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Crisis Management and Change in the Therapeutic Community

Charalampos Poulopoulos, PhD Director of KETHEA

ΚΕΤΗΕΑ Therapy Center for dependent Individuals

11th EFTC European Conference on Rehabilitation & Drug Policy

Ljubliana, 06-09 June 2007

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Critical Incidents in T.C.

• Drop-out

• use of violence

• use of drugs and relapse

• suicidal attempts or suicide

• death

• severe illnesses such as HIV/AIDS and

• extreme acting out behaviors

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T.C. as Family Representation

• interaction amongst members and staff• personal and community change• dynamic affected by overt reality and past

experiences • childhood experiences influential on the present• crisis brings experiences of the past• crisis provokes intense feelings and unexpected

behaviors • crisis puts under risk the treatment

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The psychoanalytic approach

• Early mourning may be provoked in adulthood

• Some introject loss, feeling guilt and anger towards themselves

• Others project loss and feel angry towards others

• In crisis early doubts about themselves and others are reactivated

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Consequences

• Withdraw from community life • Acting out behaviors • Dropout • Apathy• Loss of trust in the community system • Lack of ability in handling intense feelings• Fear about the future • Helplessness• Denial

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The question is

How members may learn to grow and mature through crises and loss?

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The Concept of Crisis

• Central to the person, the group and the therapeutic community

• Destabilization characterizes crisis

• Partial or total deconstruction of the system

• Under risk whole function

• Opportunity for change

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Personal level

• Loss is lived as a shock• Affects person’s mental stability • Puts under question attitudes and behaviors• Internal cohesion and cohesiveness are lost • Sense of loosing homeostasis • New attitudes, ideas and behaviors are needed • Mourning a necessary process for finding new balance • Fear, pain, anger and guilt confuse the vision • Diminish hope for the future • Lack of trust and development of paranoia

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Staff consequences

• Staff feel unable to handle the situation.

• Staff conflict

• Splitting

• Lack of communication

• Blaming one another

• Acting out behavior amongst staff members

• Burn out

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The question remains

Can we prevent crisis in a therapeutic community?

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Definitions of Crisis

Chinese: • Two parts: the first part means risk and the second

challenge

Ancient Greek:• Setting apart, making a choice and a decision

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The process of crisis• Painful • Experienced as a shock• Influences the psychological balance • Challenges attitudes and behaviours • Internal coherence is lost• People experience mourning • Desire to maintain what is lost • Fear of the unknown• Loss of the familiar psychosocial context • Fear that cost greater than benefit

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Prolonged crisis

• Therapeutic community may be led to regression and decomposition

• Great degree of latent paranoia• Members and staff seek for secret motives• Dishonesty, suspicion, fear and self-depreciation

prevail • Members often form negative alliances• Formation of subgroups • Completing tasks becomes a burden • Disorganization upset personal relationships

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Reproduction of Crisis• Unexpected incidents • Continuous failure and frustration• Extreme ‘acting out’ behaviours • Violence• Drug abuse• High rates of dropout • Relapse • Serious staff problems • Alienation and Splitting • Developmental and organisational problems

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Five stages of crisis intervention

• Immediate intervention at personal and group level

• Stabilization by using social networks• Facilitation of understanding by discussing the

event and expressing emotions. • Focus on problem solving and identifying

alternative solutions • Encouragement of self-reliance by developing

strategies

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Categories of Crisis

• Situational Crisis (unexpected, unwanted or accidental events)

• Developmental Crisis (transitional situations)

• Complex Crisis (relevant to the internal life and the external environment)

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Sources of crisis

• Members’ behaviour and attitudes

• Staff behaviour

• Organizational structure, methods of treatment and policy

• External environment

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Staff crisis

• Not experienced and/or committed • Does not develop therapeutic alliance • Operates in an autocratic or chaotic style • High turn over rates• Sickness leave • Burn out• Rotation  • Splitting • Unresolved conflicts

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Staff Pathology• Extreme narcissism • Feelings of isolation • Aggressiveness• Suspicion• Arrogance • Abuse of power • Powerful defence mechanisms • Rationalization• Projection • Displacement

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System pathology

• Lack of recognition and justice

• Excessive or lack of control

• Conflicts

• Double binds and manipulation

• Staff experience anxiety and frustration• People feel used, dried-up, without energy

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Organizational & External Sources

• Habits,experiences, knowledge and methods no longer effective

• Responsibility placed on clients • Therapeutic community stops changing• Confusion and uncertainty in policy • Conflicts between policy and goals • Lack of balance between power and responsibility,

formal and informal structure.• Reduction of resources

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The question is

How to facilitate change in an organization that goes through a crisis situation or a pathological condition?

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Crisis intervention vs. Crisis management

• Crisis intervention refers to an intervention that applies to a person or a group during a destabilization time

• Crisis management includes several components of crisis intervention on members, staff and parents and the broader system

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Process of crisis

• stimuli that creates severe stress • person tries to respond the usual ways • efforts fail• person feels emotional distress • stress level increases • person feels emotionally blocked• blocking of emotions does not allow problem

solving and reinforces emotional distress

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Resolving crisis

• Understanding and becoming aware of the problem

• Be relieved from feelings

• Explore cognitively alternative solutions

• Develop new skills for coping with the problem

• Use social support networks

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Learning organization

• Humanitarian ideology• Respect for others• Equality, justice and honesty• Democracy • Communication on any hierarchical level • Members and staff participation in decision making • Transparency and control in power distribution• Adoption of code of ethics• Continuous education and supervision

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KETHEA THERAPY CENTER for DEPENDENT INDIVIDUALS 24 Sorvolou str, 11636 Athens, GreeceTel. ++ 30 210 9241993-6fax ++ 30 210 9241986E-mail: admin@kethea.gr

www.kethea.gr