Pauline McKeown, CEO Coolmine TC

1. Treatment Pathways and Outcomes of Therapeutic Community clientsPreliminary findings from a longitudinal mixed methods study Pauline McKeown, CEO Coolmine TC

2. Background/context • Internally- no outcomes research • Irish National Drug Strategy 2009-2016 • Recruited & established Best Practice Advisory group • Key partners TCD, HRB(Ireland) • Ethical approval late 2010

3. Study Aims To gather baseline data on drug use, health & behaviour status upon point of entry to TC To track clients longitudinally over the period of treatment engagement & 18 month follow up To compare outcomes for Coolmine TC clients internally and externally

4. Study design • Primary treatment services- 2 residentials male(Lodge:n76), female (Ashleigh: n38) & out-patient (drug free day programme- DFDP:n32) • Mixed methods • All admissions Feb 2011-2012 • n146 quantitative • n28 qualitative

5. Methodology • Quantitative data- Treatment Outcomes Profile (TOPs) & NDTRS • 20 item self reporting measure by National Treatment Agency UK (Marsden & Farrell) • Qualitative data set- semi structured interviews • Client motivation/readiness to change • Client progression feedback on structure/treatment approach • Retention & premature exit • Transition to Phase 2/Integration

6. Quantitative key findings 146/109 (75%) study retention of study participants Retention rate in treatment 53% Female rehab (55%), Male rehab (54%), DFDP (41%) 77% had not used illicit substances (included alcohol) 52%, n57 reported injecting drug use; 3% n3 at follow up Health improvements, psychological, physical, better quality of life Social functioning improvements, higher employment, education and housing

7. Emergent client profile (Quant) Gender: 69%/n101 male & 31%/n45 female Ave. age 30years (range 18-50) 57%/n84 reported drug free at baseline intake Of this, 28%/n41 prescribed methadone at baseline

8. Primary drug of choice

9. 6 month Tx retention rates (n=146)

10. Percentage of individual reporting drug use- baseline & follow up • Marked reductions in drug use • 37% reported baseline drug use, 20% ceased any drug use 28 days prior to follow up

11. Frequency of injecting behaviour Risk behaviour of injecting use more prominent in female study population

12. Changes in health outcomes(n=109)

13. Work & Education rate(30 days prior to baseline & follow up) • Positive increase social functioning • >9% emp’t & >15% education

14. Qualitative findings n28 57%/n16 male; 42%/12 female Ave age 33 (range 20-47) Drug careers varied (range 6-33yrs) Cannabis & alcohol main first drugs n12 reported serious health issues (Hep C & Depression) n15 reported criminal activity Opiate main drug seeking treatment

15. Emergent themes Main themes emergent from data: • Readiness for treatment • Satisfaction with treatment • Structure, routine & responsibility • Group and 1:2:1 interventions • Explore retention & premature exit • Transition period Phase 1 to Phase 2 (integration)

16. Readiness for Treatment Legal issues & social workers significant role Women notably more barriers to contend with Childcare & Social workers/child protection services Ashleigh House childcare service invaluable Female early leavers- first time tx/conditioned Motivation appeared to dip for the women as time progressed. Anxiety & depression significant contributor

17. Readiness for Treatment Men: legal pressure impetus to seek treatment Questioned readiness prior to entry Good first impressions critical to engage/remain with Out-patient (DFDP): no significant gender variances Majority had prior experience of treatment and appeared highly motivated and ready for treatment Data suggests motivations for treatment is not the same as readiness for treatment

18. Satisfaction with treatment • Study elicits that the majority of all clients were satisfied with phase 1 treatment programme • However, significant Gender differences • Women struggled with rules, responsibilities and “community as method”. • Adjusting and conforming very difficult • welcomed the Community Reinforcement Approach. • All found the staff to be very helpful, understanding and approachable. No client/staff divide • Perceived staff to be under resourced/desire for more staff interaction

19. Structure/Routine/Responsibility Men: happy with peer led community and staff only acting as facilitators. Wary of authority at entry. Men embraced “community as method”, structure, rules and responsibility. Big Brother/Orientation/Pull up system much stronger in the men's residential. Men appeared to embrace this.

20. Group Work/ 1: 2: 1 Work • Majority of all clients stated they were satisfied with the range and selection of groups. • Gender differences noted in experience of group work. • Women: found participating in groups daunting/difficult task. • Prevalent for first time treatment experience • For many, group work was not addressing their needs and expressed a desire for more 1:2:1 counselling • Trust major issue

21. Cont’d…. Group work/1:2:1 work Lodge: Most of the men reported group work as the best part of the programme Felt safe opening up in groups Embraced the peer led, self help approach to treatment Behaviour change a result of group participation and peers

22. Cont’d….Group work/ 1:2:1 work Day Programme- Most clients had prior experience of residential treatment and group work Most comfortable in group work 1: 2: 1 Key working sessions very important for day programme clients

23. Retention and Premature Exit A total of 28 clients agreed to take part in qualitative interviews at the start of their treatment. 15 of the 28 (53%) successfully completed phase 1 of treatment and progressed to phase 2, 13 left the services early Average time in the programme before premature exit was 4.4 months. Reasons for premature exit included substance use, breaking contractual agreements, and personal and practical issues Follow up contact highlighted reduced relapse period & quicker re-engagement

24. Factors relating to premature exit No one factor Shared characteristics Young (18-25) Conditional entry No prior tx episode Struggled with groupwork

25. Transition to phase 2 Transition from phase 1 to phase 2 challenging Report being unprepared for this transition CTC did not provide enough support Securing stable housing was priority for many clients leaving phase 1 Shared housing appeared to be problematic for a number of clients, while transitional housing appeared to be preferential route

26. Transition to phase 2 ‘New identity’ theme Busy structure- meaningful activity Community employment scheme schemes played a significant role External network of support 12 step/fellowships meetings

27. Conclusions & recommendation Positive changes for CTC clients Increase project staff resources (female TC) Consider orientation phase for detox clients Increase counselling/psychotherapy (Female TC)

28. Recommendations Cont’d…. Address better depression and anxiety related disorders prevalent Develop further social and fun activities in phase 1 More personal development- confidence and self esteem Phase 2/Transition more resources Increase client/staff contact Phase 2

29. Current study status Tracking 12, 18 & 24 month periods Early results 57% (n65) drug free at 12 month 7 graduates/24 in service 32 premature exit (n106 at 6 month) 3rd/4th qualitative data sweeps underway

30. Thank you for your time!!Feedback/Q&As Contact : anita@coolminetc.ie for further detail/mid term report