leisure activities, social work, work counselling, sheltered housing, sheltered employment and qualification, work with family members and health care. Intensive aftercare programme usually lasts 6-12 months; it raises the treatment efficacy rates and shortens the duration of aftercare. (Kalina, 2003) It seems to be helpful to provide the clients with certain benefits when attending the programme successfully. Among these can be internet use, washing of clothes, more counselling etc.
Aftercare programmes are under the auspices of the Government Council for Drug Policy Coordination (GCDPC) and the Ministry of Labour and Social Affairs. In order to obtain funding from government subsidies, the programmes must follow certain rules and comply with the conditions set by GCDPC. One of the most important conditions for obtaining the subsidy is obtaining a certification of the services. Certificate of professional competency is issued or withdrawn by GCDPC, based on a proposal of the Committee for Granting Certification, after a certification assessment is realized by a Certification Agency that acts based on a request for such assessment and attaching the required documents.
The granting of certification may be requested by any natural or legal person providing services to the target group of narcotic drug and psychotropic substance users, the content and assessment criteria of which are defined in the approved Standards of Professional Competency, specifically in the special section of these standards. (Kalina, 2001)
As a concrete example the structure of the services provided by The Aftercare Centre in P-centre in Olomouc can be mentioned. This centre fulfils the Standards of Professional Competency. Reasons for mentioning the programme of this centre are as follows: 1. It is the workplace of the author, 2. the centre was one of the places where the research described below was undertaken, 3. the facility is very similar to other aftercare centres.
The length of the programme in P-centre is usually 6 to 8 months depending on the needs of the client, the shortest being 3 months. The client may decide to use the sheltered housing that usually lasts 4 months. The sheltered housing is not available, however, without attending the aftercare programme.
In the early days, when the client enters the programme, he is introduced to the operation and staff of the centre, attends the first morning sessions, as well as the first session with his advisor and together they develop a plan for the first several weeks and write an agreement for the provision of services. On the following days he participates at thematic groups and clubs, explores the city of Olomouc, is introduced to other clients of the programme, looks for a job and starts working with his advisor on the therapeutic contract.
The aftercare programme comprises of compulsory and optional activities. Attendance at the compulsory activities is one of the conditions for accepting the client into the programme. The compulsory activities are:
Individual therapy – individual consultation is between the advisor and the client. The client usually attends it once a week; more frequently at the beginning of the programme. The length of one session is approximately 45-60 minutes. The date of the session is agreed on by both parties beforehand and it is their responsibility to attend the consultation or excuse one’s self at least one day before. At the individual sessions the client has an opportunity to talk about his or her feelings, moods, tastes, relationships and, most importantly, works on the tasks in the contract.
Social work – a social worker assists the client in solving social matters. He or she sends documentation to the jobcentre office and other relevant departments at the city council about participation in the aftercare programme, changes the contact address to be in Olomouc, files requests for monthly payments in case of debts, contacts the probation and mediation services for clients with legal punishments, conditions, etc. The worker also passes contact information of general practitioners and other specialists and assists in finding a job. The worker does not solve problems for the clients, rather accompanies them so that they learn to solve these problems themselves.
Reflection groups – these are held every 14 days. The client, other members of the group and the therapists reflect on the past two weeks. They reflect on the therapeutic contract together, seal and introduce new contracts and celebrate significant events such as getting a job or housing, finishing the programme and similar. If the client is not able to attend the group for special reasons they must excuse themselves to one of the team members.
Dynamic group – is held every 14 days on Mondays just like the reflection groups but these do not have a set theme. The client is expected to bring up a topic and share it with others, to willingly accept advice, critique, opinions and suggestions, to try to express his or her feelings, moods and to show interest in other clients. Dynamic psychotherapy and cognitive-behavioural psychotherapy is used in the dynamic groups.
The goals of the group therapy are: changing the non-adaptive scheme, support maturation of personality, interpersonal communication skills, etc. (Polínek, 2013)
Thematic groups – are held once a week. The respective themes concern typical problems that the clients encounter. Programme of the thematic group consists of theoretical introduction into the theme, discussion and enacting problematic situations and possible solutions of individual problems on the given theme. In some cases the themes are brought up by clients and in others the therapists prepare a series of themes.
Housing groups – are held once a week. The group is attended only by clients using the sheltered housing and the social worker. At these sessions the running, upkeep, division of duties in care for the sheltered housing, assessment of the house manager’s work and the monthly shifting of the function to another client are addressed. The housing group is chaired by managers of the two sheltered houses together.
Morning groups – are held each working day in the morning and are compulsory for the clients in the sheltered housing who do not have a stable job or are incapable of work. This group is managed by clients and the social worker. During the meeting every member makes an individual plan for the day, cleaning duties are set and practical daily problems are solved.
Clubs – are held once a week unless a different schedule is agreed on. The purpose is to spend leisure time actively and to relax. The clients and the social worker, and sometimes selected external workers take turns in its preparation.
These are among the optional activities:
Family and relationship therapy – participation of client’s relatives at the therapy is very important. The parents are recommended to at least visit the P-centre to be introduced to the therapeutic programme, the team and the whole centre. If the client is not happy with the family relationships and would like to improve them he is offered a regular therapy. Clients may also be offered family or relationship therapy with specialists outside the P-centre.
Qualification – the clients receive help with choosing an accredited retraining course or distance study programme. The clients are provided with maximum support during the course. So far all clients have finished their qualification courses.
Computers and internet – altogether three computers with internet access are provided for the use of the clients. The computers should be used to acquire at least basic computer and internet skills. The clients should be careful not to become internet addicted.
Sports equipment rental – sports equipment is available for rent: mountain bikes, balls, squash rackets, rafts Palava for two with accessories, backpacks, tents and so forth. These are also available on the weekends when the clients organise their activities alone. The service is free of charge. Clients who are not accommodated at the sheltered house are required to pay an adequate deposit.
Gallery U Mloka – the gallery is open for public and various types of events are held here such as exhibitions, film-screening, drumming, poetry-reading, photographic course etc. The gallery also serves as a teahouse open for public where volunteer students help out. Clients may invite their guests here or borrow books from the gallery library. Talent for arts is not rare in ex-users. Works of art created by the clients of the aftercare programme are displayed in the gallery.
1.3. Description of the sheltered housing
The clients who are accommodated in sheltered apartments have certain responsibilities and rules connected with this service. Those are paying the rent, locking the main door, rules concerning accepting guests, washing, the internet, curfew, cleaning, phone-calling, correspondence, appointing a house manager etc. These are described in detail in the Aftercare Centre’s Guide which is a manual that the client receives at the introductory consultation.
As part of the sheltered housing random testing of the clients for addictive substances in urine is carried out. The testing may be done during the day or as part of the night check. The night check is carried out usually twice a month. Not only do the clients have responsibilities but they also have their rights and one of them is for example the right for privacy. The P-centre’s staff members enter the clients’ rooms only when necessary and always after knocking. Clients should behave the same way to each other.
In relation to the Ministry of Labour and Social Affairs aftercare programmes must comply with the registration conditions and follow the quality standards of social services. The registration is adjudicated by the county office according to the permanent residency of a natural person or in case of a legal person the headquarters and when the provider of the organisation of social services is the Ministry itself it also issues the registration.
1.4. The client of an aftercare centre
Each aftercare centre is designed for a certain target group. Usually it is for people who were addicted to narcotic substances, underwent a treatment or had been abstinent for some time.
The Social Services Act puts the person who wants to actively use the services to the position of a contracting party. The person becomes a social services user at the time of signing the contract. The new law therefore uses the term user. A social services user can be anyone who has a contract with a social services provider as determined by law.
The types of clients in aftercare centres vary according to the requirements that the client should fulfil at entering the aftercare programme. For example The Aftercare Centre with Sheltered Housing Sananim provides its services to clients with a diagnosis of non-alcoholic drugs dependency or combined dependency on alcohol and non-alcoholic drugs. Other requirements may concern abstinence from illegal drugs and alcohol for an uninterrupted period of three months or previous fully completed treatment in an inpatient or outpatient setting. The same length of abstinence applies to persons who have not undergone previous treatment.
1.4.1. The characteristics of the client of an aftercare centre
People entering an aftercare programme come with certain previous experience and experiences, some positive and some negative. During aftercare it is necessary to bear in mind that the client possesses a unique personality and the approach must be individual. Human personality is shaped partly by genetic code, for example as in the case of the temperament, and partly by qualities gained during socialisation in which the society and family influence the values and patterns of behaviour. Some theoretical models consider temperament as crucial in the process of developing addiction to drugs and alcohol.
Supporters of psychoanalytic models consider substance dependent individuals to have severe mental conflicts, in terms of a strict superego. The use of alcohol or other substances is an escape from feelings of anger and fear. According to behavioural models substance use is learned and maintained through classical or operant conditioning. Science considers thoughts and feelings to be important determinants of behaviour in response to the environment. Given the fundamental role of the family in the learning process family factors must be noted. Majority of addicts had experienced a “polar” approach from their parents: over-protection, authoritarianism, dominance combined with inconsistency, reduced interest and hostility. In a pathogenic family there may be observed fewer activities done together and more frequent conflicts, trauma and deprivation. Individuals may also be affected by the dependence of family members on non-alcoholic drugs or alcohol.
The loss of self-esteem which is a dysfunction with a focus on the needs and behaviour of others also significantly contributes to the formation of dependency. The addicted person first binds to a person, and only later to alcohol or drugs. The use of drugs is not always associated with pathological influence of family, genetic predisposition or personality disorders. Sometimes the person is only curious about the effects of the drugs, is bored and wants to try something new. Friends and acquaintances can then be those who offer him the drug and mention its positive effects. It is well known that peer group influences the behaviour, attitudes and values of individuals.
Among the special characteristics of persons entering the aftercare programmes are a reduced resistance to stress, problems with self-esteem, an inability to maintain a lasting relationship, a fear of rejection, a low emotional response, a smaller degree of responsibility, personality disorders (disharmonious development of the personality, polymorphic psychopathy, social maladaptive disorders and asthenic disorders) and in former cannabis-based drug users also a reduced memory. (Jeřábek in Miovský, 2006)
1.4.2. The rights and responsibilities of the client in an aftercare centre
For effective functioning of an aftercare programme it is important to clearly set rules to be followed both by the client and the staff of the centre. The rights and duties of the clients are similar in all aftercare centers. The rights of the client can be adjusted by the Workers Code of Ethics which describes the procedures for the staff. The duties and rights of the clients are included in the Aftercare Centre‘s Guide, the knowledge of which is often a condition for the client‘s acceptance into the programme. Prospective service users are informed of their rights and duties before so that they know how to behave and what to expect from the staff.
Specifically, we present the rights and duties in the Aftercare Centre at P-centre in Olomouc. The staff of this centre expect from the clients willingness to work on self-improvement, an active participation in the programme, abstinence and a respect for certain basic rules such as non-violence (mental and physical) to everyone in the P-centre, a respect for the private property of the clients and the P-centre and no planning or committing crimes.
2. Research concerning aftercare
In the world a whole series of research concerning the importance of addictions treatments whether it is detoxification, inpatient or outpatient treatment or aftercare has been undertaken. Among these are for example the American research DATOS (Drug Abuse Treatment Outcomes Study) or the British NTORS (National Treatment Outcomes Research Study) (Radimecky, 2009). In the Czech Republic it is the research by the National Monitoring Centre for Drugs and Drug Addiction. The results of this research show that treating drug-users is effective, necessary and beneficial to the state. Even if the clients are not successful in staying abstinent their health and social state improves in such measure that they require less specialist care. Majority of users who undergo treatment show low-risk behaviour and a tendency to start another treatment earlier in the case of a relapse. On the website about addictology mentioned above (Radimecký, 2009) it is also stated that American and British research showed same conclusions concerning the aftercare for dependent persons. According to these, aftercare programmes raise the success rates of the treatment by 80 %, meaning that they maintain the changes, especially abstinence, that occured during treatment. It is because of what has been already mentioned above: the help with the transition from the treatment to the conditions of the normal life and the provided psychological support in overcoming the problems of everyday life.
One of note-worthy works carried out at the Palacky University is the research by Eva Maierova (2009). In her work she examined the motivation of substance users in her diploma thesis entitled: „Motivation of Female Drug Users in Compulsory and Voluntary Treatment“.
The author focused the research primarily on women. In her research she aimed to determine what motivation the female clients in compulsory treatment have compared to the clients in voluntary treatment. The answers obtained using a questionnaire and semi-structured interview showed greater motivation for treatment in women who are treated based on their own voluntary decision.
Clients recovering in voluntary treatment were most motivated by an improvement in mental health (86 %) and relationships (83 %), furthermore by improvements in the area of work (69 %), living standard (68 %), legal matters (49 %) and physical health (47%). The respondents of compulsory treatment were most motivated by relationships (68 %), mental health (61 %), work area (52 %), living standard (51 %), legal matters (45 %) and physical health (43%).
In both groups there is a notable match in motivation. The only difference between the groups is shown in mental health and relationships where the greatest motivating factor in voluntarily treated clients is mental health and in clients under compulsory treatment the first position is taken by an improvement in relationships.
Another subject in the research were the therapists working in organisations providing voluntary treatment and therapists providing compulsory treatment. In this respect, the interest focuses on the confrontation of the therapists‘ opinions about the motivation in the treatment of the obtained responses from the interviewed clients.
According to therapists of the compulsory treatment group there are three types of motives. Firstly, some motives are external, concerning relationships with parents and close friends, and about 70 % of the clients are motivated by these. Other motives are children and the clients themselves. The same can be seen in clients under voluntary treatment. In both cases the clients enter the treatment at the instigation of someone else or as a result of adverse circumstances; in some it is for criminal offense and in some clients under voluntary treatment the reasons are parental pressure or unfavorable financial situation. Initially, their motivating force is external and negative and only later in the course of the treatment it starts transforming into inner and positive motivation.
We will attempt to summarise here the research realised at the Institute of Special Education Studies at the Palacky University’s Faculty of Education in 2009-2013.
Research no. 1: Possibilities of social rehabilitation in aftercare programmes (Růžička, Martínková, 2009)
This research confirms the importance of aftercare programmes. It shows that aftercare programmes help the clients to find a job and friends outside the drug environment. These are two pillars of a successful social rehabilitation.
Research no. 2: The quality of life in graduates of aftercare programmes (Růžička, Klusová, 2010)
This research focused on the motivation for abstinence in graduates of The Aftercare Centre in P-center, Olomouc. The gender of the respondents was not emphasized; both women and men in an age range 24 -35 years were interviewed. However, there were more men in the group.
The results obtained using a structured interview showed that respondents‘ motivation for abstinence lies in negative experience gained at times of the addictive behaviour. Mental and health problems associated with drug use, unsatisfactory financial situation, living on the street, poor or no relationships with family members or close persons and the subordination to the drug were among the experience. A positive motivation for abstinence was independence, self-control, achievements in treatment, plans for the future and positive relationships with close people. Some degree of similarity with the results of Eva Maierova’s research may be noted here.
Research no. 3: The quality of aftercare programmes in men addicted to alcohol (Růžička, Opavová, 2013)
The results show that there is a significant difference between the clients‘ needs and the services the aftercare centres provide. In other words, the research revealed differences between what clients want and need and what they encountered in a particular facility . One of possible solution seems to be regular surveys on this issue by respective aftercare facilities and whenever possible and appropriate a change of the offered services or some of its aspects.
It has also been shown that the importance of aspects of offered services is comparable in clients who have used the services of an aftercare facility in the past and those who attended an aftercare facility for the first time. It seems it would be useful to pay more attention both to the newly-enrolled clients as well as the existing ones, especially in the area of aspects of the services in order to increase the credibility and thereby the support of the services. Another outcome of the research confirms that the dependency on the therapist does not change with the number of enrollment in an aftercare facility. The research results show that the therapist is a key element in an aftercare facility for the clients and this fact does not change during the aftercare treatment. Finally, the research looks at whether there is a connection between an assessment of the services of an aftercare facility and their importance and education and place of residence of the clients. No significant differences between the mentioned characteristics were noted.
Research no. 4: The quality of life in aftercare programmes clients as viewed by the staff (Růžička, Hutyrová, 2013)
This research examined the views of aftercare centres staff on four criteria of life quality in clients. These are housing, work, relationships and leisure time. The results show that the management of sheltered housing should be the responsibility of the provider with one appointed client. This is a policy frequently used in practice.
It is interesting to note that despite the impacts of economic crisis the clients have expectation of employment and many are able to find and keep a job. As regards to the relationships the clients aim to establish a long-term relationship. A new stable partner is often a motivational element for a new life without drugs.
The responses in regards to the leisure time vary significantly. This topic is very popular and it seems that clients coming from communities are more successful in planning their leisure time than clients released from psychiatric hospitals. The respondents agree that the quality of leisure time is proportional to the success of abstinence. Many aftercare programmes support this and guide the clients towards many different activities like hiking, water sports, arts etc.
The results of the research realised at our department correspond with the results of international research and clearly show the importance and impact of aftercare. For this reason we consider it beneficial to apply the principles of aftercare to the area of institutional education.
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The text aims to fulfil two purposes; the first purpose being to create a theoretical outline of aftercare. The second purpose comprises of presenting and comparing research regarding the explored subject. Most of the research presented in the paper was undertaken at the Institute of Special Education Studies at the Palacky University’s Faculty of Education. The results of three diploma theses supervised by the author of this text are also used.
We hope, that the text can desribe the aftercare problems in Czech Repulic.
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