This annual report marks the end of the first year of operations for sedqa . During this short period of time we have had to develop our vision and mission, design strategies for service development, quantify staffing levels, recruit personnel, train them and launch the services. Some of the services were taken over from the Department of Health and where appropriate, re-structuring was made by re-defining the objectives and re-deploying existing staff.
Applying change is not an easy process but by and large the staff responded well although the culture of management systems was fairly new. We have dedicated time to building a management structure, internal control systems for recruitment, finance and quality control. Further move, a cost centre budgetary system was developed to have better control over expenditure while considerable time has been taken to establish clear operational procedures. Training was emphasized in order to provide a quality service and in the last 12 months all employees in the Agency have undergone intensive theoretical and on the job training. Research and Information was highlighted and now we are in a position to view monthly current usage of drug and alcohol services and a better view of the local drug and alcohol situation, although this is constantly being enlarged and improved with new and additional information.
Against this backdrop of management systems, most of the planned services for drug and alcohol dependent clients came to fruition. The Community Services for these clients took off immediately as expected, while the residential services are steadily increasing in numbers. A multi-disciplinary approach was established and a professional team of consultants, review the treatment plans and supervise clinical interventions. A monitoring and evaluation system is gradually being developed as the culture of quality of service will continue to be re-enforced.
In responding to the changing and challenging needs generated by substance misuse, we are developing a battery of prevention programmes that will target mainly, the local communities, schools and the work places. A number of pilot projects were introduced some of which have already been evaluated and launched while others are lined up for the coming weeks. Our priority will be to continue to promote on programmes that develop leadership skills in the young. While the peer leadership training programme for 14 to 16 year olds will continue to expand, a leadership programme for leaders in the community is being prepared and the target areas will be those new housing areas which seriously lack adequate social structures. Schools will continue to be an important setting as a means to reach the young. Closer collaboration with the Education Department will be sought in the months to come.
However, the three pronged approach to tackle the drug and alcohol problem, namely : prevention, treatment and law enforcement were best demonstrated during the last twelve months. The Advisory Boards for the three sectors which constitute the Commission Against Drug and Alcohol Abuse, contributed considerably to create closer cooperation at policy level, while collaboration in daily operations has become a way of life for most professionals. Sedqa is committed to this and we welcome new initiatives of joint venture with individuals and agencies, particularly Non-Government Organizations, who share our common ideals of healthy living without drugs and the misuse of alcohol.
However, it would be wrong to think that the fight against drugs is fought by the institutions. The menace of drugs is an attack on the people and therefore institutions have to empower the people to face this challenge. The way forward is making our institutions more accessible and responsive to the people. They are of the people and for the people. Our minds and energies are very much set in this direction.
Background
The Meli Report has been the main catalyst behind the restructuring of the drug and alcohol sector. The working committee chaired by Magistrate Silvio Meli with representatives from both sides of the House was set up by the Minister for Social Development to evaluate the drug and alcohol treatment services in Malta.
The Report was presented in August of 1993. In less than 10 months, the restructuring recommended in the Report has been implemented. However, the restructuring did not only lead to the creation of sedqa but the former I.C.A.D.A.I.T. was dissolved and a new Commission K.A.D.A. - Kummissjoni Kontra l-Abbuz tad-Droga w l-Alkohol - came into being.
A crucial factor that was made evident by the report was the need for the creation of a new agency that coordinated existing services operating under the government umbrella so that their full potential may be realized. In addition, this infrastructure would provide the basis through which new services may be implemented where the need arises and by further executing its coordinating role between non-governmental organizations prevent the duplication of these resources.
In the long term, the strategy of the Agency should be
one of upgrading the existing services and introducing new ones on a par
that meet the clients needs in every sense. In implementing such services
it is envisaged that all will develop at a similar pace with the result
that the whole service will be elevated to one of excellence. Thus, a centre
of excellence in the field of drug and alcohol abuse in the middle of the
Mediterranean may become a valuable resource, not only for Malta, but for
those countries making up the Mediterranean basin (Both European Union
members and Mediterranean Non-Community countries).
Current Trends
Over the past five years the increase in the use of illicit drugs and alcohol in Europe has continued to spiral upwards with no sign of there being a leveling off of this progression.
During 1994 in Europe, this situation has been characterized by the rising number of abusers, an increase in the frequency and quantities of drug seizures and the emergence of new trafficking routes.
Cannabis, in its various constituent forms, still continues to be the most common drug seized by European as well as American drug law enforcement agencies. In 1994, Europe witnessed the largest hall of cannabis to date, a staggering 700 tonnes . These figures are sure to be surpassed in 1995, as only in June 1995 the Spanish police seized the phenomenal catch of 1,700 tonnes. This trend closely mirrors that observed on our Islands. Morocco, which is close to home, still is the major source of cannabis for western and now increasingly so, eastern Europe.
Heroin also continues to be a problem as the volume of traffic in this most life threatening drug of abuse, escalated in 1994, with most countries in Europe recording a sharp rise in the number of seizures. An equally worrying aspect in the trafficking of heroin is the increase in the number of illegal laboratories that are able to refine the coarse product. Narcotics, of which heroin is the most popular of this class of drugs, are defined in medical terms as "substances which alter the structure and function of the body" and as such are regarded with fear and distrust by most of the population. This is not purely for moral reasons but primarily because they make those that use such substances unpredictable and literally inhuman in their response to life events. One only has to look at the innumerable cases of motiveless attacks and excessive violence including suicide where the reason put forward was that the person was under the influence of drugs.
Despite the fact that 30 tonnes of cocaine were seized in Europe during 1994, availability does not seem to pose any problem to the user. Illicit traffic in crack cocaine, particularly in Britain, continues to be a grave cause of concern as this has been associated with an increase in violent crime and the spread of abuse to most major European cities. That we are immune to such crime may be dispelled by the occurrence of the double murder in Mosta, where the arrested individual has admitted to imbibing cocaine for at least three days prior to the event.
Psychotropic substances, such as amphetamine, are now finding their way from the licit to the illicit market. The fact that this substance is now the most widely abused of the many psychotropics and is now only second after cannabis in the popularity stakes gives great cause for concern. A more worrying aspect is the increase in the use of MDMA (ECSTASY) among young people particularly in night clubs and all-night dance parties and the trends to cultures the use of such designer drugs . The use and abuse of lysergic acid diethylamide (LSD), phencyclidine and amphetamine also remained high in several European countries.
The spread of auto-immune deficiency syndrome, commonly known as AIDS especially among the drug abusing population has resulted in a number of strategies that have been implemented throughout Europe and to some extent in America, to reduce the risk of infection within this population subgroup. Among which, include the distribution of free syringes. This policy is currently implemented on our Islands and the results of which may be reflected by the fact that to date, no drug abuser attending any one of the services available has been diagnosed as having contracted AIDS.
Alcohol use among populations throughout Europe still
seems to be on the rise even though a recommended daily intake has been
established by the World Health Organization. The implications and prognosis
of superseding these quantities have also been given clearly elaborated
yet there still seems to be a rise in alcohol related deaths be they through
automobile accidents or most notably, cirrhosis of the liver.
Legislation
In 1986, Malta's drug laws were amended, introducing a number of provisions which preceded the 1988 United Nations Convention Against Illicit Trafficking in Narcotic Drugs and Psychotropic Substances; severer penalties for drug traffickers, freezing and forfeiture of assets, introduction of the concept of conspiracy to sell or deal in drugs.
It goes without saying that in addition to introducing
novel ways to coordinate-ordinate existing services and the introduction
of new ones, a front line policy to strengthen existing legislation that
explicitly deals with those who manufacture and trade in drugs is of the
utmost importance as is the enforcement of these new laws. To this end
the government with the view of acceding to the 1988 convention has introduced
further amendments to existing legislation that were introduced in 1994.
The Dangerous Drug Ordinance of 1939, now provides inter alia, the
possibility of coerced treatment, controlled delivery and financial investigation.
In a further attempt to control the movements of moneys raised by drug
related activities (transactions) The Prevention of Money Laundering Act
was passed through parliament last year and came into effect on the 30th
December 1994.
Law Enforcement
Police, Armed Forces and Customs
The following sectors fall under a number of different ministries and are subject to their own agenda but all actively interact with one another as a result of a government initiative that seeks cooperation-operation of the law enforcing agencies in the fight against the illicit drug trade.
Armed Forces Prime Minister
Police and Correctional Facilities Ministry for Home Affairs
Customs Ministry of Finance
These law enforcement agencies are all involved in the front line assault against illicit drug trafficking. The National Drug Intelligence Unit (NDIU) was created in 1994 as part of the new government initiative mentioned above. It is primarily responsible for collating drug related information, processing it and passing it back to the various units/squads to enhance their effectiveness in their battle against drug related crime.
The vice squad, responsible for drug related crimes, within the Police Force is made up of a Superintendent who manages four Inspectors and their teams. In line with an attempt to provide experienced staff when undertaking such a dangerous task, training has been provided in the first instance by the DEA as well as the USA Coast Guard and H.M. Customs.
Plans were drawn up to fill strategic positions within the NDIU by recruiting experienced personnel.
Intelligence Strategist - NDIU
Intelligence Analyst - NDIU
Training Coordinator - NDIU, Police Force,
Armed Forces and Customs.
The Armed Forces carries out a number of significant activities in aiding and abetting Police Force operations such as patrolling of coastal waters via patrol boats or helicopter and road blocks.
The Drug Unit at the Customs Department supplements human
resources with a team of sniffer dogs. The unit possesses the relevant
hardware and software to manage its information. It is also in contact
with its UK equivalent as most of the incoming passengers (tourists) originate
from the UK and a sizeable proportion of the Maltese travelling population
opt for the UK when taking their holidays. It is also apparent that the
Maltese business community carries out a significant proportion of its
trade with the UK.
MARINFO
The Marinfo Organization encourages international cooperation between customs services and facilitates the exchange of information with particular attention to the illegal traffic of drugs by sea. Operation between the member countries goes beyond giving information on particular cases. In fact during these meetings combined international operations are planned and later on carried out in different localities using operational personnel from different countries.
Malta participated for the first time at the meeting held between the 21st and 22nd October, 1992 in La Rochelle, France. The Comptroller of Customs, Mr. A. Pavia and Head of Investigations, Mr. J. Miceli attended this meeting. During this meeting and the next three meetings held in Lisbon, Rome and Paris, Malta was accorded observer status. Finally, during the meeting held in Madrid, Spain, Malta was accepted as a full member and was also entrusted in hosting the last Marinfo Sud Meeting in May, 1995.
The type and quantity of drug seized by the Custom Authorities (see below) also shows the same pattern as that of police seizures which would suggest that most if not all illicit drugs are imported illegally by air or sea. There is no evidence to date to imply that these drugs are manufactured locally and this is borne out by the finger printing tests (FTA analysis) carried out by the Police Forensic Department that establish place of origin. The forensic department also plays a major role in the analysis of any suspect substance confiscated by the Armed Forces, Police Force, Customs officers at the airport or seaport.
The Police have arraigned before the courts a number of individuals in 1994 for trafficking, importation, cultivation and possession.
It is also evident from the table presented below that the age mode of persons arraigned in court for trafficking, cultivation and importation is primarily between 20-24 years of age.
With respect to the number of offenders interned at Corradino Correctional Facility for drug related offences it is apparent that this cohort now makes up 20% of the total population. The problem of addiction/dependence does not disappear on entry to such an establishment and as such the management of such inmates is a constant problem from the curative aspect as well as the impact they may have on the rest of the prison population.
These figures for the number of seizures with respect to heroin can be realistically ascertained by the high cost of unnecessary deaths that result from an overdose. The figures below reveal the sad state of affairs and in the main reinforce the life threatening consequences following a relatively short period of heroin abuse.
What is absolutely apparent from these figures and by all accounts the situation in Europe is that the drug problem is getting worse and is not going to fade away on its own. From all accounts however, it is still manageable if the stricter laws being introduced are enforced and the services offered in the form of treatment and rehabilitation are organized in such a way as to give a realistic hope to the users that life without drugs is a feasible alternative.
The need for a review of existing policies related to
law enforcement, and existing services related to treatment and prevention
in this field, proved to be timely (Meli Report 1993). In the field of
law enforcement, a review of all legislation pertaining to the illicit
use of drugs has been commissioned and proposals are underway to ensure
harmonization of existing and any new legislation.
K.A.D.A. (Kummissjoni Kontra l-Abbuz tad-Droga u l-Alkohol)
K.A.D.A., is a policy formulating body that brings together various organizations, government departments, professionals and interested individuals to discuss issues, make recommendations and also oversee the quality of the service. The board has to date, met on seven occasions.
K.A.D.A. has three sub-commissions, one dealing with Prevention, one with Treatment and the other with Law Enforcement
Both the advisory board on Prevention and Illicit Trafficking has met on eight occasions while the advisory board on Treatment and Rehabilitation has meet on three occasions.
K.A.D.A. has mainly concentrated its efforts on developing a national policy for the sector. This policy has been finalized and will soon be submitted to Government for its consideration. The sub-commissions have paid particular attention to developing a strategy in the fields of Prevention and Law Enforcement. The sub-commissions facilitated the cross fertilization of ideas and objectives and above all brought into effect a sense of partnership which is so crucial in this sector. A marked improvement in collaboration was registered between most organizations. This collaboration ranged from joint publications and information material between sedqa and the non-government organizations, client referral and case conferences, joint ventures in research studies, to law enforcement operations conducted jointly by all enforcement agencies in Malta.
This closer collaboration brought into being a series of work related networks so vital when addressing the drug and alcohol problems at a national level.
The creation of these policy level networks was one of the key factors in a strategy to upgrade the whole sector of drug and alcohol related services.
Diagram networks - Prevention
Treatment
Enforcement
Research
Training
The best example is that in the area of Information and
Research, where a number of agencies are contributing statistics which
are compiled into one report every month.
Sedqa - Agency Against Drug and alcohol Abuse
The Agency sedqa was officially set up on the 26th June, 1994, the United National Day Against Drugs. In his inaugural address, The Hon. Louis Galea said:
" Sedqa's role is cross-departmental and therefore, together with other partners ensure that all institutions can and are able to respond to the menace of drug abuse."
sedqa is a government funded executive agency which has been entrusted to:
Sedqa forms part of the Foundation for Medical Sciences and Services. It has a contractual obligation with the Director General for Social Welfare to provide services according to the needs as specified by Government.
Sedqa is a parastatal organization and therefore is regulated by the standards and procedures applicable to parastatal organizations. Having this status, Sedqa manages its own budget, can recruit staff and can undertake legal contracts.
The organization has two operating divisions, namely, :
These are supported by three teams:
Prevention Services
Although the maxim has always been prevention is better than cure, society
in the main has opted for the contrary and invested heavily in curative services rather than preventative measures. Fortunately, this attitude is changing worldwide, and more resources are now being channeled to educate and train the general population particularly those most at risk.
Sedqa's Prevention strategy is mainly divided into six sectors in the following order of priority:
Community
Schools
Workplace
Professionals
Media
Leisure Industry
In seven months since the first nucleus of the prevention team came on board, a lot of time and effort has been invested in establishing contacts and laying the grounds for cooperation. From the outset sedqa sought a consensus in the prevention strategy and in July 1994, a National Seminar was organized to set these common objectives. A number of institutions participated in the seminar, amongst whom were representatives of local councils, individuals engaged in social work, school teachers, parents and representatives of various government departments. A draft plan was presented by those present which now has been reshaped into an extensive document. In the event, the Advisory Board on Prevention has now finalized its consultations and soon will publish the national drug and alcohol prevention strategy document for Malta.
A major impetus that Sedqa must fulfill,
which on her part is being realized, is the enabling and empowering of
the various organizations and individuals, particularly those operating
at the local level, to conduct their own prevention programmes. In this
direction, great emphasis has been made at targeting the recently formed
Local Councils as these provide the forum through which such programmes
may be initiated for the population at large.
Community Prevention Outreach
In June a pilot study to reach those adults in the "market
place" with the prevention message was initiated. From the experience of
this first venture, the programme was updated and an exhibition was added
along with the inclusion of promotional material and leaflets. Eight localities
were reached between the 15th and 21st October 1994, to mark European Prevention
Week. It is calculated that between four to five thousand people received
leaflets and other material. This project in conjunction with Local Councils,
is to continue during the summer months and after. It will also cover new
localities in Malta and Gozo.
Parental Skills Programme
The enormous amount of interest shown in the parental
skills training programme prompted sedqa to initiate this
course ahead of time. To date, three pilot courses have been conducted
between March and June. Original material from "Active Parenting of Teens"
programme was utilized. The 12 hour video based skills building programme
was very well received by the 28 couples in attendance. Some of the couples
have shown sufficient interest to be given further training in July, to
act as facilitators. In October, a Maltese version will also be available
for the general public which will include a section on nutrition through
the participation of the Health Promotion Unit.
Peer Leadership Programme
Schools were the second priority area for Sedqa with particular attention given to secondary schools. The Peer Leadership Training Programme was piloted during four consecutive weekends between 25th November and 18th December 1994. The aim of this programme is to reach the youths between the ages of 14 to 16 and provide them with initial training in leadership and team building skills. The feedback to date, from some 114 participants, trainers and parents is very encouraging.
During a certificate ceremony held in January, 1995, for which the Minister for Social Welfare was present, Mr. Pace presented his report on these pilot courses. This event was attended by approximately 400 people. The programme is now being marketed as a package, inclusive of publication material to form a manual. Between January and May of this year, the programme was delivered to over 400 students. It is hoped that these young leaders will act as a catalysts in the setting up of prevention programmes in their schools and communities. A manual for trainers is in its final stages of preparation and in July a number of facilitators from both the government and private schools/associations will be given the necessary training to be able to deliver the programme themselves. Sedqa will provide the necessary materials and logistic support were possible.
Two developments arose as a result of this programme.
One was the concept for a follow-up course in leadership that was piloted
in May by two students following a course in Youth Studies. The other,
for all those teams who participated in the programme, is a competition
that will take the form of a project related to prevention, A substantial
rally for 144 Peer Leaders is planned for October 1995.
Global Approach for Schools
Sedqa is promoting a strategic approach in schools where prevention and health promotion will become a way of life. The Global Approach specifically aims to achieve this desired goal by placing emphasis on the fact that prevention must be promoted by all concerned, which include, heads of schools, teachers, auxiliary staff and parents.
In line with such a strategy, a highlight for this year were the visits to Malta by Mr. Ernst Servais, a Belgian prevention expert. During his visits he provided an introductory training programme for 50 professionals in the field and in December started a programme with 16 private and 5 state secondary schools in the practical application of the global approach intended for 13 year old students. This programme, which made use of material that has been published in the book "Before its Too Late", and contains the global approach as the situation pertains to Malta, is to run throughout 1995. Towards this end, three follow-up seminars were held in January, April and June, with another to follow in September. Mr. Servais also met representatives from two Local Councils, Mosta and Tarxien, in an attempt to spread the global approach to local communities. Further contacts are planned and the Local Councils have expressed the desire to forge twinning programmes with their Belgian counterparts.
This approach is also being developed for the Primary
schools. Three meetings for the Heads of 7 private schools who have shown
interest in the project, were held in February and March, where a common
strategy and programme were decided upon. A meeting for 48 teachers from
5 of these schools was held in March and a small team of volunteers is
presently scrutinizing material which may be included for 8 to 11 year
old students. This material will be presented to the school teachers in
September.
Training for Professionals
Apart from training of teachers the need to raise the
level of awareness among all sectors of society is tantamount. The professionals,
which include, medical officers, trade unionists, personnel executives
and youth leaders are in a privileged position when it comes to the provision
of advice in matters related to drug and alcohol abuse.
Awareness to general Practitioners
Dr. Checinski was the main speaker at a symposium for
general practitioners at the Malta Medical School held in March this year.
A follow up meeting was also held where a number of Sedqa
personnel explained the Agency's strategy in prevention and treatment.
Networking with Medical Doctors
In consonant with its strategy to create a network of
professionals at the community level to support the preventative and curative
efforts of Sedqa, a half day seminar was organized in May
at the University of Malta. The seminar was addressed by Professor Eugene
Shoener, Wayne State University, Detroit, Michigan.
Substance Abuse Module for Undergraduates
Through various contacts and with the intervention of
Dr. Gauden Galea, Dr. Madeline Naegel and key note speaker, Dr. Eugene
Shoener, a seminar was organized in May to focus on the needs of undergraduate
professionals in the caring professions. The aim is to develop an introductory
module that will enhance students awareness of the current situation. It
is hoped that this will lead to a number taking up a career in this field.
The module is to be launched by the Institute of Health Care and will be
available to all students in the Faculty of Arts, Science and Medicine
in October 1995.
Policy for Support to NGO's
Sedqa's new policy is to aid local organizations in their prevention campaigns.
Technical and financial assistance was granted to the National Council for Youth and the Health Promotion Unit for the organization of an open air concert and forum on AIDS. Jon Lukas, the well known Maltese singer was the main attraction. Leaflets sponsored by Sedqa were printed for the occasion.
One of the most far reaching projects being undertaken
by the prevention department is the resourcing of libraries in schools
and youth organizations in Malta and Gozo. Some 70 items, ranging from
booklets to reference material and videos were sent to these respective
entities for them to place their orders. These are being processed and
a formal presentation of material will be made in October in time for the
new scholastic year.
Seminars and Talks
The prevention team supported the preparation of and participated
in 5 seminars organized by Local Councils and three private schools. No
less than 40 meetings were held for people interested in prevention which
included, Guidance Teachers and Councillors (7), State and Private school
authorities (3), Local Councils (16), parents and students from particular
schools (6) project participants (8) and various organizations (10).
Promotional Material
During this short period, the prevention unit has produced
a series of promotional material in the form of leaflets, posters, key
chains, biros, T-shirts, book marks, and shopping bags in an attempt to
get the message delivered to the general public. This material is used
in the many activities organized at the school or community level.
Participation in Caring Awareness Fair
In September, sedqa participated in the
first Caring Awareness Fair held in the grounds of Naxxar. A stand was
prepared by the prevention executive and sedqa employees
volunteered to man it during the four days of the fair. Around 1000 people
visited the stand and were given handouts.
International Contacts
In October, the Prevention Senior Executive visited Baltimore and Washington to conduct negotiations for Malta to become an international member of the Center for Substance Abuse Prevention (CSAP). In January, sedqa received official recognition from CSAP and this has provided the platform for various initiatives. In addition to the vast expertise which has now become available, membership will also provide the opportunity for Malta to become the established international regional training and distribution centre for prevention in the Mediterranean.
To gain further support for such an initiative, sedqa submitted a proposal on this very matter to over 100 Humphrey Fellows during their conference in Cairo in March. The proposal was well received.
During his short visit to the US, the services of three
American experts at no extra charge were procured. They arrived in Malta
in May and conducted a three day seminar on prevention. Over 60 people
attended, among them, personnel from industry, the caring professions,
education establishments and non-governmental organizations. This 15 hr
course gave instruction to the use of non-medical methodologies for the
diagnosis of drug abuse as well as insight into the use of an efficient
referral system. Delegates were also exposed to current US models and programmes
used in the community, youth and industry. Mr. Mike Gimbel, Director of
the Baltimore County Office of Substance Abuse, headed the American delegation,
which included, Ms. Melissa Ruff and Ms. Jan Ferra.
Social Marketing
The prevention programmes developed by sedqa and those in the making need to be marketed like any other product or service offered by the business community. However, the impact of such an endeavour would be made more fruitful if the new concept of social marketing is applied. In essence, social marketing is defined as the design, implementation and control of programmes developed to influence social acceptability of a novel social idea. It has its roots in both commercial marketing and social reform campaigns.
Using commercial marketing practices, social marketing targets the audience, in this instance the general population and thus they become the focus of the programme.
A prerogative of social marketing is to change human behaviour. In addition, it attempts to alter the behaviour of a large proportion of the population unlike product marketing which is usually satisfied with small shifts in market share.
Sedqa is now applying the techniques of
social marketing to convey prevention messages. Over the past seven months,
care has been taken to produce well planned brochures, posters, promotional
material, TV and radio advertising. During the month of July, the first
set of TV slots will go on air. The task has not been made any easier as
a result of the parallel development of prevention programmes, which in
the first instance had to be piloted before being implemented. The agency
has also catered for the numerous requests for speakers by youth clubs,
schools, parishes and organizations to the extent that between January
and May 1995, 94 such talks were delivered. In addition, the provision
of literature for newspapers, contributions to TV and radio programmes
have always been acceded to.
Care Services
A planning team was set up at the beginning of 1994 with a brief to, amongst other things, prepare plans for the setting up of an Executive Agency and to put into effect a restructuring exercise of the treatment services. Consultancy was sought locally and from experts from Belgium and the United Kingdom. A three year strategic plan for treatment services was drawn up. The major goal of the plan was to make available a continuum of services which is accessible to those who need them. Operational plans were drawn up for 1994 and 1995. The plans for 1994 mainly addressed the organizational restructuring while those for 1995 targeted the introduction of new services.
A series of meetings were held with other organizations
related to the field with an aim of describing the role of the agency and
building up relations. These facilitated collaboration and paved the way
for further cooperation.
Physical structures
Centrally located property was sought and premises were
hired in Valletta, Floriana and Gwardamangia. Within a few months a refurbishment
exercise was carried out which included works at Komunita' Santa Marija,
Luqa. It is worth mentioning that works at the Floriana premises were mostly
carried out by inmates at Corradino Correctional Facility. Currently, maintenance
and refurbishment works are under way at 2 and 3 Braille Street, Santa
Venera, at St. Luke's Hospital Detox Out-Patients and at Komunita' Santa
Marija, Luqa. Most of this work is being done by a group of ex Komunita'
Santa Marija residents.
Human Resources
A review of staffing levels was carried out and an analysis
of competencies was made. Projections for staff requirements, training
needs analyses and training plans were made. A deployment and recruitment
exercise was subsequently put in motion. 26 new full-time staff were recruited
in the Care Services. Still, the initial staff complement taken over at
the beginning of 1994, was reduced from 78 to 20 full-timers, as the majority
were wither industrial or unqualified staff.
Operational Policies and Procedures
The process of providing the aims and objectives for all units and teams in the whole continuum of care services was immediately taken up. This is in line with the direction indicated in the Meli Report of 1993 and by the proposals made by staff through an ongoing service development process. A manual including Operational Policies, service specifications and guidelines is on the way to completion.
Sedqa's Care Services are integrated in a continuum of services made up of:
Based at Santa Venera, the team offers support to any
drug users and their families in the community. The team which includes,
community workers, social workers and a medical officer, attend to the
public both at their base and in homes. The team also links up with the
Out-Patient Detox Clinic at St. Luke's General Hospital. The team works
in close relation with other agencies when clients are referred from or
to them.
Counselling Team
The Counselling Team led by a Clinical Psychologist, conducts both one to one counselling and group therapy. Clients are referred for Counselling by the Community Team, however, the Care Plan is drawn up and adopted by a multi-disciplinary team. This approach is based on a model which provides the client with a battery of professionals who together draw up and execute a Care Plan. It also allows for the direct participation of the client and his/her family.
Between November 1994 and April 1995, 264 contacts by
clients were made to the Community Team, 116 of these were clients being
seen by the Community Team for the first time. During the same period,
683 sessions were held, 606 of which were one-to-one support sessions.
This approach is consonant with the policy of sedqa of providing
a personalized service .
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The Out-Patient Detoxification Clinic is located at St.
Luke's Hospital. Those abusing of drugs are given medical attention three
times a week and dispensed methadone on a daily basis, inclusive of Saturdays
and Sundays. The Out Patient Clinic provides, in addition to the above,
services in the form of social support through the Community Workers who
attend the clinic on a regular basis. They establish closer contact with
clients and motivate them to undergo subsequent treatment programmes. During
the Out Patient Clinics, family members are asked to participate and support
is given on request.
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Family Services
In February, 1995, sedqa introduced the
Family Services which gives support to families with a drug abusing member.
The team offers counselling work and involves families in the clients'
treatment process. Most of the clients whose family is receiving this service
are also attending other sedqa services. Between February
and April, 307 sessions were carried out, most of which involved parents
of the abusers.
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In Patient Detoxification Unit
Dar Inpenn
The facility was moved from St. Luke's Hospital to premises located close to the hospital, which offers a very homely environment. In addition to detoxification, one to one counselling and group psychotherapeutic sessions within a structures programmes are held. The premises has accommodation for eight persons with separate quarters for females. The In Patient Detoxification Programme has a duration of around three weeks after which the clients may opt whether to go back to Community Services or join a long term residential rehabilitation programme at Komunita Santa Marija or Caritas San Blas.
Twenty-four hour nursing and care work cover is provided
for at the home in addition to the daily visits by sedqa's
medical officers. Between November and April of this year, 31 clients successfully
completed this phase.
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Residential Rehabilitation Programme
Komunità Santa Marija - Luqa
The objective of the therapeutic programme at Komunita Santa Marija is to offer residents a life experience based on re-building self esteem and learning skills to assume responsibility for themselves and responsibility towards others in society. The programme is based on a gradual maturing process of daily living, a normal life without the need to use drugs. It aims to lead the client towards abstinence.
The previous assessments of the client while in attendance at the community services and detoxification phases are reviewed once again by the multi-disciplinary team responsible for the care plan of the client. The client is given six to eight weeks to integrate with other residents during which he/she has time to adapt to the structure of the programme and is monitored for assessment purposes. Once the client completes this induction period he/she becomes a fully fledged member of the house with the added responsibility.
The programme is based on principles and rules which instill in the client a sense of responsibility for himself/herself and for others. The model emphasizes the responsibility that each member has to demonstrate in daily living. Time is divided between personal maintenance, productive work and upkeep of the house and therapy.
The former nursing staff were replaced by programme facilitators and care workers. They are supported by counsellors who give group therapy and one to one counselling. The co-ordinator of the residence enjoys autonomy in managing the house who together with the staff and residents manages a budget and the programme for the community. At present this residence is offering services to fifteen clients.
Alcohol Community Services
270 persons have attended the alcohol community services and Day Programmes between January and April, of which 161 had serious alcohol problems. A major input is group therapy and individual counselling. Emphasis is placed on support for the family. Home visits and assessments are also carried out. Close collaboration exists between the Agency and Alcohol Anonymous (AA). Sedqa is currently sponsoring premises for Alcoholics Anonymous in Valletta.
Out Patient Clinic - St. Luke's Hospital
A recent development is the once a week clinic at St.
Luke's Hospital for those clients admitted to St. Luke's Hospital and others
in the community who have an alcohol problem. Referrals by professionals
as well as the general practitioners practicing in the community are made
to the clinic which is staffed by personnel from Dar Zerniq in Floriana.
Day Programme and Rehabilitation Facility
Dar Zerniq
The new community based facility at Dar Zerniq, Floriana which started operating in January of 1995, is perhaps one of the more evident shifts from institutionalized care to care in the community. Most clients with alcohol problems have in the past been given treatment at Mount Carmel mental hospital. Such an environment is not conducive to treatment and rehabilitation of these individuals. From the outset, sedqa made the effort to acquire premises in the community and Dar Zerniq came to fruition in January of this year. The premises serve two major purposes - a base for community service and a Day Programme, and a residence for short term rehabilitation programme.
Residential Rehabilitation Programme
A short term residential rehabilitation programme is based
at Dar Zerniq, Floriana. This residence has accommodation for 12 persons,
male/female and offers a homely and attractive environment. Various professionals
are available to provide one to one counselling, group therapy, social
work support and medical support if the need arises. A twenty-four hour
care work cover is also provided for residents.
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Continuum
Integrating such a widespread continuum of services is
a constant challenge, monitoring coordination is therefore of the utmost
importance. This process is constantly under review. Plans are already
underway to computerize all client records for easy access and updating
of care plans. The re-entry and aftercare phases are in the process of
development.
Evaluation of services
From the outset, sedqa realized the need
to develop a monitoring and evaluation mechanism to ensure a high quality
of service. An external evaluation exercise of the Agency's Care Services
has been carried out recently by St. George's Medical School personnel.
Such evaluations give the impetus for the review of objectives, operational
procedures and outcomes. However, the final objective is to introduce a
collaborative participative approach to enable the organization to get
practically acquainted with the design and implementation of evaluation
methods.
Information and Research Team
Pre-1994, drug and alcohol data existed, to varying extents, within all organizations in the drug and alcohol sector. However, because of data inaccessibility, use and coordination, an accurate understanding of the overall situation, patterns and trends in drug and alcohol use and abuse was lacking. As a result of the clear need to coordinate, sedqa, the Agency Against Drug and Alcohol Abuse responded at its very early stages of creation by giving prominence to information and research.
In May 1994, a Research Executive and Epidemiology Consultant were recruited to undertake the coordination of ongoing information; to contribute towards the development of data collection and usage; to disseminate common information to other institutions and organizations in the sector; and to lay the foundations for implementing a long term policy of action based on extensive and valid data. In September a scientific consultant and a research assistant were added to the Information and Research Team (IRT).
An identified priority of the IRT has been the need to undertake an initial review of all existing information thus far available among all concerned institutions and organizations, either in their day-to-day activities or of any special studies undertaken. Such was necessary in order to review the existing material and resources within the current systems, and therefore determine what information systems need to be developed to enable data gathering and the initiation of various research projects.
As a development of this, the IRT started monitoring and monthly publishing of existing data from the various agencies involved in the drug and alcohol sector. Through these reports, the team attempted to standardize routine data, while looking at international standards for conformity. The move towards 1996 now involves an effort to conform with these international standards through the already existing projects.
Yearbook
Another of the IRT projects is the 1984-1995 Yearbook, and subsequent annuals thereafter. The aim is to publish an annual yearbook containing data available within the period (published or otherwise) on the problems of drugs and alcohol in Malta.
Initially, the Agency established coordination links with
all types of organizations that come in contact in one way or another with
drug & alcohol use/abuse in Malta in order to carry out the most complete
literature review possible. In so doing, it identified data thus far not
made available to workers in the field. This did not only incorporate aspects
of care, treatment and rehabilitation at the relevant centres, but also
other governmental and NGO's that are somewhat involved in the prevention
and control of the abuse of these substances.
Drug and Alcohol Prevalence Studies
Compared to other countries, Malta is in many ways advantaged in attempting a description of its overall drug and alcohol problems. The national population is relatively small, homogenous and stable and not fragmented by ethnic groups. Local domestic production (in designer drugs, and in alcohol, mainly wine and beer) is not widely spread, but rather, consumption and trafficking (in drugs only) is concentrated on a small set of imported substances. Additionally, the size and population of the country is small enough to enable a team of researchers to easily locate and assess trouble areas and risk groups in the context of prevalence studies and their limitations.
The IRT has plans to collaborate with local researchers to conduct prevalence studies in both the drugs and alcohol sector in 1995. Such snap-shot studies would require follow-up studies in the future to detect variations in trends and factors being researched.
Developing Information Systems
In exploring the current situation regarding information assistance in the field of drugs and alcohol, it was noted with concern that while many were actively engaged in providing support and assistance, these had little capability and awareness for the need to collect and appraise the relevant information. This set-back was a natural development of the overriding importance given to anonymity and the real fear of stored data passing into the wrong hands. The efficiency and effectiveness could be greatly enhanced with the provision of support in the form of;
This on-going project, aimed to develop an information
collection, storage and utilization system to enhance the decisions made
by the management of the organizations involved in drug and alcohol abuse
on the Maltese islands. Such a system would be geared to fulfilling the
data needs of the respective organizers, while retaining a basis for standardized
essential and confidential reporting at a national level.
International Studies and Contacts
The IRT has established various contacts and collaboration projects with International organizations, namely, United Nations, WHO, EU, USA Information Networks and the Council of Europe (through the Pompidou Group) in various areas of the drug and alcohol sector, specifically:
Surveys
To have a nation-wide perspective, it is of utmost importance
that the IRT promotes research from organizations and individuals interested
in the sector from any profession or sphere of study. There are a number
of research projects that are specifically aimed at the whole or subgroups
of the population, and/or specific areas. The IRT supported various organizations
and individuals who intend to conduct surveys (of both quantitative and
qualitative nature). The extent of spheres of study from which such projects
emanate parallels the variety of professionals interested in the drug and
alcohol sector.
Library
The drug and alcohol sector engages a variety of professionals who, in turn, have developed a diversity of interests and studies. The sedqa Resource Library tries to encompass, as much as possible, the body of information involved to satisfy the needs of researchers coming from the equally various fields of study.
From the onset, sedqa, invested heavily in the collection of valid resources, material and literature and assigned the ordering and organization of this project to the IRT , to coordinate its retrieval system and facilitate its use. The collecting and inputting of a catalogue was undertaken by drawing upon the resources of voluntary individuals and knowledge of its staff. At the present moment in time (June 1995), some 2500 books, 800 articles and 50 videos have been indexed and are available for a computerized retrieval word-search by their title, subtitle, author and other usual library catalogue variables - making this collection of resources the largest in existence of its kind on our islands.
TRAINING
From the outset, sedqa placed training very high on its list of priorities. The strategy adopted for training was determined from:
(a) sedqa's strategy for the development of its care services.
(b) recommendations proposed by the Meli Report.
The Training and Human Resources Department has developed several training programs for the different divisions and Departments.
Care Services Division
Certificate in Substance Misuse (March 1994- September 1995)
This thirteen week modular course has been organized with the aim of enabling professionals to develop further understanding, knowledge, appropriate skills and attitudes in the care and management of individuals with drug and alcohol problems. The course was organized by sedqa in association with St. George's Hospital Medical School, University of London.
The thirty eight participants are from sedqa (24), Mount Carmel Hospital (4), Caritas (2), Centru Hidma Socjali (2), Police (1), Armed Forces of Malta (2), Others (3).
Certificate Course in Gestalt Therapy (November 1994-October 1995)
The aim of this course is to equip professionals carrying out individual/group Counselling with therapeutic techniques so as to enhance a more effective service. The course, which is run by Dr. Lidja Pecotic, Ph.D., sedqa's clinical psychologist consists of 300 hours of lectures, group sessions, and supervised interventions. All the counselors employed with sedqa are participants.
Assessment Techniques
(December 1994 - May 1995)
The aim of this intensive course is to study in depth various assessment methods and procedures carried out during treatment of substance misusers. This 60-hour course was run by Joris Berger Professor in Psychodiagnosis from the University of Belgrade. The ten participants are from sedqa (5), Caritas (1) OASI (1), and Mount Carmel Hospital (1) and the Richmond Fellowship (1) The participants have been comparing Assessment Methods and this is already bearing fruit in the communication between the different Agencies.
Supervision Skills for Social Work Placements
(February 1995 - May 1995)
Two participants from sedqa are currently attending this course at the University. The course aims to provide prospective supervisors for social work placements with the necessary information and skills for effective student supervision.
Orientation Course for Care Workers
(November 1994 - December 1994)
Twenty care workers participated in this course. The aim of the forty-hour course was to give a basic introduction to all care workers to the field of substance misuse. The course covered medical, social and psychological aspects of substance misuse and the Agency's aims, plans and services.
Certificate Course in care work
(March 1995 - November 1995)
The aim of this course is to prepare the twenty one participants to be able to perform their role of care worker effectively. The course covers all aspects of the job, which include basic Counselling skills, boundaries, basic training on substance abuse, first aid, HIV, youth and delinquency and other areas. The course consists of approximately 120 hours of direct training input and intensive supervised practical training.
Team Building Sessions for Staff members at Detox and Community Services (March 1995 - May 1995)
The aim of this sessions is to help the twenty participants from the above mentioned units to develop a common approach to dealing with clients in the initial phases of the treatment process. The sessions are being led by Patricia Brookes, who holds a Masters' Degree in Health Management.
Taking care of Alcoholics Undergoing Rehabilitation
(December 1994, May 1995)
This course is intended to give care workers working at the Rehabilitation unit for Alcoholics the basic skills and attitudes to handle clients in a professional and caring manner.
Community Team Training
Training has started with a basic course in family counselling by Mr. Nelio Malvani, senior social worker, Mount Carmel Hospital. This will be followed by training in other areas such as crisis intervention, outreach work and designer drugs.
Training for Administration and Management
Various training initiatives in training for administration and management have been taken. These include:
Training in Office Management skills, Business Letter Writing and other Office Related Skills
20 members of staff attended a course in the above areas.
Certificate Course in Training and Development
(October 1994 - June 1995)
The Executive responsible for training in the Care Services, attended this course. The aim of the course is to equip participants with the necessary knowledge and skills to be able to carry out training needs analysis, plan, design conduct and evaluate effective training courses and to identify and overcome obstacles to a better understanding of the training and development of a work force.
Developmental Planning
Mr. Christopher Bezzina who holds a Masters Degree in Management and is currently reading for his Ph.D. delivered a forty hour course on developmental planning for fifteen professionals involved in care service development.
Management Training
Other training was attended by various sedqa personnel. The training covered computer skills, creative thinking, evaluation and monitoring, the integration of personal and organizational values and other related topics.
Training for the Enforcement Sector
sedqa has also contributed to training in the enforcement agencies. In January and February of 1995, sedqa conducted a training needs analysis of the Maltese Drug Enforcement Agencies and a training plan, to consist of 10-12 courses, for the rest of the year was finalised at a seminar held at the Holiday Inn on the 4th March.
Three-day course on Financial Regulations, Money Laundering and Asset Tracing (May 11 - 13).
Sedqa, in collaboration with the Central
Bank of Malta organized a three day course for twenty enforcement officers
and other interested professionals. The course was conducted by Mr. H.
Zammit Laferla and Mr. O. Bonello, both from the Central Bank.
Workshop on Money Laundering
(May 20).
Sedqa, in collaboration with the Central Bank of Malta organized a one day workshop for the top decision makers in the Enforcement Agencies. The workshop was led by Mr. H. Zammit Laferla, Manager, Banking Supervision, Central Bank of Malta. Also in attendance were the Central Bank reporting officers and Magistrate David Scicluna, Chairman of the National Commission against Drug and Alcohol Abuse (K.A.D.A.).
Training Abroad
MSc in Addictive Behaviour
(October 1994 - September 1995)
One of sedqa's Medical Officers, Dr. Moses Camilleri is currently reading for a full time Master's Degree in Addictive Behaviour with St. George's Hospital Medical School, University of London.
Other Overseas Training
Five executives visited Belgium on an orientation visit during the month of May 1994. This course was funded by the Med Campus as part of the funding for the Mental Health reform.
Dr. George Grech, Mr. Joe Galea and Mr. Charles Cassar from Sedqa attended a three day conference organized by Communita' Incontro, in Italy. During their stay, the group also visited various therapeutic communities.
Mr. Simon Testa and Mr. Gerald Gouder visited Amelia Italy to further develop their understanding of the therapeutic approach of Communita' Incontro and to determine the training opportunities available in Italy and Sicily.
A Gestalt Therapy Seminar was organized in Italy and amongst
sedqa personal, Ingrid Bonnici, Caroline Mallia, Audrey Sciberras,
Dr. Lidija Pecotic and Charles Cassar attended. Whilst in Italy they took
the opportunity to visit various therapeutic communities in the region.
Finance, Administration & Personnel
The Agency is regulated by an Operational and Financial Agreement drawn up between the President of the Foundation for Medical Sciences and Services and the Director General for Social and Family Affairs. This document lays down the Agency's basic policies, regulations and practices to be followed. It also puts forward the necessary steps to be taken to provide for an efficient financial control system and sets out the procedures for the purchase of goods and services. In order to complement the main governing agreement and to further strengthen its internal control structure, Sedqa has drawn up certain policy documents which are as follows:
Policy Document 1 includes the regulations and procedures
for the Recruitment Process. Policy Document 2 provides the regulations
through which a financial system may be implemented and sets out the procedures
for purchasing as well as for control over expenditure. It also lays down
a detailed list of procedures that must be followed when the need for a
call for tenders arises. To-date, the Agency has successfully issued and
completed the practice of tendering on two occasions, namely, for its computer
system and air conditioning equipment. Policy Document 3 governs the custody
and care of fixed assets. As of its first days of operation, the Agency
immediately drew up an inventory of all its assets. Separate categorized
inventories had to be drawn up to include assets that were directly taken
over from the Government of Malta, those that were donated by the Friends
of St Mary's and others that fell under direct ownership of Sedqa.
Budgets
The Agency's main source of funds is in the form of a
government grant, which budget vote in 1995 amounted to Lm680,000. Most
of these funds were previously managed by different government departments.
Staff deployment
Following the re-structuring exercise in the existing care services, particular attention was given to appropriate deployment of staff to ensure that the expertise is provided for where it is needed. Nursing staff previously employed in group therapy were transferred to the Detoxification centres to carry out nursing duties. Psychosocial interventions are now initiated by appropriately trained personnel at a lower cost. Medical Officers provide a 24 hour on call cover for all of the units operated by Sedqa. This arrangement has been achieved at a lower cost per unit than hitherto. Practically all industrial staff, including nine security officers, were deployed at the Department of Health, thus saving over Lm30, 000 annually. This re-structuring contributed to a 35% savings over all the expenditure of the treatment services which were in existence before sedqa was created.
The largest savings were made at Santa Marija Hospital at Luqa, now renamed Komunita' Santa Marija. The annual cost of this centre, Lm194,088, has been reduced to an estimate for 1995 of Lm58,641, a saving of 70%. It is planned to reduce this figure even further through the generation of income related activities. The Detoxification services which now include two units, having additional services at Dar L-Impenn, Guardamangia, in turn increased their spendings from Lm93,724 in 1993, to an estimated Lm100,996 in 1995. The increase in the services offered in the alcohol sector also resulted in an increase in expenditure from Lm26,689 in 1993 to an estimated Lm44, 857 in 1995. This increase is mainly attributed to the introduction of a 24 hour staff cover at the new residential facility, Dar Zerniq, Floriana, and the new community services.
Moreover, Sedqa in the main has made major
monetary investments in human resources. In fact 63% of Sedqa's
budgeted costs are for high calibre professionals that come from various
disciplines. All staff are governed by a contract of service and an agreement
was reached with the respective trade unions in April 1995 for staff seconded
from Government Departments.
Accounting System
The Agency's accounting system makes particular use of cost centres and the need to attribute specific costs thereto. This system ensures budgetary control over every individual cost centre run by the Agency. To-date, the following cost centres are run by the Agency;
1. Prevention Department,
2. Research and Information Department,
3. Training Department,
4. Administration Department,
5. Drugs Community Services,
6. Alcohol Community Services,
7. Out-patients Detoxification Department,
8. In-patients Detoxification Services,
9. Drugs Residential Rehabilitation Services.
The main objective behind the implementation of this particular accounting system is to a establish a data base of information that provides a listing of each service cost that can be matched to a pre-established budget.
Appendix A
The purpose of substance abuse prevention is to promote human development by establishing or enhancing an individual's personal resources, skills and experiences. This involves increasing an individual's ability to cope with stress, to make reasoned decisions about daily problems, to satisfy emotional needs and to have a strong self-concept.
To accomplish these goals, the process requires strengthening of family and community ties so that people have the resources to deal with crisis situations that could precipitate drug/alcohol use.
The key objectives of a good prevention effort are;
To promote healthier, more attractive alternatives to drug use and help the individual's ability to rely on inner resources, skills and experiences; build more constructive relationships with parents or family; and to improve relationships with peers, schools and the community.
To promote reliance on peers, schools and the community as the most effective channel for informing and guiding young people and to assist these groups in developing prevention programs, relevant and appropriate for their unique situations.
To provide clear, factual, honest and relevant information about drugs and to disseminate this information to appropriate audiences.
To plan and develop materials for the special challenges facing women, ethnic minorities, the poor, the elderly, those in rural areas and other special populations.
To incorporate an evaluation component in programs to prevent drug and alcohol abuse.
PRIMARY PREVENTION - means that level of activity which is aimed at keeping the general population from becoming part of, or contributing to an already existing population of illegal users/and or abusers.
SECONDARY PREVENTION (INTERVENTION) - means that level of activity which is aimed at keeping the experimenting and/or using populations from becoming part of, or contributing to, and already existing population with a chronic pattern of behavior of drug and/or alcohol misuse.
TERTIARY PREVENTION - means that level of activity which is aimed at dealing with chronic patterns of drug or alcohol use or abuse, referred to as treatment projects.
RELAPSE PREVENTION - means that level of activity which is aimed at keeping the recovering person from falling back into an addictive pattern.
Besides the biological and sociological aspects of addiction, there are also psychological aspects that, during the last six months work, have been treated with Gestalt psychotherapeutic method.
Gestalt Therapy bridges the gap between cognitive and behavioural therapies by also including emotions, the senses and the body in therapeutic approach to healing. Gestalt Therapy requires one to understand the person's behaviour in context with his/her environment and views coping mechanisms as creative adjustments to the stresses of life at the contact boundary.
Gestalt Therapy is a holistic approach, it is suited for the treatment of substance abuse/addiction from prevention, pre-addiction through the various stages of the recovery process and the unfolding life. The Gestalt Therapy approach is equally applicable to the various types of addictions and related problems; co-dependency, eating disorders, sexual and other traumas, couples/family issues and other related issues.
The dilemma of modern man is the result of a need to integrate into modern society without losing one's individuality. The first process is one of joining and merging with one's environment.
The organism falls out of step of this process after balance disorder (homeostasy) in the organism has begun. The aim of the organism's activity is to re-establish this balance through environmental contacts. Simultaneously, the organism attempts to satisfy the other tendency, that is to maintain and develop one's individuality. Co-ordination of both the needs in the same process, successfully may facilitate a condition where new levels of experience spiritual fulfilment may be experienced.
Environmental joining and sense of harmony (confluence) in the developmental process of a person, is primary experience.
For new born organism, this state is acquired through the developmental process. Through relations with reality, the organism separates from its ecstatic experience of the omnipotent, and integrates with the environment.
This experience remains periodically present. However, now it is influenced by a sense of difference and effort in environmental contact. Through revealing and developing of its individuality, the organism develops complete behaviour repertoire that enables creative adaptation through expression of these tendencies.
In critical situations, the organism regresses very often to the lower level of development, which is known as pre-dental period or oral phase in Gestalt Therapy. The organism tends to re-establish immediate, general, maximum and permanent satisfaction without efforts. This regression process represents one of the important psychological characteristics of addiction, an inadequate attempt of the organism realize archaic and primitive ways of pleasure.
The Gestalt Therapy considers the addiction process within mechanism of introjection and regression of the patient on the oral developing stage. Basically, the addict wishes to; take in (to drink, to inject) the environment into himself, to experience confluention or climax without necessary efforts and natural aggression without excitement that naturally originates from creation of the contacts with the environment and assimilation of the environment. An addict becomes i.e. regradate to "bottle-baby" that swallows, yet unable to take solid food i.e. unable to confront his responsibilities.
This development principle as applied to real life situations is one in which we are constantly wrestling with the life. The addict, on the other hand, is looking for a solution in completely remodelled form, in that the only thing he has to do is to swallow or inject the very thing that will give him pleasure and thus the solution to his problem.
Socially, the addict is searching for the confluence that he has not been able to accomplish with his peers and friends but only with himself, rejecting those parts of self that are to perform discrimination (Ego), identification of needs (Id) and decreasing a natural consciousness process. As the patient does not use the natural positive aggression to resolve problems, social contacts are superficial, and thus the non invested surplus of the aggression is turned into a senseless fight and feelings of guilty.
In the development process, why does the ego give up its struggle and cede its place to more primitive mechanisms ? How does one reawaken the functions of the ego, awareness and organism boundaries in the environmental contact ? The questions and answers the Gestalt therapist seeks in treatment of the client are thus of great importance.
According to the existing Agency setting, the client starts his therapy in the early preparation stages on entry to the Detox In-patient unit. The therapist examines Awareness/Contact/Experience cycle and its interruptions in the context of the individual's problems, relationships and environmental field. In this stage, work is based mostly on the exploration of the awareness process with mild therapeutic interventions. From the beginning, the sessions are individual and group, two/three times a week that continue during the complete program throughout all the units.
When a client leaves the Detox In-patient Unit and refers to the rehabilitation phase of the program, the treatment formally remains the same. The intervention content changes.
The therapist continues to explore the way the client faces the life field, "unfinished business" from the past as possible traumas that influence the ego functions. Gestalt techniques and methods are used to strengthen relations organism/environment, polar aspects of organism are discovered and worked upon so that integration may become feasible.
The latest work with clients shows that they willingly participate in therapeutic groups and easily accept the intervention method although it differs from their previous experience; they have also made it known that therapeutic activity increases the level of awareness about themselves. (At the moment, the students are reaching the effects of the method on the Agency's clients).
Certainly, the registered changes to the clients are not a guarantee that a change has occurred but that the modification process has begun. Whether the initiated modification process will result with the expected changes, depends on numerous specific and non-specific environmental and individual factors. In that sense, it is necessary to support simultaneously the prevention process and continuous family work that has as yet not been achieved in a satisfactory manner. In addition, it is envisaged that the program be offered to clients in the event of possible relapse.
Therapeutic work as an element of a regular structured program has been accepted by the clients as well as the staff. Feed-back is being exchanged in informal and formal meetings (once a week) with members of staff and also through the group-supports that provide information and personal support.
It is only possible to introduce this method of treatment if there are trained personnel; thus it is imperative that the existing training programme for psychologists within the Agency is given all the support it needs in order that the programme may be utilised by all those in need, now and in the future.
As the programme has been running for a few months now, the benefits of the psychotherapeutic activities carried out by the Agency is beginning to emerge. Collaboration with other centres is more evident now and mutual feed-back to the point where it is explicit, helps the client make contacts in a more successful way with the environment with the aim to satisfy his own needs and further development.
This help we all give in our own way and none is primary.
" Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter and jests, as well as our sorrows, pains grief and tears. Through it, in particular, we think, see, hear, and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant. It is the same thing which makes us mad or delirious, inspires us with dread and fear, whether by night or day, brings sleeplessness, inopportune mistakes, aimless anxieties, absent-mindedness, and acts that are contrary to habit.
BUT ALL THE TIME THE BRAIN IS STILL A MAN IS INTELLIGENT."
Hippocrates, Fifth Century, B.C.
The brain, the organ of the mind, is composed of a particular type of cell known as a nerve cell which has a definite shape and structure. Each nerve cell consists of a cell body and branching dendrites that act like antennae to receive incoming information form other nerve cells. The signal that is received by this part of the cell is then processed by the cell body and then transferred down an axon, or trunk of the nerve cell, to other areas of the brain that contain these nerve cells. Interactions between nerves takes place mainly through the means of a synapse.
The synapse, in essence, is the place at which the electrical signal carried by the axon of a nerve cell is transformed into a chemical signal. Thus, from the workings of the brain, a synapse converts an electrical signal into a chemical one in the sender and then back into an electrical signal in the receiver. Synapses within the brain are usually of one type or another in that they are excitatory or inhibitory, that is they either allow the signal to pass onto the next line of communication or they prevent the signal from being passed on.
The chemicals released by these terminal regions of the nerve cell into the synaptic space are known as neurotransmitters. They in turn, then act on receptors on the dendrites of following nerve cells. In effect, the synapse releases a particular chemical which acts like a Key to fit the receptor, lock, on the next nerve cell. On combining to the receptor, several changes take place, one of which involves the opening of a particular door (channel) to let in charged ions so that an electrical signal may be generated in the next line of communication. Thus, the brain contains some eighty different types of chemicals, neurotransmitters, that are either excitatory or inhibitory in their effects on the following cells. The ones that have been extensively studied include, opiates, dopamine, noradrenaline, adrenaline, acetycholine, serotonin, glutamate and GABA.
Thus these structures, synapses, provide for functional diversity within the central nervous (brain) but more importantly they provide the point of access through which it is possible to alter nerve cell activity. Therapeutic drugs, in psychiatry have been developed to either mimic the chemical in question or inhibit a particular chemicals effect. In schizophrenia, for example, the current view is that some areas of the brain produce too much dopamine which cause the resultant hallucinations and thought disorders in these patients. The treatment offered in the form of neuroleptic drugs, work because they sit on the receptors (lock) for dopamine and prevent the said chemical from combining to them.
In the case of drugs of abuse, namely heroin and cocaine, these compounds enhance the action of a particular chemical within the brain that is responsible for pleasure and here lies the reason for their potential to be abused.
Heroin, extracted from the poppy, gets into the brain rather more easily than its active ingredient, morphine. Once in the brain, it is morphine, which then mimics the effects of one of the opiate chemicals known as, endorphin. This results in the presence of both the endorphin and morphine such that the response to the chemicals by the opiate receptors is now enhanced. However, with repeated use, the brain learns that there is excess of chemical within the opiate system and thus reduces its own release of endorphin. If this state of affairs continues to occur, the user now has to take on board heroin more frequently. If for one reason or another, he/she is unable to get a fix, withdrawal and the accompanying symptoms are precipitated, which include, vomiting, sweating, shivering, anhedonia, pain, in other words cold turkey sets in.
With regard to cocaine, this chemical works in the brain by potentiating the effect of the brain neurotransmitter, dopamine. This chemical seems to be involved in the coding of signals that are pleasant to us. The user seeks to produce the high by taking cocaine and thus in an artificial sort way create the feelings, positive affective state, that is normally accompanied by achieving some desired goal, for example passing ones exams, learning to appreciate art and music or the aesthetic beauty of sunset. Thus with continued use, these abilities of the mind to process such information are now forgotten. This in turn, is brought about by the effect of cocaine on these dopamine nerve cells that now alter the way in which they work. This change involves an alteration in the way theses nerve cells now pass on their electrical signals and the psychological states that accompany such alterations.
These changes in nerve cell function take some time to
appear but in the same instance they also need time to, in effect, relearn
how to operate in the absence of the drug (cocaine, heroin). It is for
these reasons that the misuse/abuse of such drugs is not to be taken lightly
as the process of asking the brain nerve cells to operate under no drug
conditions other than that which it has become accustomed to over a period
of five years is no easy matter. To this end, certain treatments, e.g.
Ibogaine, used to relieve the discomforts of withdrawal, have appeared
and are now being tested in Italy and the USA. The point must be made that
such treatments do not cure the addict but make the first stages in the
long process of rehabilitation more endurable.
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