11th EFTC European 11th EFTC European Conference on Conference on

Rehabilitation and Rehabilitation and DrugPolicy .DrugPolicy .

Ljubljana- Slovenia – Ljubljana- Slovenia – 2007.2007.

Phoenix House Haga – Phoenix House Haga – Norway.Norway.

Some recent research Some recent research indicators of positive indicators of positive treatment outcome.treatment outcome.

OrganisationOrganisation• Phoenix House Haga is a small drug Phoenix House Haga is a small drug

free therapeutic community.free therapeutic community.• Located in South Eastern Norway, Located in South Eastern Norway,

approximately 68 kilometres south east approximately 68 kilometres south east from Oslo.from Oslo.

• Primary residential treatment capacity Primary residential treatment capacity is 35 beds.is 35 beds.

• In addition we have 3 re-socialisation / In addition we have 3 re-socialisation / re-entry houses. Two are close to the re-entry houses. Two are close to the main community, the other in the main community, the other in the closest local town, 3 kilometres away.closest local town, 3 kilometres away.

OrganisationOrganisation

• The programme has a board of The programme has a board of directorsdirectors

• Is a not for profit foundationIs a not for profit foundation• Regional Health Authority East are Regional Health Authority East are

allocated 22 places in the residential allocated 22 places in the residential programmeprogramme

• Other beds are purchased by various Other beds are purchased by various regional health authorities throughout regional health authorities throughout the country. the country.

Target GroupTarget Group

• The target group is young men & womenThe target group is young men & women• Key issues are, frenquent & dependent drug Key issues are, frenquent & dependent drug

use, disfunctional family, loss of education use, disfunctional family, loss of education prospects, loss of friends, unemployment.prospects, loss of friends, unemployment.

• Who require long term residential treatmentWho require long term residential treatment• From 2004 the primary treatment is 12 From 2004 the primary treatment is 12

months.months.• The age range is 18 – 30 yrsThe age range is 18 – 30 yrs• Admissions are accepted according to Admissions are accepted according to

Pargraph 12, of the justice system.Pargraph 12, of the justice system.

Mental health concernsMental health concerns• People with serious mental health People with serious mental health

problems are not part of this target group.problems are not part of this target group.• However, it is unaviodable that some However, it is unaviodable that some

persons have additional co-morbity persons have additional co-morbity problems.problems.

• There have been instances where mental There have been instances where mental health issues emerge after admission.health issues emerge after admission.

• Phoenix House Haga has an excellent Phoenix House Haga has an excellent cooperation with the local district cooperation with the local district psychiatric team.psychiatric team.

• Consultant psychiatrist – 24 hrs cover.Consultant psychiatrist – 24 hrs cover.• General physician for all members General physician for all members • Regular dentistRegular dentist

Some examples of co-Some examples of co-morbidity, over recent morbidity, over recent

years:years:• ADHDADHD• SchizophreniaSchizophrenia• Tourette’s syndromeTourette’s syndrome• Eating disordersEating disorders• Reading & writing problemsReading & writing problems• DepressionDepression• Social anxiety issues.Social anxiety issues.• Sexual abuse traumaSexual abuse trauma

• Through close working relationshipThrough close working relationship• With specialist agencies and support staffWith specialist agencies and support staff• Many of those residents are graduates of Many of those residents are graduates of

the programmethe programme• Living drug free lives.Living drug free lives.• Each community member has an Each community member has an

individual treatment - action plan.individual treatment - action plan.• Action plan continues through primary & Action plan continues through primary &

post primary treatmentpost primary treatment

IdeologyIdeology

• Phoenix House Haga is a 3rd Phoenix House Haga is a 3rd generation therapeutic community.generation therapeutic community.( Broekaert)( Broekaert)

• The model ’Community as The model ’Community as Method”( De Leon) is modified for the Method”( De Leon) is modified for the realities of the Norwegian culture, realities of the Norwegian culture, traditions and individual needs.traditions and individual needs.

• Our historical roots can be found in Our historical roots can be found in both the U.S.A and Europe.both the U.S.A and Europe.

Values Values • Central to the value system is respect for the Central to the value system is respect for the

individualindividual• Belief in the persons inner capacity for Belief in the persons inner capacity for

positive growthpositive growth• Equality for each person, regardless where Equality for each person, regardless where

they may be within the structure of the they may be within the structure of the organisation.organisation.

• The strength of the community itself, as a The strength of the community itself, as a tool for change.tool for change.

• The capacity of individuals to help others, The capacity of individuals to help others, whilst helping themselves. whilst helping themselves.

RecoveryRecovery• The fundamental principles of the recovery The fundamental principles of the recovery

paradigim are published ( De Leon)paradigim are published ( De Leon)• The essential elements required for recovery The essential elements required for recovery

are within existing literature (Kooyman) are within existing literature (Kooyman) • Recovery invloves self and mutal self helpRecovery invloves self and mutal self help• Consistent motivationConsistent motivation• Involvement of the individual in his / her own Involvement of the individual in his / her own

processprocess• Social LearningSocial Learning• An understanding that treatment is an An understanding that treatment is an

important episode, in recovery.important episode, in recovery.• Treatment is a beginning – not an end. Treatment is a beginning – not an end.

Primary Treatment Goals at Primary Treatment Goals at Phoenix House Haga.Phoenix House Haga.

• Develop new effective cognitive strategies to Develop new effective cognitive strategies to constructively tackle risk situations, constructively tackle risk situations, unpleasent emotions & challengesunpleasent emotions & challenges

• Without resorting to substance abuse.Without resorting to substance abuse.• Experience a longer period of drug freedom Experience a longer period of drug freedom

than previously.than previously.• Keep a healthy distance from former drug Keep a healthy distance from former drug

using friends and criminals and the value using friends and criminals and the value system of the street. system of the street.

• Resumed education ( to high school/college) Resumed education ( to high school/college) where needed. where needed.

• Replace former destructive alliances with a Replace former destructive alliances with a healthy constructive lifestyle.healthy constructive lifestyle.

• Develop a value system for a life without Develop a value system for a life without substance abuse ( right living)substance abuse ( right living)

• Develop a good relationship with non drug Develop a good relationship with non drug using personsusing persons

• Where possible re-establish relationship Where possible re-establish relationship with the family of originwith the family of origin

• Develop the foundation of a social network, Develop the foundation of a social network, before entering the re-socialisation phase.before entering the re-socialisation phase.

• Form a realistic strategy regarding economic Form a realistic strategy regarding economic debtsdebts

• Begin negotiations with creditors where Begin negotiations with creditors where needed.needed.

• Have experienced voluntary work Have experienced voluntary work opportunities, prior to re-socialisation phases.opportunities, prior to re-socialisation phases.

• Engage in constructive free time activities, Engage in constructive free time activities, which often contribute to enhancing a new which often contribute to enhancing a new social network.social network.

• Have developed the ability to be responsible Have developed the ability to be responsible through the community structure.through the community structure.

• Be able to deal with employment challenges in Be able to deal with employment challenges in a new independent employment situation.a new independent employment situation.

Integrated Re-socialisation Integrated Re-socialisation Phases.Phases.

• Cultural differences.Cultural differences.• In Norway treatment laws discourage integrated re-In Norway treatment laws discourage integrated re-

socialisation phases provided by the treatment socialisation phases provided by the treatment progamme.progamme.

• Each individual is expected to return to the home Each individual is expected to return to the home kommune / municipality, for post treatment support.kommune / municipality, for post treatment support.

• Phoenix Haga does not accept this regluation as Phoenix Haga does not accept this regluation as effective.effective.

• Treatment and Recovery Alliances have formed during Treatment and Recovery Alliances have formed during primary treatment.primary treatment.

• The alliance continues effectively during post primary The alliance continues effectively during post primary treatment treatment

• Phoenix House Haga provides re-socialisation / re-Phoenix House Haga provides re-socialisation / re-entry support for up to 5 years, post primary entry support for up to 5 years, post primary treatment.treatment.

Treatment outcome / Treatment outcome / evaluation 1997-2002.evaluation 1997-2002.

• The first external evaluation of Phoenix House Haga The first external evaluation of Phoenix House Haga was conducted between September 2005 – April was conducted between September 2005 – April 2006.2006.

• From 1997 – 2002: 202 persons were admitted.From 1997 – 2002: 202 persons were admitted.• 92 available for interview from Phoenix data.92 available for interview from Phoenix data.• The regional health authority for Eastern Norway The regional health authority for Eastern Norway

contributed significantly towards the cost.contributed significantly towards the cost.• The evaluation was conducted by Patrick Verde & The evaluation was conducted by Patrick Verde &

Bente Vindedal from AIM Researchbasedconsulting Bente Vindedal from AIM Researchbasedconsulting – Oslo, Norway. www.aim.no– Oslo, Norway. www.aim.no

• Deputy administrative director, Ms. Solfrid Finstad Deputy administrative director, Ms. Solfrid Finstad acted as project co-ordinator, on behalf of Phoenix acted as project co-ordinator, on behalf of Phoenix House Haga. House Haga.

Objectives of the Objectives of the evaluationevaluation

• The objectives were two-fold from The objectives were two-fold from the researchers’ perspective:the researchers’ perspective:

1.1. How or if treatment at Phoenix Haga How or if treatment at Phoenix Haga impacted on the community members.impacted on the community members.

2.2. Establish the key elements of the Establish the key elements of the programme on the overall objective of programme on the overall objective of rehabiltiation, and establish where rehabiltiation, and establish where added resources could be applied to added resources could be applied to improve effectiveness.improve effectiveness.

Phoenix House Phoenix House Objectives Objectives

• Our objectives were similar:Our objectives were similar:1.1. Discover what could be enhanced in Discover what could be enhanced in

primary residential treatment.primary residential treatment.2.2. Validate the need for Integrated Re-Validate the need for Integrated Re-

Socialisation Phases.Socialisation Phases.3.3. Develop evidence based external Develop evidence based external

research regarding these issues.research regarding these issues.4.4. Form the groundwork for a new cost Form the groundwork for a new cost

effectiveness study.effectiveness study.

Comparison with other Comparison with other recent research in Norwayrecent research in Norway

• Researchers chose to compare with Researchers chose to compare with • Sirus Report 4/ 2003 ”What benefit, for Sirus Report 4/ 2003 ”What benefit, for

who and at what cost”? Ravndal et al.who and at what cost”? Ravndal et al.• ””Life after the treatment community”, Life after the treatment community”,

Halvor Fauske 2004.Halvor Fauske 2004.• This is a study of a treatment collective This is a study of a treatment collective

called ”Sollia”, covering a period 1997 -called ”Sollia”, covering a period 1997 -2004.2004.

• 52 persons were interviewed from Sollia.52 persons were interviewed from Sollia.• 92 from Phoenix Haga sample.92 from Phoenix Haga sample.

Age and GenderAge and Gender

• The majority of Phoenix residents are The majority of Phoenix residents are below 30 yrs.below 30 yrs.

• Sollia and Cost Benefit have clients Sollia and Cost Benefit have clients with slightly higher age range, 31 yrs with slightly higher age range, 31 yrs average.average.

• Both the Phoenix and Sollia samples Both the Phoenix and Sollia samples show a female population of approx show a female population of approx 22 %22 %

• The cost benefit study is approx 30%The cost benefit study is approx 30%

Age differenceAge differenceFigure 1

The majority of the PH-clients are younger than 30 years.

Sollia- and the cost/benefit- surveys on residentialrehabilitation clients have a slightly higher average age than

PH; about 31 years.

Both the PH and Sollia samples have a female proportion of22%. For residential rehabilitation institutions in the

cost/benefit- survey the female proportion is 30%.

Age difference (%) at admittance

0

5

10

15

20

25

30

35

40

Under 20 20-25 25-30 30-35 Above 35

All 202

Interviewed 92

Sollia 52

Substance AbuseSubstance Abuse

• There is one significant difference There is one significant difference between the Sollia group and those between the Sollia group and those from Phoenix Hagafrom Phoenix Haga

• Sollia group are primarily Heroin usersSollia group are primarily Heroin users• Phoenix group itself, are approx equal Phoenix group itself, are approx equal

in that 40% used Heroinin that 40% used Heroin• The the others from Phoenix used a The the others from Phoenix used a

variety of stimulants as drug of choice variety of stimulants as drug of choice

Preferred drug before Preferred drug before admittanceadmittance

Figure 2Preferred drug before admittance

0

10

20

30

40

50

60

70

80

Cannabis Opiates Stimulants Benzo Unknown

All 202Interviewed 92Sollia 52

Onset of problematic Onset of problematic drug use drug use

• On average both the Sollia group and On average both the Sollia group and Phoenix sample have a drug career of Phoenix sample have a drug career of about 10 yrs pre – treatment.about 10 yrs pre – treatment.

• Of the Phoenix group about half Of the Phoenix group about half devloped a drug problem between the devloped a drug problem between the ages of 15 – 20 yrs.ages of 15 – 20 yrs.

• 1 in 5 began before 15 yrs.1 in 5 began before 15 yrs.• Almost equal number after 20 yrs of Almost equal number after 20 yrs of

age.age.

Age of problem drug Age of problem drug misuse.misuse.

Figure 3

Sample and respondents; age for problematic drug use (%)

0

10

20

30

40

50

60

Under 15 15-20 20-25 Above 25 Unknown

All 202Interviewed 92

Crime. Crime. • The data indicates that up to The data indicates that up to

between 32 – 50% of Phoenix group between 32 – 50% of Phoenix group have served prison sentences.have served prison sentences.

• Fairly equally distributed in jail time Fairly equally distributed in jail time served.served.

• 3 months or less3 months or less• 3 -12 months.3 -12 months.• More than 12 months.More than 12 months.• Cost benefit survey shows an average Cost benefit survey shows an average

of 14 months. of 14 months.

Interesting IndicationsInteresting Indications

• Clear advantage to join the community at Clear advantage to join the community at Phoenix after 2000.Phoenix after 2000.

• Female residents seem to have better Female residents seem to have better prognosis.prognosis.

• Over 30 yrs seems to be a disadvantage.Over 30 yrs seems to be a disadvantage.• Drug debut between 15 -20 yrs shows good Drug debut between 15 -20 yrs shows good

prognosis.prognosis.• Stimulant abusers seem to do better than Stimulant abusers seem to do better than

opiate.opiate.• Paragraph 12 conditions enhance prognosis. Paragraph 12 conditions enhance prognosis. • Unpaid drug debts enhance re-socialisation.Unpaid drug debts enhance re-socialisation.

Rehabiliation results.Rehabiliation results.

• The follow up interviews showThe follow up interviews show• Almost 80% are not using drugs at Almost 80% are not using drugs at

follow up, this includes those few follow up, this includes those few who are receiving substitution who are receiving substitution treatment.treatment.

• 68% are abstinent or have very 68% are abstinent or have very moderate alcohol comsumption.moderate alcohol comsumption.

• Approx 40% are teetotal. Approx 40% are teetotal.

Comparison – Phoenix – Comparison – Phoenix – Sollia – last 6 monthsSollia – last 6 monthsFigure 9

Drugs last 6 months

0

5

10

15

20

25

30

35

40

45

50

Abstaining/teetotal LAR (MAR) Relapse Considerableabuse

PH 92Sollia 52

Cost benefit – last 6 Cost benefit – last 6 monthsmonths

• The cost benefit survey showsThe cost benefit survey shows• In that group from residential treatment, In that group from residential treatment,

approx 26% were drug free at the time of approx 26% were drug free at the time of follow up.follow up.

• The Phoenix data indicates a higher number, The Phoenix data indicates a higher number, though there are ”comparability” issues to though there are ”comparability” issues to consider.consider.

• 20% of drop outs from primary treatment, 20% of drop outs from primary treatment, receive methadone.receive methadone.

• 6.5% of those who completed primary 6.5% of those who completed primary treatment. treatment.

Degree of complete Degree of complete rehabilitation.rehabilitation.

Figure 14Degree of complete rehabilitation

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

drug-free(temperate +some alcohol)

drug-free +only drug-free

friends

drug-free +work/school

more than 15days per month

drug-free +work/school

more than 20days per month

drug free + onlydrug-freefriends +

work/school>15 days per

month

drug free + onlydrug-freefriends +

work/school>20 days per

month

Summary.Summary.• The treatment programme is effective.The treatment programme is effective.• Rehabilitation results are beyond the average Rehabilitation results are beyond the average

of the cost benefits survey ( Sirus 2003).of the cost benefits survey ( Sirus 2003).• Effect due to: Key Points.Effect due to: Key Points.• A sytematic residential treatment where all A sytematic residential treatment where all

the aspects contribute: ”Community as the aspects contribute: ”Community as Method”.Method”.

• An Integrated Re-socialisation Programme. An Integrated Re-socialisation Programme. Offering Extended Support.Offering Extended Support.

• Key Worker & Peer Group.Key Worker & Peer Group.• An Aftercare which works as intended. An Aftercare which works as intended.

Climbing the mountainClimbing the mountain