The patients
More than three-quarters of the patients are homeless when they come to the unit and they all suffer from extensive substance addiction. Most of them use several illegal substances, the most common being a combination of amphetamine, hash, benzodiazepines and alcohol, and roughly half also use opiates. The majority of our patients are discharged with a psychotic disorder. Two-thirds are men, and the average age is 30 (frame 1). The average duration of stay is less than three months.
Frame 1
The man who stopped talking
Einar, about 30 years old, has in recent years lived in low-threshold accommodation for people with dual diagnosis problems without permanent housing. His life has been characterised by intense substance abuse, and there have been many episodes of bizarre behaviour and restlessness. He has appeared to have disturbed thought processes, and his speech has constantly been incoherent. It has been difficult to understand him, and it is uncertain how much he has understood of what others have said to him. His ability to look after himself was totally absent – for example he went outdoors in winter in his socks.
One autumn a few years ago Einar was committed to an acute psychiatric department. He was then psychotic and was transferred to a department for long-term treatment since the interdisciplinary unit for dual diagnosis did not have a place for him. He was then transferred to us some months later. He had tried being allowed out while he was in the long-term department, and had without exception returned after taking intoxicants. He was still psychotic when he came to us, in spite of taking adequate antipsychotic medication for two months. He said very little, and in general there was a long time-lag before he answered any queries.
In the cognitive environmental therapy, emphasis was placed on behavioural interventions with written weekly plans and on reinforcement and encouragement of the desired behaviour. He struggled with social anxiety, which was reinforced by low self-esteem and disturbed thought processes. He needed clear confirmation of his qualities as a human being as well as encouragement and guidance in handling social situations. It was crucial that he gradually felt ownership of his treatment, and he perceived hope that change was possible. He saw an alternative to a desperate life situation.
The psychotic symptoms diminished during the winter, and Einar was transferred to voluntary treatment. He now participated actively in the unit’s activities. He was allowed out during the last few months, was reliable and compliant, looked after himself well, and conscientiously followed up both his own plans and the tasks he was assigned. The contact and relationship of trust with his parents was strengthened through systematic work with next of kin, and he re-established contact with his family.
Einar wanted to work, and started work training in a café. He carried out the tasks he was given properly, but struggled when talking to others. The greatest changes could be seen in his ability to make facial expressions and eye contact and in his sense of humour.
Einar had periodically drunk some beer before he returned to the ward, and he immediately informed us of this himself, but he did not misuse illegal substances. He was discharged to a supported housing unit for patients with mental problems. It soon became clear that he struggled with ordinary daily activities: he bought beer in the shop but not food, and had to be given training in how he was to do this. He also needed a little more time in the interdisciplinary unit for dual diagnosis. After three weeks he moved back to the supported housing unit with the goal of acquiring his own permanent accommodation. During the past year he has gone to work every day and is now moving into his own place.
Many patients need considerable time and an untraditional approach to persuade them to accept support, but it is seldom that they refuse support from us. It is common for patients not to come on the agreed day, and many are under the influence of intoxicants when they do come. This we do not sanction, but – to spare the patient and to protect the other patients – we can isolate the patient if he/she is extremely mentally unstable or intoxicated. Urine samples are taken to acquire information on substance abuse («It’s a good idea to find out what you’ve taken») or to create motivation («It’s three weeks now since you’ve had positive tests»). Patients are informed that they are not permitted to remain in the environment when they are under the influence of intoxicants, and that it is the staff who determine whether or not they are intoxicated.
We are always willing to admit patients who leave without the permission of the staff and who come back to the unit after taking drugs – at any time and with the offer of transport back to the department. Since we do not threaten to discharge patients, they themselves do not threaten to leave. Very few of the patients discharge themselves from the unit against our advice.
A treatment plan is drawn up in the department in collaboration with the patient, with goals and sub-goals that are changed as things progress. All the patients have their own treatment plan and their own rules in the department. The department is responsible for the structure that is to form the basis for treatment plans and goals. The daily rhythm and meals can be a problem at the start. The treatment includes organised activities, individual therapy consultations, group sessions, instruction, classes and physical activity.
We try to progress to gradual discharges where the services are wound down at the same time as the new option involving where the patient is to live is built up. New relationships are established while the patient is still with us. Much of this activity takes place outside the unit. Some patients have continued to work while they have been in the unit.
We do not discharge patients to low-threshold initiatives such as social welfare centres and bed-sit accommodation, and there is a huge need for specially-adapted and permanent housing. Currently we have a two-year project financed by Husbanken bank and the regional resource centre for the dual diagnosis of substance abuse and psychiatry that aims to find better solutions (7).
We do not view re-admissions as a defeat but rather as part of the patient’s change process. We offer planned short re-admissions for particularly vulnerable patients, and in some cases a reserved crisis place for some patients for a period after discharge.