In 1993, when I first trained in the TC process, SELF was firm in implementing this policy of being a drug free community. This meant that treatment success was to be achieved not only without illegal drugs but also without administering any prescription drugs or psychiatric medication. We were fast to discharge any prospect whose profile presented any mental illness or other disorders. We were reluctant to admit clients who manifested any form of psychosis or personality disorder, fearful of disrupting the recovery process of the general drug dependent population. I was taught that residents under medication would not be able to internalize the TC process and arrive at the insights required to achieve recovery.Well, all of this has changed. Many respected psychiatrists who address addiction issues now say that clients who need medication to cope with psychiatric or personality disorders will also benefit a lot from enrolment in a TC program, especially for the acquisition of life skills. They also note that the number of clients diagnosed with disorders other than their substance dependency is fast growing. Thus, more and more TC practitioners, SELF included, have modified their views regarding the maintenance of a strictly drug free community.

In 2002, SELF opened its doors to these clients and, with lots of care and professional intervention, we successfully managed some of these persons. In the process, we identified three factors essential to successfully undertaking this challenge: 1) comprehensive assessment; 2) individualized treatment; and 3) TC family education and support.

Comprehensive Assessment

SELF began to realize many of its prospective clients had special needs. Towards this end, we established the Pre-Admission Department, a separate building where prospects would undergo a complete medical and psychiatric evaluation. During a minimum two-week assessment period, prospects are carefully observed for signs of defiant or unusual behavior. They are evaluated by a government accredited psychiatrist who checks them not only for substance dependency, but also for signs and symptoms of chemical imbalances or impending personality disorders.

Prospects also undergo a comprehensive battery of psychological tests to identify attitudes and patterns of behavior that the clinical team will have to take note of when they develop an effective treatment plan. Clients identified to have special needs — like those diagnosed with clinical depression, schizophrenia, and other psychoses — are prescribed medication to help them cope with the rigors of daily activities. They are also made to attend regular psychotherapy sessions and are monitored directly by the clinical team. With these treatment protocols, some of these so called dual-diagnosed clients have been successfully integrated into the TC program.

Individualized Treatment

The clinical team works closely with the attending psychiatrist to make sure that treatment plans prescribed for dual-diagnosed residents are strictly followed. Such residents are now fully accepted by the entire resident community and are treated with much care and respect. While some adjustments are made in their programs (i.e., low-stress job positions, less confrontation, more counseling, etc.), we also ensure that they participate in important group processes that help develop interpersonal relationships with other residents. Special activities under strict supervision are also provided, so they can learn self-discipline and the importance of taking responsibility.

It is important to note that dual-diagnosed clients seem to require longer periods of treatment in the program. One such case had to stay in the Pre-Admission unit for more than 8 months before himself choosing to join the regular TC program. With the administration of the required medication combined with regular psychotherapy sessions and TC processes, he dramatically improved social, emotional, mental and physical skills, and hence managed to handle a special job after treatment.

TC Family Education & Support

In the past, dual-diagnosed residents were not easily accepted by some residents simply because they did not know how to deal with them. Due to their strange behavior, dual-diagnosed residents were usually blamed for incidents in the facility. To address this problem, SELF conducted seminars to educate the community about dual-diagnosed clients, and prepare them for what to expect. With these, the TC family learned to adopt and support their program.

The successful program of any dual-diagnosed clients, however, also requires the full participation and support of their family throughout the duration of the recovery process. If the family is in denial, the chances that the prospect will relapse are great as their medication would likely not be continued due to their disbelief in the dual disorder. A pattern has been discovered that relapse to drugs in these types of clients happens after discontinuing medication.

In summary, there is still plenty to learn about how to best integrate dual-diagnosed clients into the regular TC program. SELF, however, has found that dual-diagnosed clients can be successful when they: 1) learn to accept their diagnosis; 2) develop the discipline and commitment to take their medications as directed, and 3) acquire life skills offered by the TC program.


Former VP Programs & Marketing, SELF
December 2006